When the arrector pili muscles contract,

Correct Answer: A

Rationale: When the arrector pili muscles contract, they pull on the hair follicles, causing the hair to stand upright, resulting in goosebumps. This physiological response is triggered by emotions or cold temperature to trap air and increase insulation. The other choices are incorrect because sweat release is controlled by sweat glands, skin color changes are unrelated to arrector pili muscles, and shivering is a response to generate heat, not directly caused by arrector pili muscle contraction.

Correct Answer: D

Rationale: The correct answer is D: malignant melanoma. Malignant melanoma is the most dangerous type of skin cancer as it originates in pigment-producing cells called melanocytes. It has the potential to spread to other parts of the body if not detected and treated early. Melanoma has a high mortality rate compared to other types of skin cancer. A: Melanosome is incorrect as it refers to the cellular organelles responsible for producing and storing melanin. B: Metastasis is incorrect as it refers to the spread of cancer cells from one part of the body to another. C: Cyanosis is incorrect as it is a bluish discoloration of the skin due to low oxygen levels in the blood.

Correct Answer: A

Rationale: The correct answer is A: the epidermis. The epidermis is not an accessory structure of the skin; it is the outermost layer of the skin responsible for protection. Lamellar corpuscles, sweat glands, and hair follicles are accessory structures because they are not part of the main structure of the skin but serve specific functions like detecting pressure, producing sweat, and generating hair respectively. The epidermis is essential for skin integrity, while the accessory structures play roles in sensory perception and temperature regulation.

Correct Answer: B

Rationale: In this scenario, the correct answer is option B - the client who has just arrived from the emergency department with facial burns associated with a house fire. This client should be assessed first because facial burns can compromise the airway and breathing, posing an immediate threat to life. As a nurse, ensuring adequate airway, breathing, and circulation (ABCs) is a top priority in emergency situations. Option A may seem urgent due to the severe leg pain, but deep partial-thickness burns do not immediately jeopardize airway or breathing. Option C, while important, involves a client who has already received treatment and is not currently in an acute life-threatening situation. Option D, the client waiting for discharge teaching, is the least urgent as their condition has been stable for weeks. Educationally, this question highlights the critical thinking needed in prioritizing care based on the acuity of the situation. Understanding the immediate threats posed by certain conditions, such as facial burns and potential airway compromise, is crucial for nurses working in emergency or critical care settings. It reinforces the importance of ABC assessments and quick decision-making in prioritizing care to ensure the best outcomes for patients.

Correct Answer: C

Rationale: In this scenario, the best nursing action to delegate to an experienced nursing assistant is option C, which is to remind the family to help the client to the commode every 2 hours during the day. This action directly addresses the factors contributing to impaired skin integrity, such as immobility and bladder incontinence. Option A would require more specialized knowledge and skill to ensure proper application of skin barrier cream. Option B involves assessing and making recommendations regarding the client's nutrition, which falls more under the scope of a nurse's responsibilities. Option D involves evaluating and documenting improvements in skin integrity, which requires nursing assessment and clinical judgment. Educationally, it's important to understand the principles of delegation in nursing practice. Delegating tasks to nursing assistants should be based on their skill level, the complexity of the task, and the client's condition. By delegating appropriate tasks, nurses can optimize efficiency and ensure quality care for clients while promoting teamwork within the healthcare team.