The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. How should the nurse document this finding?
Nodule
Wheal
Papule
Pustule
The Correct Answer is C
Choice A reason: A nodule is a solid, elevated lesion, typically greater than 1 cm in diameter, often extending deeper into the dermis or subcutaneous tissue. The lesion described is less than 1 cm, making nodule an incorrect term for this superficial, smaller skin finding.
Choice B reason: A wheal is a transient, elevated lesion caused by dermal edema, often associated with allergic reactions or urticaria. It is not solid and typically lacks the circumscribed nature of the described lesion, making wheal an inappropriate documentation term.
Choice C reason: A papule is a solid, elevated, circumscribed lesion less than 1 cm in diameter, often due to localized skin changes like inflammation or benign growths. This matches the described lesion’s characteristics, making papule the correct term for documentation.
Choice D reason: A pustule is an elevated lesion containing pus, often associated with infections like acne. The described lesion is solid, not fluid-filled, so pustule does not fit the clinical presentation, making it an incorrect choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Superficial tenderness is assessed with light palpation, which evaluates surface sensitivity. Deep palpation probes deeper structures, like organs, and is not primarily for detecting superficial pain, making this an incorrect rationale.
Choice B reason: Bowel motility is assessed via auscultation, which detects bowel sounds, not palpation. Deep palpation evaluates organ size or masses, not dynamic motility, making this an incorrect purpose for the technique.
Choice C reason: The overall impression of skin and superficial musculature is gained through inspection and light palpation. Deep palpation targets deeper structures like organs, not surface characteristics, making this an incorrect rationale.
Choice D reason: Deep palpation is used to assess for enlarged organs, such as hepatomegaly or splenomegaly, by probing deeper abdominal structures. This allows detection of abnormal masses or organ sizes, making this the correct rationale.
Correct Answer is A
Explanation
Choice A reason: Clubbing, characterized by bulbous nail bed enlargement, is associated with chronic hypoxemia from conditions like asthma or COPD. It results from long-term low oxygen levels, making it the expected finding in this patient with chronic respiratory issues.
Choice B reason: Onychomycosis is a fungal nail infection unrelated to hypoxemia or asthma. Clubbing is directly linked to chronic oxygen deficiency, so this is not the expected nail condition in this patient’s context.
Choice C reason: Spooning (koilonychia) is associated with iron deficiency anemia, not hypoxemia or asthma. Clubbing is the nail abnormality seen in chronic respiratory conditions, so this is incorrect for the patient’s condition.
Choice D reason: Paronychia is an infection around the nail, typically from trauma or bacteria, not hypoxemia. Clubbing is the hallmark nail change in chronic asthma with low oxygen, so this is not the expected finding.
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