When assessing a lesion on the skin, which of the following findings are concerning? Select all that apply.

Asymmetry of the lesions

Red and black coloration

Flat

8 mm in diameter

Round edges

Answer and Explanation

Correct Answer : A,B,D

A.   A lesion that is asymmetrical is concerning, as melanoma and other skin cancers tend to be irregular in shape. This is an important warning sign.
B.   Red and black coloration in a lesion is concerning because it can indicate changes in blood flow or necrosis, both of which are suspicious for malignancy.
C.   A flat lesion does not automatically indicate a problem, as many benign lesions, like moles, can be flat. The texture or elevation of the lesion is not always a concern unless there are other risk factors.
D.   A lesion larger than 6 mm is concerning, especially if it is changing in size or shape. Larger lesions should be evaluated by a healthcare provider for potential malignancy.
E.   Round edges are typically a characteristic of benign lesions, so this is not as concerning unless there are other warning signs present.

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

Explanation

A. The groin area is prone to skin breakdown due to friction, moisture, and pressure, especially in immobile patients.
B. The coccyx (tailbone) is a high-risk area for pressure ulcers due to constant pressure when sitting, particularly in bedridden patients.
C. The heels are vulnerable to pressure ulcers because they are under constant pressure when lying down or when standing for prolonged periods.
D. While the scapula may be at risk in certain conditions (e.g., if the patient is immobile and lying on their back), it is generally not as high-risk as other areas like the coccyx or heels.
E. This area is at risk due to moisture, friction, and pressure from the breast tissue, especially in obese or immobile patients.

A. Exposed bone B. Blood filled blisters C. Necrotic subcutaneous tissue D. Partial-thickness skin loss

Correct Answer is C

Explanation

A. Exposed bone refers to a stage 4 pressure ulcer, which involves full-thickness tissue loss with bone, muscle, or tendon exposure.
B. Blood-filled blisters are more indicative of a stage 2 ulcer, which involves partial-thickness skin loss with blister formation.

C. A stage 3 ulcer is characterized by full-thickness skin loss, with damage extending into subcutaneous tissue, where necrosis may occur.
D. Partial-thickness skin loss is a characteristic of a stage 2 pressure ulcer, not stage 3.

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When assessing a lesion on the skin, which of the following findings are concerning? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing a skin assessment, which areas of the skin are at the highest risk for skin breakdown? Select all that apply.

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

Explanation

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

Correct Answer is C

Explanation

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