Which finding, obtained during a skin assessment, should the school nurse report to the healthcare provider?
Multiple maculopapular pustules over forehead and chin on an adolescent.
Bilateral patellar abrasions with eschar formation on a preschool-aged child.
Red, swollen, painful nodule located on upper back on a school-aged boy.
Small, white flecks on the hair shafts throughout scalp on a school-aged girl.
The Correct Answer is A
A. Multiple maculopapular pustules over the forehead and chin are suggestive of acne vulgaris or possibly another dermatologic condition that may require medical intervention. If the pustules are widespread or persistent, it should be reported for further evaluation.
B. Bilateral patellar abrasions with eschar formation are common in children and are usually non- threatening unless there are signs of infection. This finding may not require immediate reporting unless the condition worsens.
C. A red, swollen, painful nodule on the upper back is likely a boil or abscess, but it’s important to consider the overall presentation and if there is a risk for systemic infection. This may not need immediate reporting unless symptoms worsen.
D. Small, white flecks on the hair shafts indicate possible head lice, which, while needing treatment,
doesn’t require immediate reporting unless there is a larger health concern associated with it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Battle sign refers to bruising behind the ears and is a sign of head trauma, not intoxication.
B. Chvostek's sign is related to hypocalcemia, not intoxication.
C. Romberg sign assesses for balance issues when standing with eyes closed and is commonly positive in clients with neurological impairment, including intoxication.
D. Babinski sign is related to neurological disorders and would not be directly associated with intoxication.
Correct Answer is D
Explanation
A. Frozen or non-movable joints typically refer to severe joint damage such as in cases of rheumatoid arthritis or advanced osteoarthritis, but Heberden's nodes are characterized by bony growths at the distal interphalangeal joints and do not indicate frozen joints.
B. Heberden's nodes are bony enlargements found at the distal interphalangeal joints. However, they are not typically associated with deviation of the joints, which might occur with other conditions like rheumatoid arthritis.
C. Proximal intertarsal joint swelling, particularly of the big toe, is more likely associated with gout, not osteoarthritis. Heberden's nodes specifically refer to changes in the distal interphalangeal joints of the fingers.
D. Heberden's nodes are typically non-painful enlargements of the distal interphalangeal joints that result from osteoarthritis. The nurse should document the presence of these nodes and note if they are non-painful.
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