When assessing a lesion on the skin, which of the following findings are concerning? Select all that apply.

Asymmetry of the lesions

Red and black coloration

Flat

8 mm in diameter

Round edges

Answer and Explanation

Correct Answer : A,B,D

A.   A lesion that is asymmetrical is concerning, as melanoma and other skin cancers tend to be irregular in shape. This is an important warning sign.
B.   Red and black coloration in a lesion is concerning because it can indicate changes in blood flow or necrosis, both of which are suspicious for malignancy.
C.   A flat lesion does not automatically indicate a problem, as many benign lesions, like moles, can be flat. The texture or elevation of the lesion is not always a concern unless there are other risk factors.
D.   A lesion larger than 6 mm is concerning, especially if it is changing in size or shape. Larger lesions should be evaluated by a healthcare provider for potential malignancy.
E.   Round edges are typically a characteristic of benign lesions, so this is not as concerning unless there are other warning signs present.

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Correct Answer is A

Explanation

A. Skin tenting, where the skin remains pinched after being pulled up, is a classic sign of dehydration due to a lack of adequate fluid in the tissues.
B. Low body temperature is not typically associated with dehydration; instead, a fever or elevated temperature is more commonly seen with infection.
C. High blood pressure (178/90 mm Hg) could indicate hypertension or another condition, but it is not a direct sign of dehydration.
D. Jugular vein distention is more commonly associated with fluid overload, heart failure, or other circulatory issues, rather than dehydration.

A. Reposition the client every 2 hr. B. Assess the client's skin for increased coolness. C. Keep the client's skin moist. D. Massage the client's red bony prominences.

Correct Answer is A

Explanation

A. Reposition the client every 2 hr: This is an essential action to prevent pressure ulcers and skin breakdown, especially for bedridden patients. Frequent repositioning helps alleviate pressure on bony prominences.
B. Assess the client's skin for increased coolness: While assessing skin temperature is important, it is not as immediate as repositioning the patient. Increased coolness may suggest poor circulation.
C. Keep the client's skin moist: Keeping the skin moist can lead to skin breakdown and increases the risk for pressure ulcers. Dry skin is typically preferred to avoid moisture-related damage.
D. Massage the client's red bony prominences: Massaging reddened skin can actually damage the tissue and worsen pressure injuries. It is advised to avoid massaging bony prominences that show signs of pressure.

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When assessing a lesion on the skin, which of the following findings are concerning? Select all that apply.

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