A nurse is assessing a client who presents to the provider’s office for evaluation of multiple nevi. Which of the following findings should the nurse report to the provider as a possible sign of malignancy?
Intense pruritus
Irregular borders
Uniform pigmentation
Purulent drainage
The Correct Answer is B
Choice A reason:
Intense pruritus: While itching (pruritus) can be a symptom of skin conditions, it is not a definitive sign of malignancy in nevi. Pruritus can be associated with benign conditions such as eczema or allergic reactions. However, if a mole starts to itch, it should be monitored closely, but it is not as strong an indicator of malignancy as irregular borders.
Choice B reason:
Irregular borders: This is a significant sign of potential malignancy in nevi. Melanomas often have uneven, notched, or scalloped borders, unlike benign moles, which typically have smooth, even borders. The irregularity in the border is due to the uncontrolled growth of melanocytes, which can spread unevenly.
Choice C reason:
Uniform pigmentation: Uniform pigmentation is generally a sign of a benign mole. Malignant moles often have multiple colors or an uneven distribution of color, which can include shades of brown, black, red, white, or blue. A mole with uniform color is less likely to be malignant.
Choice D reason:
Purulent drainage: While purulent drainage (pus) indicates an infection, it is not a typical sign of malignancy in nevi. Infections can occur in any skin lesion, but they do not specifically indicate cancer. Malignant moles are more likely to change in size, shape, or color rather than produce pus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Obtain a 12-lead ECG
Obtaining a 12-lead ECG is a critical action when a client has a potassium level of 6.8 mEq/L, which indicates hyperkalemia. Hyperkalemia can cause serious cardiac dysrhythmias, including life-threatening arrhythmias such as ventricular fibrillation or asystole. An ECG can help detect these abnormalities early, allowing for prompt intervention to prevent cardiac complications. The ECG may show characteristic changes such as peaked T waves, widened QRS complexes, and prolonged PR intervals, which are indicative of hyperkalemia.
Choice B reason: Suggest that the client use a salt substitute
Suggesting that the client use a salt substitute is not appropriate in this situation. Many salt substitutes contain potassium chloride, which can further increase the potassium level in the blood. For a client with hyperkalemia, it is crucial to avoid additional sources of potassium to prevent exacerbating the condition. Therefore, recommending a salt substitute could be harmful.
Choice C reason: Advise the client to add citrus juices and bananas to her diet
Advising the client to add citrus juices and bananas to her diet is also inappropriate. Both citrus juices and bananas are high in potassium and can contribute to an increase in serum potassium levels. For a client with hyperkalemia, it is essential to limit dietary potassium intake to help lower the potassium levels in the blood. Encouraging the consumption of high-potassium foods would be counterproductive and potentially dangerous.
Choice D reason: Obtain a blood sample for a serum sodium level
While obtaining a blood sample for a serum sodium level can be part of a comprehensive assessment, it is not the immediate priority in managing hyperkalemia. The primary concern with a potassium level of 6.8 mEq/L is the risk of cardiac dysrhythmias. Therefore, obtaining an ECG to monitor the heart’s electrical activity is the most urgent and appropriate action. Once the immediate risk is addressed, further laboratory tests, including serum sodium levels, can be conducted as part of the overall assessment and management plan.
Correct Answer is C
Explanation
Choice A reason: Apply Bilateral Wrist Restraints
Applying bilateral wrist restraints can be necessary in some cases to prevent the child from touching or interfering with the surgical site. However, restraints should be used as a last resort and only when absolutely necessary. They can cause distress and discomfort to the child and should be monitored closely to prevent any complications.
Choice B reason: Administer Opioids for Pain
Administering opioids for pain management is a common practice post-surgery to ensure the child is comfortable. However, opioids should be used cautiously due to the risk of side effects and potential for dependency. Non-opioid pain management strategies, such as acetaminophen or ibuprofen, are often preferred unless the pain is severe.
Choice C reason: Implement a Soft Diet
Implementing a soft diet is crucial for a child who is 24 hours postoperative following a cleft palate repair. The surgical site in the mouth is still healing, and a soft diet helps prevent any damage or irritation to the area. Soft foods are easier to swallow and less likely to cause pain or disrupt the healing process. Examples of soft foods include mashed potatoes, yogurt, and pureed fruits.
Choice D reason: Offer Fluids Through a Straw
Offering fluids through a straw is not recommended for a child who has undergone cleft palate repair. The suction created by using a straw can put pressure on the surgical site and potentially cause complications. Instead, fluids should be offered using a cup or a spoon to minimize any risk to the healing palate.
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