An older adult client reports that they are experiencing severe trunk pain and is concerned that it might be shingles. Which type of lesion would the nurse most likely assess if shingles were present?

Papule

Crust

Bulla

Vesicle

Answer and Explanation

The Correct Answer is D

A. A papule is a small, raised lesion that is solid and does not contain fluid, which is not characteristic of shingles.
B. A crust forms as a lesion heals but is not the primary lesion seen in shingles.
C. A bulla is a large, fluid-filled lesion seen in conditions like burns or insect bites, but shingles lesions are typically smaller.
D. A vesicle is correct. Shingles (herpes zoster) presents with clusters of vesicles on an erythematous base, typically in a unilateral, dermatomal pattern. These vesicles are filled with clear fluid and become pustular before crusting over.

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Correct Answer is B

Explanation

A. This is incorrect because it describes an actual nursing diagnosis, not a risk diagnosis.
B. A risk diagnosis describes a situation in which a problem will likely occur if the nurse does not intervene. It identifies a potential health problem that has not yet developed but could occur due to the client’s risk factors.
C. This is incorrect because it describes a health promotion diagnosis, which focuses on enhancing well-being rather than preventing a problem.
D. This is incorrect because it describes a syndrome diagnosis, which is a group of related nursing diagnoses that occur together.

A. Drink fluids before and after, but not during, meals B. Sit with the head of the bed at a 45-degree angle during meals C. Thoroughly chew small amounts of food with each mouthful D. Be aware of the possibility of temporomandibular joint pain

Correct Answer is C

Explanation

A. Drinking fluids before and after meals but not during meals is incorrect. Clients with dysphagia may require thickened liquids and should sip fluids as needed to facilitate swallowing.
B. Sitting with the head of the bed at a 45-degree angle is incorrect. Clients with dysphagia should be positioned at a 90-degree angle (fully upright) during meals to reduce the risk of aspiration.
C. Thoroughly chewing small amounts of food with each mouthful is correct. Clients with dysphagia should eat slowly, take small bites, and chew food thoroughly to prevent choking and aspiration.
D. Temporomandibular joint pain is not a common issue associated with dysphagia following a stroke. The primary concern is the risk of aspiration.

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An older adult client reports that they are experiencing severe trunk pain and is concerned that it might be shingles. Which type of lesion would the nurse most likely assess if shingles were present?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nursing student correctly describes a risk diagnosis by which of the following statements?

Correct Answer is B

Explanation

The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. What would be most appropriate for the nurse to include in the education?

Correct Answer is C

Explanation

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