The nurse is performing a skin assessment on an African American ...

[Zulu123]

The nurse is performing a skin assessment on an African American client and notes an elevated, irregular band of jagged tissue on the client's left arm. The client states, I had a burn here a long time ago, but it seemed to keep on getting bigger.
 
  Which term will the nurse use when documenting this finding in the client's medical record?
  1. Ulcer.
  2. Keloid.
  3. Fissure.
  4. Scar.

Question 2

The nurse is assessing the skin of a newborn and notes a bright red, raised lesion on the lateral aspect of the thigh.
 
  The lesion is 4.5 centimeters in diameter. When light pressure is applied to the lesion, the site does not blanch. The mother expresses concern about the appearance of this site, and asks the nurse if it should be removed. Which response by the nurse is the most appropriate?
  1. Your pediatrician can make a surgical referral for you.
  2. It really is not that noticeable.
  3. You should be happy that your baby is healthy overall.
  4. These types of lesions usually disappear by the time a child turns 10 years old.

[amandanbreshears]

Answer to Question 1

Correct Answer: 2

This is most likely a keloid, which is an elevated, irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. It extends beyond the site of the original injury. There is higher incidence in people of African descent. An ulcer is a deep, irregularly shaped area of skin loss extending into the dermis or subcutaneous tissue. A fissure is a crack in the skin extending to the dermis. A scar is connective tissue left after healing, but is flat and usually linear. This tissue is best described as a keloid.
Cognitive Level: Understanding

Answer to Question 2

Correct Answer: 4

The lesion described is a hemangioma, which is a cluster of immature capillaries that can be found on any part of the body. These lesions usually disappear by age 10, and no intervention is needed. The nurse should educate the mother about the lesion. The mother does not require comments suggesting she should ignore the lesion or be happy that the infant does not have more serious problems. The nurse should not state that the mother should be happy with the overall health of the newborn. The mother is concerned about the appearance of the lesion and should be educated about the lesion and its normal course.