A nurse is assessing a client who presents to the provider’s office for evaluation of multiple nevi. Which of the following findings should the nurse report to the provider as a possible sign of malignancy?
Intense pruritus
Irregular borders
Uniform pigmentation
Purulent drainage
The Correct Answer is B
Choice A reason:
Intense pruritus: While itching (pruritus) can be a symptom of skin conditions, it is not a definitive sign of malignancy in nevi. Pruritus can be associated with benign conditions such as eczema or allergic reactions. However, if a mole starts to itch, it should be monitored closely, but it is not as strong an indicator of malignancy as irregular borders.
Choice B reason:
Irregular borders: This is a significant sign of potential malignancy in nevi. Melanomas often have uneven, notched, or scalloped borders, unlike benign moles, which typically have smooth, even borders. The irregularity in the border is due to the uncontrolled growth of melanocytes, which can spread unevenly.
Choice C reason:
Uniform pigmentation: Uniform pigmentation is generally a sign of a benign mole. Malignant moles often have multiple colors or an uneven distribution of color, which can include shades of brown, black, red, white, or blue. A mole with uniform color is less likely to be malignant.
Choice D reason:
Purulent drainage: While purulent drainage (pus) indicates an infection, it is not a typical sign of malignancy in nevi. Infections can occur in any skin lesion, but they do not specifically indicate cancer. Malignant moles are more likely to change in size, shape, or color rather than produce pus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Administer the Medications 5 Minutes Apart
Administering the medications 5 minutes apart is crucial when using multiple eye drops. This practice ensures that each medication has enough time to be absorbed without being washed out by the subsequent drop. This is particularly important for medications like timolol and pilocarpine, which are used to manage intraocular pressure in glaucoma.
Choice B reason: Hold Pressure on the Conjunctival Sac for 2 Minutes Following Application of Drops
Holding pressure on the conjunctival sac (punctal occlusion) for 2 minutes after applying eye drops can help reduce systemic absorption and increase the local effect of the medication. However, this instruction is not as critical as the timing between administering different eye drops.
Choice C reason: It Is Not Necessary to Remove Contact Lenses Before Administering Medications
This statement is incorrect. Contact lenses should be removed before administering eye drops to prevent contamination and ensure proper absorption of the medication. The lenses can be reinserted after a sufficient amount of time has passed, usually around 15 minutes.
Choice D reason: Administer the Medications by Touching the Tip of the Dropper to the Sclera of the Eye
This statement is incorrect. The tip of the dropper should never touch the eye or any other surface to avoid contamination. The correct method is to hold the dropper above the eye and squeeze out the prescribed number of drops into the conjunctival sac.
Correct Answer is A
Explanation
Choice A reason:
Obtaining a 12-lead ECG is crucial for a client with a potassium level of 6.8 mEq/L, which indicates hyperkalemia. Hyperkalemia can cause life-threatening cardiac dysrhythmias, and an ECG can help detect these abnormalities early.
Choice B reason:
Suggesting that the client use a salt substitute is not appropriate in this situation. Many salt substitutes contain potassium chloride, which can further increase potassium levels and exacerbate hyperkalemia.
Choice C reason:
Asking the client to add citrus juices and bananas to her diet is also inappropriate. These foods are high in potassium and can worsen hyperkalemia.
Choice D reason:
While obtaining a blood sample for a serum sodium level can be part of the overall assessment, it is not the immediate priority. The primary concern with hyperkalemia is the risk of cardiac dysrhythmias, which makes obtaining a 12-lead ECG the most urgent action.
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