A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. The nurse should be concerned with which additional finding?
A mole that is symmetric
Irregular edges of the mole
Mole diameter less than 6 mm
Consistent color of the mole
The Correct Answer is B
hoice A reason: Symmetry is a benign mole feature; asymmetry is concerning for melanoma. Burning and bleeding with irregular edges raise cancer risk, so symmetry is not the concerning finding here.
Choice B reason: Irregular edges, combined with burning and bleeding, are concerning for melanoma, per the ABCDE criteria (Asymmetry, Border irregularity). This suggests malignancy, making it the correct additional finding to worry about.
Choice C reason: Diameter less than 6 mm is less concerning; melanomas are often >6 mm. Irregular edges with symptoms are more indicative of cancer, so this is not the priority finding.
Choice D reason: Consistent color is benign; variegated colors suggest malignancy. Irregular edges with burning/bleeding are more alarming, so consistent color is incorrect for the concerning finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Writing a series of numbers tests attention or working memory, not recent memory recall. Recalling words after a delay specifically assesses short-term memory, which is more relevant for a 70-year-old, so this is not the best method.
Choice B reason: Asking a patient to recall four words after 10 minutes directly tests recent memory, a key cognitive function in older adults. This method is standard in assessments like the Mini-Mental State Exam, making it the best choice for evaluating memory.
Choice C reason: Verifying information like a mother’s maiden name tests long-term memory, not recent recall. Recent memory involves retaining new information, so recalling words after a delay is more appropriate, making this incorrect.
Choice D reason: Naming past presidents relies on long-term memory and general knowledge, not recent memory. Recalling newly learned words after 10 minutes better assesses short-term memory, so this is not the best approach for recent memory.
Correct Answer is A
Explanation
Choice A reason: In a conscious, alert, and oriented patient, the subjective report is the most reliable pain indicator, as pain is a subjective experience. The patient’s description of intensity, location, and quality directly reflects their perception, guided by neurological pain pathways, making this the gold standard.
Choice B reason: Vital signs like elevated heart rate or blood pressure may suggest pain but are nonspecific, as they can result from anxiety, exertion, or other conditions. They are less reliable than the patient’s verbal report, which directly conveys the pain experience.
Choice C reason: X-ray results may identify structural issues but cannot directly assess pain, a subjective sensation processed by the brain’s pain pathways. They are diagnostic, not experiential, making them unreliable for gauging pain in a conscious patient.
Choice D reason: Physical examination findings, like guarding or grimacing, are indirect pain indicators and less reliable than the patient’s subjective report. These signs may be absent or misleading in some patients, making the verbal description more accurate for pain assessment.
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