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. Applying pressure proximal to the IV site is not appropriate and could cause further complications.
B. Assessing the radial pulse is important but is not the immediate response to the occlusion alarm.
C. Straightening the arm can help relieve a positional occlusion, which is a common cause of such alarms.
D. Elevating the arm may help with venous return but is not a first-line action for addressing the occlusion alarm.
Correct Answer is C
Explanation
Rationale:
A. Palpating muscle tone is important but should be done in conjunction with resistance testing to assess strength.
B. Asking the client to close his eyes is not necessary for assessing muscle strength.
C. Applying resistance while the client extends and flexes his arms helps evaluate the muscle strength and function accurately.
D. Providing an object to hold is not relevant for assessing muscle strength in this context.