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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A) Blockage of the tear ducts causing excessive tearing:

Blockage of tear ducts (dacryostenosis) results in excessive tearing (epiphora) due to inadequate drainage of tears into the nasal cavity. It does not directly contribute to glaucoma, which primarily involves increased intraocular pressure (IOP) and optic nerve damage.

B) Inflammation of the cornea resulting in blurry vision:

Corneal inflammation (keratitis) can cause blurry vision, pain, and sensitivity to light, but it is not the primary pathophysiology of glaucoma. Glaucoma primarily involves damage to the optic nerve due to elevated IOP.

C) Increased intraocular pressure (IOP) leading to optic nerve damage:

Glaucoma is characterized by elevated IOP, which puts pressure on the optic nerve and can lead to progressive damage and vision loss if untreated. This is the primary pathophysiological process in most types of glaucoma.

D) Degeneration of the lens leading to cataracts:

Cataracts involve the clouding of the lens of the eye, leading to visual impairment. While cataracts are a common condition in older adults, they are not directly related to the pathophysiology of glaucoma, which primarily involves elevated IOP and optic nerve damage.

A. At the angle of the mandible B. temporal area C. The posterior base of the skull D. Area in front of the ears

Correct Answer is C

Explanation

A) At the angle of the mandible:

Lymph nodes located at the angle of the mandible are the submandibular lymph nodes, not the occipital lymph nodes. These nodes are situated below the jawline and are assessed when looking for infections or abnormalities in the oral cavity and throat.

B) Temporal area:

The temporal area is not a typical location for lymph node palpation. This region is primarily related to the temporal artery and muscles, not to lymph nodes. Thus, palpating for lymph nodes here would not be relevant.

C) The posterior base of the skull:

The occipital lymph nodes are located at the posterior base of the skull, near the nape of the neck. These nodes drain the scalp and are assessed when there are scalp infections or other related conditions.

D) Area in front of the ears:

The lymph nodes in front of the ears are the preauricular lymph nodes. These nodes drain the eyes and the surrounding skin. They are not the occipital lymph nodes, which are situated at the back of the head.

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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.)

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Correct Answer is C

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Explanation

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