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A nurse is inspecting a lesion on a client who has basal cell carcinoma. Which of the following findings should the nurse expect?

A weeping vesicle

A red, edematous macule

A rough, scaly tumor

A pearly, shiny nodule with defined borders.

Answer and Explanation

The Correct Answer is D

A. A weeping vesicle:
More typical of eczema or contact dermatitis, not basal cell carcinoma.

B. A red, edematous macule:
Suggests inflammation or allergic reaction, not a basal cell lesion.

C. A rough, scaly tumor:
Describes squamous cell carcinoma or actinic keratosis.

D. A pearly, shiny nodule with defined borders:
Classic presentation of basal cell carcinoma, especially on sun-exposed areas.

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Correct Answer is D

Explanation

A. Apply cornstarch to keep the skin dry
Cornstarch can cause skin irritation and create a medium for fungal growth in moist environments.

B. Massage bony prominences to promote circulation
This may cause skin breakdown over fragile skin and bony areas, especially in older adults.

C. Reposition the client every 3 hr
Clients at risk should be repositioned at least every 2 hours to prevent pressure injury

D. Provide the client with a diet high in protein
Protein is essential for wound healing and maintaining skin integrity, especially in older adults at risk for pressure injuries.

A. Sanguineous drainage in the suction device B. Granulation tissue on the surface of the wound C. Musty odor from the foam dressing upon removal D. Peeling of the edges of the transparent dressing

Correct Answer is B

Explanation

A. Sanguineous drainage in the suction device:
May occur early on, but persistent sanguineous drainage is not a sign of healing.

B. Granulation tissue on the surface of the wound:
Granulation tissue is pink, healthy tissue that indicates wound healing.

C. Musty odor from the foam dressing upon removal:
Could indicate infection or dressing degradation, not healing.

D. Peeling of the edges of the transparent dressing:
Could compromise the seal of the VAC system and does not reflect wound healing.

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A nurse is inspecting a lesion on a client who has basal cell carcinoma. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the client's skin integrity?

Correct Answer is D

Explanation

A nurse is caring for a client who has a large wound that has a vacuum-assisted closure device placed over it. Which of the following findings by the nurse indicates healing of the wound?

Correct Answer is B

Explanation

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