Nokea
While performing an initial assessment of a patient admitted with appendicitis, the nurse observes an elevated blue-black lesion on the patients ear. The nurse knows that this lesion is consistent with what type of skin cancer?
- A. Basal cell carcinoma
- B. Squamous cell carcinoma
- C. Dermatofibroma
- D. Malignant melanoma
Correct Answer: D
Rationale: Malignant melanoma often appears as a blue-black lesion with irregular colors and borders. Basal cell carcinoma is waxy with pearly borders, squamous cell carcinoma is scaly and may bleed, and dermatofibroma is a benign, firm nodule.
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A nurse educator is teaching a group of medical nurses about Kaposis sarcoma. What would the educator identify as characteristics of endemic Kaposis sarcoma? Select all that apply.
- A. Affects people predominantly in the eastern half of Africa
- B. Affects men more than women
- C. Does not affect children
- D. Cannot infiltrate
- E. Can progress to lymphadenopathic forms
Correct Answer: A,B,E
Rationale: Endemic Kaposis sarcoma is prevalent in eastern Africa, affects men more, and can progress to lymphadenopathic forms. It can affect children and may infiltrate.
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.
A patient diagnosed with a stasis ulcer has been hospitalized. There is an order to change the dressing and provide wound care. Which activity should the nurse first perform when providing wound care?
- A. Assess the drainage in the dressing.
- B. Slowly remove the soiled dressing.
- C. Perform hand hygiene.
- D. Don non-latex gloves.
Correct Answer: C
Rationale: Hand hygiene is the first step in wound care to prevent infection, per standard precautions. Assessing drainage, removing the dressing, and donning gloves follow.
A patient has just undergone surgery for malignant melanoma. Which of the following nursing actions should be prioritized?
- A. Maintain the patient on bed rest for the first 24 hours postoperative.
- B. Apply distraction techniques to relieve pain.
- C. Provide soft or liquid diet that is high in protein to assist with healing.
- D. Anticipate the need for, and administer, appropriate analgesic medications.
Correct Answer: D
Rationale: Analgesic administration is critical post-melanoma excision to manage pain from wide excision. Bed rest and modified diets are unnecessary, and distraction is secondary to analgesia.
A patient with squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse should anticipate that treatment for this type of cancer will primarily consist of what intervention?
- A. Chemotherapy
- B. Radiation therapy
- C. Surgical excision
- D. Biopsy of sample tissue
Correct Answer: C
Rationale: Surgical excision is the primary treatment for squamous cell carcinoma to remove the tumor entirely. Radiation is used for non-surgical candidates, chemotherapy is less common, and biopsy is diagnostic, not therapeutic.