A client who is receiving chemotherapy is admitted with widespread herpes simplex lesions of the oral mucosa and lips. The admission assessment data includes a marked recent decrease in oral intake, level 9-10 burning oral pain (0-10 pain scale), and statements by the client indicating emotional distress about the appearance of the lesions. Based on this information, which of these nursing diagnoses is of highest priority?

Correct Answer: B

Rationale: In this scenario, the highest priority nursing diagnosis is B) Acute Pain related to the presence of extensive herpes simplex lesions. This is the most critical because the client is experiencing severe pain rated at level 9-10 on a pain scale, which is significantly impacting their quality of life and ability to function. Pain management is a fundamental aspect of nursing care and addressing it promptly is crucial for the client's well-being and overall comfort. Option A) Risk for Infection is not the highest priority in this case as the client already has herpes simplex lesions, and the focus should be on managing the pain and discomfort they are currently experiencing. Option C) Imbalanced Nutrition is also important, but it is secondary to managing the client's acute pain. Once the pain is under control, addressing the decreased oral intake and nutritional needs can be addressed. Option D) Disturbed Body Image is relevant due to the client's emotional distress about the appearance of the lesions, but it is not as critical as managing the acute pain. Pain relief should be the priority before addressing emotional concerns. From an educational perspective, this scenario highlights the importance of prioritizing nursing diagnoses based on the client's immediate needs and focusing on interventions that will have the most significant impact on their well-being. Effective pain management is essential in providing holistic care and improving the client's overall quality of life.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Dehydration. Dehydration is a significant risk factor for pressure ulcers because it can lead to reduced blood flow to the skin, making it more susceptible to damage and slower wound healing. In a client with symptoms of nausea, vomiting, diarrhea, and immobility, dehydration is a common occurrence due to fluid loss and decreased intake. Proper hydration is crucial for maintaining skin integrity and preventing pressure ulcers. Option B) Hypokalemia is not directly linked to pressure ulcer development. While electrolyte imbalances can impact overall health, they do not have a direct correlation to skin breakdown. Option C) Hypernatremia, an excess of sodium in the blood, is not a common risk factor for pressure ulcers. It is more related to fluid balance and can lead to dehydration, which is a risk factor for pressure ulcers. Option D) Fluid overload is also not a typical risk factor for pressure ulcers. While excessive fluid retention can cause swelling and affect circulation, leading to other health issues, it is not a primary risk factor for pressure ulcer development. Educationally, understanding the relationship between hydration status and pressure ulcer risk is crucial for healthcare professionals caring for immobile patients. By recognizing dehydration as a risk factor, healthcare providers can implement preventive measures such as regular skin assessments, repositioning schedules, and adequate hydration protocols to reduce the incidence of pressure ulcers in vulnerable patients.

Correct Answer: B

Rationale: The correct answer to the question is B) It should take up to 4 months for healing at the site of the navel. This answer is correct because body piercings, especially in areas like the navel which have limited blood supply, typically take a longer time to heal compared to other areas. The navel area is prone to movement and friction which can prolong the healing process. Option A) It should take up to 8 weeks for healing at the site of the navel is incorrect because healing in the navel area typically takes longer due to its location and limited blood flow. Option C) It should take up to 9 months for healing at the site of the navel is incorrect as this is an excessive amount of time for a navel piercing to heal under normal circumstances. Option D) It should take up to 2 weeks for healing at the site of the navel is incorrect as healing a navel piercing in just 2 weeks is unrealistic and does not align with the typical healing process for body piercings. In an educational context, understanding the healing times associated with body piercings is crucial for healthcare professionals to provide accurate information to patients. Educating patients on proper piercing aftercare and expected healing times can help prevent complications and ensure successful healing of the piercing site.

Correct Answer: C

Rationale: The correct answer is C) Epidermis, dermis, subcutaneous tissue, fat, fascia, muscle, and bone. In a fourth-degree burn, all layers of the skin (epidermis, dermis, subcutaneous tissue) are destroyed, extending to deeper tissues like fat, fascia, muscle, and even bone. This level of tissue involvement results in significant damage and potential complications like tissue necrosis and loss of function. Option A (Epidermis, dermis, subcutaneous tissue) describes a third-degree burn, not a fourth-degree burn. Option B (Deeper layer of the dermis with damage to sweat and sebaceous glands) is more characteristic of a second-degree burn. Option D (Epidermis and dermis, hair follicles intact) is indicative of a first-degree burn, where only the superficial layers of the skin are affected. Understanding the depth of burns is crucial in healthcare, as it guides treatment decisions, predicts outcomes, and influences patient management. Educating healthcare professionals on burn classifications helps them provide appropriate care, prevent complications, and promote optimal healing for patients with burn injuries.

Correct Answer: D

Rationale: The correct answer is D) Lesion has irregular color and asymmetric shape. Dysplastic nevus syndrome is characterized by atypical moles that exhibit irregular coloration, asymmetry in shape, and uneven borders. These moles are considered precursors to melanoma, a type of skin cancer. Understanding this characteristic is crucial in identifying potential early signs of melanoma and differentiating them from common moles. Option A) Associated with sun exposure is incorrect because dysplastic nevus syndrome is not primarily linked to sun exposure but rather to genetic factors. Option B) Precursor of squamous cell carcinoma is incorrect as dysplastic nevus syndrome is specifically associated with an increased risk of melanoma, not squamous cell carcinoma. Option C) Slow-growing tumor with rare metastasis is incorrect as dysplastic nevi are not typically slow-growing tumors; they are more concerning due to their potential to progress into melanoma, which can metastasize. Educationally, recognizing the features of dysplastic nevi is essential for healthcare professionals, particularly dermatologists and primary care providers, in conducting skin assessments, detecting early signs of melanoma, and advising patients on skin cancer prevention strategies like sun protection and regular skin checks. This knowledge can ultimately lead to early diagnosis and improved outcomes for individuals at risk for skin cancer.