A 15-year-old boy shows the school nurse a bump on his neck. The nurse observes a raised, erythematous, solid, 0.3-by-0.2 cm mass. How would the nurse document this finding?

Macule

Nodule

Pustule

Papule

Answer and Explanation

The Correct Answer is D

A. A macule is a flat, non-palpable skin lesion. The described lesion is raised, making macule incorrect.
B. A nodule is a deeper, larger, and firmer lesion (>0.5 cm in diameter). The lesion described is too small to be classified as a nodule.
C. A pustule is a pus-filled lesion. The description does not mention purulent content, ruling out pustule.
D. A papule is correct. A papule is a small, raised, solid lesion that is <1 cm in diameter, which fits the description of the bump on the boy’s neck.

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Correct Answer is D

Explanation

A. "Lungs clear to auscultation bilaterally" is a physical assessment finding and should be documented in the physical examination, not the review of systems (ROS).
B. "High school diploma plus 2 years of college" is part of the social history, not the ROS.
C. "Caregiver reliable source of information" pertains to the history's reliability or source of information, not the ROS.
D. "Menarche at age 13" is correct because the ROS consists of subjective information reported by the client regarding different body systems, including the reproductive system.

A. Document the client's bradycardia. B. Apply oxygen via nasal cannula at 2 liters per minute. C. Reassess the vital signs in five minutes. D. Notify the provider of the findings.

Correct Answer is C

Explanation

A. Documenting bradycardia is incorrect because the client is experiencing tachycardia (HR 108), not bradycardia.
B. Applying oxygen at 2L/min is incorrect because the oxygen saturation is normal (96% on room air). Oxygen therapy is not indicated at this time.
C. Reassess the vital signs in five minutes is correct because the slightly elevated heart rate and respiratory rate may be due to recent physical activity after prolonged bedrest. It is important to allow the client time to recover and reassess before taking further action.
D. Notifying the provider is incorrect because there is no immediate concern; the elevated HR and RR are expected post-activity.

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A 15-year-old boy shows the school nurse a bump on his neck. The nurse observes a raised, erythematous, solid, 0.3-by-0.2 cm mass. How would the nurse document this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has completed the review of systems component of the client's health history. Which assessment finding should the nurse document under the review of systems?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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