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A nurse is caring for a client who has a nonpalpable skin lesion that is less than 0.5 cm (0.2 In) in diameter. Which of the following terms should the nurse use to document this finding?

Papule

Vesicle

Nodule

Macule

Answer and Explanation

The Correct Answer is D

A. Papule – A papule is a raised, solid lesion (e.g., a mole) and is palpable, not flat.

B. Vesicle – A vesicle is a fluid-filled blister (e.g., herpes, chickenpox), which is not the case here.

C. Nodule – A nodule is a deep, raised lesion that extends into the dermis or subcutaneous tissue.

D. Macule – A macule is a flat, nonpalpable skin discoloration that is less than 1 cm (e.g., a freckle or petechiae).

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Correct Answer is B

Explanation

A. Initiate a new IV line below the original insertion site. – If phlebitis or infection is present, a new IV should be placed in another limb or at a site above the previous insertion, not below.

B. Discontinue the infusion. – The first step in treating suspected phlebitis or IV infiltration is stopping the infusion to prevent further tissue damage.

C. Raise the head of the bed. – Elevating the head of the bed is not relevant in managing IV site complications.

D. Obtain a culture from the area of the insertion site. – Cultures are not necessary unless infection is suspected and prescribed by a provider.

A. Dry skin B. Increased urinary output C. Dilated pupils D. Hyperactive bowel sounds

Correct Answer is C

Explanation

A. Dry skin: More commonly associated with dehydration or skin conditions, not a direct response to stress.

B. Increased urinary output: Stress usually triggers the release of antidiuretic hormone (ADH), leading to decreased urinary output rather than an increase.

C. Dilated pupils: Stress activates the sympathetic nervous system (fight-or-flight response), leading to pupil dilation to enhance vision in a perceived emergency.

D. Hyperactive bowel sounds: Stress can affect digestion, but it is more commonly associated with nausea, not necessarily hyperactive bowel sounds.

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A nurse is caring for a client who has a nonpalpable skin lesion that is less than 0.5 cm (0.2 In) in diameter. Which of the following terms should the nurse use to document this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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