Question

When assessing a lesion on the skin, which of the following findings are concerning? Select all that apply.

Answer 1

Correct Answers:

Asymmetry of the lesions
Red and black coloration
8 mm in diameter

Rationale :

🟢 Asymmetry in lesions suggests irregular growth, often seen in malignant melanoma.

🟢 Red and black coloration are considered atypical pigmentations, often associated with skin cancers.

🟢 A diameter greater than 6 mm (e.g., 8 mm) increases suspicion of melanoma.

🟢 Lesions that are not round or uniform require further evaluation.

🟢 The ABCDE rule (Asymmetry, Border, Color, Diameter, Evolving) helps identify concerning lesions.

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Answer 2

Correct Answers:

Perform a Romberg's test.

Rationale :

🔹 The Romberg test assesses proprioception and balance, key indicators of ataxia.

🔹 A positive result indicates instability when eyes are closed, suggesting sensory ataxia.

🔹 It is a standard neurological test to evaluate fall risk.

🔹 Helps determine vestibular or cerebellar dysfunction.

🔹 It is simple and non-invasive, making it ideal for bedside evaluation.

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Answer 3

Correct Answers:

“As a nurse, I am required by law to report suspected child abuse.”

Rationale :

✅ Nurses are mandated reporters in all states for suspected child abuse or neglect.

✅ The response is factual, professional, and non-defensive.

✅ It supports legal and ethical practice and protects the child.

✅ It avoids blaming or escalating the situation with the parent.

✅ The statement reinforces the nurse's obligation and neutrality.

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Answer 4

Correct Answers:

Groin
Соссух
Heels
Under the breasts

Rationale :

🟠 Skin breakdown is common over bony prominences and moist skin folds.

🟠 The groin and under breasts are high-moisture areas, increasing friction and maceration risk.

🟠 The coccyx and heels bear pressure during immobility, leading to ischemia and ulcers.

🟠 Scapula is a high-risk site in supine or immobilized clients.

🟠 Early assessment and offloading are crucial to prevent pressure injuries.

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Answer 5

Correct Answers:

Necrotic subcutaneous tissue

Rationale :

🔵 Stage 3 pressure injuries show full-thickness skin loss with damage into subcutaneous tissue.

🔵 Necrosis of subcutaneous fat is a classic feature.

🔵 No exposed bone/tendon (Stage 4) or partial skin loss (Stage 2) is present.

🔵 Slough or eschar may be visible but do not obscure the wound base.

🔵 May include undermining and tunneling.

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Answer 6

Correct Answers:

Genetic predisposition
Previous skin injury
Overexposure to ultraviolet light

Rationale :

🟢 Genetic predisposition increases susceptibility to skin cancers like melanoma.

🟢 Previous skin injuries can increase risk due to repeated cell turnover.

🟢 UV light exposure is a major preventable risk factor, particularly in light-skinned individuals.

🟢 Skin cancer can develop at any age, but risk increases with repeated exposure and genetic factors.

🟢 Dark skin has more melanin, which offers some protection—not immunity.

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Answer 7

Correct Answers:

Grouped

Rationale :

🔴 Grouped lesions appear in clusters, such as seen in herpes simplex or contact dermatitis.

🔴 They are close together but not merging.

🔴 This pattern differs from confluent lesions, which merge.

🔴 Documentation of lesion patterns helps identify cause and treatment.

🔴 Consistent use of dermatologic terminology improves interprofessional communication.

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Answer 8

Correct Answers:

Place suction equipment at the client's bedside.

Rationale :

🟣 CN IX and X impair swallowing and airway protection, increasing aspiration risk.

🟣 Suction equipment is needed to clear secretions or prevent obstruction.

🟣 This action prepares for emergency airway management.

🟣 Other options involve CN VII or V, not CN IX/X.

🟣 It reflects anticipatory safety planning.

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Answer 9

Correct Answers:

The ability to identify an object placed in the hand with eyes closed

Rationale :

✔️ Stereognosis evaluates sensory perception and cortical function.

✔️ It tests the brain’s ability to integrate tactile information.

✔️ Loss may indicate parietal lobe or sensory nerve dysfunction.

✔️ This is a key part of neurological sensory assessment.

✔️ It requires no equipment beyond common objects (e.g., key, coin).

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Answer 10

Correct Answers:

"Seeing spots is a manifestation of diabetic retinopathy."

Rationale :

hemorrhages and floaters.

🔶 Visual disturbances like “spots” or blurred vision are early signs.

🔶 It is a progressive complication of poorly managed diabetes.

🔶 Regular retinal exams (every year, not 2 years) are necessary.

🔶 Retinopathy differs from glaucoma (intraocular pressure) and cataracts (lens clouding).

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QLexNursing

1 :
When assessing a lesion on the skin, which of the following findings are concerning? Select all that apply.

2 :
A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?

3 :
A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?

4 :
When performing a skin assessment, which areas of the skin are at the highest risk for skin breakdown? Select all that apply.

5 :
A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

6 :
A nurse in a dermatologist's office is planning an educational session about skin cancer. Which of the following should the nurse include as risk factors for skin cancer? (Select all that apply.)

7 :
When assessing a client's skin, the nurse finds clusters of lesions. How would the nurse document the lesions?

8 :
A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?

9 :
What is stereognosis?

10 :
A nurse is teaching a client who has diabetes mellitus about diabetic retinopathy. Which of the following statements should the nurse make to the client?

QLexNursing

1 : When assessing a lesion on the skin, which of the following findings are concerning? Select all that apply.

2 : A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?

3 : A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?

4 : When performing a skin assessment, which areas of the skin are at the highest risk for skin breakdown? Select all that apply.

5 : A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

6 : A nurse in a dermatologist's office is planning an educational session about skin cancer. Which of the following should the nurse include as risk factors for skin cancer? (Select all that apply.)

7 : When assessing a client's skin, the nurse finds clusters of lesions. How would the nurse document the lesions?

8 : A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?

9 : What is stereognosis?

10 : A nurse is teaching a client who has diabetes mellitus about diabetic retinopathy. Which of the following statements should the nurse make to the client?

1 :
When assessing a lesion on the skin, which of the following findings are concerning? Select all that apply.

2 :
A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?

3 :
A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?

4 :
When performing a skin assessment, which areas of the skin are at the highest risk for skin breakdown? Select all that apply.

5 :
A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

6 :
A nurse in a dermatologist's office is planning an educational session about skin cancer. Which of the following should the nurse include as risk factors for skin cancer? (Select all that apply.)

7 :
When assessing a client's skin, the nurse finds clusters of lesions. How would the nurse document the lesions?

8 :
A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?

9 :
What is stereognosis?

10 :
A nurse is teaching a client who has diabetes mellitus about diabetic retinopathy. Which of the following statements should the nurse make to the client?