The nurse is doing a focus assessment on a 25-year-old college student who presented to the clinic secondary to fever and lethargy. When recording the findings of the lymph glands, a nurse should note all except:

Size

Consistency

Shape

Color

Answer and Explanation

The Correct Answer is D

A) Size:

When assessing lymph nodes, noting the size is crucial as enlarged lymph nodes can indicate infection, inflammation, or malignancy. Size helps in determining the extent and severity of the underlying condition.

B) Consistency:

The consistency of lymph nodes (whether they are hard, rubbery, or soft) provides important diagnostic information. For instance, hard lymph nodes may suggest malignancy, while soft nodes might indicate an infection.

C) Shape:

Recording the shape of lymph nodes is essential in the assessment process. Regular, oval, or round shapes can be normal, while irregularly shaped nodes might be concerning and warrant further investigation.

D) Color:

Color is not typically assessed or noted when examining lymph nodes. Lymph nodes are internal structures, and their color cannot be directly observed without invasive procedures. The focus is usually on palpable characteristics like size, consistency, and shape.

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Correct Answer is ["A","B","C","D","E"]

Explanation

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.

A. Acanthosis Nigricans B. Cyanosis C. Jaundice D. Carotenemia

Correct Answer is C

Explanation

A. Acanthosis Nigricans:

Acanthosis nigricans is characterized by dark, velvety patches of skin, often found in body folds such as the neck, armpits, and groin. It does not present as the yellow discoloration seen in the photo.

B. Cyanosis:

Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. The image shows yellow discoloration, not the blue tint associated with cyanosis.

C. Jaundice:

Jaundice is indicated by a yellowish tint to the skin and sclera due to elevated bilirubin levels, commonly associated with liver dysfunction. The photo clearly shows this yellow discoloration, consistent with jaundice, often seen in chronic alcoholics with liver disease.

D. Carotenemia:

Carotenemia presents as a yellow-orange discoloration of the skin, especially on the palms and soles, due to high levels of carotene in the blood. It does not typically affect the sclera, which differentiates it from jaundice. The uniform yellowing of the skin and eyes in the photo aligns more with jaundice.

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The nurse is doing a focus assessment on a 25-year-old college student who presented to the clinic secondary to fever and lethargy. When recording the findings of the lymph glands, a nurse should note all except:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.)

Correct Answer is ["A","B","C","D","E"]

Explanation

A 75-year-old male who is a chronic alcoholic present to the medical office for his annual wellness visit. How would describe the findings found in photo?

Correct Answer is C

Explanation

The nurse measures a male client's waist circumference as 43 inches (109 cm). Which statement is most appropriate for the nurse to make given this finding?

A nurse is instructing a group of clients regarding nutrition. Which of the following is a good source of omega-3 fatty acids that the nurse should include in the teaching?

At which location would a nurse palpate a client's occipital lymph nodes?

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Which of the following would a nurse expect to assess in a client with esotropia?

Which risk factor for traumatic brain injury (TBI) should a nurse include in a discussion about prevention for a group of adolescents?

During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack?

While working in the Emergency department a Rapid response nurse is evaluating a patient in acute respiratory failure after a motor vehicle crash. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?