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.
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Correct Answer is C
Explanation
Rationale:
A. Hypertension is not a common side effect of phenytoin. It is not typically associated with the medication.
B. Peripheral edema is not commonly linked to phenytoin use.
C. Gingival hyperplasia, or overgrowth of the gums, is a common side effect of phenytoin, particularly with long-term use.
D. Hematuria is not a typical side effect of phenytoin and may indicate a different medical issue.
Correct Answer is A
Explanation
Rationale:
A. Pyridostigmine is most effective when taken before meals to improve muscle strength for swallowing. Knowing the client's recent oral intake helps in timing the medication appropriately.
B. Difficulty with urination is not directly related to pyridostigmine use.
C. Trouble sleeping is not typically associated with pyridostigmine.
D. Unexplained weight loss may be related to myasthenia gravis but is not directly relevant to the immediate administration of pyridostigmine.