A nurse is performing a focused skin assessment for a client as part of a comprehensive health screening. The nurse notes a mass which is hard, deep, and elevated 2 cm (0.8 in) in diameter on the client's back. Which of the following terms should the nurse use to document this finding?
Macule
Vesicle
Papule
Nodule
The Correct Answer is D
A. Macule: A macule is a flat, discolored spot on the skin, less than 1 cm in diameter. The described mass is elevated, so this term is incorrect.
B. Vesicle: A vesicle is a small, fluid-filled blister. The described mass is not fluid-filled, so this term is incorrect.
C. Papule: A papule is a small, solid, elevated lesion, usually less than 1 cm in diameter. The described mass is larger than a papule.
D. Nodule: A nodule is a solid, elevated lesion that is larger than a papule (usually more than 1 cm in diameter). The described mass fits this description.
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Related Questions
Correct Answer is A
Explanation
A. Verify the client's understanding beyond affirmative nodding. It's crucial to ensure that the client truly understands the information, as nodding may not always indicate comprehension.
B. Encourage the client to drink iced water to manage an elevated temperature. This advice is not culturally specific and may not be appropriate for all clients.
C. Avoid using gestures when communicating with the client. Gestures can be helpful but should be used with caution as they can have different meanings in different cultures.
D. Inform the client that herbal remedies are not effective in treating tuberculosis. This dismisses the client's cultural beliefs and practices and can be seen as culturally insensitive. Instead, the nurse should provide evidence-based information and work with the client's beliefs.
Correct Answer is C
Explanation
A. Shut all the doors on the unit. Shutting doors helps to contain the fire and prevent its spread, but it is not the immediate priority.
B. Initiate the facility's fire alarm. Initiating the fire alarm is crucial for alerting others and ensuring the safety of everyone in the facility. However, immediate action should focus on client safety.
C. Evacuate the client's room. Evacuating the client's room is the priority for ensuring the client's safety in the event of a fire. This action should be taken before attempting to address the fire or other tasks.
D. Extinguish the fire. While extinguishing the fire is important, the immediate priority should be the safety of individuals in the room. Extinguishing the fire can be attempted if safe to do so, but evacuation comes first.
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