Page 1232 - Saunders Comprehensive Review For NCLEX-RN

carcinoma is a firm, nodular lesion topped with a crust or a central area of
ulceration.
Test-Taking Strategy: Note the strategic words, most likely. Recall characteristics
and etiology of basal cell cancer to direct you to the correct options.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Integumentary
Health Problem: Adult Health: Cancer: Skin
Priority Concepts: Cellular Regulation; Tissue Integrity
Reference: Ignatavicius, Workman, Rebar (2018), pp. 475-476.

430. Answer: 4

Rationale: Assessment findings in frostbite include a white or blue color; the skin
will be hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin,
the development of blisters or blebs, or tissue edema appears. Options 1, 2, and 3 are
incorrect.
Test-Taking Strategy: Focus on the subject, assessment findings in frostbite.
Noting the words insensitive to touch in the correct option should direct you to this
option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Integumentary
Health Problem: Adult Health: Integumentary: Inflammations/Infections
Priority Concepts: Clinical Judgment; Tissue Integrity
Reference: Ignatavicius, Workman, Rebar (2018), pp. 144-145.

431. Answer: 4

Rationale: In a stage II pressure injury, the skin is not intact. Partial-thickness skin
loss of the dermis has occurred. It presents as a shallow open ulceration with a red-
pink wound bed, without slough. It may also present as an intact or open/ruptured
serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in
stage III. Exposed bone, tendon, or muscle is present in stage IV.
Test-Taking Strategy: Focus on the subject, assessment of a pressure injury.
Focusing on the words stage II and visualizing the appearance of a stage II pressure
injury will direct you to the correct option.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Integumentary
Health Problem: Adult Health: Integumentary: Inflammations/Infections
Priority Concepts: Clinical Judgment; Tissue Integrity
Reference: Lewis et al. (2017), pp. 172-173.

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