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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Homan sign tests for deep vein thrombosis, not balance. Swaying with eyes closed indicates a positive Romberg sign, so this is incorrect for the documented finding.

Choice B reason: Lack of coordination is vague and not specific to the Romberg test, which assesses proprioception. Positive Romberg sign describes the sway, so this is incorrect for documentation.

Choice C reason: A positive Romberg sign is documented when a patient sways or loses balance with eyes closed, indicating proprioceptive or cerebellar issues. This is the correct term for the finding.

Choice D reason: Ataxia describes general movement, not the specific Romberg test outcome. Swaying in this context is a Romberg sign, so this is incorrect for the nurse’s documentation.

A. “We need to determine the areas of tenderness before using percussion and palpation.” B. “Auscultation allows the patient more time to relax and therefore be more comfortable with the physical examination.” C. “Auscultation prevents distortion of vascular sounds, such as bruits and hums, that might occur after percussion and palpation.” D. “Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation.” E. None F. None

Correct Answer is D

Explanation

Choice A reason: Tenderness is assessed by palpation, not auscultation, which focuses on sounds. Auscultation precedes to avoid altering bowel sounds, so this is incorrect for the reason given.

Choice B reason: Patient relaxation is beneficial but not the primary reason for auscultation first. Preventing bowel sound distortion by avoiding percussion and palpation is key, so this is incorrect.

Choice C reason: Vascular sounds like bruits are less affected by percussion/palpation than bowel sounds. Bowel sound distortion is the main concern, so this is incorrect for the primary reason.

Choice D reason: Auscultation before percussion and palpation prevents distortion of bowel sounds, which can be altered by manipulation. This is the correct reason, reflecting proper abdominal assessment technique.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When the nurse asks an older patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. How should the nurse document this finding?

Correct Answer is C

Explanation

The nurse is watching a new graduate nurse perform auscultation of a patient’s abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?

Correct Answer is D

Explanation

A nurse understands that a patient’s race is most related to which of the following?

A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. The nurse should be concerned with which additional finding?

A patient arrives at the emergency center with a severe head injury. During assessment, the nurse observes that the patient is unresponsive, adducts the arms tightly against the thorax, and plantar flexes the feet while internally rotating them. How would the nurse document this abnormal posture?

The nurse is examining a 3-year-old child. Which bruise, if found, would be of most concern?

A 40-year-old Asian male with no family history of cancer is in the office for his annual physical examination. What should the nurse teach the patient regarding the PSA blood test according to the American Cancer Society?

The nurse is assessing a patient’s pain. Which would be the most reliable indicator of pain in a conscious, alert, and oriented patient?

Which is the best statement by the nurse to ensure that a patient is performing breast self-examination correctly?

A 62-year-old man states that his physician told him that he has an inguinal hernia. He asks the nurse to explain what a hernia is. How should the nurse respond?