A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?
Advise the client to see his healthcare provider for immediate evaluation.
Encourage the client to keep checking the mole with a magnifying mirror.
Ask the client if he often spends time outside in the sun without a shirt.
Offer to teach a family member how to monitor the skin around the mole.
The Correct Answer is A
Rationale:
A. Changes in a mole's color, size, or shape could indicate melanoma, a serious type of skin cancer. Immediate evaluation by a healthcare provider is critical for early diagnosis and treatment.
B. While monitoring the mole is important, immediate professional evaluation is the priority to rule out malignancy.
C. Assessing sun exposure is relevant for skin cancer risk, but it is not the immediate priority in this scenario.
D. Teaching a family member to monitor the mole is not sufficient when there is a significant change that requires professional evaluation.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
Rationale:
A. Avoiding pain-causing activities would not address the problem of activity intolerance, nor would it promote recovery.
B. The goal is for the client to ambulate with minimal or no discomfort, which would indicate successful pain management and adherence to the postoperative plan.
C. Incision healing is important but does not directly relate to the problem of activity intolerance due to pain.
D. Taking analgesics as prescribed is a component of managing pain, but the outcome should focus on the result of this intervention, which is pain-free ambulation.
Correct Answer is D
Explanation
Rationale:
A. Applying antibiotic ointment is not appropriate for this situation as the issue is likely compromised blood flow, not infection.
B. Checking oxygen saturation is not related to the color change of the stoma.
C. Switching to non-latex supplies is important for clients with latex allergies but is not relevant to the immediate problem.
D. A dark red to bluish color of the stoma suggests compromised blood flow and possible ischemia, which requires immediate medical attention. The nurse should notify the healthcare provider immediately to address this potentially serious complication.