The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct?
Select all that apply.
a.
Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color
b.
Bulla: Elevated, circumscribed lesion filled with turbid fluid (pus)
c.
Papule: Hypertrophic scar
d.
Vesicle: Known as a friction blister
e.
Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm
ANS: A, D, E
A pustule is an elevated, circumscribed lesion filled with turbid fluid (pus). A hypertrophic scar is a keloid. A bulla is larger than 1 cm and contains clear fluid. A papule is solid and elevated but measures less than 1 cm.
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When a patient denies any problems related to addiction, the nurse's most therapeutic response is:
a. "What do you call this hospitalization?" b. "How can anybody help you if you don't see a problem?" c. "Would your family agree that you have no problems?" d. "Can you think of any time your behavior created an unpleasant situation in your life?"
The nurse is caring for a child with an epidural hematoma. The nurse should assess for what signs that can indicate Cushing triad? (Select all that apply.)
a. Fever b. Flushing c. Bradycardia d. Systemic hypertension e. Respiratory depression
Creatinine clearance is an indicator of the rate at which the liver filters blood
Indicate whether the statement is true or false
The nurse is completing the intake and output record for a preschool-age client admitted for fluid volume deficit. The client has had the following intake and output during the shift:
Intake: 4 oz of Pedialyte ½ of an 8-oz cup of clear orange Jell-O 2 graham crackers 200 mL of D 5 ½ sodium chloride IV Output: 345 mL of urine 50 mL of loose stool The nurse documents the client's intake as ____ milliliters. What will be an ideal response?