The nurse notices the client's physical appearance, behavior, mobility, and neurological status when they enter the room.
Which of the following is the nurse assessing?

General survey.

Medical history.

Biographical data.

Social history.

Answer and Explanation

The Correct Answer is A

Choice A rationale

The general survey is an overall assessment of a client's physical appearance, behavior, mobility, and neurological status. It provides a comprehensive overview of the client's health and well-being, making it the focus of the nurse's observations in this scenario.

Choice B rationale

Medical history includes past and current health conditions, surgeries, medications, and family health history. While important, it is not the focus of the nurse's immediate observations in this scenario.

Choice C rationale

Biographical data involves personal information such as age, gender, occupation, and marital status. While relevant to the client's health, it is not the primary focus of the nurse's observations in this scenario.

Choice D rationale

Social history includes information about the client's lifestyle, habits, and social environment. While valuable for understanding the client's overall health context, it is not the focus of the nurse's immediate observations in this scenario. .

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Correct Answer is A

Explanation

Choice A rationale

Flatness is the percussion sound typically heard over muscles and solid tissues. It is characterized by a high-pitched, soft sound, which indicates that the underlying tissue is denser and less air-filled compared to lungs.

Choice B rationale

Dullness is heard over solid organs such as the liver or spleen but not typically over muscles.

Choice C rationale

Tympany is a drum-like sound heard over areas filled with gas, such as the stomach or intestines.

Choice D rationale

Resonance is heard over air-filled lungs and not over muscles and solid tissues.

A. Color. B. Characteristics. C. Crepitus. D. Coping methods.

Correct Answer is A

Explanation

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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The nurse notices the client's physical appearance, behavior, mobility, and neurological status when they enter the room.Which of the following is the nurse assessing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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The nurse notices the client's physical appearance, behavior, mobility, and neurological status when they enter the room.
Which of the following is the nurse assessing?