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 B
Explanation
Rationale:
A. Insulin glargine is a long-acting insulin, and its dose is not based on before-meal blood sugar readings.
B. The client needs to be taught how to self-administer insulin glargine, as it is given subcutaneously once daily, usually at the same time each day.
C. Increasing the dosage in response to ketoacidosis is inappropriate; emergency treatment is required for this condition.
D. Insulin glargine does not have a role in treating severe hypoglycemia; fast-acting glucose or glucagon is used for such situations.
Correct Answer is C
Explanation
Rationale:
A. Examining feet daily is important for preventing foot complications, such as ulcers, in diabetics but is not directly related to preventing retinopathy and nephropathy.
B. Wearing compression stockings is not specifically recommended for preventing retinopathy or nephropathy in diabetes.
C. Maintaining stable blood glucose levels is crucial for preventing or slowing the progression of diabetic complications such as retinopathy and nephropathy. Good glycemic control minimizes the damage to blood vessels in the eyes and kidneys.
D. While regular eye exams are important for detecting retinopathy early, maintaining stable blood glucose levels is key to preventing the development of complications in the first place.