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Skin Assessment

Highlight the abnormal findings that the nurse should be concerned about. Select all that apply.

A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past.

change in mole size

color changes

itching

burning

bleeding

has had many blistering sunburns in the past

dark complexion

no family history of skin cancer

Answer and Explanation

The Correct Answer is ["A","B","C","D","E"]

A change in the size of a mole is a significant red flag and should be concerning for potential skin cancer, particularly melanoma. A mole that enlarges over time, especially if it changes size rapidly, can indicate the development of malignant melanoma.

Color changes in a mole, such as darkening, lightening, or developing multiple colors, should raise concern for melanoma. Melanomas often present with uneven pigmentation, where the mole may become more than one color, such as black, blue, red, or brown. This change in color is abnormal and requires further investigation.

Itching and burning are abnormal symptoms associated with skin lesions and can be indicative of skin cancer. These sensations can occur when the skin becomes irritated or inflamed due to a growing malignancy such as melanoma.

Bleeding from a mole is a red flag and is concerning for skin cancer, especially melanoma. A mole that bleeds or oozes may be ulcerating or eroding, which are signs of more advanced skin cancer.

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Correct Answer is B

Explanation

A. Increased tactile fremitus and dull percussion tones would suggest consolidation or pathology, which is not normal.
B. Muffled voice sounds and symmetric tactile fremitus are normal findings in healthy lung tissue.
C. Adventitious sounds and limited chest expansion would indicate pathology such as pneumonia or other lung diseases.
D. Absent voice sounds and hyper resonant percussion tones would be indicative of a pneumothorax or emphysema, not normal lung findings.

A. Tympany B. Hyperresonance C. Resonance D. Dullness

Correct Answer is B

Explanation

A. Tympany is a high-pitched sound typically heard over a hollow organ such as the stomach.
B. Hyperresonance is often heard in patients with COPD, as the lungs are hyperinflated, leading to an increased resonance when percussed.
C. Resonance is normal and would be heard in healthy, air-filled lungs.
D. Dullness would suggest a solid or fluid-filled area, which is not typical of COPD unless there is a complication like pleural effusion.

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Naxlex Comprehensive Predictor Exams

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:

Correct Answer is B

Explanation

The nurse percusses a client with COPD and expects to hear:

Correct Answer is B

Explanation

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