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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

This statement indicates a need for further teaching. Synthetic clothing and woolen socks can generate static electricity, which poses a risk around oxygen due to its flammable nature. The client should be advised to wear cotton clothing and avoid synthetic fabrics to prevent static-related accidents.

Choice B rationale:

This statement is correct. Oxygen supports combustion, so ensuring visitors don't smoke near the client is crucial. However, it does not indicate a need for further teaching.

Choice C rationale:

This statement is incorrect. The client cannot determine the oxygen flow rate by visual inspection of the flowmeter. The flow rate should be set based on the healthcare provider's instructions, and this information should have been covered in the teaching.

Choice D rationale:

This statement indicates the client understands the potential cognitive effects of oxygen therapy and when to seek medical assistance. It does not necessarily indicate a need for further teaching.

A. Asthma. B. Pneumothorax. C. Atelectasis. D. Pneumonia.

Correct Answer is B

Explanation

Choice A rationale:

Asthma - Asthma is a chronic respiratory condition characterized by bronchoconstriction, inflammation, and increased mucus production. It does not typically present with absent breath sounds, deviation of the trachea, or hyperresonant percussion sounds. Wheezing is a common finding in asthma.

Choice B rationale:

Pneumothorax - This is the correct choice. The scenario describes classic signs of a tension pneumothorax, which is a medical emergency. The tracheal deviation, absence of breath sounds, and hyperresonant percussion note on the affected side are indicative of air accumulation in the pleural space, leading to lung collapse and displacement of mediastinal structures.

Choice C rationale:

Atelectasis - Atelectasis refers to the collapse or incomplete expansion of a lung or part of a lung. It can lead to decreased breath sounds on auscultation but does not usually cause tracheal deviation or hyperresonance on percussion. It is not the best fit for the described signs.

Choice D rationale:

Pneumonia - Pneumonia is an infection of the lung tissue that can cause symptoms like fever, cough, and productive sputum. Breath sounds may be diminished over the affected area due to consolidation, but the absence of breath sounds, tracheal deviation, and hyperresonance point more strongly toward a pneumothorax in this case.

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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.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Correct Answer is B

Explanation

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