A nurse on the Medical-Surgical unit is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.).

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.

Choice A rationale:

(Correct Choice) Checking pupillary response to light is a critical first step in the assessment of a client with multiple injuries following a motor vehicle crash. Pupillary changes can indicate neurological issues, increased intracranial pressure, or damage to the brainstem. Rapidly assessing pupil size, equality, and reactivity helps identify potential life-threatening conditions.

Choice B rationale:

Checking the client's response to questions about place and time is important but not the highest priority in this scenario. Neurological and physiological stability should be addressed first to ensure the client's overall well-being.

Choice C rationale:

Assessing capillary refill is valuable in assessing peripheral circulation and hydration status. However, it is not the primary concern when dealing with a client who has potentially sustained traumatic injuries, where neurological and intracranial issues need to be ruled out or addressed urgently.

Choice D rationale:

Evaluating chest expansion is relevant for assessing lung function and detecting potential injuries like rib fractures. However, given the context of a trauma client, focusing on neurological assessment takes precedence over respiratory assessment in the immediate term.