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 C

Explanation

A. To prevent further dehydration:

While preventing dehydration is important, it is not the primary reason for bringing a cup of water when assessing the thyroid gland. Dehydration is addressed through overall fluid management rather than during a specific thyroid exam.

B. To assist the client to feel more comfortable:

Providing comfort is essential, but bringing a cup of water specifically for comfort during a thyroid exam is not typically necessary. The primary focus of the water in this context is related to the assessment process.

C. To observe the movement of the thyroid gland:

Observing the movement of the thyroid gland during swallowing can help the nurse assess for abnormalities. Having the client drink water allows the nurse to observe the thyroid gland's movement, which can indicate the presence of goiters, nodules, or other irregularities.

D. To promote the nurse-client relationship:

Promoting a good nurse-client relationship is always beneficial, but bringing a cup of water for this specific purpose is not relevant to the physical assessment of the thyroid gland. The water's main purpose is to facilitate the physical examination process.

A. Facial edema B. Diarrhea C. Tachycardia D. Heat intolerance

Correct Answer is A

Explanation

A) Facial edema: Myxedema is a severe form of hypothyroidism that is often characterized by the accumulation of mucopolysaccharides in the skin and other tissues, leading to facial and peripheral edema. This is a classic symptom of myxedema and is expected in clients with this condition.

B) Diarrhea: Diarrhea is more commonly associated with hyperthyroidism rather than hypothyroidism. Clients with myxedema typically experience constipation due to slowed gastrointestinal motility.

C) Tachycardia: Tachycardia is associated with hyperthyroidism. In contrast, myxedema is associated with bradycardia or a slow heart rate because of the overall slowing of the body's metabolic processes.

D) Heat intolerance: Heat intolerance is a symptom of hyperthyroidism. Clients with myxedema usually experience cold intolerance due to decreased metabolic activity and impaired thermoregulation.

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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

When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism, why is it important to bring a cup of water to the physical examination?

Correct Answer is C

Explanation

A nurse is assessing a client who has myxedema. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

Which of the following is a potential adverse reaction to silver sulfadiazine in burn victims?

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In which disease process should a nurse expect to see a client with the presence of pitting edema?

The nurse is preparing to assess a client's near vision. The nurse would use which piece of equipment for the assessment?

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.)

Which nutritional data obtained from a client needs MOST validation by a nurse?