Author Question: A nurse teaches a client to perform total skin self-examinations on a monthly basis. Which ... (Read 32 times)

Medesa · **on:** Jun 25, 2018

A nurse teaches a client to perform total skin self-examinations on a monthly basis. Which statements should the nurse include in this client's teaching? (Select all that apply.)

a. Look for asymmetry of shape and irregular borders.
b. Assess for color variation within each lesion.
c. Examine the distribution of lesions over a section of the body.
d. Monitor for edema or swelling of tissues.
e. Focus your assessment on skin areas that itch.

Question 2

A nurse plans care for a client who has a wound that is not healing. Which focused assessments should the nurse complete to develop the client's plan of care? (Select all that apply.)

a. Height
b. Allergies
c. Alcohol use
d. Prealbumin laboratory results
e. Liver enzyme laboratory results

tranoy · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A, B
Clients should be taught to examine each lesion following the ABCDE features associated with skin cancer: asymmetry of shape, border irregularity, color variation within one lesion, diameter greater than 6 mm, and evolving or changing in any feature.

Answer to Question 2

ANS: A, C, D
Nutritional status can have a significant impact on skin health and wound healing. The care plan for a client with poor nutritional status should include a high-protein, high-calorie diet. To determine the client's nutritional status, the nurse should assess height and weight, alcohol use, and prealbumin laboratory results. These data will provide information related to vitamin and protein deficiencies, and obesity. Allergies and liver enzyme laboratory results will not provide information about nutrition status or wound healing.