The nurse is caring for a client who has smoked for many years ...

[hbsimmons88]

The nurse is caring for a client who has smoked for many years and documents that clubbing is present. Which technique is the best way for the nurse to determine the presence of clubbing?
 
  1. Place two thumbs touching side-by-side.
  2. Place two of the same fingers from each hand together.
  3. Place two index fingers together tip-to-tip.
  4. Place the hands out straight with the palm sides down.

Question 2

The nurse is performing a skin assessment on a client and notes a round, elevated, fluid-filled mass approximately 0.4 cm in size. Which term is the most appropriate for the nurse to use when documenting this finding in the medical record?
 
  1. Vesicle.
  2. Macule.
  3. Papule.
  4. Tumor.

[ladyjames123]

Answer to Question 1

Correct Answer: 2

To assess for clubbing the nurse can use the Schamroth technique, in which the nurse asks the client to bring the dorsal aspect of corresponding fingers together and if there is clubbing, a diamond is not formed and the distance increases at the fingertip. Placing the thumbs together side-by-side is not an appropriate way to determine the presence of clubbing. Placing the index finger tip-to-tip is not an appropriate way to determine the presence of clubbing. Placing the hands straight out with the palms facing downward is not an appropriate way to determine the presence of clubbing.

Answer to Question 2

Correct Answer: 1
The area described is a vesicle and may be caused by herpetic lesions, poison ivy, and small burn blisters. A macule is a flat, nonpalpable change in skin color. A papule is an elevated, solid, palpable mass. Tumors are elevated but solid, hard, or soft palpable, and extend deeper into the dermis.

[hbsimmons88]

TYSM

[yeungji]

Excellent