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When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which finding?
- A. An irregularly shaped lesion
- B. A small papule with a dry, rough scale
- C. A firm, nodular lesion topped with crust
- D. A pearly papule with a central crater and a waxy border
Correct Answer: D
Rationale: Basal cell carcinoma typically appears as a pearly papule with a central crater.
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During an assessment the nurse notes skin changes on the patient's elbows and knees. Which findings support that these changes are plaque psoriasis?
- A. Red raised areas with inconsistent borders
- B. Thick red plaques covered with silvery scales
- C. Large reddened areas of weeping and maceration
- D. Small raised and reddened areas with fluid-filled pustules
Correct Answer: B
Rationale: Plaque psoriasis typically presents as thick red plaques with silvery scales, especially on extensor surfaces like elbows and knees, distinguishing it from other descriptions.
The nurse is caring for a client with a left fractured humerus. Which data warrant intervention by the nurse?
- A. Capillary refill time is less than three (3) seconds.
- B. Pain is not relieved by the patient-controlled analgesia.
- C. Left fingers are edematous and the left hand is purple.
- D. Warm and dry skin on left fingers distal to the elastic bandage.
Correct Answer: C
Rationale: Edema and purple discoloration indicate potential compartment syndrome, requiring urgent intervention.
The client with viral skin lesions is experiencing pruritus. Which statement would be an appropriate long-term goal?
- A. The client will refrain from scratching the skin.
- B. The client will maintain intact skin integrity.
- C. The client will have relief from itching.
- D. The client will not develop a secondary bacterial infection.
Correct Answer: B
Rationale: Maintaining intact skin integrity is a key long-term goal for managing pruritus and preventing complications like infections.
A nurse teaches a client to perform total skin self-examinations on a monthly basis. Which statement should the nurse include in this client's teaching?
- A. Look for asymmetry of shape and irregular borders.
- B. Assess for color variation within each lesion.
- C. Examine the distribution of lesions over a section of the body.
- D. Monitor for edema or swelling of tissues.
Correct Answer: A
Rationale: Clients should be taught to examine each lesion following the ABCDE features associated with skin cancer, including asymmetry of shape and border irregularity.
The parents of a 2-year-old child diagnosed with measles call the pediatric clinic about the child being uncomfortable, irritable, and fretful. Which recommendation should the nurse discuss?
- A. Alternate ibuprofen with children's aspirin every 4 hours.
- B. Apply diphenhydramine cream to the rash.
- C. Administer acetaminophen elixir to the child.
- D. Tell the parents that there is no medication for the child.
Correct Answer: C
Rationale: Acetaminophen reduces discomfort in measles. Aspirin risks Reye's syndrome, diphenhydramine cream isn't suitable, and denying medication ignores symptom relief options.