While performing a focused assessment on the client, the nurse ...

[809779]

While performing a focused assessment on the client, the nurse notes a skin rash, which the nurse correctly documents as:
 
  1. Rash on face, arms, and trunk.
  2. Maculopapular rash over trunk that client says itches.
  3. 2cm boil noted on the client's shoulder.
  4. Erythematous butterfly-shaped rash noted over the client's cheeks and nose.

Question 2

The nurse notes mucous shreds in the urine of a client with an ileal diversion. The nurse's priority action is to:
 
  1. Document the finding.
  2. Notify the supervisor.
  3. Ensure that the client is ordered an antibiotic.
  4. Encourage the client to increase fluids.

[moormoney]

Answer to Question 1

4
Rationale: The student describes the color, size, shape, and location of the butterfly rash, which is correct. Rash on face, arms, and trunk does not include shape, color, or any other properties. The boil on the shoulder gives the size but not the color or presence of drainage or discomfort. Maculopapular rash on the trunk is not specific enough in location, and does not describe the color or size. Documentation of assessment findings should be done in such a way that the reader can see the finding even if he hasn't yet seen the client.

Answer to Question 2

1
Rationale: This is a normal finding, and no action is required other than documentation.

[809779]

Wow, this really help

[Kedrick2014]

Thanks for the timely response, appreciate it