The nurse is assessing a lesion on a patient and observes a focal loss of epidermis and dermis, a depression extending into the dermis, irregularly shaped, and bleeding. This type of wound is known as a/an

Ulcer

Erosion

Nodule

Cyst

Answer and Explanation

The Correct Answer is A

A.   Ulcer refers to a wound with a loss of epidermis and dermis, often irregular and deeper, potentially bleeding.
B.   Erosion involves a shallow loss of the epidermis only, not extending into the dermis.
C.   Nodule is a solid, raised lesion that is typically firm and not ulcerated.
D.   Cyst is a sac-like structure containing fluid or semi-solid material, not a wound with loss of tissue.

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Correct Answer is ["B","D","E","F"]

Explanation

A. The client has not received the pneumococcal vaccine, but pneumococcal vaccination would help prevent pneumonia, particularly from Streptococcus pneumoniae. However, because the client has nothad the vaccine, this option would be a risk factor for pneumonia, but it is not an immediate concern in terms of assessing the current risks in their medical record.
B. The client appears lethargic and has difficulty answering questions due to shortness of breath, which suggests a decrease in the level of consciousness. Decreased mental status or level of consciousness increases the risk of aspiration, which can lead to pneumonia. For example, an altered level of consciousness makes it harder for patients to protect their airways (e.g., coughing or swallowing properly), which may increase the risk of aspiration and subsequent infection.
C. The client has not received the influenza vaccine, which does increase the risk of contracting
pneumonia, especially if the person develops influenza. However, the patient’s primary issue is likely already in progress, so this is another unvaccinated status contributing to risk rather than an immediate finding.
D. The client’s medical history is notable for no significant conditions other than the acute issue at hand. However, the lack of a pneumococcal vaccine (despite being at higher risk due to age) and not receiving the annual influenza vaccination can contribute to the development of pneumonia. Pneumonia is more common in individuals who do not receive these vaccines, as they provide protection against common respiratory pathogens, including Streptococcus pneumoniae and influenza viruses.
E. The client reports decreased fluid intake over the past 24 hours due to a sore throat, which increases the risk of dehydration. Dehydration can lead to thicker mucus, making it more difficult to clear respiratory secretions. This increases the likelihood of bacterial growth and the development of pneumonia.
F. The client is 70 years old, which places them at higher risk for pneumonia. Older adults have a weakened immune system, and their respiratory function may not be as effective as in younger individuals, making it easier for infections such as pneumonia to take hold. Age is a significant risk factor for more severe respiratory infections.
G. There is no mention of smoking history in the social history provided, so it cannot be included as a risk factor for pneumonia in this case. Smoking is a known risk factor for respiratory infections, but since it isn’t specified here, we cannot assume it is relevant.

A. Fixed lymph nodes B. Lymph nodes that are large, firm, and fixed to the tissue C. Nonpalpable lymph nodes D. Rubbery, discrete, and mobile lymph nodes

Correct Answer is C

Explanation

A. Fixed lymph nodes suggest possible malignancy or infection and are not typical for a healthy individual.
B. Lymph nodes that are large, firm, and fixed to the tissue also suggest infection or malignancy and would be abnormal in a healthy patient.
C. Nonpalpable lymph nodes are a normal finding.
D. Rubbery, discrete, and mobile lymph nodes are indicative of a pathological process.

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The nurse is assessing a lesion on a patient and observes a focal loss of epidermis and dermis, a depression extending into the dermis, irregularly shaped, and bleeding. This type of wound is known as a/an

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department (ED) is admitting a client. Exhibits Select 4 findings in the client's medical record that place them at risk for pneumonia.

Correct Answer is ["B","D","E","F"]

Explanation

The nurse has just completed a lymph node assessment on a healthy 40-year-old female patient. Which of the following is an expected finding?

Correct Answer is C

Explanation

A nurse is examining a patient and finds a lesion that is a linear arrangement along a unilateral nerve route. The nurse would document this finding as

A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?

The nurse palpates a swollen inguinal lymph node. Which assessment should the nurse perform next?

During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. How do acutely infected lymph nodes typically appear?

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During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects:

A nurse in a provider's office is preparing to auscultate and percuss a client’s thorax as part of a comprehensive physical examination. Which of the following are considered normal findings? Select all that apply