A nurse is assessing a patient who presents with a scaly, crusted lesion with a central ulceration on the lower leg, as shown in the image. The lesion appears rough, firm, and does not heal despite previous treatments. The nurse suspects squamous cell carcinoma (SCC). What is the priority nursing action?

Apply an antibiotic ointment and reassess in two weeks.

Refer the patient to a dermatologist for a biopsy.

Reassure the patient that the lesion is benign and monitor for changes.

Educate the patient on proper wound care and sun protection.

Answer and Explanation

The Correct Answer is B

A. Apply an antibiotic ointment and reassess in two weeks. SCC is a form of skin cancer and requires biopsy for diagnosis. Simply applying an antibiotic and waiting could delay necessary treatment.

B. Refer the patient to a dermatologist for a biopsy. The priority action for a suspicious lesion that does not heal is to refer the patient for biopsy and further evaluation, as early detection and treatment of SCC are crucial.

C. Reassure the patient that the lesion is benign and monitor for changes. SCC can be aggressive if untreated, and assuming benignity without biopsy could result in delayed diagnosis and worsening prognosis.

D. Educate the patient on proper wound care and sun protection. While wound care and sun protection are important, the priority is obtaining a definitive diagnosis through biopsy.

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Correct Answer is B

Explanation

A. “I will reposition every 2 hours to prevent pressure injuries." Repositioning every 2 hours is a key preventive measure to relieve pressure and reduce the risk of pressure ulcers. This is an appropriate statement and does not indicate a need for further teaching.

B. “I should apply warm compresses to any red areas to improve circulation and prevent ulcers." This statement indicates a need for further teaching. Applying warm compresses to reddened areas can actually worsen tissue damage by increasing moisture and promoting skin breakdown. Instead, pressure should be relieved from the area immediately.

C. “I will encourage a diet rich in vitamin C, zinc, and protein to support skin healing." A diet high in protein, vitamin C, and zinc helps support skin integrity and promotes wound healing, making this a correct statement.

D. “I should use foam cushions and heel protectors to relieve pressure on bony prominences." Foam cushions and heel protectors help redistribute pressure, reducing the risk of pressure ulcers on bony areas like the sacrum and heels. This statement does not indicate a need for further teaching.

A. "Psoriasis is a contagious skin disorder, so I should avoid close contact with others." B. "Stress and hormonal changes can trigger flare-ups of my condition.” C. “I will need to use antiviral medication to have some relief of the symptoms." D. “I should use hot water and harsh soaps to remove the thick scales.”

Correct Answer is B

Explanation

A. "Psoriasis is a contagious skin disorder, so I should avoid close contact with others." Psoriasis is an autoimmune condition, not an infectious disease, so it is not contagious. Close contact does not spread the condition.

B. "Stress and hormonal changes can trigger flare-ups of my condition." Psoriasis flare-ups can be triggered by stress, hormonal changes, infections, and certain medications. Managing stress and other triggers can help reduce flare-ups.

C. “I will need to use antiviral medication to have some relief of the symptoms." Psoriasis is not caused by a viral infection, so antiviral medications are not an effective treatment. Treatment usually involves topical corticosteroids, phototherapy, and immunomodulatory medications.

D. “I should use hot water and harsh soaps to remove the thick scales.” Hot water and harsh soaps can worsen skin irritation and dryness, leading to increased inflammation and exacerbation of psoriasis symptoms. Instead, lukewarm water and mild, fragrance-free soaps should be used.

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Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a caregiver about preventing pressure ulcers in a bedridden patient. Which statement by the caregiver indicates a need for further teaching?

Correct Answer is B

Explanation

A nurse is teaching a patient diagnosed with psoriasis about disease management. Which statement made by the patient indicates a correct understanding of the condition?

Correct Answer is B

Explanation

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