When assessing a client diagnosed with basal cell carcinoma, which of the following findings will the nurse expect?
A blister-like pustule on the face that oozes clear fluid
A dark brown lesion that is flat
A small scaly, dry lesion on the elbow
Location on the top of the head where exposed frequently to sunlight
The Correct Answer is C
Choice A Reason: This is incorrect because a blister-like pustule on the face that oozes clear fluid may indicate impetigo, which is a bacterial skin infection, not basal cell carcinoma. Basal cell carcinoma is a type of skin cancer that arises from the basal layer of the epidermis, which is the outermost layer of the skin. Basal cell carcinoma lesions are usually not blistered or pustular, but rather smooth, shiny, or waxy.
Choice B Reason: This is incorrect because a dark brown lesion that is flat may indicate a mole, which is a benign growth of melanocytes, which are cells that produce pigment, not basal cell carcinoma. Basal cell carcinoma lesions are usually not dark brown or flat, but rather flesh-colored, pink, or red, and may have a raised or indented center.
Choice C Reason: This is correct because a small scaly, dry lesion on the elbow may indicate basal cell carcinoma. Basal cell carcinoma lesions are often small, scaly, and dry, and may bleed or crust over. They can occur anywhere on the body, but are more common on areas that are exposed to the sun, such as the face, neck, arms, or legs.
Choice D Reason: This is incorrect because location on the top of the head where exposed frequently to sunlight may indicate squamous cell carcinoma, which is another type of skin cancer that arises from the squamous layer of the epidermis, not basal cell carcinoma. Squamous cell carcinoma lesions are usually rough, scaly, or crusted, and may have a firm or hard texture. They can also occur anywhere on the body, but are more common on areas that are exposed to the sun.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because rotating nursing staff may not provide emotional support for the client who is rehabilitating from major burns. The client may benefit from having consistent and familiar staff who can establish rapport and trust with him. The nurse should assign staff who are experienced and comfortable with burn care and who can communicate effectively and empathetically with the client.
Choice B Reason: This is incorrect because keeping family members aware of his condition may not provide emotional support for the client who is rehabilitating from major burns. The client may have privacy or confidentiality concerns or may not want his family members to see him in his current state. The nurse should respect the client's wishes and preferences regarding family involvement and obtain his consent before sharing any information.
Choice C Reason: This is correct because talking with the client during wound care can provide emotional support for the client who is rehabilitating from major burns. Wound care can be painful and stressful for the client, so the nurse should use therapeutic communication skills to distract, reassure, and encourage him. The nurse should also explain the procedures and rationale for wound care and allow the client to express his feelings and concerns.
Choice D Reason: This is incorrect because assigning assistive personnel to keep his room neat and clean may not provide emotional support for the client who is rehabilitating from major burns. The client may appreciate a clean environment, but he may also need more direct and personal contact with the nurse. The nurse should spend time with the client and provide holistic care that addresses his physical, psychological, social, and spiritual needs.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because atrial fibrillation is the risk factor that puts the client at
the highest risk for embolic stroke. Atrial fibrillation is an irregular and rapid heart rate that causes poor blood flow and blood pooling in the heart chambers. This can lead to the formation of blood clots that can travel to the brain and block an artery, causing an embolic stroke.
Choice B reason: This is incorrect because hypertension is not the risk factor that puts the client at
the highest risk for embolic stroke. Hypertension is high blood pressure that puts stress on the blood vessels and increases the risk of bleeding or rupture. This can lead to a hemorrhagic stroke, but not an embolic stroke.
Choice C reason: This is incorrect because diabetes is not the risk factor that puts the client at
the highest risk for embolic stroke. Diabetes is a condition that causes high blood sugar levels and damages the blood vessels and nerves. This can lead to poor circulation and increased risk of infection and ulcers, but not an embolic stroke.
Choice D reason: This is incorrect because alcohol abuse is not the risk factor that puts the client at
the highest risk for embolic stroke. Alcohol abuse is excessive consumption of alcohol that affects liver function and blood clotting factors. This can lead to liver disease and bleeding disorders, but not an embolic stroke.
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