When assessing a client's skin, the nurse finds freckles. How would the nurse document the lesions?

Nodule

Papule

Wheal

Macule

Answer and Explanation

The Correct Answer is D

A.   A nodule is a solid, raised lesion that is typically larger than 1 cm in diameter and extends deeper into the skin.
B.   A papule is a small, raised, solid lesion, less than 1 cm, but not typically used for documenting freckles.
C.   A wheal is a raised, erythematous area, often a result of an allergic reaction, not a freckle.
D.   A macule is a flat, pigmented area of skin, less than 1 cm in diameter, which accurately describes freckles.

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Correct Answer is D

Explanation

A. Partial-thickness skin loss with red tissue in wound bed: This is a characteristic of stage 2 pressure injuries, not stage 1.
B. Full thickness skin loss with visible adipose tissue: This is a characteristic of stage 3 pressure injuries.
C. Full thickness skin loss with visible bone: This is a characteristic of stage 4 pressure injuries.

D. Intact skin with localized erythema: This is the characteristic of stage 1 pressure injuries, which present as non-blanching erythema (redness) of intact skin.

A. Assess risk for immediate harm. B. instruct the client on how to leave the relationship. C. Implement a safety plan. D. Refer the client to a community support group.

Correct Answer is A

Explanation

A. Assess risk for immediate harm should be the priority. The nurse needs to evaluate whether the client is in immediate danger and take the necessary steps to ensure their safety.
B. Instructing the client on how to leave the relationship is important, but the priority is to assess if the client is in immediate danger first.
C. Implementing a safety plan is essential, but first, the nurse must assess the immediate risks to the client's safety.
D. Referring the client to a community support group is a supportive action but should follow the priority steps of ensuring safety and assessing immediate harm.

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When assessing a client's skin, the nurse finds freckles. How would the nurse document the lesions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is caring for a client who has reported experiencing abuse at home. Which of the following actions should be a priority for the nurse?

Correct Answer is A

Explanation

A nurse is planning care for a client who is confined to bed. Which of the following actions should the nurse include in the plan?

A nurse is assessing the reflexes of a client who has an unrepaired femur fracture and has suddenly become stuporous. For which of the following findings should the nurse identify that the client exhibits Babinski's sign?

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A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve VII?

A nurse is teaching a client about risk factors for skin cancer. Which of the following statements by the client indicates an understanding of the teaching?

The nurse is performing a neurologic assessment of a 41-year-old patient the patient is able to open eyes to pain, uses inappropriate words, and has flexion withdrawal from pain. What is their GCS score?

When assessing a lesion on the skin, which of the following findings are concerning? Select all that apply.