Nokea
When assessing a lesion diagnosed as malignant melanoma, the nurse most likely expects to note which of the following?
- A. A smooth, uniform lesion
- B. A small, red bump
- C. An irregularly shaped lesion
- D. A painful, oozing sore
Correct Answer: C
Rationale: Malignant melanoma typically presents with asymmetry, irregular borders, and varying colors, distinguishing it from benign lesions.
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A nurse assesses a pressure ulcer on a child and finds full-thickness loss of the dermal layer and visible subcutaneous fat. At which stage does the nurse document this pressure ulcer to be?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
Correct Answer: C
Rationale: A stage III pressure ulcer involves the full thickness of the dermis, possible visible subcutaneous fat, possible sloughing, and possible tunneling.
Which diagnostic test is most accurate for diagnosing osteoporosis?
- A. X-ray of the femur
- B. Serum alkaline phosphatase
- C. Dual-energy x-ray absorptiometry (DEXA)
- D. Serum bone Gla-protein test
Correct Answer: C
Rationale: DEXA accurately measures bone density, diagnosing osteoporosis.
A 20 year-old is brought in by ambulance to the emergency department after being involved in a motorcycle accident. The patient has an open fracture of his tibia. The wound is highly contaminated and there is extensive soft-tissue damage. How would this patient's fracture likely be graded?
- A. Grade I
- B. Grade II
- C. Grade III
- D. Grade IV
Correct Answer: C
Rationale: Open fractures are graded according to the following criteria. Grade I is a clean wound less than 1 cm long. Grade II is a larger wound without extensive soft-tissue damage. Grade III is highly contaminated, has extensive soft-tissue damage, and is the most severe. There is no grade IV fracture.
The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding?
- A. Temperature of 101.6°F (38.7°C) orally
- B. Complaints of discomfort during repositioning
- C. Old bloody drainage outlined on the surgical dressing
- D. Discomfort during coughing and deep-breathing exercises
Correct Answer: A
Rationale: A fever of 101.6°F suggests a possible postoperative infection, a serious complication after spinal fusion with hardware, requiring immediate attention.
What would the nurse dressing a necrotic pressure injury with a minimal exudate most likely use?
- A. Hydrocolloid dressing
- B. Alginate dressing
- C. Hydrofiber dressing
- D. Transparent film
Correct Answer: A
Rationale: Hydrocolloid dressings are useful in necrotic wounds with little exudate. Alginate and hydrofiber dressings are used for wounds with copious exudate. Transparent film is not absorbent.