When performing a skin assessment, the nurse notices a mole on ...

[imanialler]

When performing a skin assessment, the nurse notices a mole on the patient's upper back. What are the appropriate actions by the nurse in further investigation of the mole? Select all that apply.
 
  a. Ask the patient about any new moles or changes in moles.
  b. Do not alarm the patient by asking questions about the mole.
  c. Measure the mole's diameter and elevation.
  d. Assess for any exudate on or around the mole.

Question 2

The nurse on a medical unit notes a moderate amount of fluid accumulation in the feet and ankles of a 75-year-old patient. The nurse will further assess this patient for indications of which conditions? Select all that apply.
 
  a. Kidney disease
  b. Heart failure
  c. Thyroid disease
  d. Common age-related changes

[irishcancer18]

Answer to Question 1

A, C, D
Evaluate all skin lesions for the possibility of malignancy, especially those located in a site exposed to chronic rubbing or other trauma. Ask the client whether he has any newly developed moles or skin lesions or whether there has been any change in the appearance of existing lesions. The nurse will further assess for asymmetry, border irregularity, color variation, diameter, and elevation above the skin surface, exudate, itching, or pain.

Answer to Question 2

A, B
Edema, or an excessive amount of fluid in the tissues, is an abnormal finding. It is common in patients with congestive heart failure, kidney disease, peripheral vascular disease, or low albumin levels. It is not related to thyroid disease and it is not a normal or common finding in older adults.

[imanialler]

Thanks

[irishcancer18]

Welcome