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

Nodule

Papule

Wheal

Macule

Answer and Explanation

The Correct Answer is D

A.   A nodule is a solid, raised lesion that is typically larger than 1 cm in diameter and extends deeper into the skin.
B.   A papule is a small, raised, solid lesion, less than 1 cm, but not typically used for documenting freckles.
C.   A wheal is a raised, erythematous area, often a result of an allergic reaction, not a freckle.
D.   A macule is a flat, pigmented area of skin, less than 1 cm in diameter, which accurately describes freckles.

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Correct Answer is B

Explanation

A. Pinpoint pupils: Pinpoint pupils may indicate opioid use or a brainstem injury but are not related to Babinski's sign.
B. Dorsiflexion of the great toe: This is the characteristic response for a positive Babinski sign, which occurs when the toes fan out and the big toe dorsiflexes (moves upward) when the sole of the foot is stroked. It indicates an abnormal response and potential upper motor neuron damage.
C. Jerking contractions of the head and neck: This is indicative of a seizure activity, not Babinski's sign.
D. Pronation of the arms: This could be indicative of decerebrate posturing, not Babinski's sign.

A. Intact skin with localized erythema. B. Partial-thickness skin loss with red tissue in wound bed. C. Full thickness skin loss with visible adipose tissue. D. Full thickness skin loss with visible bone

Correct Answer is B

Explanation

A. Intact skin with localized erythema: This describes a stage 1 pressure injury.
B. Partial-thickness skin loss with red tissue in wound bed: This is characteristic of stage 2 pressure injuries, where there is damage to the epidermis and partial dermis.
C. Full thickness skin loss with visible adipose tissue: This describes a stage 3 pressure injury.
D. Full thickness skin loss with visible bone: This describes a stage 4 pressure injury.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the reflexes of a client who has an unrepaired femur fracture and has suddenly become stuporous. For which of the following findings should the nurse identify that the client exhibits Babinski's sign?

Correct Answer is B

Explanation

A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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

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