MTAP.M3

Match the following

• Insect bites, allergic reaction, hives

• 
• Pinpoint (1 - 3 mm) reddish-purple spots

• 
• Collection of petechiae and ecchymosis

• 
• Freckle, mole, measles, scarlet fever

• 

• One method used for inspecting suspicious skin lesions is called the _____rule.

Answer explanation

The ABCDE rule is a method of memorizing an assessment checklist to recognize important danger signs of abnormal pigmented lesions. It makes sure all the most suspicious features that might indicate a melanoma are evaluated. It is not a useful rating tool for lesions without pigmentation. If two or more of these five aspects are present, the risk of melanoma is high, and the client should be referred for a biopsy of the lesion.

Each of the letters of the ABCDE rule stands for a possible danger sign, as follows.

A

---

Assymetry: Compare one side of the lesion with the other side. The two halves of the lesion do not look the same. They are not a simple round circle or an oval shape. They look radically different from each other.

B

---

Border: The Lesion has an irregular outline (for example, notching, scalloping, jagged edges, or blurred and vague boundries).

C

---

Color: Color variation within the lesion (areas of brown, tan, black, blue, red, white, or a combination of those colors.

D

---

Diameter: Diameter of the lesion greater than 6 mm (the size of a pencil eraser) at its largest dimension. At the size, some clinicians would consider ordering a biopsy without any additional data. However, not all melanomas may be diagnosed in small lesions.

E

---

Evolving: Lesions change rapidly in size, symptoms, or composition. Of all the criteria for evaluating the possibility of the lesion being a melanoma, evolution is the most sensitive to malignancy. This feature alonemight prompt an immediate biopsy of a lesion otherwise appearing benign.

• Another approach to detect possible malignant lesions is to inspect the skin for “ugly ducklings.” This method is helpful when inspecting the skin of a client who has many nevi (moles). An ugly duckling is the mole that looks or acts quite different from the client’s neighboring nevi. It may itch, burn, or bleed and its features stand out in stark contrast to others.

Pressure injuries are often located on the back or the side of the body. Identify the risk factors of pressure injuries.

Answer explanation

• Limited ability to reposition

• Thinner skin (due to aging)

• Poor nutritional state, which affects healing

• Presence of moisture due to incontinence, wound drainage or perspiration

• Clients being pulled up or across the bed linens resulting in a friction injury.

• Partial loss of dermis

• Shiny or dry ulcer with pink wound bed

• May present as intact or ruptured blister

b

Stage 4

Stage 2

Stage 1

Stage 3

• Full-thickness skin loss with damage or necrosis to subcutaneous tissue

• Subcutaneous fat may be visible

• Dead tissue may be present in the wound bed.

c

Stage 4

Stage 3

Stage 2

Stage 1

Identify nursing interventions that are aimed at preventing the occurrence or the worsening of pressure Injuries and promoting wound healing.

Answer explanation

• Inspect the skin of at-risk clients frequently (typically every four hours or according to facility policy) daily for signs of breakdown.

• Reposition clients who have decreased mobility every 2 hr.

• Elevate the head of the bed no more than 30° to prevent a shearing injury, which occurs when the client slides downward in a bed or chair.

• Remove sources of excessive moisture due to incontinence, drainage, or diaphoresis.

• Provide dietary supplements as indicated to improve nutritional status.

• Never rub a reddened area (stage I pressure injury). This action will further compromise circulation to the area and increase tissue destruction.

• Provide wound care per the facility guidelines.

• Use a lift device or have a team to lift the client when moving them up in bed. Shearing of the skin can occur if the client’s weight is not off the bed.

Reorder the following: Checking bilateral skin temperature on extremities

• Repeat the above technique for the client's lower extremities, by starting above their anterior knees and moving down their shins to their toes.

• Touch both of the client's arms above their elbows with the back of your hands to compare the extremity temperature.

• Move the back of your hands down the client's arms simultaneously to their fingers.

• Determine if the skin temperature of their arms and fingers are equal.

Match the following terms with the correct demonstration:

• Checking pitting edema

• 
• Checking capillary refill

• 
• Checking skin turgor

• 

This is where new growth appears

a

Follicle

Lunula

Hair shaft

Nailbed

myc/o