A nurse is performing a skin assessment for a client who expresses concern about skin cancer.
Which of the following findings should the nurse identify as a potential indication of a skin malignancy?

A lesion with uniform pigmentation.

New appearance of petechiae.

A mole with an asymmetrical appearance.

The presence of a papule.

Answer and Explanation

The Correct Answer is C

Choice A rationale

A lesion with uniform pigmentation is not typically a sign of skin malignancy. Most benign moles are uniform in color, including shades of tan, brown, and black.

Choice B rationale

The new appearance of petechiae, or small, pinpoint hemorrhages under the skin, is not typically associated with skin cancer. Petechiae can be a sign of a number of conditions, including certain infections, low platelet count, or certain medications.

Choice C rationale

A mole with an asymmetrical appearance is a potential indication of skin malignancy. Asymmetry, where one half of the mole does not match the other, is one of the ABCDEs (Asymmetry, Border irregularity, Color variation, Diameter greater than 6mm, and Evolving size, shape, or color) of melanoma detection.

Choice D rationale

The presence of a papule, a small, raised bump on the skin, is not necessarily indicative of skin cancer. Papules can be a sign of many different skin conditions, including acne, skin infections, or dermatitis.

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Correct Answer is C

Explanation

Choice A rationale

While the top of the cane should be parallel to the client’s greater trochanter, this alone does not indicate correct use of the cane.

Choice B rationale

Advancing the cane 46 cm (18 in) forward while walking is too far. To maintain balance, the client should advance the cane about 15-30 cm (6-12 in) at a time.

Choice C rationale

The client should hold the cane on the stronger side of their body to increase support and maintain alignment. This is an indication of correct use.

Choice D rationale

The client should move their weaker leg forward with the cane. This divides the client’s body weight between the cane and the stronger leg.

A. Use a bed exit alarm system. B. Raise four side rails while the patient is in bed. C. Apply one soft wrist restraint. D. Dim the lights in the patient’s room.

Correct Answer is A

Explanation

Choice A rationale

Using a bed exit alarm system is a common intervention to minimize the risk of injury in patients with dementia. These systems alert staff when a patient attempts to leave the bed, allowing for timely intervention to prevent falls.

Choice B rationale

Raising four side rails while the patient is in bed is not a recommended practice. This could be considered a form of restraint and could increase the risk of injury if the patient attempts to climb over the rails.

Choice C rationale

Applying one soft wrist restraint is not a recommended practice for patients with dementia. Restraints should be used as a last resort and only when necessary for the patient’s safety.

Choice D rationale

Dimming the lights in the patient’s room is not a recommended practice to minimize the risk of injury in patients with dementia. Adequate lighting can help prevent falls and other accidents.

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A nurse is performing a skin assessment for a client who expresses concern about skin cancer.Which of the following findings should the nurse identify as a potential indication of a skin malignancy?

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A nurse is performing a skin assessment for a client who expresses concern about skin cancer.
Which of the following findings should the nurse identify as a potential indication of a skin malignancy?