An older adult client reports that they are experiencing severe trunk pain and is concerned that it might be shingles. Which type of lesion would the nurse most likely assess if shingles were present?
Papule
Crust
Bulla
Vesicle
The Correct Answer is D
A. A papule is a small, raised lesion that is solid and does not contain fluid, which is not characteristic of shingles.
B. A crust forms as a lesion heals but is not the primary lesion seen in shingles.
C. A bulla is a large, fluid-filled lesion seen in conditions like burns or insect bites, but shingles lesions are typically smaller.
D. A vesicle is correct. Shingles (herpes zoster) presents with clusters of vesicles on an erythematous base, typically in a unilateral, dermatomal pattern. These vesicles are filled with clear fluid and become pustular before crusting over.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Lying on the left side does not aid in abdominal palpation and may not provide additional diagnostic information.
B. Asking the client to exhale and hold their breath is useful in certain liver or gallbladder assessments but is not relevant for general abdominal palpation.
C. Raising the head off the pillow is a technique used to assess for diastasis recti or hernias but is not beneficial for assessing right lower quadrant pain.
D. Assisting the client in flexing their knees is correct because it relaxes the abdominal muscles, reducing guarding and making palpation more effective. This is especially important when assessing for conditions like appendicitis.
Correct Answer is C
Explanation
A. Palpating for pitting edema assesses for fluid overload, but this client is more likely experiencing fluid deficit rather than retention.
B. Assessing oral temperature is important, but there is no indication of infection or fever contributing to fluid loss in this scenario.
C. Inspecting the oral mucosa is correct because the client's total intake (1,245 mL) is significantly lower than their total output (1,928 mL), indicating a negative fluid balance. Signs of dehydration, such as dry oral mucosa, should be assessed first.
D. Auscultating adventitious lung sounds is relevant for fluid overload but is not the priority in a case of fluid deficit.
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