A nurse is performing an integumentary assessment for a client. Which of the following findings should the nurse identify as possible squamous cell carcinoma?
Painless, raised purple nodules on the hard palate.
A small macule with a yellow-brown scale.
A firm nodule with a hard crust.
Yellow white patches of growth on the tongue.
The Correct Answer is C
Choice A reason: This choice is incorrect as painless, raised purple nodules on the hard palate are not typically indicative of squamous cell carcinoma.
Choice B reason: This choice is incorrect because a small macule with a yellow-brown scale does not describe squamous cell carcinoma, which often presents as a firm nodule with a scaly crust.
Choice C reason: This choice is correct. Squamous cell carcinoma can present as a firm nodule with a hard, scaly crust on the skin.
Choice D reason: Yellow white patches of growth on the tongue are more indicative of conditions such as oral leukoplakia, not squamous cell carcinoma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Placing the client in a sitting position helps to lower blood pressure by promoting venous return and is the first action to take in cases of autonomic dysreflexia.
Choice B reason: Checking for a fecal impaction is important as it can be a trigger for autonomic dysreflexia, but it is not the first action to take.
Choice C reason: Examining for areas of skin breakdown is part of ongoing care for clients with spinal cord injuries but is not the immediate priority in autonomic dysreflexia.
Choice D reason: Checking blood pressure is important for monitoring the severity of autonomic dysreflexia, but the first action is to address the positioning of the client to manage the hypertensive crisis.
Correct Answer is A
Explanation
Choice A reason: A blood pressure reading of 124/79 mm Hg is considered elevated. The normal range for blood pressure is less than 120/80 mm Hg. Elevated blood pressure is when readings consistently range from 120129 systolic and less than 80 mm Hg diastolic.
Choice B reason: Stage 1 hypertension is defined by a systolic blood pressure ranging from 130 to 139 mm Hg or a diastolic pressure ranging from 80 to 89 mm Hg. The client's blood pressure does not fall into this category.
Choice C reason: Stage 2 hypertension is characterized by a systolic blood pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher. The client's blood pressure is below these levels.
Choice D reason: A normal blood pressure reading is typically below 120/80 mm Hg. Although the client's diastolic pressure is within the normal range, the systolic pressure is above normal, thus it does not qualify as a normal blood pressure reading.
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