A 30-year-old African American had surgery 6 months ago and the incision site is now raised, indurated, and shiny. This is most likely which type of tissue growth?
Melanoma
Keloid
Nevus
Angioma
The Correct Answer is B
A. Melanoma:
Melanoma is a type of skin cancer that arises from melanocytes, the cells that produce pigment (melanin) in the skin. Melanoma lesions are typically irregularly shaped, often asymmetrical, with varying shades of color (brown, black, tan, red, blue). They may have an uneven border and can evolve over time. Melanomas can be raised but are not typically described as indurated (firm) and shiny. They are also more commonly associated with changes in color, size, and shape.
B. Keloid:
A keloid is an abnormal overgrowth of scar tissue that extends beyond the boundaries of the original wound or incision site. Keloids are characterized by their raised appearance, firm or indurated texture, and shiny surface compared to the surrounding skin. They may also be darker than the surrounding skin due to increased collagen deposition. Keloids can develop months after an injury or surgery and are more common in individuals with darker skin tones, such as African Americans.
C. Nevus:
A nevus, commonly known as a mole or birthmark, is a benign growth of melanocytes or other skin cells. Nevus lesions can vary in appearance but are often flat or slightly raised, with a uniform color (brown, black, tan, or flesh-colored). They are usually not described as indurated or shiny. Nevus lesions can be present at birth (congenital nevus) or develop later in life (acquired nevus).
D. Angioma:
Angiomas are benign tumors that originate from blood vessels or lymphatic vessels. They can present as red or purplish raised lesions on the skin. Angiomas are typically not described as indurated or shiny. Common types of angiomas include cherry angiomas (small, red papules) and spider angiomas (red, spider-like lesions with central vessels).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Inform the client that the recovery nurse will instruct them how to manage postoperative pain:
This is an important aspect of postoperative care, but it is typically addressed by the post-anesthesia care unit (PACU) or recovery nurse after surgery rather than in the preoperative education phase. While pain management education is crucial, the focus of preoperative education is usually on what to expect before, during, and immediately after surgery.
B. Remind the client they will return to their room after surgery:
This information is part of the preoperative instructions and helps alleviate anxiety by providing clarity about the post-surgical process. However, it may not be the most critical aspect of preoperative education compared to other options.
C. Provide instructions about how to cough and deep breathe effectively:
This is a key nursing intervention to include in preoperative education. Teaching the client how to cough and deep breathe effectively helps prevent postoperative complications such as atelectasis and pneumonia. These breathing techniques are typically taught preoperatively to ensure the client understands and can perform them correctly after surgery.
D. Notify the client that they will receive a food tray in the recovery room:
While it's important for the client to understand the postoperative diet plan, including any dietary restrictions or instructions, this information is usually provided after surgery rather than in the preoperative education phase.
Correct Answer is ["E"]
Explanation
A. Increased pulse rate:
This is a common manifestation of fluid overload. Excess fluid volume can lead to an increase in cardiac output, causing the heart to pump faster and resulting in an increased pulse rate.
B. Decreased blood pressure:
Fluid overload typically leads to increased blood volume, which can initially cause an increase in blood pressure. However, as fluid overload progresses, it can lead to fluid redistribution, venous congestion, and decreased systemic vascular resistance, ultimately resulting in decreased blood pressure.
C. Skeletal muscle weakness:
Skeletal muscle weakness is not a direct manifestation of fluid overload. It is more commonly associated with electrolyte imbalances, such as hypokalemia or hypomagnesemia, which can occur as a consequence of fluid shifts but are not specific to fluid overload itself.
D. Warm and pink skin:
Warm and pink skin is not typically associated with fluid overload. Instead, it is more indicative of adequate tissue perfusion and oxygenation. In fluid overload, skin changes may include edema, cool and clammy skin due to venous congestion, or signs of skin breakdown in areas of pressure.
E. Distended neck veins:
Distended neck veins, specifically jugular venous distention (JVD), are commonly seen in patients with fluid overload, especially if there is right-sided heart failure or increased central venous pressure. JVD is a result of increased venous return to the heart due to fluid accumulation.
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