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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. 20 represents the distance you are placed from the chart and 40 represents the distance a normal eye reads the chart:

This is correct. The first number (20) represents the distance in feet the patient is from the Snellen chart. The second number (40) indicates the distance at which a person with normal vision can read the same line. Therefore, 20/40 means that what the patient can read at 20 feet, a person with normal vision can read at 40 feet.

B. 20 represents the distance a normal eye can read and 40 represents the distance your eye reads the chart:

This is incorrect. The first number should represent the distance the patient is from the chart, not the normal eye's reading distance.

C. 20 represents the distance you are placed from the chart and 40 represents the distance your eye reads the chart:

This is incorrect. While the first number is correct (the distance from the chart), the second number should represent the distance a person with normal vision can read the same line, not the patient's distance.

D. 40 represents the distance you are placed from the chart and 20 represents the distance a normal eye reads the chart:

This is incorrect. The standard for visual acuity measurements is that the first number represents the testing distance (usually 20 feet), and the second number represents the distance at which a normal eye can read the line.

A. At the angle of the mandible B. temporal area C. The posterior base of the skull D. Area in front of the ears

Correct Answer is C

Explanation

A) At the angle of the mandible:

Lymph nodes located at the angle of the mandible are the submandibular lymph nodes, not the occipital lymph nodes. These nodes are situated below the jawline and are assessed when looking for infections or abnormalities in the oral cavity and throat.

B) Temporal area:

The temporal area is not a typical location for lymph node palpation. This region is primarily related to the temporal artery and muscles, not to lymph nodes. Thus, palpating for lymph nodes here would not be relevant.

C) The posterior base of the skull:

The occipital lymph nodes are located at the posterior base of the skull, near the nape of the neck. These nodes drain the scalp and are assessed when there are scalp infections or other related conditions.

D) Area in front of the ears:

The lymph nodes in front of the ears are the preauricular lymph nodes. These nodes drain the eyes and the surrounding skin. They are not the occipital lymph nodes, which are situated at the back of the head.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a complete physical examination on a patient. After examining the patient with the Snellen chart, the nurse documented distance vision in both eyes 20/40. The patient asks the nurse what 20/40 means:

Correct Answer is A

Explanation

At which location would a nurse palpate a client's occipital lymph nodes?

Correct Answer is C

Explanation

Which of the following would a nurse expect to assess in a client with esotropia?

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What data collected during an integumentary assessment should cause the nurse to be concerned that a client is at risk for the development of skin cancer? (Select all that apply.)

The nurse performs the action shown in this image during the assessment of a client. What is the nurse assessing?