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Skin Assessment

Highlight the abnormal findings that the nurse should be concerned about. Select all that apply.

A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past.

change in mole size

color changes

itching

burning

bleeding

has had many blistering sunburns in the past

dark complexion

no family history of skin cancer

Answer and Explanation

The Correct Answer is ["A","B","C","D","E"]

A change in the size of a mole is a significant red flag and should be concerning for potential skin cancer, particularly melanoma. A mole that enlarges over time, especially if it changes size rapidly, can indicate the development of malignant melanoma.

Color changes in a mole, such as darkening, lightening, or developing multiple colors, should raise concern for melanoma. Melanomas often present with uneven pigmentation, where the mole may become more than one color, such as black, blue, red, or brown. This change in color is abnormal and requires further investigation.

Itching and burning are abnormal symptoms associated with skin lesions and can be indicative of skin cancer. These sensations can occur when the skin becomes irritated or inflamed due to a growing malignancy such as melanoma.

Bleeding from a mole is a red flag and is concerning for skin cancer, especially melanoma. A mole that bleeds or oozes may be ulcerating or eroding, which are signs of more advanced skin cancer.

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Correct Answer is B

Explanation

A. Trapezius: The trapezius is a muscle of the upper back and neck and does not play a primary role in normal respiration.
B. Diaphragm: The diaphragm is the most important muscle for respiration. It contracts and moves downward during inhalation, increasing the thoracic cavity's volume and drawing air into the lungs.
C. Rectus abdominus: The rectus abdominus is a core muscle that helps in forced expiration but is not essential in normal breathing.
D. Sternocleidomastoid: This muscle assists with forced inspiration, but it is not the primary muscle for regular breathing.

A. Improper positioning B. Fatigue or weakness C. Respiratory distress D. Increased comfort and relaxation

Correct Answer is C

Explanation

A. Improper positioning does not apply in this case; the position described is often associated with respiratory distress.
B. Fatigue or weakness may be present, but the described position is more indicative of difficulty breathing.
C. Respiratory distress is suggested by the patient leaning forward, which is a common position for patients with shortness of breath as it helps expand the lungs and ease breathing.
D. Increased comfort and relaxation is unlikely; this position is more often associated with discomfort and difficulty breathing.

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Naxlex Comprehensive Predictor Exams

Which of the following is the most important muscle in the normal respiratory process of an adult?

Correct Answer is B

Explanation

Mrs. Helms is sitting on the side of the bed, leaning forward, with her arms on the bedside table. What would this indicate to you?

Correct Answer is C

Explanation

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