A nurse is performing a skin assessment on a patient and suspects basal cell carcinoma (BCC). Which of the following findings would support this suspicion?

A rapidly growing, irregular brown lesion with uneven borders

A slow-growing, pearly or waxy nodule with visible blood vessels with central ulceration

A dark, flat lesion with a satellite pattern of spreading pigmentation

A firm, scaly lesion with a rough, honey crusted surface

Answer and Explanation

The Correct Answer is B

A. A rapidly growing, irregular brown lesion with uneven borders. This description is more characteristic of melanoma, which presents as an asymmetrical, dark lesion with irregular borders and rapid growth.

B. A slow-growing, pearly or waxy nodule with visible blood vessels with central ulceration. BCC typically appears as a pearly, waxy nodule with visible telangiectasia (small blood vessels). It grows slowly and may develop a central ulceration over time.

C. A dark, flat lesion with a satellite pattern of spreading pigmentation. This description aligns more with melanoma, which often spreads in a radial pattern with satellite lesions.

D. A firm, scaly lesion with a rough, honey-crusted surface. This description is more consistent with squamous cell carcinoma (SCC), which presents as a rough, scaly lesion that may ulcerate.

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Correct Answer is C

Explanation

A. Infection. Infection is a major concern in burn patients due to loss of skin integrity, but airway compromise is the most immediate life-threatening risk.

B. Paralytic ileus. Burn patients may develop paralytic ileus due to stress response and fluid shifts, but this is not the highest priority compared to airway obstruction.

C. Airway obstruction. Burns involving the face, neck, and chest increase the risk of airway swelling and obstruction. The nurse should assess for signs of respiratory distress, stridor, or hoarseness and be prepared for early intubation if needed.

D. Fluid imbalance. Fluid shifts can cause hypovolemia and shock, making fluid resuscitation critical. However, airway management remains the highest priority, especially in burns affecting the upper airway.

A. The surgical dressing has a small amount of serosanguinous drainage. B. The patient's hemoglobin dropped from 12 g/dL to 10 g/dL within 24 hours postoperatively. C. The patient reports mild discomfort at the surgical site and rates pain as 4/10 on a pain scale. D. The surgical extremity is cool to touch, pale, with weak pedal pulses compared to the contralateral limb.

Correct Answer is D

Explanation

A. The surgical dressing has a small amount of serosanguinous drainage. Light serosanguinous drainage is expected postoperatively and does not require immediate intervention.
B. The patient’s hemoglobin dropped from 12 g/dL to 10 g/dL within 24 hours postoperatively. A mild drop in hemoglobin postoperatively is expected due to blood loss during surgery. This does not require immediate intervention.
C. The patient reports mild discomfort at the surgical site and rates pain as 4/10 on a pain scale. Mild discomfort is expected and can be managed with prescribed analgesics.
D. The surgical extremity is cool to touch, pale, with weak pedal pulses compared to the contralateral limb. These findings indicate impaired circulation or vascular compromise, which could suggest compartment syndrome or arterial occlusion. Immediate intervention is required to prevent limb ischemia.

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A nurse is performing a skin assessment on a patient and suspects basal cell carcinoma (BCC). Which of the following findings would support this suspicion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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