A nurse is performing an integumentary assessment for a client. Which of the following findings should the nurse identify as possible squamous cell carcinoma?

Painless, raised purple nodules on the hard palate.

A small macule with a yellow-brown scale.

A firm nodule with a hard crust.

Yellow white patches of growth on the tongue.

Answer and Explanation

The Correct Answer is C

Choice A reason: This choice is incorrect as painless, raised purple nodules on the hard palate are not typically indicative of squamous cell carcinoma.

Choice B reason: This choice is incorrect because a small macule with a yellow-brown scale does not describe squamous cell carcinoma, which often presents as a firm nodule with a scaly crust.

Choice C reason: This choice is correct. Squamous cell carcinoma can present as a firm nodule with a hard, scaly crust on the skin.

Choice D reason: Yellow white patches of growth on the tongue are more indicative of conditions such as oral leukoplakia, not squamous cell carcinoma.

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Correct Answer is C

Explanation

Choice A reason: Offering the bedpan every 2 hours is not specifically related to preventing urinary tract infections (UTIs) and may not be necessary unless the client has other needs that require frequent toileting.

Choice B reason: Cleansing the perineum from front to back is a standard practice to prevent the spread of bacteria from the anal area to the urethra, which can reduce the risk of UTIs.

Choice C reason: Encouraging fluid intake is crucial for clients with a spinal cord injury because it helps to flush out the urinary tract, preventing the buildup of bacteria that can cause UTIs.

Choice D reason: An indwelling urinary catheter may be necessary for a client with a T4 spinal cord injury who cannot effectively empty the bladder, but it should be used with caution as it can also increase the risk of UTIs. The decision to use an indwelling catheter should be based on a thorough assessment and consideration of all other options.

A. Diabetes mellitus B. Hyperlipidemia C. Gallstones D. Criminal record

Correct Answer is C

Explanation

Choice A reason: Diabetes mellitus is not directly associated with acute pancreatitis. However, longstanding diabetes can lead to chronic pancreatitis due to the damage it causes to the pancreas over time.

Choice B reason: Hyperlipidemia, specifically high levels of triglycerides in the blood, can be a risk factor for acute pancreatitis. Elevated triglyceride levels above 1000 mg/dL can precipitate an episode of acute pancreatitis.

Choice C reason: Gallstones are a common cause of acute pancreatitis. They can block the bile duct, leading to pancreatitis. It's estimated that gallstone disease is responsible for 3040% of acute pancreatitis cases.

Choice D reason: A criminal record is not a medical condition and has no relevance to the development of acute pancreatitis.

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A nurse is performing an integumentary assessment for a client. Which of the following findings should the nurse identify as possible squamous cell carcinoma?

Nursing Test Bank

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