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 B

Explanation

A. The cone of light at 7 o'clock in the right ear and 5 o'clock in the left ear with a pink and moist tympanic membrane is not a typical finding, as the tympanic membrane should be pearly gray.
B. The cone of light at 7 o'clock in the right ear and 5 o'clock in the left ear with a pearly gray tympanic membrane is the expected finding for a normal ear exam, showing the healthy tympanic membrane and the proper positioning of the cone of light.
C. The cone of light at 5 o'clock in the right ear and 7 o'clock in the left ear with a pink and moist tympanic membrane is incorrect, as the tympanic membrane should be pearly gray, not pink and moist.
D. The cone of light at 5 o'clock in the right ear and 7 o'clock in the left ear with a pearly gray tympanic membrane is an incorrect positioning of the cone of light (should be at 7 o'clock for the right ear and 5 o'clock for the left).

A. Partial-thickness skin loss with red tissue in wound bed B. Full thickness skin loss with visible adipose tissue. C. Full thickness skin loss with visible bone D. Intact skin with localized erythema

Correct Answer is D

Explanation

A. Partial-thickness skin loss with red tissue in wound bed: This is a characteristic of stage 2 pressure injuries, not stage 1.
B. Full thickness skin loss with visible adipose tissue: This is a characteristic of stage 3 pressure injuries.
C. Full thickness skin loss with visible bone: This is a characteristic of stage 4 pressure injuries.

D. Intact skin with localized erythema: This is the characteristic of stage 1 pressure injuries, which present as non-blanching erythema (redness) of intact skin.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is examining a patient's ears, which of the following findings is considered the expected findings?

Correct Answer is B

Explanation

A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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