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. Erythromycin does not require the client to avoid sunlight, unlike some other antibiotics.
B. The timing of medication intake does not affect the interaction between erythromycin and oral contraceptives.
C. Erythromycin can reduce the effectiveness of oral contraceptives. It is essential to use an additional contraceptive method to prevent unintended pregnancy.
D. Stopping the oral contraceptive is not necessary but using an additional form of contraception is important.
Correct Answer is D
Explanation
Rationale:
A. The clavicle is an important landmark but not the ideal starting point for auscultating breath sounds.
B. The sternum is also not the correct starting location for breath sound auscultation.
C. The aortic site is unrelated to lung auscultation.
D. The lung apex, located above the clavicle, is the correct location to begin auscultating anterior breath sounds. This systematic approach ensures all areas of the lungs are assessed for normal and abnormal breath sounds.