Nokea
The ABCDEs of melanoma identification include which of the following? Select all that apply.
- A. Asymmetry: one half does not match the other half
- B. Birthmark: cafe au lait spot that does not fade
- C. Color: pigmentation is not uniform
- D. Diameter: greater than 6 mm
- E. Evolving: any change in size, shape, color, elevation, or any new symptom such as bleeding, itching, or crusting
Correct Answer: A, C, D, E
Rationale: The ABCDEs of melanoma are Asymmetry, Border (irregular), Color (varied), Diameter (>6 mm), and Evolving (changes in appearance or symptoms). Birthmark is not part of this mnemonic.
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The nurse is caring for a client with a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The nurse would treat the area with which dressing?
- A. Alginate
- B. Dry gauze
- C. Hydrocolloid
- D. Transparent
Correct Answer: C
Rationale: Hydrocolloid dressings are appropriate for shallow, partial-thickness pressure ulcers as they maintain a moist environment to promote healing.
The wound care nurse is caring for a client at the outpatient clinic
Item 1 of 1
Nurses' Notes
Medical History
1300 - Client presents to the clinic on a referral from the primary healthcare provider for a wound to the right ankle area. The injury developed three months ago and has worsened despite topical treatment. On assessment, the wound is 5 cm x 4 cm and is shallow. The wound bed is pink with some granulation tissue; scant sanguineous drainage. Wound edges are uneven. Client reports pain only when dressing changes are performed, and the pain is rated as 5 on a scale of 0 (no pain) to 10 (severe pain). The surrounding skin on the affected foot is dry, darkened, and flaky. Capillary refill < 3 seconds. Peripheral pedal pulse 2+ on the affected foot. 3+ Ankle edema was noted in both lower extremities. The client denies leg pain during ambulation but endorses ankle swelling during the day while walking, and the only relieving factor is the application of a compression hose to both legs. The client reports applying a hot compress to the extremity but states after 2-3 applications, it worsened and became painful.
For each assessment finding below, click to specify if the finding is consistent with an arterial, venous, or diabetic ulcer. Each finding may support more than one (1) disease process.
- A. swelling in affected extremity
- B. pedal peripheral pulse 2+
- C. swelling relieved with compression hose
- D. denies leg pain during ambulation
- E. shallow wound bed
- F. medical history of hypertension and diabetes mellitus
- G. worsened with hot compress
Correct Answer: A: B, D, E, F; V: A, C, E; D: E, F, G
Rationale: Arterial ulcers: normal pulse, no leg pain, shallow wounds, and hypertension/diabetes history. Venous ulcers: swelling, compression relief, shallow wounds. Diabetic ulcers: shallow wounds, diabetes history, worsened with heat.
The nurse is performing a physical assessment on a client who has a round, non-tender nodule on the left wrist. It would be appropriate for the nurse to identify this as a
- A. janeway lesion
- B. bouchard node
- C. ganglion cyst
- D. pilar cyst
Correct Answer: C
Rationale: A round, non-tender nodule on the wrist is characteristic of a ganglion cyst, a benign fluid-filled sac.
The nurse cares for a 29-year-old male in the emergency department (ED)
Item 3 of 6
Nurses' Note
Vital Signs
Assessment
2115: Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire then spread to his back and part of his chest. The client has sustained full- thickness burns to his right hand and entire arm. Deep partial thickness burns were observed to his right torso and entire back. The client arrives screaming in pain rating it as 9 on a scale of 0 (no pain) to 10 (severe pain). He endorses no pain in his right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in the left antecubital space.
Based on the clinical data, the nurse's immediate concern is the client's
- A. risk for infection
- B. thermoregulation
- C. airway patency
- D. fluid volume deficit
Correct Answer: D
Rationale: Fluid volume deficit is the immediate concern due to significant fluid loss from extensive burns, risking hypovolemic shock.
The nurse is providing discharge instructions to a client with a skin abscess that has tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following instructions should the nurse include?
- A. Avoid using alcohol-based hand sanitizer
- B. Use disposable dishes and utensils for all meals
- C. Wear a surgical mask when you are out in public
- D. Keep the wound covered with a dry bandage
Correct Answer: D
Rationale: Keeping the wound covered with a dry bandage prevents the spread of MRSA and protects the wound from further contamination.