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 A
Explanation
Choice A rationale:
Placing the client in airborne isolation is a priority because measles is highly contagious and spread through airborne droplets. Airborne precautions are necessary to prevent the transmission of pathogens that can remain suspended in the air for longer periods. Measles is known for its high infectivity, and isolating the client in a negative pressure room equipped with HEPA filtration can help prevent the spread of the virus to other patients and healthcare workers.
Choice B rationale:
While advising family members not to bring flowers into the room is a reasonable infection control measure, it is not the priority action in this scenario. The immediate concern is to prevent the spread of the highly contagious measles virus through airborne transmission.
Choice C rationale:
Obtaining a sputum sample for culture is not the priority action in this situation. Measles is a viral infection, and sputum cultures are typically used to identify bacterial infections. Additionally, the primary mode of transmission for measles is through airborne droplets, so preventing its spread takes precedence over obtaining a sputum sample.
Choice D rationale:
Placing the client on contact precaution is not the correct choice for managing measles. Measles is primarily transmitted through the airborne route, so airborne precautions, not contact precautions, are necessary to prevent its transmission.
Correct Answer is C
Explanation
A. Volunteer to provide an inservice about infection control.While providing an inservice about infection control is important, it is not the immediate priority. The nurse needs to address the current situation to prevent potential contamination and infection spread.
B. Speak with the AP when he exits the room about the appropriate protocol.Speaking with the AP about the appropriate protocol is necessary, but it should be done after ensuring the immediate safety of the client and others. Delaying action could result in exposure to infectious agents.
C. Provide the appropriate PPE to the AP.This action addresses the immediate risk of infection transmission. By providing the appropriate PPE, the nurse ensures that the AP can safely continue their duties without putting themselves or the client at risk.
D. Notify the charge nurse about the AP's need for training.Notifying the charge nurse is important for long-term improvement, but it does not address the immediate risk. The nurse must first ensure that the AP is properly equipped to handle the current situation safely.
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