Security was contacted to remove a handgun that a client, ...

[cherise1989]

Security was contacted to remove a handgun that a client, admitted with wounds sustained in a fight, had in a pants pocket. The nurse should include which of the following nursing diagnoses for this client's plan of care?
 
  1. Risk for Situational Low Self-Esteem
   2. Risk for Other-Directed Violence
   3. Fear
   4. Risk for Loneliness

Question 2

The nurse is collecting data from a client who is being seen at the ambulatory care clinic for a routine physical examination. While listening to the client's lungs, the nurse notes a small, indurated, scaled spot on the client's upper chest.
 
  The nurse records the findings. Based upon your knowledge, which of the following diagnoses most closely resembles the nurse's findings? 1. Squamous cell carcinoma
   2. Basal cell carcinoma
   3. Malignant melanoma
   4. Actinic keratosis

[abro1885]

Answer to Question 1

2. Risk for Other-Directed Violence

Rationale:
The client had a handgun in a pants pocket that could have been used on others in the client's environment. The diagnosis of risk for other-directed violence is appropriate for this client. There is not enough information to determine whether or not the client has a self-esteem disturbance, is afraid, or is at risk for loneliness.

Answer to Question 2

1. Squamous cell carcinoma

Rationale:
Squamous cell carcinoma most often appears as a flesh-colored, erythematous, indurated scaly plaque. Basal cell carcinoma presents as a small fleshy bump. Malignant melanoma manifests as black, brown, or multicolored nodules or plaques. Actinic keratosis is a precancerous condition. The lesion appears as a sore, rough, scaly plaque.