A client with a newborn asks about the lesion on her child's head. After assessing the skin, which response will the nurse offer to the client?

This is a vascular tumor that often goes away over time

This lesion will spread

This is caused by scarring from the birth process

This is a precancerous lesion and your child will need a referral to a dermatologist

Answer and Explanation

The Correct Answer is A

Choice A reason: This is correct because the lesion on the child's head is most likely a hemangioma, which is a benign tumor of blood vessels that appears as a red or purple mark on the skin. Hemangiomas are common in newborns and usually grow during the first year of life, then shrink and fade over several years. The nurse should reassure the client that hemangiomas are harmless and do not require treatment unless they interfere with vision, breathing, or feeding.
Choice B reason: This is incorrect because the lesion on the child's head will not spread, but rather grow and shrink within a limited area. The nurse should not alarm the client by suggesting that the lesion will spread to other parts of the body or become malignant. The nurse should explain that hemangiomas are not contagious or infectious and do not affect the child's overall health or development.
Choice C reason: This is incorrect because the lesion on the child's head is not caused by scarring from the birth process, but rather by abnormal growth of blood vessels in the skin. The nurse should not confuse or misinform the client about the cause of the lesion. The nurse should explain that hemangiomas are not related to trauma, infection, or genetics, but rather to unknown factors that influence blood vessel formation during fetal development.
Choice D reason: This is incorrect because the lesion on the child's head is not a precancerous lesion and does not need a referral to a dermatologist. The nurse should not scare or mislead the client by suggesting that the lesion is a sign of cancer or requires further evaluation or treatment. The nurse should explain that hemangiomas are benign and usually resolve on their own without any complications or sequelae.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A Reason: Measuring the abdominal girth is not related to asterixis, which is a tremor of the hand when the wrist is extended. It may indicate ascites, which is a complication of cirrhosis, but not asterixis.

Choice B Reason: This is the correct choice. Asterixis is a flapping tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings. It is caused by abnormal function of the diencephalic motor centers that regulate the muscles involved in maintaining posture. It is a sign of hepatic encephalopathy, which is a neuropsychiatric disorder that occurs in patients with liver disease.

Choice C Reason: Having the client flex and extend their foot is not related to asterixis, which affects the hand and wrist. It may test for ankle clonus, which is a rhythmic contraction of the calf muscles when the foot is dorsiflexed. It indicates an upper motor neuron lesion, but not hepatic encephalopathy.

Choice D Reason: Asking the client to walk heel to toe is not related to asterixis, which affects the hand and wrist. It may test for balance and coordination, which can be impaired in patients with hepatic encephalopathy, but it is not a specific sign of asterixis.

A. Heart rate 122/min B. Urinary output 25 ml/hr C. Pain of 6 on a scale of 0 to 10 D. Difficulty swallowing

Correct Answer is D

Explanation

Choice A Reason: A heart rate of 122/min is elevated, but not life-threatening. It could be due to pain, anxiety, dehydration, or infection.

Choice B Reason: A urinary output of 25 ml/hr is low, but not critical. It could indicate fluid loss, kidney damage, or inadequate fluid resuscitation.

Choice C Reason: A pain level of 6 on a scale of 0 to 10 is moderate, but not severe. It could be managed with analgesics and non-pharmacological interventions.

Choice D Reason: This is the correct answer because difficulty swallowing can indicate airway obstruction, inhalation injury, or edema of the throat. It can compromise breathing and require immediate intervention.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client with a newborn asks about the lesion on her child's head. After assessing the skin, which response will the nurse offer to the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?

Correct Answer is B

Explanation

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?

Correct Answer is D

Explanation

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence?

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics?

A nurse is caring for a client who has a complete spinal cord injury. Based on the nurse's understanding about the degree of this type of injury, what can the nurse expect will be the client's level of function?

The primary health care provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis?

A client admitted with an acute exacerbation of Ménière's disease asks the student nurse why he was prescribed diphenhydramine. Which response by the student nurse requires correction by the primary nurse?

The nurse provides instructions to a client diagnosed with inflammatory bowel syndrome (IBS) about measures to treat diarrhea caused by acute flare-ups. Which statement by the client indicates a need for further teaching?

A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?