A nurse on a Medical-Surgical unit is caring for a client who has a suspected malignant lesion. Which of the following findings should the nurse expect when assessing the lesion? (Select all that apply.).
Lesion is brown and black in color.
Irregular borders.
Symmetrical halves.
Diameter greater than 6 mm.
Regular borders.
Correct Answer : B,D,E
Choice A rationale:
Lesion is brown and black in color - This choice does not necessarily indicate malignancy. Skin lesions can be various colors, and color alone is not a definitive indicator of malignancy. Therefore, this choice is not a reliable characteristic for assessing a suspected malignant lesion.
Choice B rationale:
Irregular borders - Irregular or uneven borders are a concerning feature of skin lesions that could suggest malignancy. Malignant lesions, such as melanoma, often have irregular, jagged, or poorly defined borders. This choice is accurate in identifying a potential sign of skin cancer.
Choice C rationale:
Symmetrical halves - Symmetry is generally associated with benign lesions, while malignant lesions often have an asymmetric appearance. A lack of symmetry is considered a characteristic of potential malignancy, making this choice appropriate.
Choice D rationale:
Diameter greater than 6 mm - Lesions with a diameter greater than 6 mm are considered a worrisome characteristic for malignancy. While the size alone is not the sole determinant, larger lesions are more likely to be assessed further for malignancy. This choice accurately identifies a significant feature for evaluation.
Choice E rationale:
Regular borders - Regular, smooth borders are generally associated with benign skin lesions. Malignant lesions tend to have irregular, jagged, or uneven borders. Identifying regular borders as a characteristic of a suspected malignant lesion is inaccurate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Intramuscular administration involves injecting medication into muscle tissue, which may result in slower and variable absorption rates. It is not the optimal route for providing fast and complete absorption of Furosemide.
Choice B rationale:
Subcutaneous administration delivers medication into the fatty tissue beneath the skin. While it can be used for some medications, it generally results in slower absorption compared to intravenous administration, and it may not be suitable for Furosemide, which requires rapid action in a severe heart failure situation.
Choice C rationale:
Oral administration involves taking medication by mouth, and the absorption process can be influenced by factors such as gastric emptying and gastrointestinal transit time. In an urgent scenario of severe heart failure, oral administration might be too slow and unpredictable.
Choice D rationale:
Intravenous administration allows for the fastest and most complete absorption of Furosemide. By directly delivering the medication into the bloodstream, it bypasses the absorption barriers of the gastrointestinal tract, leading to rapid onset of action and predictable effects, which is crucial in managing acute heart failure. This route is commonly used in critical situations where immediate therapeutic effects are needed.
Correct Answer is C
Explanation
Choice A rationale:
Asking the patient why this medication has been ordered is not the appropriate action because patients might not have accurate medical knowledge to provide a valid explanation for the prescription. The nurse should rely on healthcare professionals for accurate information.
Choice B rationale:
Verifying with the hospital administration is not necessary in this situation. The decision to prescribe medication is made by the healthcare provider, not the hospital administration.
Choice C rationale:
Verifying with the prescribing healthcare provider is the most appropriate action. The healthcare provider has the medical knowledge and rationale for prescribing a specific medication. This ensures that the nurse administers the medication safely and in alignment with the patient's condition and treatment plan.
Choice D rationale:
Asking another nurse might not yield accurate information about the rationale behind the medication order. It's best to directly communicate with the healthcare provider responsible for the patient's care.
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