A nurse is assessing a client who has a new skin lesion that has a wavy border. The nurse should document the lesion using which of the following descriptions?

Annular

Circinate

Coalesced

Serpiginous

Answer and Explanation

The Correct Answer is D

Choice A reason:
Annular lesions are ring-shaped with a clear center, which does not describe a lesion with a wavy border. This term is typically used for lesions like ringworm, which present as circular rashes with normal skin in the center.

Choice B reason:
Circinate lesions are also circular but are not characterized by a wavy border. They are similar to annular lesions but often have a more rounded edge and are associated with conditions like psoriasis.

Choice C reason:
Coalesced lesions refer to multiple lesions that have merged to form a larger one. While they can have irregular borders, 'coalesced' does not specifically describe the wavy nature of the border.

Choice D reason:
Serpiginous lesions have a wavy or snake-like border, which matches the description provided by the nurse. This term is often used for parasitic infections, such as cutaneous larva migrains, which create a trail-like pattern on the skin.

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Correct Answer is ["B","C","E"]

Explanation

Choice A reason:
Increased hematocrit levels are not typically associated with fluid overload. In fact, hematocrit may decrease in fluid overload due to hemodilution, where the volume of plasma increases, diluting the concentration of red blood cells.

Choice B reason:
An increased respiratory rate can be a sign of fluid overload. As fluid accumulates in the body, it can lead to pulmonary edema, which is the buildup of fluid in the lung's air sacs. This can impair gas exchange and lead to increased respiratory rate as the body attempts to compensate for reduced oxygenation.

Choice C reason:
Increased blood pressure is a common finding in fluid overload. As the volume of fluid in the bloodstream increases, it can lead to higher blood pressure due to the extra fluid that the heart must pump and the increased resistance in the blood vessels.

Choice D reason:
Increased temperature is not a direct finding associated with fluid overload. While fever may indicate an infection or other conditions, it is not specifically related to the volume of fluid in the body.

Choice E reason:
An increased heart rate may occur in fluid overload as the heart works harder to pump the excess volume of blood through the body. This compensatory mechanism aims to maintain adequate circulation and blood pressure despite the increased fluid volume.

A. Apply a foot plate to the bed. B. Reposition the client to keep him from staying in the same position in bed. C. Remove the weights for a few minutes each hour. D. Apply lotion to the skin under the edges of the splint.

Correct Answer is B

Explanation

Choice A reason:
Applying a foot plate to the bed is not primarily intended to prevent pressure points from developing around the edges of the splint. A foot plate can help in maintaining proper alignment and preventing foot drop, but it does not address the issue of pressure points caused by the splint.

Choice B reason:
Repositioning the client is a key intervention to prevent pressure points. By changing the client's position regularly, the nurse can ensure that no single area is under prolonged pressure, which could lead to skin breakdown and pressure sores. This is particularly important in clients with limited mobility due to skeletal traction.

Choice C reason:
Removing the weights for a few minutes each hour is not a standard practice for preventing pressure points in balanced skeletal traction. The weights are integral to maintaining the necessary pull on the fractured femur, and their removal could disrupt the traction setup and potentially affect fracture healing.

Choice D reason:
Applying lotion to the skin under the edges of the splint is not recommended as it could soften the skin and make it more susceptible to injury. Instead, padding and proper positioning are used to protect the skin from the hard edges of the splint.

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A nurse is assessing a client who has a new skin lesion that has a wavy border. The nurse should document the lesion using which of the following descriptions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is caring for a client who has a prescription for balanced skeletal traction with a Thomas splint for the treatment of a fractured femur. Which of the following interventions should the nurse implement to prevent pressure points from developing around the edges of the splint?

Correct Answer is B

Explanation

A nurse is reviewing the medical records of clients on a hospital floor. Which client would the nurse expect is most at risk for hyperthyroidism?

A nurse is teaching a client who has hepatitis A about preventing the transmission of the virus. Which of the following strategies should the nurse include in the teaching?

A nurse is caring for a male client who has chronic glomerulonephritis. Which of the following findings should the nurse expect?

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)

A nurse is caring for a client who is taking aspirin for arthritis. The nurse should identify which of the following findings as an adverse effect of this medication?

A nurse is caring for a client who has just returned from the Post-Anesthesia Care Unit (PACU) with an intravenous (IV) fluid infusion and a nasogastric (NG) tube in place following abdominal surgery. Which of the following data is the priority for the nurse to assess?

A nurse is providing care for an older adult client who has diabetes insipidus (DI). The nurse should monitor the client for which of the following neurological effects?

A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of the client's affected extremity? (Select all that apply.)