When assessing a client diagnosed with basal cell carcinoma, which of the following findings will the nurse expect?

A blister-like pustule on the face that oozes clear fluid

A dark brown lesion that is flat

A small scaly, dry lesion on the elbow

Location on the top of the head where exposed frequently to sunlight

Answer and Explanation

The Correct Answer is C

Choice A Reason: This is incorrect because a blister-like pustule on the face that oozes clear fluid may indicate impetigo, which is a bacterial skin infection, not basal cell carcinoma. Basal cell carcinoma is a type of skin cancer that arises from the basal layer of the epidermis, which is the outermost layer of the skin. Basal cell carcinoma lesions are usually not blistered or pustular, but rather smooth, shiny, or waxy.

Choice B Reason: This is incorrect because a dark brown lesion that is flat may indicate a mole, which is a benign growth of melanocytes, which are cells that produce pigment, not basal cell carcinoma. Basal cell carcinoma lesions are usually not dark brown or flat, but rather flesh-colored, pink, or red, and may have a raised or indented center.

Choice C Reason: This is correct because a small scaly, dry lesion on the elbow may indicate basal cell carcinoma. Basal cell carcinoma lesions are often small, scaly, and dry, and may bleed or crust over. They can occur anywhere on the body, but are more common on areas that are exposed to the sun, such as the face, neck, arms, or legs.

Choice D Reason: This is incorrect because location on the top of the head where exposed frequently to sunlight may indicate squamous cell carcinoma, which is another type of skin cancer that arises from the squamous layer of the epidermis, not basal cell carcinoma. Squamous cell carcinoma lesions are usually rough, scaly, or crusted, and may have a firm or hard texture. They can also occur anywhere on the body, but are more common on areas that are exposed to the sun.

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Correct Answer is D

Explanation

Choice A reason: This is incorrect because increasing her voice when speaking to the client may not prevent complications, but rather annoy or offend the client. The nurse should not assume that a client with a visual impairment has a hearing impairment as well unless it is confirmed by assessment or history. The nurse should speak in a normal tone and volume and identify herself by name and role.
Choice B reason: This is incorrect because lowering the bed rails before lowering the bed may increase the risk of complications, such as falls or injuries. The nurse should keep the bed rails up until the client is ready to get out of bed and lower them only when necessary. The nurse should also lock the wheels of the bed and adjust it to a comfortable height for the client.
Choice C reason: This is incorrect because using hand gestures to point to where the client will walk may not prevent complications, but rather confuse or frustrate the client. The nurse should not use visual cues or gestures that are meaningless to a client with a visual impairment. The nurse should use verbal directions and descriptions instead, such as "The restroom is on your left, about 10 steps away."
Choice D reason: This is correct because standing slightly in front and to one side of the client can prevent complications, such as collisions or falls. The nurse should guide the client by offering her arm or shoulder for support and walking slightly ahead of him or her. The nurse should also warn the client about any obstacles or changes in terrain, such as stairs, doors, or rugs.

A. Place food trays on the left side of the client. B. Place food trays on the right side of the client. C. Perform a focused visual exam. D. Have the assistive personnel feed all meals to the client.

Correct Answer is A

Explanation

Choice A reason: This is the correct answer because right-sided homonymous hemianopsia means that the client has lost vision in the right half of both eyes, so placing food trays on the left side of the client will help them see and access their food better.

Choice B reason: This is incorrect because placing food trays on the right side of the client will make it harder for them to see and reach their food, as they have no vision on that side.

Choice C reason: This is incorrect because performing a focused visual exam is not an appropriate action for the nurse to take during meal time. The nurse should assess the client's vision before or after meals, but not interfere with their eating.

Choice D reason: This is incorrect because having the assistive personnel feed all meals to the client will decrease their independence and dignity, as well as their ability to practice using their unaffected side. The nurse should encourage and assist the client to feed themselves as much as possible, and only provide assistance when needed.

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When assessing a client diagnosed with basal cell carcinoma, which of the following findings will the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting a client with a visual impairment to use the restroom. Which of the following actions will the nurse take to prevent complications?

Correct Answer is D

Explanation

A client who recently suffered a stroke suffers from right-sided homonymous hemianopsia. What is the best action for the nurse to take when caring for the client during mealtime?

Correct Answer is A

Explanation

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