Patient Data

Exhibits

During the assessment, the nurse notes that the areas are filled with a fluid-like substance.

Which of the following primary skin lesions contain fluid? Select all that apply.

Macule

Papule

Wheal

Vesicle

Nodule

Pustule

Answer and Explanation

Correct Answer : C,D,F

Choice A Reason:
Macule is incorrect. A macule is a flat, discolored spot on the skin that is less than 1 centimeter in diameter. It does not contain fluid; instead, it represents a change in the color of the skin, such as a freckle or a flat mole. Macules are not filled with fluid; they are characterized by alterations in skin pigmentation without any elevation or depression.
Choice B Reason:
Papule is incorrect. A papule is a small, raised bump on the skin that is less than 1 centimeter in diameter. Papules do not contain fluid; instead, they result from localized cellular infiltration, inflammation, or proliferation in the skin layers. Examples of papules include acne lesions and insect bites.
Choice C Reason:
Wheal is correct. A wheal is a raised area of skin that is typically reddened and accompanied by itching. It contains fluid and is often associated with allergic reactions, insect bites, or hives.
Choice D Reason:
Vesicle is correct. A vesicle is a small, fluid-filled blister that appears on the skin. It contains clear fluid and can be caused by various factors such as infection, allergic reactions, or friction.
Choice E Reason:
Nodule is incorrect. A nodule is a solid, raised bump on the skin that is larger than 1 centimeter in diameter and extends into deeper layers of the skin. Similar to papules, nodules do not contain fluid; they are composed of tissue, such as fat, fibrous tissue, or tumors. Examples of nodules include lipomas and dermatofibromas.
Choice F Reason:
Pustule is correct. A pustule is a small, pus-filled blister that appears on the skin. It contains purulent fluid (pus) and is often associated with bacterial infections such as acne or folliculitis.

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Correct Answer is A

Explanation

Choice A Reason:
Requesting diagnostic laboratory testing for the client is appropriate action. Enlargement of the thyroid gland can be indicative of various thyroid disorders, including hyperthyroidism, hypothyroidism, or thyroid nodules. Diagnostic laboratory testing, such as thyroid function tests (TFTs), thyroid antibody testing, and possibly thyroid ultrasound, can help identify the underlying cause of the thyroid enlargement. These tests can include assessments of thyroid hormone levels (T3, T4, and TSH), antibodies, and imaging studies. Requesting diagnostic laboratory testing is essential to accurately diagnose the condition and guide appropriate management and treatment.
Choice B Reason:
Obtaining a dietary consultation for nutrition teaching is inappropriate action. While nutrition can play a role in overall thyroid health, obtaining a dietary consultation for nutrition teaching is not the most immediate action to take in response to finding an enlarged thyroid gland during palpation. Dietary consultation may be considered as part of comprehensive care for thyroid disorders, but it does not address the need for further evaluation and diagnosis of the thyroid enlargement.
Choice C Reason:
Instructing the client in the need to use iodized salt is inappropriate action. While iodine deficiency can contribute to thyroid disorders, instructing the client to use iodized salt is not the most immediate action to take in response to finding an enlarged thyroid gland during palpation. Using iodized salt may help prevent iodine deficiency, but it does not address the need for further evaluation and diagnosis of the thyroid enlargement.
Choice D Reason:
Scheduling a follow-up appointment in one month is inappropriate action. While scheduling a follow-up appointment may be necessary for ongoing monitoring and management of thyroid disorders, it is not the most immediate action to take in response to finding an enlarged thyroid gland during palpation. Further evaluation and diagnostic testing should be prioritized to determine the underlying cause of the thyroid enlargement and initiate appropriate treatment.

A. Give the client an object to hold. B. Instruct the client to close his eyes. C. Apply resistance to the client's arms. D. Palpate the client's muscle tone.

Correct Answer is C

Explanation

Choice A Reason:
Giving the client an object to hold is not the most appropriate action before asking the client to flex his arms to assess muscle strength. While providing an object to hold may engage the muscles, it does not specifically target the muscles involved in arm flexion, which are primarily the biceps brachii and brachialis muscles. Therefore, it may not accurately assess muscle strength during arm flexion.
Choice B Reason:
Instructing the client to close his eyes is not the most appropriate action before asking the client to flex his arms to assess muscle strength. Instructing the client to close his eyes primarily tests proprioception and balance rather than muscle strength. While proprioception is an important aspect of overall neurological function, it is not directly related to assessing muscle strength during arm flexion.
Choice C Reason:
Applying resistance to the client's arms is the most appropriate action before asking the client to flex his arms to assess muscle strength. Applying resistance to the client's arms during flexion allows the nurse to evaluate the client's ability to generate force against resistance, providing a more accurate assessment of muscle strength in the biceps brachii and brachialis muscles.
Choice D Reason:
Palpating the client's muscle tone is not the most appropriate action before asking the client to flex his arms to assess muscle strength. While palpating muscle tone is important for assessing muscle integrity, it does not directly evaluate muscle strength during arm flexion. Muscle tone refers to the resting tension in a muscle and may not accurately reflect muscle strength during active movement.

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Patient Data Exhibits During the assessment, the nurse notes that the areas are filled with a fluid-like substance. Which of the following primary skin lesions contain fluid? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing a physical assessment, palpation reveals to the clinic nurse that a client has an enlarged thyroid gland. What action should the nurse take in response to this finding?

Correct Answer is A

Explanation

To assess a male client's muscle strength, the nurse first asks the client to extend his arms. Before asking the client to flex his arms, what should the nurse do?

Correct Answer is C

Explanation

While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?

The nurse examines a client's right great toe. The joint is red, edematous, and very painful with limited range of motion. The client's serum uric acid levels are elevated. Which action should the nurse tell the client to make?

When assessing a client's range of motion, the nurse notes crepitation with movement of the left knee. Which information in the client's history is most likely related to this finding?

While interviewing a newly admitted older female client, the nurse observes that the client ignores questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

The nurse continues a neurologic assessment of the cranial nerve XI (Spinal accessory) for a client. Which instruction should the nurse give the client to complete this assessment?

During an admission assessment, which approach should the nurse use to assess a client's speech patterns?

Patient Data

Exhibits

During the assessment, the nurse notes that the areas are filled with a fluid-like substance.

Which of the following primary skin lesions contain fluid? Select all that apply.