A nurse is caring for a client who states he has a nevus that has increased in size and changed in color. On examination, the nurse notes an elevated two centimeter lesion that is dark brownish-black in color with irregular borders. The nurse should recognize that these findings are consistent with which of the following medical diagnoses?
Malignant melanoma
Basal cell carcinoma
Squamous cell carcinoma
Kaposi's sarcoma
The Correct Answer is A
Choice A reason: Malignant melanoma is a type of skin cancer that often presents as a mole that changes in size, color, and appearance. The description of the lesion being dark brownish-black with irregular borders is characteristic of malignant melanoma. This type of cancer can metastasize rapidly and requires prompt medical intervention for diagnosis and treatment.
Choice B reason: Basal cell carcinoma typically appears as a pearly or waxy bump, often with visible blood vessels. It is less likely to present as a dark, irregularly bordered lesion. Basal cell carcinoma is generally slow-growing and less likely to change rapidly in size and color compared to malignant melanoma.
Choice C reason: Squamous cell carcinoma often presents as a red, scaly, and thickened patch on the skin, sometimes with a crusted or ulcerated surface. While it can change in size, it does not typically appear as a dark, irregularly bordered lesion. Squamous cell carcinoma usually develops in areas of the skin exposed to the sun and has a different presentation compared to malignant melanoma.
Choice D reason: Kaposi's sarcoma presents as purplish, reddish-blue, or dark brown lesions that are often flat or slightly raised. These lesions are common in clients with AIDS but are usually smaller and less likely to have irregular borders compared to malignant melanoma. The description provided is more consistent with malignant melanoma than Kaposi's sarcoma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason: Adding the amount of bladder irrigation to the total output is incorrect. Instead, the nurse should subtract the amount of irrigation solution instilled from the total output to accurately measure the client's urine output.
Choice B reason: The correct answer is b because using sterile technique when preparing the irrigation solution is crucial to prevent introducing infections into the bladder or urinary tract during the continuous bladder irrigation process.
Choice C reason: The correct answer is c because ensuring the drainage tubing is patent and without obstruction is essential to maintain effective bladder irrigation and prevent complications such as bladder distention and clot formation.
Choice D reason: The correct answer is d because if the client reports a continual need to void, it may indicate that the irrigation is not functioning properly, and the surgeon should be contacted to assess the situation and make necessary adjustments.
Choice E reason: The correct answer is e because bright red urine or the presence of large clots can indicate active bleeding, which requires prompt notification of the surgeon for further evaluation and intervention.
Correct Answer is C
Explanation
Choice A reason: An open fracture, while needing medical attention, is not immediately life-threatening. The client's condition is stable enough to wait while more critical cases are attended to.
Choice B reason: A penetrating head injury with seizures is a critical condition. However, ensuring a patent airway takes precedence in emergency situations. This client's seizures indicate serious brain injury, but the immediate threat to life, such as airway obstruction, must be prioritized.
Choice C reason: Severe respiratory stridor and a deviated trachea indicate a life-threatening airway obstruction. This client needs immediate attention to secure the airway and prevent respiratory failure. This is the highest priority because without a clear airway, the client will not survive long enough to benefit from other interventions.
Choice D reason: A partial-thickness burn, although painful and requiring treatment, is not immediately life-threatening. This client can safely wait while those with more critical needs are attended to.
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