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A patient has recently been diagnosed with advanced malignant melanoma and is scheduled for a wide excision of the tumor on her chest. In writing the plan of care for this patient, what major nursing diagnosis should the nurse include?
- A. Deficient Knowledge about Early Signs of Melanoma
- B. Chronic Pain Related to Surgical Excision and Grafting
- C. Depression Related to Reconstructive Surgery
- D. Anxiety Related to Lack of Social Support
Correct Answer: A
Rationale: Advanced melanoma suggests a lack of early detection, indicating deficient knowledge about melanoma signs. Excision does not cause chronic pain, and depression or anxiety may not be primary concerns.
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A nurse is caring for a patient whose skin cancer will soon be removed by excision. Which of the following actions should the nurse perform?
- A. Teach the patient about early signs of secondary blistering diseases.
- B. Teach the patient about self-care after treatment.
- C. Assess the patients risk for recurrent malignancy.
- D. Assess the patient for adverse effects of radiotherapy.
Correct Answer: B
Rationale: The nurse's role includes teaching self-care after skin cancer excision. Assessing malignancy risk is the physician's role, blistering diseases are unrelated, and radiotherapy is not typically used.
A 65-year-old man presents at the clinic complaining of nodules on both legs. The man tells the nurse that his son, who is in medical school, encouraged him to seek prompt care and told him that the nodules are related to the fact that he is Jewish. What health problem should the nurse suspect?
- A. Stasis ulcers
- B. Bullous pemphigoid
- C. Psoriasis
- D. Classic Kaposis sarcoma
Correct Answer: D
Rationale: Classic Kaposis sarcoma, common in Jewish men aged 40-70, presents as nodules on the lower extremities. Stasis ulcers, bullous pemphigoid, and psoriasis have different presentations.
A public health nurse is participating in a health promotion campaign that has the goal of improving outcomes related to skin cancer in the community. What action has the greatest potential to achieve this goal?
- A. Educating participants about the relationship between general health and the risk of skin cancer
- B. Educating participants about treatment options for skin cancer
- C. Educating participants about the early signs and symptoms of skin cancer
- D. Educating participants about the health risks associated with smoking and assisting with smoking cessation
Correct Answer: C
Rationale: Educating about early signs of skin cancer promotes early detection, improving outcomes. General health, treatment options, and smoking are less directly impactful.
A nurse is caring for a patient admitted to the medical unit with a diagnosis of pemphigus vulgaris. When writing the care plan for this patient, what nursing diagnoses should be included? Select all that apply.
- A. Risk for Infection Related to Lesions
- B. Impaired Skin Integrity Related to Epidermal Blisters
- C. Disturbed Body Image Related to Presence of Skin Lesions
- D. Acute Pain Related to Disruption in Skin Integrity
- E. Hyperthermia Related to Disruptions in Thermoregulation
Correct Answer: A,B,C,D
Rationale: Pemphigus vulgaris causes blisters, leading to infection risk, impaired skin integrity, pain, and disturbed body image. Hyperthermia is not a concern; hypothermia is more likely.
A nurse is providing self-care education to a patient who has been receiving treatment for acne vulgaris. What instruction should the nurse provide to the patient?
- A. Wash your face with water and gentle soap each morning and evening.
- B. Before bedtime, clean your face with rubbing alcohol on a cotton pad.
- C. Gently burst new pimples before they form a visible head.
- D. Set aside time each day to squeeze blackheads and remove the plug.
Correct Answer: A
Rationale: Washing with mild soap and water twice daily removes oils and prevents gland obstruction in acne. Alcohol is too harsh, and manipulating pimples or blackheads worsens symptoms.