During the skin assessment of a client, the nurse observes a skin lesion that is elevated, round, and filled with serum. Identify the type of lesion.
Pustule.
Macule.
Vesicle.
Cyst.
Cyst.
The Correct Answer is C
Choice A rationale
A pustule is an elevated, round lesion filled with pus, not serum. Pustules are commonly seen in acne or infections.
Choice B rationale
A macule is a flat, discolored area of the skin that is not elevated. Macules do not contain fluid and are often seen in conditions like freckles or flat moles.
Choice C rationale
A vesicle is an elevated, round lesion filled with clear serum. Vesicles can result from conditions such as chickenpox, herpes simplex, or dermatitis.
Choice D rationale
A cyst is an elevated, round lesion filled with semi-solid material or fluid. Cysts are typically deeper in the skin compared to vesicles.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Rigidity is characterized by a continuous resistance to passive movement in any direction and does not specifically occur during abrupt dorsiflexion of the foot.
Choice B rationale
Flaccidity refers to decreased muscle tone or limpness, which is the opposite of hyperactivity or spasticity, and would not be observed with abrupt dorsiflexion.
Choice C rationale
Ataxia involves uncoordinated or erratic movements and is related to cerebellar dysfunction. This is not specifically triggered by abrupt dorsiflexion of the foot.
Choice D rationale
Clonus is the correct term for rhythmic, involuntary contractions of a muscle that occur when it is suddenly stretched, such as with abrupt dorsiflexion of the foot. It is a sign of hyperactive reflexes and upper motor neuron lesions.
Correct Answer is D
Explanation
Choice A rationale
Stupor refers to a state of near-unconsciousness or insensibility, where the patient can be briefly aroused by vigorous or repeated stimuli.
Choice B rationale
Somnolence refers to a state of strong desire for sleep or sleeping for unusually long periods (drowsiness), but it is not as severe as stupor or coma.
Choice C rationale
Normal consciousness means the patient is awake, alert, and responsive to their environment with no neurological deficits.
Choice D rationale
A score of 6 on the Glasgow Coma Scale indicates deep coma, where the patient has minimal to no response to stimuli, indicating severe brain injury.
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