When assessing a lesion diagnosed as malignant melanoma, the nurse most likely expects to note which of the following?

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NCLEX Style Questions on Skin Integrity and Wound Care Questions

Question 1 of 5

When assessing a lesion diagnosed as malignant melanoma, the nurse most likely expects to note which of the following?

Correct Answer: C

Rationale: Malignant melanoma typically presents with asymmetry, irregular borders, and varying colors, distinguishing it from benign lesions.

Question 2 of 5

A nurse assesses a pressure ulcer on a child and finds full-thickness loss of the dermal layer and visible subcutaneous fat. At which stage does the nurse document this pressure ulcer to be?

Correct Answer: C

Rationale: A stage III pressure ulcer involves the full thickness of the dermis, possible visible subcutaneous fat, possible sloughing, and possible tunneling.

Question 3 of 5

Which data indicates the fluid resuscitation is effective for a client who experienced an electrical burn resulting in full-thickness burns to the right and left hand?

Correct Answer: C

Rationale: For an electrical burn, a urine output of 75 to 100 mL/hour indicates effective fluid resuscitation due to the need to flush myoglobin from muscle damage. Less than 30 mL/hour suggests inadequate resuscitation, 50 mL/hour is sufficient for thermal burns but not electrical, and over 200 mL/hour indicates excessive fluid loss.

Question 4 of 5

Which medication or treatment should the nurse discuss with a teenage client diagnosed with mild acne?

Correct Answer: D

Rationale: Benzoyl peroxide suppresses P. acnes and promotes peeling for mild acne. Botox is for wrinkles, vitamin E worsens oiliness, and isotretinoin is for severe acne.

Question 5 of 5

The parents of a 2-year-old child diagnosed with measles call the pediatric clinic about the child being uncomfortable, irritable, and fretful. Which recommendation should the nurse discuss?

Correct Answer: C

Rationale: Acetaminophen reduces discomfort in measles. Aspirin risks Reye's syndrome, diphenhydramine cream isn't suitable, and denying medication ignores symptom relief options.

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