When assessing a client's skin, which finding should the nurse report to the healthcare provider?

Multiple yellow lesions with a grainy surface.

Large, flat, dark red irregular area on the neck.

Bluish discoloration of the nail beds.

Multiple silver striae on the abdomen

Answer and Explanation

The Correct Answer is C

A. Multiple yellow lesions with a grainy surface. These could indicate xanthomas, which are associated with lipid disorders and may warrant further investigation and treatment.

B. Large, flat, dark red irregular area on the neck. This could be a port-wine stain, which is typically a congenital condition and may not require immediate medical intervention unless associated with other symptoms.

C. Bluish discoloration of the nail beds. This indicates cyanosis, which can be a sign of hypoxia or cardiovascular issues. It requires prompt evaluation by a healthcare provider to determine the underlying cause and necessary interventions.

D. Multiple silver striae on the abdomen. Striae, or stretch marks, are usually benign and often result from rapid weight changes or hormonal variations. They typically do not require immediate medical attention.

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Correct Answer is C

Explanation

A. Notify the healthcare provider. Notifying the healthcare provider might be necessary if the kyphosis is a new finding or is associated with pain, neurological symptoms, or other complications. However, kyphosis is often a chronic condition associated with osteoporosis.

B. Observe muscle fasciculations. Muscle fasciculations are not directly related to kyphosis and osteoporosis. This option does not address the primary concern of the assessment finding.

C. Document the assessment finding. Documenting the presence of kyphosis is essential for the medical record and ongoing management of the client's osteoporosis. It ensures that the condition is noted and can be monitored over time.

D. Palpate the area for an effusion. Effusions are related to fluid accumulation in joints or tissues, which is not directly related to kyphosis. This is not an appropriate action in response to observing kyphosis.

A. Stand behind the client to avoid intimidation. B. Turn on overhead lights while giving instructions. C. Provide handouts written at a 12th grade reading level. D. Use background music to promote relaxation.

Correct Answer is B

Explanation

A. Stand behind the client to avoid intimidation. This is not an appropriate teaching strategy. Standing behind a client can actually increase intimidation and anxiety, as it does not allow for direct eye contact and clear communication.

B. Turn on overhead lights while giving instructions. Proper lighting is essential for older adults, who may have visual impairments. Turning on overhead lights ensures that the client can clearly see the materials and the nurse, enhancing understanding and engagement during the teaching session.

C. Provide handouts written at a 12th grade reading level. Handouts for patient education should be written at a lower reading level, generally around the 5th to 6th grade level, to ensure comprehension by a broad audience, including those with limited literacy skills. A 12th grade reading level is too high for effective patient education for most adults.

D. Use background music to promote relaxation. Background music can be distracting rather than relaxing during educational sessions, especially for older adults who may have hearing impairments or cognitive issues. Clear and focused communication is more effective without additional auditory distractions.

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When assessing a client's skin, which finding should the nurse report to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an admission assessment, the nurse observes the presence of kyphosis on an older adult female client with a history of osteoporosis. Which action should the nurse take in response to this finding?

Correct Answer is C

Explanation

The nurse is teaching an older adult client newly diagnosed with type 2 diabetes mellitus about symptoms and treatment of hypoglycemia. Which action should the nurse implement while teaching the client?

Correct Answer is B

Explanation

The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

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