The nurse is assessing a skin lesion using the ABCDE criteria.
The nurse understands "C" stands for:
Color.
Characteristics.
Crepitus.
Coping methods.
The Correct Answer is A
Choice A rationale
"C" in the ABCDE criteria for assessing skin lesions stands for Color. This criterion refers to the variations in the color of the lesion, which could include shades of black, brown, tan, or even white, red, or blue. Uneven or multiple colors within a single lesion can be a warning sign of melanoma, a type of skin cancer. Regularly checking the color of moles or spots on the skin is crucial for early detection of potential malignancies.
Choice B rationale
Characteristics are not part of the ABCDE criteria. The ABCDE criteria specifically stand for Asymmetry, Border, Color, Diameter, and Evolving. These criteria are used by healthcare professionals to identify suspicious skin lesions that may need further evaluation or biopsy to rule out skin cancer. Focusing on these specific aspects helps in early detection and treatment of malignant skin conditions.
Choice C rationale
Crepitus is a term used to describe a crackling or grating sound or sensation, typically associated with bones or joints, and is not related to skin lesion assessment. Crepitus can be felt or heard in conditions such as arthritis, where the cartilage in the joints has worn away, causing bones to rub against each other. It is unrelated to the ABCDE criteria for skin lesions.
Choice D rationale
Coping methods are strategies used by individuals to manage stress, emotions, or adverse situations and have no relevance to the ABCDE criteria for skin lesions. Coping methods can include techniques like exercise, meditation, or talking to a therapist, but they do not pertain to the physical examination of skin lesions for signs of cancer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Separation of the retina from the choroid, also known as retinal detachment, is a different condition altogether. Retinal detachment can cause vision loss but is not related to macular degeneration. This condition often requires immediate medical attention to prevent permanent vision loss and is typically characterized by the sudden appearance of floaters, flashes of light, and a shadow or curtain over a portion of the visual field.
Choice B rationale
Peripheral vision loss and seeing halos around light are more commonly associated with conditions like glaucoma. Glaucoma involves increased intraocular pressure, which can damage the optic nerve and lead to peripheral vision loss and seeing halos around lights. This condition can be managed with medications or surgery to lower intraocular pressure and prevent further vision loss.
Choice C rationale
Complaints of severe pain and pressure in the eye are indicative of acute angle-closure glaucoma. This is a medical emergency and requires prompt treatment to reduce intraocular pressure and prevent optic nerve damage. The symptoms of acute angle-closure glaucoma are sudden and severe and can include headache, nausea, and vomiting, along with the eye pain and pressure.
Choice D rationale
Central vision loss with intact peripheral vision is characteristic of macular degeneration, particularly age-related macular degeneration (AMD). AMD affects the macula, the part of the retina responsible for sharp, central vision. As the macula deteriorates, central vision becomes blurry or wavy, making it difficult to read, drive, or recognize faces, while peripheral vision remains largely unaffected.
Correct Answer is A
Explanation
Choice A rationale
The Romberg test evaluates equilibrium by having the client stand with feet together and eyes closed, observing for swaying or imbalance. It assesses the function of the vestibular system, proprioception, and cerebellar function, making it the most appropriate test for assessing dizziness and equilibrium.
Choice B rationale
The Weber test involves placing a tuning fork on the forehead to evaluate sound lateralization. It assesses hearing loss but not equilibrium, making it less suitable for dizziness assessment.
Choice C rationale
The Rinne test compares air and bone conduction of sound using a tuning fork. While useful for diagnosing conductive hearing loss, it does not assess equilibrium, making it inappropriate for evaluating dizziness.
Choice D rationale
The cover test evaluates eye alignment and muscle function by having the client cover one eye and observe the uncovered eye for movement. It assesses ocular motility but not equilibrium, making it unsuitable for dizziness assessment.
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