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: Checking the ophthalmoscope’s light source is unnecessary unless the device malfunctions. The red glow is a normal finding, reflecting light off the retina’s blood vessels, not indicating equipment issues, making this an inappropriate action.
Choice B reason: The red glow, or red reflex, is a normal finding during ophthalmoscopy, caused by light reflecting off the vascular retina. It indicates a clear optical pathway, ruling out opacities like cataracts, making this the correct action to document as normal.
Choice C reason: An opacity in the lens or cornea (e.g., cataract or corneal scar) would block the red reflex, causing a dark or absent glow. The presence of a red glow indicates a clear media, making this suspicion incorrect.
Choice D reason: Stopping the exam and referring the patient is unwarranted, as the red glow is a normal finding. Referral is only needed for abnormal findings like absent reflex or opacities, making this an unnecessary and incorrect action.
Correct Answer is C
Explanation
Choice A reason: Inspection visually assesses abdominal shape and distention but cannot differentiate gas from constipation, as both may cause distention. It lacks the specificity to identify the cause, making it less effective for this purpose.
Choice B reason: Auscultation assesses bowel sounds but cannot directly distinguish gas from constipation. Hyperactive sounds may suggest gas, but this is indirect, and constipation can also alter sounds, making this less specific than percussion.
Choice C reason: Percussion produces a tympanic sound over gas-filled areas, indicating air in the bowel, versus a dull sound over solid masses like feces in constipation. This directly differentiates the cause of distention, making it the correct technique.
Choice D reason: Palpation assesses tenderness or masses but cannot reliably distinguish gas from constipation, as both may feel firm or distended. It lacks the specificity of percussion’s auditory cues, making it less effective for this purpose.
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