A nurse is caring for a client who states he has a nevus that has increased in size and changed in color. On examination, the nurse notes an elevated two centimeter lesion that is dark brownish-black in color with irregular borders. The nurse should recognize that these findings are consistent with which of the following medical diagnoses?

Malignant melanoma

Basal cell carcinoma

Squamous cell carcinoma

Kaposi's sarcoma

Answer and Explanation

The Correct Answer is A

Choice A reason: Malignant melanoma is a type of skin cancer that often presents as a mole that changes in size, color, and appearance. The description of the lesion being dark brownish-black with irregular borders is characteristic of malignant melanoma. This type of cancer can metastasize rapidly and requires prompt medical intervention for diagnosis and treatment.

Choice B reason: Basal cell carcinoma typically appears as a pearly or waxy bump, often with visible blood vessels. It is less likely to present as a dark, irregularly bordered lesion. Basal cell carcinoma is generally slow-growing and less likely to change rapidly in size and color compared to malignant melanoma.

Choice C reason: Squamous cell carcinoma often presents as a red, scaly, and thickened patch on the skin, sometimes with a crusted or ulcerated surface. While it can change in size, it does not typically appear as a dark, irregularly bordered lesion. Squamous cell carcinoma usually develops in areas of the skin exposed to the sun and has a different presentation compared to malignant melanoma.

Choice D reason: Kaposi's sarcoma presents as purplish, reddish-blue, or dark brown lesions that are often flat or slightly raised. These lesions are common in clients with AIDS but are usually smaller and less likely to have irregular borders compared to malignant melanoma. The description provided is more consistent with malignant melanoma than Kaposi's sarcoma.

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Correct Answer is A

Explanation

Choice A reason: Russell's traction involves the use of a sling under the knee to apply a pulling force on the femur. This helps in aligning and stabilizing the fractured femur, allowing for proper healing. The sling supports the leg, while weights provide the necessary traction force.

Choice B reason: A cervical halter is used in cervical traction to relieve muscle spasms and align the cervical spine, not in Russell's traction. This type of traction is not related to treating femur fractures.

Choice C reason: A pelvic girdle belt is used in pelvic traction to relieve lower back pain and stabilize pelvic fractures, not in Russell's traction. Russell's traction specifically pertains to femur fractures.

Choice D reason: Skeletal pins are used in skeletal traction, where pins are inserted into the bone to apply direct traction. Russell's traction, however, does not use skeletal pins; it uses a sling and weights to apply traction.

A. Provide a diet high in protein. B. Provide ibuprofen for retroperitoneal discomfort. C. Monitor intake and output hourly. D. Encourage the client to consume at least 2 L of fluid daily.

Correct Answer is C

Explanation

Choice A reason: Providing a diet high in protein is not appropriate during the oliguric phase of acute kidney injury, as it can increase the workload on the kidneys and worsen kidney function. Protein intake should be carefully managed based on the client's condition.

Choice B reason: Ibuprofen is contraindicated in clients with acute kidney injury because it can further impair kidney function. Pain management should be approached with alternative medications that do not have nephrotoxic effects.

Choice C reason: The correct answer is c because monitoring intake and output hourly is crucial in managing acute kidney injury. Accurate measurement of fluid balance helps guide treatment decisions and prevent complications such as fluid overload or dehydration.

Choice D reason: Encouraging the client to consume at least 2 L of fluid daily is not appropriate in the oliguric phase, as the kidneys' ability to excrete fluids is impaired. Fluid intake should be carefully restricted and monitored to avoid fluid overload.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about Russell's traction with a newly licensed nurse. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?

A nurse in a health clinic is assisting in the planning of an educational program on skin cancer. Which of the following statements should be included in the presentation?

A nurse is preparing a young adult client who has a hearing impairment for surgery. Which of the following actions should the nurse take?

A nurse is caring for a client who becomes unresponsive. While administering CPR, which of the following actions should the nurse take?

A nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse identify as a risk factor for this condition?

A nurse is caring for a client who has recurrent kidney stones and a history of diabetes mellitus. The client is scheduled for an intravenous pyelogram (IVP). The nurse should collect additional data about which of the following statements made by the client?

A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?