The nurse is assessing a skin lesion using the ABCDE criteria.
The nurse understands "C" stands for:

Color.

Characteristics.

Crepitus.

Coping methods.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale

Lordosis refers to an excessive inward curvature of the lumbar spine, often referred to as swayback. This condition causes the lower back to arch more than normal, leading to a prominent abdomen and buttocks. Lordosis does not affect the thoracic spine and does not cause an exaggerated curvature in that region.

Choice B rationale

Scoliosis is a lateral curvature of the spine that results in an S- or C-shaped curve. It can occur in the thoracic, lumbar, or cervical regions of the spine. Scoliosis involves a sideways deviation rather than an exaggerated curvature in the thoracic spine.

Choice C rationale

Spinal dysplasia is a broad term that refers to various congenital abnormalities affecting the development of the spine. It includes conditions such as spina bifida, kyphosis, and scoliosis, each with distinct characteristics. The term itself does not specify an exaggerated thoracic curvature.

Choice D rationale

Kyphosis is an exaggerated outward curvature of the thoracic spine, resulting in a rounded or hunched back appearance. This condition is common in elderly individuals and can be caused by factors such as osteoporosis, vertebral fractures, or degenerative changes. It leads to a noticeable forward bend of the upper back.

A. The sides of the mouth are symmetric when the patient smiles. B. The patient's eyes move to the left, right, up, down, and obliquely during conversation. C. The patient's eyelids blink periodically. D. The patient moistens the lips with the tongue.

Correct Answer is A

Explanation

Choice A rationale

The sides of the mouth being symmetric when the patient smiles indicate intact function of the facial cranial nerve (CN VII). This nerve controls the muscles responsible for facial expressions, including smiling, frowning, and closing the eyes. Symmetry in these actions suggests that the facial nerve is functioning properly and that there is no nerve damage or weakness.

Choice B rationale

The patient's eyes moving to the left, right, up, down, and obliquely during conversation are functions of the oculomotor nerve (CN III), trochlear nerve (CN IV), and abducens nerve (CN VI), not the facial cranial nerve (CN VII). These nerves work together to control the movements of the eye muscles, enabling the eyes to move in different directions and maintain proper alignment.

Choice C rationale

Periodic blinking of the eyelids involves the oculomotor nerve (CN III) and the facial nerve (CN VII). The oculomotor nerve controls the muscles that lift the eyelid, while the facial nerve controls the muscles that close the eyelid. Blinking is a coordinated action involving both nerves, but the observation alone is not sufficient to determine the integrity of CN VII.

Choice D rationale

The patient moistening the lips with the tongue involves the function of the hypoglossal nerve (CN XII), which controls the movements of the tongue. The hypoglossal nerve is responsible for the motor control of most of the tongue muscles, allowing for actions like licking the lips, speaking, and swallowing. It is not related to the facial cranial nerve (CN VII).

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The nurse is assessing a skin lesion using the ABCDE criteria.The nurse understands "C" stands for:

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Naxlex Comprehensive Predictor Exams

The nurse is examining an elderly client and notes an exaggerated curvature of the thoracic spine.The nurse should document this finding as which of the following?

Correct Answer is D

Explanation

While taking a history, the nurse observes that the patient's facial cranial nerves (CN VII) are intact based on which behaviors of the patient?

Correct Answer is A

Explanation

In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important.The reason for this is that the upper quadrant is:

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A nurse is auscultating the breath sounds of a client who has chronic obstructive pulmonary disease.When the client exhales, the nurse hears continuous high-pitched whistling sound.The nurse should document this as?

The nurse is assessing a skin lesion using the ABCDE criteria.
The nurse understands "C" stands for: