A nurse on a Medical-Surgical unit is caring for a client who has a suspected malignant lesion. Which of the following findings should the nurse expect when assessing the lesion? (Select all that apply.).

Lesion is brown and black in color.

Irregular borders.

Symmetrical halves.

Diameter greater than 6 mm.

Regular borders.

Answer and Explanation

Correct Answer : B,D,E

Choice A rationale:

Lesion is brown and black in color - This choice does not necessarily indicate malignancy. Skin lesions can be various colors, and color alone is not a definitive indicator of malignancy. Therefore, this choice is not a reliable characteristic for assessing a suspected malignant lesion.

Choice B rationale:

Irregular borders - Irregular or uneven borders are a concerning feature of skin lesions that could suggest malignancy. Malignant lesions, such as melanoma, often have irregular, jagged, or poorly defined borders. This choice is accurate in identifying a potential sign of skin cancer.

Choice C rationale:

Symmetrical halves - Symmetry is generally associated with benign lesions, while malignant lesions often have an asymmetric appearance. A lack of symmetry is considered a characteristic of potential malignancy, making this choice appropriate.

Choice D rationale:

Diameter greater than 6 mm - Lesions with a diameter greater than 6 mm are considered a worrisome characteristic for malignancy. While the size alone is not the sole determinant, larger lesions are more likely to be assessed further for malignancy. This choice accurately identifies a significant feature for evaluation.

Choice E rationale:

Regular borders - Regular, smooth borders are generally associated with benign skin lesions. Malignant lesions tend to have irregular, jagged, or uneven borders. Identifying regular borders as a characteristic of a suspected malignant lesion is inaccurate.

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Correct Answer is B

Explanation

Choice A rationale:

Applying the pulse oximeter probe to the toe is not the most appropriate location. While toe measurements can be used, the fingers are more commonly used due to their accessibility and accuracy. Edema in the hands could affect the accuracy of readings.

Choice B rationale:

The nurse should apply the pulse oximeter probe to the earlobe. This choice is correct because the earlobe is a well-vascularized and easily accessible area that provides accurate oxygen saturation measurements. Thickened toenails and edema of the hands might compromise readings in those locations.

Choice C rationale:

Applying the pulse oximeter probe to a skin fold is not a recommended site for oxygen saturation measurement. While there are various sites where pulse oximeters can be applied, the earlobe and finger are more suitable due to their consistent blood flow and accessibility.

Choice D rationale:

While applying the pulse oximeter probe to the finger is a common and acceptable practice, in this scenario, edema of the hands could affect the accuracy of the readings. The earlobe is a better choice as it is less likely to be affected by edema and can provide accurate readings.

A. Decreased tactile fremitus. B. Pleural friction fremitus. C. Crepitus. D. Rhonchal fremitus.

Correct Answer is C

Explanation

Choice A rationale:

Decreased tactile fremitus refers to a decreased vibration felt upon palpation of the chest, which might be indicative of conditions such as pleural effusion or pneumothorax. It is not directly associated with a crackling sensation.

Choice B rationale:

Pleural friction fremitus occurs when inflamed pleural surfaces rub against each other during breathing. It typically results in a grating sensation rather than a crackling sensation. It is associated with conditions like pleuritis.

Choice C rationale:

(Correct Choice) Crepitus refers to a crackling or grating sound/sensation that occurs when gas or air accumulates in the subcutaneous tissue. It can indicate a serious condition, such as subcutaneous emphysema, which might result from lung or chest wall injury, infections, or surgery.

Choice D rationale:

Rhonchal fremitus is associated with coarse breath sounds caused by thick secretions in the larger airways. It is felt as vibration during palpation and is not related to crackling sensations.

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A nurse on a Medical-Surgical unit is caring for a client who has a suspected malignant lesion. Which of the following findings should the nurse expect when assessing the lesion? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A Cardiovascular nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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