The client tells the nurse that he has noticed that one of his moles has started to burn and bleed. The nurse should pay close attention to danger signs for pigmented lesions, and would be concerned with which additional finding?

Symmetry of lesions

Border regularity

Diameter less than 6 mm

Color variation

Answer and Explanation

The Correct Answer is D

A) Symmetry of lesions: While asymmetry can be a concern when assessing moles, it is not the most critical indicator when a lesion has already shown signs of burning and bleeding. Symmetry is one aspect of the overall assessment but does not immediately indicate danger in this scenario.
B) Border regularity: Irregular borders can suggest malignancy; however, the presence of burning and bleeding is a more pressing sign that warrants immediate attention. While border irregularity is important to assess, it is not as concerning as changes in color or the presence of symptoms like bleeding.
C) Diameter less than 6 mm: A diameter less than 6 mm is generally considered a normal size for moles and is not indicative of malignancy on its own. In this case, the burning and bleeding of the mole are more significant findings that raise concern, regardless of its size.
D) Color variation: Color variation in a pigmented lesion is a significant danger sign, as it can indicate changes that may suggest malignancy, especially when combined with other concerning symptoms like burning and bleeding. Variability in color may indicate the presence of different cell types and is a key factor in assessing the risk of melanoma.

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

Explanation

A) Impact on ADLs: Understanding how pain affects a client's activities of daily living (ADLs) is crucial for assessing the overall impact of the pain on their life. It provides insight into the functional limitations caused by the pain and helps guide treatment planning.

B) Family medical history: While family medical history can provide context for certain conditions, it is not an essential component of a focused pain assessment. The immediate concerns are more directly related to the client's current pain experience rather than their family's medical background.

C) Pain intensity rating: Assessing the intensity of pain is a fundamental aspect of pain assessment. Using scales (e.g., 0-10) allows the nurse to quantify the pain, monitor changes over time, and evaluate the effectiveness of interventions.

D) Characteristics of the pain: Understanding the characteristics of the pain—such as its quality (sharp, dull, throbbing) and location—is essential for determining its cause and guiding appropriate treatment strategies.

E) Aggravating factors: Identifying what exacerbates the pain is critical for understanding its nature and developing effective management strategies. Knowing which activities or positions worsen the pain can help in creating a comprehensive care plan tailored to the client's needs.

A. "Please remove all jewellery so that I can conduct a full assessment." B. "I will be touching your skin as part of the process." C. "I will turn the temperature down in the exam room before we begin." "Use this blanket to cover up until we are ready to begin." D. "I will need you to take off your head dress for the entire examination."

Correct Answer is ["A","B","D"]

Explanation

For a thorough assessment of the integumentary system, the nurse should provide the following instructions:

A. "Please remove all jewellery so that I can conduct a full assessment."

This is correct. Jewelry can obstruct the assessment of skin, especially in areas like the neck, chest, and hands, where it may cover or hide skin abnormalities.

B. "I will be touching your skin as part of the process."

This is correct. A thorough integumentary assessment involves palpating the skin to check for texture, moisture, temperature, and other characteristics. It's important for the client to be informed that touch will be involved.

C. "I will turn the temperature down in the exam room before we begin." "Use this blanket to cover up until we are ready to begin."

This is partially correct. The temperature in the exam room should be comfortable, but turning it down may not be necessary. The instruction to cover with a blanket is appropriate to preserve the client's privacy and warmth until the assessment begins.

D. "I will need you to take off your head dress for the entire examination."

This is correct. If the head dress covers the scalp or areas that need to be examined (like the scalp, ears, or face), it should be removed to allow for a full assessment of the integumentary system.

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The client tells the nurse that he has noticed that one of his moles has started to burn and bleed. The nurse should pay close attention to danger signs for pigmented lesions, and would be concerned with which additional finding?

Nursing Test Bank

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Correct Answer is ["A","B","D"]

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