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 B

Explanation

Choice A reason: Rubbing the client's feet briskly can increase circulation temporarily, but it may also cause discomfort or irritation, especially if the client has compromised vascular health.

Choice B reason: The correct answer is b because obtaining a pair of slipper socks for the client can help keep the feet warm and improve comfort. Warm socks are a non-invasive and safe way to address the client's complaint of cold feet.

Choice C reason: Increasing the client's oral fluid intake is important for overall health, but it is not a direct solution for addressing cold feet due to vascular occlusion.

Choice D reason: Placing a moist heating pad under the client's feet can be risky, especially for clients with vascular issues, as it can lead to burns or skin damage. Dry heat, if used, should be carefully monitored to avoid injury.

A. Apply lotion to the skin around the edges of the splint. B. Turn the client every 4 hr. C. Pad the top of the splint with protective dressings. D. The nurse should apply a footplate to the bed.

Correct Answer is C

Explanation

Choice A reason: Applying lotion to the skin around the edges of the splint may increase moisture and friction, which can contribute to skin breakdown. It is better to use protective dressings to reduce friction.

Choice B reason: Turning the client every 4 hours is not frequent enough. Clients in skeletal traction should be repositioned frequently, typically every 2 hours, to prevent pressure ulcers and maintain skin integrity.

Choice C reason: The correct answer is c because padding the top of the splint with protective dressings helps reduce friction and pressure on the skin, preventing skin breakdown and ensuring the client's comfort.

Choice D reason: Applying a footplate to the bed is not directly related to preventing skin breakdown. The primary focus should be on reducing friction and pressure around the splint.

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Naxlex Comprehensive Predictor Exams

Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

Correct Answer is B

Explanation

A nurse is caring for a client who has balanced skeletal traction with a Thomas splint for the treatment of a fracture of the femur. Which of the following actions should the nurse take to prevent skin breakdown?

Correct Answer is C

Explanation

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 reinforcing teaching with a client who has a new prescription for phenazopyridine. The nurse should reinforce to the client to expect which of the following while taking this medication?

A nurse is caring for a client who has a chest tube inserted for a pneumothorax. Which of the following actions should the nurse take?

A nurse is reinforcing nutrition teaching for a client who has chronic kidney disease about limiting foods high in potassium. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply).

A nurse is caring for a client who is suspected to have active laryngeal tuberculosis (TB). Which of the following actions should the nurse plan to take to safely care for this 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?

A nurse is reinforcing teaching for a client who has COPD. Which of the following statements by the client indicates a need for further teaching?

A nurse is reviewing the medical record of a client and identifies a serum potassium of 6.8 mEq/L. Which of the following medications should the nurse expect to administer?