When assessing a client's skin, the nurse finds clusters of lesions. How would the nurse document the lesions?

Confluent

Discrete

Grouped

Annular

Answer and Explanation

The Correct Answer is C

A.   Confluent lesions merge together, forming a larger area of affected skin, which is not the case here.
B.   Discrete lesions are separate and distinct from each other, which doesn't match the description of clusters.
C.   Grouped lesions are those that appear in clusters, which fits the assessment finding.
D.   Annular lesions have a ring-like appearance, typically seen in conditions like ringworm, and do not fit the description of clustered lesions.

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Correct Answer is C

Explanation

A. Increased intraocular pressure causes glaucoma, not diabetic retinopathy.
B. Clouding of the lens is related to cataracts, not diabetic retinopathy.
C. Seeing spots or floaters is a common symptom of diabetic retinopathy.
D. Diabetic retinopathy requires more frequent eye exams (typically annually) for early detection.

A. Skin tenting present B. Low body temperature C. Blood pressure 178/90 mm Hg D. Jugular vein distention

Correct Answer is A

Explanation

A. Skin tenting, where the skin remains pinched after being pulled up, is a classic sign of dehydration due to a lack of adequate fluid in the tissues.
B. Low body temperature is not typically associated with dehydration; instead, a fever or elevated temperature is more commonly seen with infection.
C. High blood pressure (178/90 mm Hg) could indicate hypertension or another condition, but it is not a direct sign of dehydration.
D. Jugular vein distention is more commonly associated with fluid overload, heart failure, or other circulatory issues, rather than dehydration.

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When assessing a client's skin, the nurse finds clusters of lesions. How would the nurse document the lesions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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