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 D
Explanation
A) Dysphagia:
Dysphagia refers to difficulty swallowing and is typically associated with conditions affecting the esophagus or neuromuscular function. While it can coexist with other symptoms, it does not directly explain hoarseness, fatigue, and weight gain as hypothyroidism does.
B) Gingivitis:
Gingivitis is an inflammation of the gums due to plaque buildup. It primarily affects oral health, causing redness, swelling, and bleeding of the gums. It is not associated with systemic symptoms like hoarseness, fatigue, or weight gain.
C) Aphthous ulcers:
Aphthous ulcers, also known as canker sores, are small, painful lesions that develop in the mouth. They are typically caused by stress, minor injury, or certain foods. These ulcers do not explain the systemic symptoms described by the client.
D) Hypothyroidism:
Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormones. Symptoms include hoarseness, fatigue, weight gain, dry skin, and cold intolerance. The combination of these symptoms in the client's history makes hypothyroidism the most likely cause.
Correct Answer is C
Explanation
A) Blockage of the tear ducts causing excessive tearing:
Blockage of tear ducts (dacryostenosis) results in excessive tearing (epiphora) due to inadequate drainage of tears into the nasal cavity. It does not directly contribute to glaucoma, which primarily involves increased intraocular pressure (IOP) and optic nerve damage.
B) Inflammation of the cornea resulting in blurry vision:
Corneal inflammation (keratitis) can cause blurry vision, pain, and sensitivity to light, but it is not the primary pathophysiology of glaucoma. Glaucoma primarily involves damage to the optic nerve due to elevated IOP.
C) Increased intraocular pressure (IOP) leading to optic nerve damage:
Glaucoma is characterized by elevated IOP, which puts pressure on the optic nerve and can lead to progressive damage and vision loss if untreated. This is the primary pathophysiological process in most types of glaucoma.
D) Degeneration of the lens leading to cataracts:
Cataracts involve the clouding of the lens of the eye, leading to visual impairment. While cataracts are a common condition in older adults, they are not directly related to the pathophysiology of glaucoma, which primarily involves elevated IOP and optic nerve damage.
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