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 A

Explanation

A. Reposition the client every 2 hr: This is an essential action to prevent pressure ulcers and skin breakdown, especially for bedridden patients. Frequent repositioning helps alleviate pressure on bony prominences.
B. Assess the client's skin for increased coolness: While assessing skin temperature is important, it is not as immediate as repositioning the patient. Increased coolness may suggest poor circulation.
C. Keep the client's skin moist: Keeping the skin moist can lead to skin breakdown and increases the risk for pressure ulcers. Dry skin is typically preferred to avoid moisture-related damage.
D. Massage the client's red bony prominences: Massaging reddened skin can actually damage the tissue and worsen pressure injuries. It is advised to avoid massaging bony prominences that show signs of pressure.

A. Intact skin with localized erythema. B. Partial-thickness skin loss with red tissue in wound bed. C. Full thickness skin loss with visible adipose tissue. D. Full thickness skin loss with visible bone

Correct Answer is B

Explanation

A. Intact skin with localized erythema: This describes a stage 1 pressure injury.
B. Partial-thickness skin loss with red tissue in wound bed: This is characteristic of stage 2 pressure injuries, where there is damage to the epidermis and partial dermis.
C. Full thickness skin loss with visible adipose tissue: This describes a stage 3 pressure injury.
D. Full thickness skin loss with visible bone: This describes a stage 4 pressure injury.

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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