When performing a skin assessment, the nurse notices a mole on the patient's upper back. What are the appropriate actions by the nurse in further investigation of the mole? Select all that apply
a. Ask the patient about any new moles or changes in moles.
b. Do not alarm the patient by asking questions about the mole.
c. Measure the mole's diameter and elevation.
d. Assess for any exudate on or around the mole.
A, C, D
Evaluate all skin lesions for the possibility of malignancy, especially those located in a site exposed to chronic rubbing or other trauma. Ask the client whether he has any newly developed moles or skin lesions or whether there has been any change in the appearance of existing lesions. The nurse will further assess for asymmetry, border irregularity, color variation, diameter, and elevation above the skin surface, exudate, itching, or pain.
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The nurse is caring for a patient for the first time and needs background information such as history, medications taken at home, etc. The best central location to obtain this information is the:
a. admission summary. b. discharge summary. c. flow sheet. d. Kardex.
What should the nurse recommend for the client experiencing premenstrual syndrome?
1. "Eat more chocolate and drink more caffeine beginning a week prior to when your menstrual cycle bleeding should begin.". 2. "Engage in aerobic activity often throughout the month, and continue exercising when your symptoms begin.". 3. "Decrease your dietary intake of dairy and soy slightly during the month, and especially during your days of bleeding.". 4. "Increase your consumption of red meat when you feel symptoms, and eat three large meals per day.".
A resident does not like the soap and shampoo provided by the center. She has her son buy what she likes. Which statement is correct?
a. She has to use the soap and shampoo pro-vided by the center. b. She has the right to personal choice. c. You can pretend to use what she likes. d. Her items are kept in the closet. The cen-ter's items are kept in the bedside stand.
A nurse is working with a client who says he is only a social drinker. On further questioning, he admits to occasional blackouts after drinking. Which phase of abuse does the nurse identify?
A) Prealcoholic B) Early alcoholic C) Crucial phase D) Chronic phase