A 15-year-old boy shows the school nurse a bump on his neck. The nurse observes a raised, erythematous, solid, 0.3-by-0.2 cm mass. How would the nurse document this finding?

Macule

Nodule

Pustule

Papule

Answer and Explanation

The Correct Answer is D

A. A macule is a flat, non-palpable skin lesion. The described lesion is raised, making macule incorrect.
B. A nodule is a deeper, larger, and firmer lesion (>0.5 cm in diameter). The lesion described is too small to be classified as a nodule.
C. A pustule is a pus-filled lesion. The description does not mention purulent content, ruling out pustule.
D. A papule is correct. A papule is a small, raised, solid lesion that is <1 cm in diameter, which fits the description of the bump on the boy’s neck.

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Correct Answer is D

Explanation

A. Reviewing sodium and bicarbonate levels is not the most immediate action. While these lab values may provide useful information, they do not directly assess the suspected condition.
B. Assessing for peptic ulcer disease is incorrect because a tight, distended abdomen with visible arterioles (caput medusae) is more indicative of liver disease, such as cirrhosis or portal hypertension, rather than a gastric ulcer.
C. Assessing the client’s nutritional status may be important, but it is not the priority in this situation. Malnutrition can be a consequence of liver disease, but the nurse should first focus on identifying the underlying condition.
D. Assessing the client for other signs and symptoms of liver disease is correct. A distended abdomen and visible arterioles suggest possible ascites and portal hypertension, both of which are common in liver disease. Further assessment for jaundice, hepatic encephalopathy, or changes in liver enzyme levels would be appropriate.

A. The use of two middle fingers lightly applied to area along the thumb side of the wrist. B. Application of firm pressure on the wrist area along the side of the fifth digit. C. Application of the bell of the stethoscope to the antecubital area of the upper extremity. D. Use of the thumb and index finger to obliterate the area along the thumb side of the wrist.

Correct Answer is A

Explanation

A. Using two middle fingers lightly applied to the thumb side of the wrist is correct. This technique ensures accurate detection of the radial pulse without excessive pressure, which could occlude the artery.
B. Firm pressure on the wrist along the fifth digit (ulnar side) is incorrect because the radial pulse is located on the thumb side of the wrist, not the ulnar side.
C. Using the bell of the stethoscope in the antecubital area is incorrect because this technique is used for blood pressure assessment, not radial pulse assessment.
D. Using the thumb and index finger to obliterate the pulse is incorrect because the thumb has its own pulse, which may lead to inaccurate readings.

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A 15-year-old boy shows the school nurse a bump on his neck. The nurse observes a raised, erythematous, solid, 0.3-by-0.2 cm mass. How would the nurse document this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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