A nurse is performing a skin assessment on a client who has a history of melanoma.
Which finding should alert the nurse to a possible malignant lesion?
A brown mole with a smooth border and symmetrical shape
A red macule with a flat surface and well-defined edges
A black nodule with an irregular border and asymmetrical shape
A yellow papule with a raised surface and round edges
The Correct Answer is C
A black nodule with an irregular border and asymmetrical shape
Rationale: A black nodule with an irregular border and asymmetrical shape is consistent with the ABCDE criteria for melanoma, which are: Asymmetry, Border irregularity, Color variation, Diameter greater than 6 mm, and Evolving or changing appearance.
Incorrect options:
A) A brown mole with a smooth border and symmetrical shape - This is a normal finding that does not indicate malignancy.
B) A red macule with a flat surface and well-defined edges - This is likely a benign vascular lesion, such as a cherry angioma or petechiae.
D) A yellow papule with a raised surface and round edges - This is likely a benign sebaceous lesion, such as a sebaceous cyst or milia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A black nodule with an irregular border and asymmetrical shape
Rationale: A black nodule with an irregular border and asymmetrical shape is consistent with the ABCDE criteria for melanoma, which are: Asymmetry, Border irregularity, Color variation, Diameter greater than 6 mm, and Evolving or changing appearance.
Incorrect options:
A) A brown mole with a smooth border and symmetrical shape - This is a normal finding that does not indicate malignancy.
B) A red macule with a flat surface and well-defined edges - This is likely a benign vascular lesion, such as a cherry angioma or petechiae.
D) A yellow papule with a raised surface and round edges - This is likely a benign sebaceous lesion, such as a sebaceous cyst or milia.
Correct Answer is B
Explanation
"The client has crackles in the lower lobes bilaterally."
Rationale: Objective data are observable and measurable facts that can be verified by the nurse or another health care provider. Crackles are an abnormal lung sound that can be heard with a stethoscope and indicate fluid accumulation in the alveoli.
Incorrect options:
A) "The client reports feeling short of breath and fatigued." - This is an example of subjective data, which are information that only the client can perceive and describe, such as feelings, sensations, and beliefs.
C) "The client states that he has been coughing up green sputum." - This is also an example of subjective data, as it is based on the client's verbal report.
D) "The client rates his pain as 4 out of 10 on a numeric scale." - This is another example of subjective data, as pain is a personal experience that cannot be directly measured by the nurse.
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