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 C

Explanation

Choice A rationale

The optic nerve (CN II) is responsible for vision, transmitting visual information from the retina to the brain. Dysfunction of the optic nerve would result in visual disturbances, such as loss of vision or changes in visual acuity, rather than difficulty with tongue movement. This nerve does not control motor functions of the tongue.

Choice B rationale

The abducens nerve (CN VI) controls the lateral rectus muscle of the eye, which is responsible for moving the eye outward, away from the nose. Dysfunction of the abducens nerve would result in issues with eye movement, such as double vision or inability to move the eye laterally, not tongue movement. It does not play a role in tongue motor control.

Choice C rationale

The hypoglossal nerve (CN XII) controls the muscles of the tongue, enabling movements necessary for speech, swallowing, and mastication. Dysfunction of this nerve would result in difficulty protruding the tongue and reduced strength during resistance testing. Symptoms can include atrophy of the tongue muscles, fasciculations, and deviation of the tongue to one side when extended.

Choice D rationale

The vestibulocochlear nerve (CN VIII) is responsible for hearing and balance, transmitting sound and equilibrium information from the inner ear to the brain. Dysfunction of the vestibulocochlear nerve would lead to symptoms such as hearing loss, tinnitus, or balance disorders like vertigo. It does not affect the motor control of the tongue.

A. 2nd intercostal space. B. 3rd intercostal space. C. 2nd rib. D. 4th intercostal space.

Correct Answer is A

Explanation

Choice A rationale

The Angle of Louis, also known as the sternal angle, is located at the level of the 2nd intercostal space. It is a significant landmark in clinical examinations because it is used to locate important areas of the chest, such as the aortic and pulmonic areas, for auscultation.

Choice B rationale

The 3rd intercostal space is not the correct location for the Angle of Louis. The sternal angle is found at the level of the 2nd intercostal space, not the 3rd. Therefore, this option is incorrect.

Choice C rationale

The 2nd rib attaches at the level of the Angle of Louis. The sternal angle is an anatomical landmark where the manubrium and the body of the sternum meet, and it corresponds with the attachment of the 2nd rib.

Choice D rationale

The 4th intercostal space is not the correct location for the Angle of Louis. The sternal angle is located at the 2nd intercostal space, not the 4th. Therefore, this option is incorrect. .

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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

On assessment of the client's tongue, the client is unable to protrude the tongue and has poor strength on testing against resistance.This would indicate dysfunction of which cranial nerve?

Correct Answer is C

Explanation

During cardiac examination of a client, the nurse was demonstrating to the student nurse where to locate the Angle of Louis to listen to the Aortic and Pulmonic area on the chest.The nurse should locate the Angle of Louis at the level of what rib?

Correct Answer is A

Explanation

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