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. Consulting clinical resources is helpful but should be done after reviewing the client’s specific information.
B. Performing a mini overview of body systems occurs during the assessment, not before meeting the client.
C. Gathering materials is important but comes after understanding the client’s history.
D. Reviewing the client’s medical record is correct because it helps the nurse gather baseline information, understand past medical history, and prepare for the assessment effectively.

A. Malignancy B. Aneurysm C. Hernia D. Peritonitis

Correct Answer is D

Explanation

A. Malignancy can cause abdominal pain, but it does not typically present with acute sharp pain and involuntary guarding.
B. Aneurysms, particularly abdominal aortic aneurysms, may present with a pulsatile mass and deep, dull pain rather than sharp pain and guarding.
C. Hernias can cause pain, but they typically present with a bulging mass that increases with straining, not sharp pain with reflex guarding.
D. Peritonitis is correct because it causes severe abdominal pain, involuntary guarding, and rebound tenderness due to inflammation of the peritoneum. Reflex guarding is a protective mechanism indicating peritoneal irritation.

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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

The nurse is preparing to meet a client and perform a comprehensive health assessment. Which action should the nurse perform first?

Correct Answer is D

Explanation

While assessing a client's abdomen, the nurse observes sharp pains and involuntary reflex guarding on expiration. What complication does the nurse suspect based on these findings?

Correct Answer is D

Explanation

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