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 B
Explanation
Choice A rationale:
Stage I Pressure ulcer - This choice is not correct because a Stage I pressure ulcer is characterized by intact skin with non-blanchable redness over a bony prominence. There is no partial-thickness skin loss at this stage.
Choice B rationale:
Stage II Pressure ulcer - This is the correct choice. A Stage II pressure ulcer involves partial-thickness skin loss that presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also manifest as an intact or open/ruptured serum-filled blister.
Choice C rationale:
Stage IV Pressure ulcer - This choice is not correct because a Stage IV pressure ulcer involves full-thickness tissue loss with exposed bone, tendon, or muscle. There is no mention of such extensive tissue loss in the given scenario.
Choice D rationale:
Stage II Pressure ulcer - This choice is a duplicate of Choice B and is not correct for the reasons stated above.
Correct Answer is C
Explanation
Choice A rationale:
Cranberry juice causing bad breath is not a well-known side effect or outcome associated with its consumption. This information is not a commonly taught aspect of cranberry juice use.
Choice B rationale:
Bloating is not a common or widely recognized outcome of drinking cranberry juice. While cranberry juice might have some gastrointestinal effects, bloating is not a significant concern associated with its consumption.
Choice C rationale:
Informing the client that drinking cranberry juice daily can prevent recurrent urinary tract infections is accurate. Cranberry juice is often recommended for its potential to reduce the risk of urinary tract infections due to its anti-adhesive properties that may inhibit the adherence of bacteria to the urinary tract.
Choice D rationale:
Cranberry juice's effect on lowering cholesterol is not a well-established benefit of its consumption. Cholesterol management typically involves dietary changes, exercise, and sometimes medications, but cranberry juice is not a primary intervention for this purpose.
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