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
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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Related Questions
Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"E"}
Explanation
The nurse is planning care for the client. The nurse should place the client in a High Fowler's or Semi Fowler's position.
- High Fowler's Position: Elevating the head of the bed to a high Fowler's position (60-90 degrees) can help improve breathing and oxygenation by allowing the lungs to expand more easily.
- Semi Fowler's Position: A semi Fowler's position (30-45 degrees) is also beneficial for respiratory distress, providing some elevation to aid in breathing while being more comfortable than lying flat.
Correct Answer is B
Explanation
A. "I need to have an attorney sign my advance directives." An attorney is not required to sign an advance directive. The document typically requires the client’s signature and witnesses but does not need legal counsel unless state laws specify otherwise.
B. "I have a living will that outlines my wishes if I am unable to make decisions." A living will is a type of advance directive that specifies the client’s preferences for medical care if they become unable to make decisions. This statement shows understanding.
C. "I must have a family member appointed to make my health care decisions." While a client can appoint a family member as a healthcare proxy, it is not required. The client may choose any trusted individual to act as their healthcare power of attorney.
D. "I will need to sign a document stating that I want to be resuscitated if I require CPR." A Do Not Resuscitate (DNR) order is signed when a client chooses not to receive CPR. If the client wants resuscitation, no additional documentation is required—healthcare providers automatically provide life-saving measures unless a DNR order is in place.
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