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A nurse is caring for a client who has a nonpalpable skin lesion that is less than 0.5 cm (0.2 In) in diameter. Which of the following terms should the nurse use to document this finding?

Papule

Vesicle

Nodule

Macule

Answer and Explanation

The Correct Answer is D

A. Papule – A papule is a raised, solid lesion (e.g., a mole) and is palpable, not flat.

B. Vesicle – A vesicle is a fluid-filled blister (e.g., herpes, chickenpox), which is not the case here.

C. Nodule – A nodule is a deep, raised lesion that extends into the dermis or subcutaneous tissue.

D. Macule – A macule is a flat, nonpalpable skin discoloration that is less than 1 cm (e.g., a freckle or petechiae).

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Correct Answer is ["A","B","E"]

Explanation

A. Turn on the bed alarm. A bed alarm alerts staff when the client attempts to get up, helping prevent falls.

B. Maintain the bed in the lowest position. Keeping the bed low reduces the risk of injury in case the client attempts to get up unassisted.

C. Place the client in a vest restraint. Restraints should be used only as a last resort after less restrictive measures fail. They can cause distress and increase agitation in clients with dementia.

D. Administer a sedative. Sedatives can increase confusion, risk of falls, and respiratory depression, making them an inappropriate first-line intervention.

E. Encourage the family to stay with the client. Having familiar caregivers present can provide reassurance and reduce agitation, making it a beneficial intervention.

A. "I can exercise as late as 1 hour before bedtime." B. "I should reduce my fluid intake 2 hours before bedtime." C. "I should take a 1 hour nap each day. D. "I can eat a large meal as late as 1 hour before bedtime."

Correct Answer is B

Explanation

A. "I can exercise as late as 1 hour before bedtime." Exercise close to bedtime can increase alertness and make it harder to fall asleep. It is recommended to finish exercising at least 3-4 hours before bedtime.

B. "I should reduce my fluid intake 2 hours before bedtime." Reducing fluid intake before bedtime helps minimize nocturia, which can disrupt sleep.

C. "I should take a 1-hour nap each day." Long or frequent naps can interfere with nighttime sleep. If naps are needed, they should be limited to 20-30 minutes earlier in the day.

D. "I can eat a large meal as late as 1 hour before bedtime." Eating a heavy meal before bed can cause discomfort and acid reflux, which may disrupt sleep. A light snack is preferable.

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A nurse is caring for a client who has a nonpalpable skin lesion that is less than 0.5 cm (0.2 In) in diameter. Which of the following terms should the nurse use to document this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has dementia and frequently tries to get out of bed. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

A nurse is providing teaching about measures to promote sleep with a client who has Insomnia. Which of the following client statements Indicates an understanding of the teaching?

Correct Answer is B

Explanation

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