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 C
Explanation
A. Using a commercial medicine to remove a corn is not recommended, as it can cause skin damage and infection; diabetic clients should seek professional care for such issues.
B. Soaking feet daily in cool water can lead to skin maceration and should generally be avoided; it is better to wash and dry feet gently.
C. Utilizing a mirror to examine the soles of the feet indicates proper awareness and self-care, as diabetic clients need to monitor for any injuries or changes that could lead to complications.
D. Cutting nails in a concave manner is incorrect; nails should be cut straight across to prevent ingrown toenails.
Correct Answer is B
Explanation
A. Measuring abdominal girth may be relevant for assessing potential complications like abdominal distention, but it is not the immediate priority in response to serosanguinous drainage from the nasogastric tube.
B. Continuing to monitor the drainage is appropriate, as serosanguinous fluid is common immediately after surgery and may gradually change as healing progresses. Monitoring allows for the identification of any changes that may require further intervention.
C. Notifying the physician may be necessary if the drainage increases or changes significantly, but immediate action is to observe and assess the drainage trend.
D. Irrigating the nasogastric tube is not warranted unless there is an obstruction or significant change in the drainage; it should only be done based on specific orders or protocols.