After completing an integument physical examination, the nurse is documenting information concerning observed lesions. What characteristics will the nurse include in this documentation? (Select all that apply.)
Location
Color
Condition of surrounding skin
Elevation
Distribution pattern
Correct Answer : A,B,C,D,E
A) Location: Documenting the exact location of lesions is crucial for monitoring changes over time, assessing potential spread or resolution, and providing accurate information for future reference. This information helps in the diagnosis and in tracking the effectiveness of treatments.
B) Color: The color of lesions can provide important clues about their nature and cause. For example, red or inflamed lesions might indicate infection or irritation, while darker lesions could suggest malignancy or chronicity. Color changes can also signify healing or worsening of the lesion.
C) Condition of surrounding skin: Noting the condition of the skin around the lesions helps assess whether there is additional inflammation, infection, or other skin conditions that may be related to the primary lesion. This provides a more comprehensive understanding of the patient’s skin health and any secondary complications.
D) Elevation: Elevation refers to whether the lesion is raised, flat, or depressed compared to the surrounding skin. This characteristic helps in identifying the type of lesion, such as a papule, plaque, or ulcer. Elevated lesions might suggest certain dermatological conditions, while depressed lesions might indicate scarring or loss of tissue.
E) Distribution pattern: The pattern of how lesions are distributed on the body can provide diagnostic clues. For example, a linear distribution might suggest contact dermatitis, while a symmetrical distribution could indicate a systemic condition. Understanding the distribution pattern helps in identifying the underlying cause and planning appropriate treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
(a) Liver Disease:
Pitting edema is commonly seen in liver disease, especially in conditions like cirrhosis. Liver disease can lead to hypoalbuminemia, where low levels of albumin in the blood cause fluid to leak into the interstitial spaces, resulting in edema. Additionally, liver disease often leads to portal hypertension, which can also contribute to the development of edema.
(b) Diabetes mellitus:
While diabetes can cause complications such as diabetic nephropathy, which may lead to fluid retention, pitting edema is not a primary symptom directly associated with diabetes mellitus. Diabetic patients may develop edema due to kidney issues, but it is not as directly associated as with liver disease.
(c) End Stage Renal Disease:
End-stage renal disease (ESRD) can indeed cause significant fluid retention and edema, including pitting edema. The kidneys' inability to excrete excess fluid leads to its accumulation in tissues. However, the question seems to point towards liver disease, which directly leads to conditions causing pitting edema.
(d) Colon Cancer:
Colon cancer is not typically associated with pitting edema. While advanced cancer can lead to various complications, including fluid imbalances, it is not a primary cause of pitting edema. Edema related to cancer is often more localized and associated with tumor sites or treatment areas.
Correct Answer is C
Explanation
The Body Mass Index (BMI) is calculated using the formula:
BMI = weight(kg) / height(m)2
First, we need to convert the height from feet and inches to meters.
There are approximately 0.3048 meters in a foot and 0.0254 meters in an inch.
So, 5 feet 5 inches is approximately 1.65 meters.
Substituting the given values into the formula:
BMI = 60 / (1.65)2
This gives us a BMI of approximately 22 when rounded to the nearest whole number.
Therefore, the correct answer is 22 BMI.
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