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 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.

A. "It is acceptable to use alcohol-based hand products after most client contact.” B. "I should wash my hands before I provide client care.” C. "I will not wear artificial nails when providing client care.” D. "As long as I change gloves between clients, it is not necessary to wash my hands.”

Correct Answer is D

Explanation

Choice D rationale:

This statement by an assistive personnel (AP) indicates a need for further teaching. Hand hygiene is crucial to prevent the transmission of microorganisms, and it involves both handwashing and the appropriate use of gloves. Changing gloves between clients is important to prevent cross-contamination, but it doesn't replace the need for handwashing. Hands can become contaminated even with the use of gloves, and proper hand hygiene should be practiced before and after glove use.

Choice A rationale:

The statement about using alcohol-based hand products after most client contact is accurate. Alcohol-based hand sanitizers are effective in reducing the number of microorganisms on the hands when soap and water are not readily available. They are especially useful in healthcare settings.

Choice B rationale:

Washing hands before providing client care is a fundamental principle of infection control. It helps remove dirt, debris, and transient microorganisms from the hands, reducing the risk of infection transmission.

Choice C rationale:

The statement about not wearing artificial nails when providing client care is correct. Artificial nails can harbor microorganisms and are challenging to clean thoroughly. They pose an infection risk and are generally not recommended for healthcare workers who provide direct patient care.

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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

A nurse is caring for an Islamic client who is recovering from a motor vehicle accident. The patient is observing Ramadan, the ninth lunar month. The nurse understands that a good diet is important for the client's wounds to heal. Which action should the nurse take regarding the client's diet?

Correct Answer is D

Explanation

A nurse is providing teaching to a group of assistive personnel (AP) about hand hygiene. Which of the following statements by one of the APs indicates a need for further teaching?

Correct Answer is D

Explanation

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