clinical manifestation of a malignant melanoma?
Rough, dry, scaly lesion
Firm nodule with crust
Pearly papule with ulcerated center
Irregularly shaped lesion with blue tones
Malignant melanomas are irregularly shaped and can be blue, red, or white in tone. They
often occur on the client's upper back and lower legs.
A nurse is planning care for a client who has been admitted for treatment of a malignant
melanoma of the upper leg without metastasis. The nurse should plan to prepare the client for
which of the following procedures?
Curettage
External radiation therapy
Regional chemotherapy
Surgical excision
A nurse is caring for a client who has a lesion on the back of his right hand. The client asks the
nurse which type of skin cancer is the most serious. Which of the following responses by the
nurse is appropriate?
Basal cell carcinomas
Melanomas
Actinic keratoses
Squamous cell carcinomas
A nurse in the emergency department is caring for a client who has a snakebite on her arm.
Which of the following interventions should the nurse implement?
Immobilize the limb at the level of the heart.
Apply a tourniquet to the affected limb.
Use a sterile scapula to incise the wound.
Apply ice to the skin over the snakebite wound.
The emergency management of a client who has a snakebite focuses on limiting the
spread of venom. Any constrictive clothing or jewelry should be removed before swelling
worsens, and the affected limb should be immobilized at the level of the heart.
A nurse is caring for a client who has burn injuries to his trunk. The nurse is explaining what to
expect from the prescribed hydrotherapy. Which of the following statements by the client
indicates an understanding of the teaching?
"I will be on a special shower table."
"The water temperature will be very cool to ease my pain."
"The nurse will use a firm-bristled brush to remove loose skin."
"The nurse will use scissors to open small blisters."
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, The special shower table facilitates examination and debridement of the wound during
hydrotherapy. An advantage of using the showering technique as opposed to a tub bath is
that the water can be kept at a constant temperature and there is a lower risk of wound
infection.
A nurse in a provider's office is assessing a client's skin lesions. The nurse notes that the lesions
are 0.5 cm (0.20 in) in size, elevated, and solid, with very distinct borders. The nurse should
document the findings as which of the following skin lesions?
Papules
Macules
Wheals
Vesicles
A papule is a small, solid, elevated lesion with distinct borders. It is usually smaller than
10 mm in diameter. Papules are common lesions of warts and elevated moles.
A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following
a major burn. Which of the following laboratory findings should the nurse expect?
Hemoglobin 10 g/dL
Sodium 132 mEq/L
Albumin 3.6 g/dL
Potassium 4.0 mEq/dL
This laboratory finding is below the expected reference range. The nurse should
anticipate a low sodium level because sodium is trapped in interstitial space.
A nurse is assessing a client who sustained superficial partial-thickness and deep partial-
thickness burns 72 hr ago. Which of the following findings should the nurse report to the
provider?
Edema in the burned extremities
Severe pain at the burn sites
Urine output of 30 mL/hr
Temperature of 39.1° C (102.4° F)
An elevated temperature is an indication of infection and the nurse should report this
finding to the provider. Sepsis is a critical finding following a major burn injury. Initially,
burn wounds are relatively pathogen-free. On approximately the third day following the
injury, early colonization of the wound surface by gram-negative organisms changes to
predominantly gram-positive opportunistic organisms.
A nurse is assesing a client who is bedridden and was admitted from home. The nurse notes a
shallow crater in the epidermis of the client's sacral area. The nurse should document that the
client has a pressure ulcer at which of the following stages?
IV
I
III
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