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:
Asking the client's closest kin to convince him to stop fasting due to his injuries is not an appropriate action. Respecting the client's religious beliefs and practices is crucial, and attempting to persuade the client to stop fasting would infringe upon their autonomy and cultural values.
Choice B rationale:
Encouraging the client to stop fasting goes against respecting the client's religious observance and autonomy. The nurse should prioritize culturally competent care and support the client in their religious practices, while also ensuring their nutritional needs are met.
Choice C rationale:
Calling dietary to reschedule the client's meals might seem like a reasonable action, but it does not address the client's religious needs or their wound healing process. Ramadan fasting is an important religious practice, and the nurse should find a way to accommodate the client's fasting while also ensuring appropriate nutritional support.
Choice D rationale:
Starting enteral tube feedings if the client refuses to take food orally is the correct action. Beneficence, a principle of ethical nursing care, emphasizes promoting the well-being of the patient. In this case, the nurse should prioritize the client's wound healing by ensuring they receive necessary nutrition through enteral feeding while still respecting their fasting during Ramadan.
Correct Answer is A
Explanation
Choice A rationale:
The nurse is demonstrating the phase of nursing care known as "Implementation." During this phase, the nurse carries out the interventions and actions that were planned in the previous stages of the nursing process. In this scenario, applying warm compresses to the client's joint is a planned intervention that is being executed by the nurse.
Choice B rationale:
Planning is not the correct choice for this scenario. Planning is the phase of nursing care where the nurse sets goals, outcomes, and develops a plan of action based on the assessment data. It occurs before the implementation phase.
Choice C rationale:
Evaluation is not the correct choice for this scenario. Evaluation is the phase where the nurse assesses the outcomes of the interventions and determines whether the goals have been met. It comes after the implementation phase.
Choice D rationale:
Assessment is not the correct choice for this scenario. Assessment is the initial phase of the nursing process where the nurse collects data about the client's health status. It precedes the planning, implementation, and evaluation phases.
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