A client has sought care because they are concerned that a mole on the scalp may be skin cancer. Which finding would the nurse identify as being most suggestive of melanoma?

Solid, dark brown color

Asymmetric, irregular borders

Flat with silvery scales

Diameter of 3 mm

Answer and Explanation

The Correct Answer is B

A. A solid, dark brown color alone is not necessarily indicative of melanoma. Melanomas often have multiple colors, including black, brown, blue, or red.
B. Asymmetric, irregular borders is correct. Melanoma lesions are often asymmetrical, with irregular, poorly defined borders. They also tend to have varied pigmentation and may change over time. The ABCDE rule (Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolution) is used to assess suspicious moles.
C. Flat with silvery scales describes psoriasis, not melanoma.
D. A diameter of 3 mm is smaller than the typical >6 mm size seen in melanoma.

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Correct Answer is D

Explanation

A. Consulting clinical resources is helpful but should be done after reviewing the client’s specific information.
B. Performing a mini overview of body systems occurs during the assessment, not before meeting the client.
C. Gathering materials is important but comes after understanding the client’s history.
D. Reviewing the client’s medical record is correct because it helps the nurse gather baseline information, understand past medical history, and prepare for the assessment effectively.

A. Malignancy B. Aneurysm C. Hernia D. Peritonitis

Correct Answer is D

Explanation

A. Malignancy can cause abdominal pain, but it does not typically present with acute sharp pain and involuntary guarding.
B. Aneurysms, particularly abdominal aortic aneurysms, may present with a pulsatile mass and deep, dull pain rather than sharp pain and guarding.
C. Hernias can cause pain, but they typically present with a bulging mass that increases with straining, not sharp pain with reflex guarding.
D. Peritonitis is correct because it causes severe abdominal pain, involuntary guarding, and rebound tenderness due to inflammation of the peritoneum. Reflex guarding is a protective mechanism indicating peritoneal irritation.

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A client has sought care because they are concerned that a mole on the scalp may be skin cancer. Which finding would the nurse identify as being most suggestive of melanoma?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to meet a client and perform a comprehensive health assessment. Which action should the nurse perform first?

Correct Answer is D

Explanation

While assessing a client's abdomen, the nurse observes sharp pains and involuntary reflex guarding on expiration. What complication does the nurse suspect based on these findings?

Correct Answer is D

Explanation

While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. How would the nurse document this finding?

A nurse has completed the client's initial assessment and is preparing to identify abnormal data and the client's strengths. Which of the following is required to successfully complete this phase of the nursing process?

A student nurse is completing a radial pulse assessment on their client and is uncertain about the assessment findings and the amplitude of the pulses. What is the priority action by the student?

A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to assure they are able to auscultate the heart sounds?

An older adult client has presented to the emergency department with signs and symptoms of dehydration. When assessing the client for risk factors that may have contributed to this condition, what question should the nurse prioritize?

A nursing student correctly describes a risk diagnosis by which of the following statements?

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiologic process?

The nurse is assessing vital signs on a client admitted to the medical-surgical unit. What is the correct technique for assessing the radial pulse?