After completing an integument physical examination, the nurse is documenting information concerning observed lesions. What characteristics will the nurse include in this documentation? (Select all that apply.)
Location
Color
Condition of surrounding skin
Elevation
Distribution pattern
Correct Answer : A,B,C,D,E
A) Location: Documenting the exact location of lesions is crucial for monitoring changes over time, assessing potential spread or resolution, and providing accurate information for future reference. This information helps in the diagnosis and in tracking the effectiveness of treatments.
B) Color: The color of lesions can provide important clues about their nature and cause. For example, red or inflamed lesions might indicate infection or irritation, while darker lesions could suggest malignancy or chronicity. Color changes can also signify healing or worsening of the lesion.
C) Condition of surrounding skin: Noting the condition of the skin around the lesions helps assess whether there is additional inflammation, infection, or other skin conditions that may be related to the primary lesion. This provides a more comprehensive understanding of the patient’s skin health and any secondary complications.
D) Elevation: Elevation refers to whether the lesion is raised, flat, or depressed compared to the surrounding skin. This characteristic helps in identifying the type of lesion, such as a papule, plaque, or ulcer. Elevated lesions might suggest certain dermatological conditions, while depressed lesions might indicate scarring or loss of tissue.
E) Distribution pattern: The pattern of how lesions are distributed on the body can provide diagnostic clues. For example, a linear distribution might suggest contact dermatitis, while a symmetrical distribution could indicate a systemic condition. Understanding the distribution pattern helps in identifying the underlying cause and planning appropriate treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
(a) "Your metabolism is slowing down.":
Hypothyroidism leads to a decrease in the production of thyroid hormones, which are critical in regulating metabolism. With lower levels of these hormones, the body's metabolic rate decreases, resulting in reduced calorie burning and subsequent weight gain. This explanation directly addresses the underlying cause of weight gain in hypothyroidism.
(b) "You should be exercising for longer periods of time.":
While exercise is beneficial for overall health and can help manage weight, it does not directly address the reason for weight gain in hypothyroidism. The primary issue is the slowed metabolism due to thyroid hormone deficiency, not a lack of exercise.
(c) "You could be making healthier food choices.":
Although diet plays a role in weight management, this response does not explain the root cause of weight gain in hypothyroidism. The condition itself slows metabolism, leading to weight gain even if dietary habits remain unchanged.
(d) "You are retaining fluid.":
Fluid retention can occur in hypothyroidism but is not the primary reason for weight gain in this condition. The main cause is a decreased metabolic rate, which leads to the accumulation of body fat. Fluid retention might contribute to some weight gain, but it is not the best explanation in this context.
Correct Answer is D
Explanation
A) Dysphagia:
Dysphagia refers to difficulty swallowing and is typically associated with conditions affecting the esophagus or neuromuscular function. While it can coexist with other symptoms, it does not directly explain hoarseness, fatigue, and weight gain as hypothyroidism does.
B) Gingivitis:
Gingivitis is an inflammation of the gums due to plaque buildup. It primarily affects oral health, causing redness, swelling, and bleeding of the gums. It is not associated with systemic symptoms like hoarseness, fatigue, or weight gain.
C) Aphthous ulcers:
Aphthous ulcers, also known as canker sores, are small, painful lesions that develop in the mouth. They are typically caused by stress, minor injury, or certain foods. These ulcers do not explain the systemic symptoms described by the client.
D) Hypothyroidism:
Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormones. Symptoms include hoarseness, fatigue, weight gain, dry skin, and cold intolerance. The combination of these symptoms in the client's history makes hypothyroidism the most likely cause.
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