A nurse is performing a focused skin assessment for a client as part of a comprehensive health screening. The nurse notes a mass which is hard, deep, and elevated 2 cm (0.8 in) in diameter on the client's back. Which of the following terms should the nurse use to document this finding?
Macule
Vesicle
Papule
Nodule
The Correct Answer is D
A. Macule: A macule is a flat, discolored spot on the skin, less than 1 cm in diameter. The described mass is elevated, so this term is incorrect.
B. Vesicle: A vesicle is a small, fluid-filled blister. The described mass is not fluid-filled, so this term is incorrect.
C. Papule: A papule is a small, solid, elevated lesion, usually less than 1 cm in diameter. The described mass is larger than a papule.
D. Nodule: A nodule is a solid, elevated lesion that is larger than a papule (usually more than 1 cm in diameter). The described mass fits this description.
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Related Questions
Correct Answer is D
Explanation
A. Assist the client to make autonomous decisions about his treatment options. Assisting the client to make autonomous decisions is important, but it cannot be done effectively until the client is aware of his diagnosis. This action would follow once the client is informed.
B. Reflect on her own opinion about withholding the diagnosis from him. Reflecting on her own opinion can help the nurse understand her biases but does not directly address the family's request or the client's immediate needs.
C. Inform the family that he has a legal right to be informed of his diagnosis. Informing the family about the client's legal right is essential, but first, the nurse should understand the family's perspective and concerns.
D. Determine the family's reasons for not telling him about his diagnosis. This is correct. Understanding the family's reasons provides context and helps the nurse address their concerns appropriately while advocating for the client’s right to know his diagnosis.
Correct Answer is B
Explanation
A. Cleanse the urethral meatus. This step occurs after preparing the sterile field and donning sterile gloves.
B. Apply sterile gloves. This is correct. The first step in the standardized procedure is to apply sterile gloves to maintain aseptic technique throughout the catheter insertion process.
C. Attach the pre-filled syringe to the inflation bulb. This step is part of the preparation but comes after the sterile gloves are applied.
D. Saturate the cotton balls with antiseptic. This step occurs after donning sterile gloves.
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