A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCD" characteristic of malignant melanoma?

Asymmetrical shape

Diameter less than 6mm

Color is uniform

Borders well demarcated

Answer and Explanation

The Correct Answer is A

A) Asymmetrical shape: One of the key "ABCD" characteristics of malignant melanoma is asymmetry. Melanomas often have an irregular shape where one half does not match the other, unlike benign moles, which are typically symmetrical. This characteristic helps in distinguishing malignant lesions from benign ones.
B) Diameter less than 6mm: Malignant melanomas are often larger than 6 mm in diameter, especially as they progress. While smaller lesions can still be malignant, a diameter less than 6 mm is not a distinguishing feature for melanoma. Typically, melanomas are identified as growing larger over time.
C) Color is uniform: Malignant melanomas usually exhibit multiple colors or uneven pigmentation rather than uniform color. Uniform color is more characteristic of benign moles. Melanomas can show a mix of colors, including shades of brown, black, and sometimes red or white.
D) Borders well demarcated: Malignant melanoma often has irregular, not well-defined borders. The edges of a melanoma are usually uneven or not clearly defined, unlike benign moles, which typically have smooth, well-demarcated borders.

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Correct Answer is A

Explanation

A) Instruct the patient on Tripod positioning: Tripod positioning involves the patient sitting or standing with their hands on their knees or a table, which helps in optimizing lung expansion and improving breathing. This position can help clients with COPD ease their breathing by increasing the use of accessory muscles and allowing the diaphragm to work more efficiently.
B) Restrict the client's fluid intake to less than 2 L/day: Restricting fluid intake is generally not recommended for COPD patients unless there are specific signs of fluid retention or other contraindications. Adequate fluid intake is important to keep mucus thin and easier to expel. Restricting fluids may worsen mucus thickness and make it harder to clear secretions.
C) Provide the client with a low-protein diet: COPD patients often need a higher-protein diet to help maintain muscle mass and support overall nutritional status. A low-protein diet would not be appropriate as it could lead to muscle wasting and decreased respiratory muscle strength.
D) Have the client use the early-morning hours for exercise and activity: While physical activity is important, the timing of exercise should be tailored to the client's individual tolerance and condition. Early-morning exercise might not be suitable for all patients, especially if they experience morning respiratory symptoms or have other considerations. The key is to find an optimal time that aligns with the patient's energy levels and condition.

A. "Let's stop and take your vital signs." B. "We can take a break anytime." C. "Keep taking deep breathes; you will be okay." D. "Let's stop: I have all of the information we need."

Correct Answer is D

Explanation

A) "Let's stop and take your vital signs": While taking vital signs can be important, it might not address the immediate discomfort the client is experiencing from the deep palpation. This response may not fully address the need to pause the assessment in light of the client’s discomfort.
B) "We can take a break anytime": Offering a break is considerate, but it does not directly address the immediate situation. If the client is already in significant discomfort, it's more appropriate to stop the procedure entirely if the information gathered so far is sufficient.
C) "Keep taking deep breaths; you will be okay": Encouraging deep breathing may help manage some discomfort, but it doesn’t acknowledge the client's need to stop the procedure or the fact that the assessment may have already provided sufficient information.
D) "Let's stop: I have all of the information we need": Stopping the palpation when the client is experiencing pain or discomfort and when enough information has been obtained is the most appropriate response. It shows sensitivity to the client's pain and prioritizes their comfort, while also acknowledging that the assessment may have achieved its purpose.

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A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCD" characteristic of malignant melanoma?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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