The nurse is educating adolescent high school students about when to seek medical attention regarding suspected cancerous skin lesions. Which of the following are included in the nurse's teaching? The lesion has:
An irregular border.
Asymmetrical shape.
Been increasing in size.
A diameter of less than 4 mm.
Ecchymosis.
Correct Answer : A,B,C
A. An irregular border is a key characteristic of potentially cancerous skin lesions, particularly melanoma. Melanomas often have uneven, poorly defined edges.
B. Asymmetry is another sign of melanoma. If one half of a lesion does not match the other in shape or size, it should be evaluated by a healthcare professional.
C. Any lesion that has been increasing in size, particularly over a short period, is a concern and should be checked. Rapid growth can be a sign of malignancy.
D. A lesion with a diameter of less than 4 mm is generally less concerning, as most cancerous lesions are larger. However, the other factors (such as asymmetry and border irregularity) are more significant for diagnosis.
E. Ecchymosis (bruising) is not typically associated with cancerous skin lesions. Skin cancers like melanoma present as new or changing moles, not bruising.
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Correct Answer is B
Explanation
A. Inserting an oral airway and suctioning may be indicated for airway management, but the primary concern is the impaired function of the glossopharyngeal and vagus nerves, which affects swallowing and the risk of aspiration.
B. Withholding oral fluids or foods is crucial because impaired function of these cranial nerves increases the risk of aspiration and can lead to choking or pneumonia, making this the priority action.
C. Speaking clearly while facing the client is a good communication practice but does not address the immediate concern of impaired swallowing and risk of aspiration.
D. Applying artificial tears is important for protecting the cornea, but it is not directly related to the functions of CN IX and CN X or the immediate management of swallowing difficulties.
Correct Answer is B
Explanation
A. While a diet of soft foods and liquid protein may be beneficial for a client undergoing chemotherapy, it is not the most critical intervention related to thrombocytopenia. Nutritional needs can be managed but do not address the immediate risk of bleeding or injury.
B. Teaching safety in the home to reduce injury and falls is the most important intervention. Clients with thrombocytopenia have a significantly increased risk of bleeding and bruising, making it essential to prevent falls and injuries that could lead to serious complications.
C. Spacing activities throughout the day can help manage fatigue, but it is not as urgent as ensuring the client is safe from injuries related to low platelet counts.
D. Frequent hand hygiene is important to prevent infections, especially in immunocompromised patients, but it does not directly address the primary concern of preventing injuries related to thrombocytopenia.