The nurse is assessing a client who had a surgical excision of a basal cell carcinoma one week ago. Assessment findings include redness, warmth, and serosanguinous drainage from the site. What would be the priority action by the nurse?
Request a prescription to culture the wound
Request a prescription for broad spectrum antibiotics
Assure the client this is normal in the healing process
Clean the wound with sterile normal saline
The Correct Answer is A
A. Requesting a prescription to culture the wound is the priority action because the presence of redness, warmth, and serosanguinous drainage could indicate an infection that needs to be confirmed and treated appropriately.
B. While antibiotics may be necessary if an infection is confirmed, it is crucial to first determine the presence of infection through culturing the wound.
C. Assuring the client that these findings are normal may delay necessary intervention if an infection is present, which could worsen the client's condition.
D. Cleaning the wound with sterile normal saline may be appropriate as part of wound care, but it does not address the underlying concern of possible infection and would not be prioritized over obtaining a culture.
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Correct Answer is B
Explanation
A. This statement is accurate as Mohs surgery involves examining each layer of skin for cancer cells before proceeding with further removal.
B. The client indicates a misunderstanding; Mohs surgery does not typically involve a needle biopsy of the lymph node at the time of the procedure, as it focuses on the local removal of skin cancer.
C. This statement is correct as the goal of Mohs surgery is to remove the cancer while preserving as much healthy tissue as possible.
D. This statement is also true as Mohs surgery is designed to minimize healthy tissue removal, often resulting in better cosmetic outcomes
Correct Answer is B
Explanation
A. Requesting antidepressant medication may be appropriate later, but it does not address the immediate need for emotional support and communication.
B. Encouraging the client to verbalize feelings about their diagnosis provides an opportunity for the client to express their concerns and emotions, fostering a therapeutic relationship and aiding in emotional processing.
C. While explaining improved prognosis can provide hope, it may minimize the client’s feelings of fear and uncertainty and could be perceived as dismissive.
D. Allowing time for reflection is important, but it should be balanced with the need for communication and support to prevent isolation.