Health Assessment PrepU Ch. 9-10
A nurse receives report from the shift nurse that a client has new onset of peripheral cyanosis. Where should the nurse focus the assessment of the skin to detect the presence of this condition?
Fingers and toes Explanation: Peripheral cyanosis is usually a local problem with manifestations of cyanosis, a blue-tinged color to the skin, caused by problems resulting in vasoconstriction. Changes in color around the mouth are called circumoral. Bluish tints to the chest and abdomen cyanosis is called central cyanosis.
Which risk factor for traumatic brain injury should a nurse include in a discussion about prevention for a group of adolescents?
Modes of transportation are the leading cause Explanation: All modes of transportation, such as motor vehicle & bicycles, are the leading cause of traumatic brain injuries for people age 5 to 64 years. Males have twice the risk of females. Firearm injuries are high in the violence category and two thirds are suicidal in intent. Fall occur most frequently in the over 65 years of age population.
When assessing a client with Graves disease, how would you expect the thyroid gland to be?
Soft Explanation: Soft in Graves disease; firm in Hashimoto thyroiditis, malignancy. Benign and malignant nodules, tenderness in thyroiditis.
What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?
Wood's light Explanation: The nurse should inspect the lesion under Wood's light to confirm the presence of fungus on the lesion. Wood's light is an ultraviolet light filtered through a special glass that shows a blue-green fluorescence if the lesion is due to fungal infection. The lesion can be inspected in sunlight and artificial light, but it may not indicate the type of infection in the lesion. Lesions cannot be inspected properly using a flashlight.
While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of
macules. Explanation: Freckles are flat, small macules of pigment that appear following sun exposure.
To assess an adult client's skin turgor, the nurse should
use two fingers to pinch the skin under the clavicle. Explanation: To assess turgor, gently pinch the skin over the clavicle with two fingers.
A client presents to the emergency department with reports of neck pain and a sudden onset of a headache. Upon examination, the nurse finds that the client has an increased temperature and nuchal rigidity. The nurse recognizes these findings as most likely to be caused by what condition?
Meningeal inflammation Explanation: Meningeal inflammation is a likely cause of this condition which manifests as sudden headache, neck pain with stiffness, and fever. Migraine headaches are accompanied by nausea, vomiting, and sensitivity to noise or light and not by fever and neck stiffness. Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pains that last from seconds to minutes. Parkinson's disease is not manifested by headache and neck pain.
A client presents to the emergency department with reports of neck pain and a sudden onset of a headache. Upon examination, the nurse finds that the client has an increased temperature and neck stiffness. The nurse recognizes these findings as most likely to be caused by what condition?
Meningeal inflammation Explanation: Meningeal inflammation is a likely cause of this condition, which manifests as sudden headache, neck pain with stiffness, and fever. Migraine headaches are accompanied by nausea, vomiting, and sensitivity to noise or light, not by fever and neck stiffness. Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pains that last from seconds to minutes. Parkinson's disease is not manifested by headache and neck pain.
Palpation of a 15-year-old boy's submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse's most reasonable interpretation of this assessment finding?
There is an infection in the area that these nodes drain. Explanation: Whenever a lymph node is enlarged or tender, the nurse should assess for infection in the area that the particular nodes drain. Thyroid or muscular involvement is less likely, and infection does not likely underlie the nodes directly.
A client seeks medical attention for sharp, shooting facial pain that lasts for several minutes at a time. For which health problem should the nurse assess this client?
Trigeminal neuralgia Explanation: Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pain that lasts from seconds to minutes. The pain occurs over the divisions of the fifth trigeminal cranial nerve. A headache associated with a fever or high blood pressure is a cluster headache. Tension headaches are caused by tightening of facial and neck muscles. Migraine headaches are provoked by hormone fluctuations.
The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following?
Pressure ulcer Explanation: An older adult client most likely would have thin, fragile skin, which can result in easy breakdown and slower wound healing. Evidence of a pressure ulcer would require additional assessment. A cherry angioma usually is not clinically significant. A cutaneous horn or seborrheic keratosis is considered a common skin variation.
An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse?
The client has chronic hypoxia Explanation: Clubbing of the nails indicates chronic hypoxia. Clubbing is identified when the angle of the nail to the finger is more than 160 degrees. Melanoma does not present with the symptom of clubbing. The scenario described does not give enough information to indicate that the client has COPD or asthma.
The nurse is assessing the face of a client with a diagnosis of Parkinson's disease. What would the nurse most likely assess?
Mask-like expression Explanation: A client with Parkinson's disease often exhibits a masklike face. A sunken face with depressed eyes and hollow cheeks is typical of cachexia. Drooping of one side may suggest a stroke or Bell's palsy. Asymmetry of the earlobes occurs with parotid gland enlargement from an abscess or tumor.
A client is being assessed for a headache. Symptoms include throbbing and severe pain lasting for the last 8 hours. The client also has a history of vomiting with the headache. What type of headache could these findings indicate?
Migraine Explanation: A throbbing, severe, unilateral headache that lasts 6 to 24 hours and is associated with photophobia, nausea, and vomiting suggests migraine. The scenario does not indicate tension, cluster, or benign headaches.
The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the
areola of the breast. Explanation: The apocrine glands are associated with hair follicles in the axillae, perineum, and areola of the breast. Apocrine glands are small and non-functional until puberty at which time they are activated and secrete a milky sweat.
A client's skin color depends on melanin and carotene contained in the skin, and the
volume of blood circulating in the dermis. Explanation: The major determinant of skin color is melanin. Other significant determinants include capillary blood flow, chromophores (carotene and lycopene), and collagen.
Upon inspection of a client with reports of a fever, the nurse notices that the client's earlobes are asymmetrical in appearance. The nurse recognizes that the most common cause for the asymmetry of the earlobes is what condition?
Parotid enlargement Explanation: Earlobe asymmetry can be due to parotid gland enlargement caused by an abscess or tumor. Bell's palsy is a neurologic condition that may cause drooping of one side of the face. Acute pharyngitis causes swelling in the throat, which is not usually visible on the outside of the face. Thyroid enlargement affects the neck and has no effect on the symmetry of the earlobes.
A nurse is assessing a 49-year-old client who questions the nurse's need to know about sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment?
"Having bad sunburns when you're a child puts you at risk for skin cancer later in life." Explanation: Experiencing severe sunburns as a child is a risk factor for skin cancer. The nurse is not directly assessing the client's pattern of moles in this way, nor the skin's ability to heal. The nurse is not assessing the parents' care of their child's overall skin health by asking this question.
The nurse assesses the client's pulses to be normal. These would be documented how?
2+ Explanation: Normal pulses are 2+. Absent pulses are 0. Weak pules are 1+. Increased pulses are 3+.
A client is diagnosed with a stage III pressure ulcer. Which diagram should the nurse use when teaching the client and family about this skin lesion?
A Stage III pressure ulcer has full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. A Stage I pressure ulcer has intact skin with non-blanchable redness of a localized area usually over a bony prominence. A Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. This wound may also present as an intact or open/ruptured, serum-filled blister. A Stage IV pressure ulcer has full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.
A woman and her teenager have come to the clinic. The teenager has acne lesions and says that the lesions are not well controlled. The mother asks the nurse what causes acne. What would be the nurse's best response?
Acne is caused by the impedance of sebum secretion onto the skin's surface Explanation: As children approach puberty, the apocrine glands enlarge and become active. At puberty, sebaceous glands increase activity, resulting in large amounts of sebum secreted into the hair follicles of the face, neck, chest, and back. Anything impeding sebum secretion onto the skin's surface may result in the formation of closed comedones and ultimately acne.
Upon examination of the head and neck of a client, a nurse notes that the submandibular nodes are tender and enlarged. The nurse should assess the client for further findings related to what condition?
Acute infection Explanation: The lymph nodes are enlarged and tender in acute infections. Normally, lymph nodes are not sore or tender and are usually not palpable. Chronic infection causes the nodes to become confluent. In metastatic disease, the nodes enlarge and become fixed in place and are nontender. The lymph node findings may vary in Cushing's disease.
A nurse notes that a client looks much older than his chronologic age. Which of the following conditions would most likely contribute to this appearance?
Alcoholism Explanation: A client may appear older than actual chronologic age due to a hard life, manual labor, chronic illness, alcoholism, or smoking. Parkinson's disease is associated with stiff, rigid movements. Marfan syndrome is associated with arm span being greater than height and pubis to sole measurement exceeding pubis to crown measurement. Cushing syndrome is associated with central body weight gain with excessive cervical obesity (Buffalos hump).
The student nurse learns that examining the skin can do all of the following except?
Allow early identification of neurologic deficits Explanation: Examination of the skin can reveal signs of systemic diseases, medication side effects, dehydration or overhydration, and physical abuse; allow early identification of potentially cancerous lesions and risk factors for pressure ulcer formation; and identify the need for hygiene and health promotion education.
The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an "itching rash." Which question would be most important for the nurse to ask?
Are you allergic to foods, medications, or other substances? Explanation: The lesions most likely appear to be urticaria, which is caused by capillary dilatation in response to an allergic reaction. Asking about anyone else in the family with a similar rash might be appropriate if the lesions were vesicles or pustules. Once the nurse determines the possible cause of the rash, it would be appropriate to gather additional information such as a history of a previous or similar rash and measures to address the itching.
An 81-year-old client complains of neck pain and demonstrates decreased range of motion on examination. Which of the following causes should the nurse most suspect in this client?
Arthritis Explanation: Older clients who have arthritis or osteoporosis may experience neck pain and a decreased range of motion. Sudden head and neck pain seen with elevated temperature and neck stiffness may be a sign of meningeal inflammation. Stress and tension may increase neck pain. Neck pain may accompany muscular problems or cervical spinal cord problems.
A 66-year-old woman has come to the clinic with complaints of increasing fatigue over the last several months. She claims to frequently feel lethargic and listless and states that, "I can never seem to get warm, no matter what the thermostat is set at." How should the nurse proceed with assessment?
Assess the woman for hypothyroidism. Explanation: Fatigue, weakness, and cold sensitivity are symptoms of hypothyroidism. These symptoms are not associated with Cushing's syndrome, hyperthyroidism, or any of the disorders that result in parotid gland enlargement.
A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCDE" characteristic of malignant melanoma?
Asymmetrical shape Explanation: Malignant melanomas are evaluated according to the mnemonic ABCDE: A for asymmetrical, B for irregular borders, C for color variations, D for diameter exceeding 1/8 to 1/4 of an inch, and E for elevated.
During the physical examination of a client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiological cause for this finding is related to what disease process?
Atelectasis Explanation: Atelectasis can cause the trachea to be pushed to one side from its midline position. Endocarditis is an infection in the muscle of the heart which does not cause the trachea to shift. Bronchitis is an inflammation of the mucous membrane of the bronchial tubes. Tuberculosis is an infection in the lungs. Both bronchitis and tuberculosis are not responsible for the tracheal shift.
A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?
Auscultate with the bell over the lateral lobes Explanation: If a nurse palpates an enlargement of the thyroid, auscultation should be performed with the bell of the stethoscope to assess for the presence of a bruit. A bruit is a soft, swishing sound produced because of an increase in blood flow through the thyroid arteries. The nurse should also ask the client about past history of thyroid problems, the findings must be documented, then the health care provider notified once assessment is complete to obtain further orders.
Which assessment technique should a nurse use to assess for the presence of a bruit in a client with hyperthyroidism?
Auscultation Explanation: A bruit is a soft, blowing, swishing sound auscultated over the thyroid lobes with the bell of the stethoscope that is often heard in hyperthyroidism because of an increase in blood flow through the thyroid arteries. A bruit can be elicited through auscultation in a client with hyperthyroidism. A bruit cannot be elicited through inspection, palpation, and percussion. Inspection can only reveal swelling of the neck and palpation can indicate only the enlarged mass.
A nurse is assessing the head and neck of an adult client. Which vertebra should the nurse identify as a landmark in order to locate the client's other vertebrae?
C7 Explanation: The vertebra prominens is C7, which can easily be palpated when the neck is flexed. Using C7 as a landmark helps the nurse to locate other vertebrae.
Why is it important to collect a thorough and accurate subjective history in regards to a client's nail problems?
Can be caused by an underlying systemic illness Explanation: Diseases or disorders of the nails can be a local problem or they may be a sign of an underlying systemic disease that needs to be assessed. A nurse should be sensitive when interviewing a client with nail problem because they can be damaging to a person's self image. A nurse should ask questions in a nonjudgmental manner if the client has abnormalities of the nails that are due to poor hygiene.
A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what?
Carotene Explanation: Carotene is a golden yellow pigment that exists in subcutaneous fat and in heavily keratinized areas such as the palms and soles.
Which vessel is the nurse assessing if the major artery of the neck is being examined?
Carotid Explanation: The common carotid artery exits the aorta and extends upward in the neck to branch into the internal and external carotid arteries. It is the major artery carrying blood to the brain. The internal jugular veins are located in the neck. The temporal artery is located between the top of the ear and the eye. The radial artery is located at the wrist.
What is the rationale for asking the client whether he or she has noticed any new or changed moles?
Changes in existing moles or the appearance of new moles can indicate melanoma. Explanation: Assessment of moles, both by client and clinician, is important in the early detection of melanomas. Moles are not a relevant finding in cases of psoriasis, vitamin D deficiency, and excess sweat production.
When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics?
Consistency, delineation, mobility, tenderness Explanation: Parameters of lymph node assessment include size, shape, delimitation, mobility, consistency, and tenderness.
Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?
Dermis Explanation: The second layer, the dermis, functions as support for the epidermis. The dermis contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands, which support the nutritional needs of the epidermis and provide support for its protective function. the top layer of the skin is the dermis layer outermost skin layer, and serves as the body's first line of defense against pathogens, chemical irritants, and moisture loss. The subcutaneous layer provides insulation, storage of caloric reserves, and cushioning against external forces. Composed mainly of fat and loose connective tissue, it also contributes to the skin's mobility. The connective layer is a distracter to the question.
A nurse has performed a head and neck assessment of an adult client and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?
Document this as an expected assessment finding Explanation: It is not unusual for the thyroid lobes to be non-palpable using the posterior approach.
The nurse is beginning the examination of the skin of a 25-year-old teacher. She previously visited the office for evaluation of fatigue, weight gain, and hair loss. The previous clinician had a strong suspicion that the client has hypothyroidism. What is the expected moisture and texture of the skin of a client with hypothyroidism?
Dry and rough Explanation: A client with hypothyroidism is expected to have dry and rough skin. This is a good example of how the skin can give clues to systemic diseases.
A nurse needs to assess a client who is experiencing chronic headache to determine how it is affecting her activities of daily living. Which of the following interventions should the nurse implement?
Headache Impact Test Explanation: The Headache Impact Test may be used to assess the impact of headache on a client's activities of daily living. A mnemonic assessment tool is used to assess for the character, onset, location, duration, severity, pattern, and associated factors of pain. It does not assess for the effect of pain on the client's activities of daily living. Auscultation is use of a stethoscope to assess the client's blood pressure, heart sounds, or respiration. The family health history portion of the interview is used to assess for health conditions of family members that might help shed light on the client's chief complaint.
When talking to a client before starting the physical exam, the nurse notes that the client consistently tilts her head to one side. What would the nurse examine first?
Hearing acuity Explanation: A head tilted to one side may indicate unilateral vision or hearing deficiency, which should be ruled out before proceeding with the examination. The nurse would not need to evaluate the thyroid gland, mental status, or lymph nodes based on this finding.
A client presents to the health care clinic with reports of new onset of generalized hair loss for the past two months. The client denies the use of any new shampoos, or other hair care products; no new medications. The nurse should ask the client questions related to the onset of which disease process?
Hypothyroidism Explanation: Generalized hair loss can be a finding in hypothyroidism. Diabetes is a problem with glucose regulation. Crohn's disease is an inflammatory process in the large intestines. Liver disease results in many problems with fluid regulation, metabolism of drugs, and storage of glucose.
Mrs. Hill is a 28-year-old woman of African ancestry with a history of systemic lupus erythematosus (SLE). She has noticed a raised dark red rash on her legs. When the nurse presses on the rash, it doesn't blanch. What would the nurse tell the client regarding her rash?
It is likely to be related to her lupus. Explanation: A "palpable purpura" is usually associated with a vasculitis. This is an inflammatory condition of the blood vessels often associated with systemic rheumatic disease. It can cut off circulation to any portion of the body and mimic many other diseases. While allergic and chemical exposures may be a possible cause of the rash, this client's SLE should make the nurse consider vasculitis.
A nurse is teaching a group of 5th grade children about characteristics of the skin. Which of the following should she mention? Select all that apply.
Largest organ of the body Protects against damage to the body from sunlight Helps make vitamin D in the body Aids in maintaining body temperature Explanation: The skin is the largest organ of the body. The skin is a physical barrier that protects the underlying tissues and organs from microorganisms, physical trauma, ultraviolet radiation, and dehydration. It plays a vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis. The heart, not the skin, circulates blood throughout the body. The digestive system, not the skin, is involved in digestion of food.
A nurse is caring for a client admitted with neck pain. The client is febrile. What is the most likely medical diagnosis for this client?
Meningitis Explanation: Neck pain associated with fever and headache may signify serious illness such as meningitis and should be carefully evaluated.
A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms?
Migraine headache Explanation: Migraine headaches are usually located around the eyes, temples, cheeks, and forehead. They are often accompanied by nausea and vomiting. Bell's palsy is a one sided facial paralysis caused by inflammation of the facial nerve. A tension headache usually presents with stress, anxiety, or tension and is located in the frontal, temporal, or occipital region. Temporal arteritis produces pain around the temple but no nausea or vomiting.
A client complains of a unilateral headache near the scalp line and double vision. The nurse palpates the space above the cheekbone near the scalp line on the affected side, and the client complains of tenderness on palpation. What is the nurse's next action?
Notify the healthcare provider immediately. Explanation: Temporal arteritis is a painful inflammation of the temporal artery. Clients report severe unilateral headache sometimes accompanied by visual disturbances. This condition needs immediate care. A biopsy may be necessary for diagnosis; however the healthcare provider immediately. The temporal artery pulse can be palpated; but the carotid artery pulses should never be palpated simultaneously so that the client does not pass out from lack of blood flow to the brain.
Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse?
Open the mouth Explanation: While performing the assessment of the temporomandibular joint, the nurse should ask the client to open the mouth. This gives an easy access to the joint. Telling the client to sit upright and not move helps in performing the overall examination; however, it does not contribute to the examination of the temporomandibular joint. Telling the client to perform a chewing action is not appropriate.
During a health history, a client reports complaints of headaches. What would lead the nurse to suspect that the client is experiencing cluster headaches?
Pain radiating from eye to temporal region Explanation: Cluster headaches are typically localized in the eye and orbit and radiate to the facial and temporal regions. Throbbing severe pain, reports of ringing in the ears prior to the headache, and sensitivity to light suggest migraine headache.
While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 0.75 cm. The nurse documents this as a
Papules are elevated, palpable, solid masses smaller than 1 cm. Plaques are greater than 1 cm and may be coalesced papules with a flat top.
A young man comes to the clinic with an extremely pruritic rash over his knees and elbows, which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. Examination reveals scabbing and crusting with some silvery scales. The nurse also notices small "pits" in the nails. What would account for these findings?
Psoriasis Explanation: This is a classic presentation of plaque psoriasis. Eczema is usually over the flexor surfaces and does not scale, whereas psoriasis affects the extensor surfaces. Pityriasis usually is limited to the trunk and proximal extremities. Tinea has a much finer scale associated with it, almost like powder, and is found in dark and most areas.
When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer?
Stage II Explanation: A stage II ulcer is manifested by a partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough; an intact or open/ruptured serum-filled blister; a shiny or dry shallow ulcer without slough or bruising (bruising indicates suspected deep tissue injury). A stage I ulcer is manifested by intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III ulcer is manifested by full-thickness tissue loss; possible visible subcutaneous fat with no exposure of bone, tendon, or muscle; possible slough that does not obscure the depth of tissue loss; possible undermining and tunneling. A stage IV ulcer is manifested by full-thickness tissue loss with exposed bone, tendon, or muscle; possible slough or eschar on some parts of the wound bed; often with undermining and tunneling.
A nurse has been asked to assess an older adult resident of a long-term care facility. During assessment of the resident's skin, the nurse notes a break in the skin, erythema, and a small amount of serosanguineous drainage over the resident's sacrum. Inspection reveals that the area appears blister-like. The nurse should interpret this finding as indicating which stage of pressure ulcer?
Stage II Explanation: A stage II ulcer is manifested by a partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough; an intact or open/ruptured serum-filled blister; a shiny or dry shallow ulcer without slough or bruising (bruising indicates suspected deep tissue injury). A stage I ulcer is manifested by intact skin with nonblanchable redness of a localized area, usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III ulcer is manifested by full-thickness tissue loss; possible visible subcutaneous fat with no exposure of bone, tendon, or muscle; possible slough that does not obscure the depth of tissue loss; possible undermining and tunneling. A stage IV ulcer is manifested by full-thickness tissue loss with exposed bone, tendon, or muscle; possible slough or eschar on some parts of the wound bed; often with undermining and tunneling.
What finding upon assessment would indicate the client is experiencing shock?
Systolic blood pressure 50 Explanation: A systolic blood pressure of 50 would indicate the client is experiencing shock. All other vital signs, while elevated do not indicate shock
The nurse is admitting a 79-year-old man for outpatient surgery. The client has bruises in various stages of healing all over his body. Why is it important for the nurse to promptly document and report these findings?
The client may have been abused. Explanation: Multiple ecchymoses may be from repeated trauma (falls), clotting disorder, or physical abuse.
When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?
The underlying bones Explanation: Regions of the head take their names from the underlying bones of the skull, not from the names of anatomists, anatomical positions, or vasculature.
A nurse is interviewing a client regarding her lifestyle and health practices to obtain subjective information to assist in her assessment of her skin. She asks her, "Do you spend long periods of time sitting or lying in one position?" Which of the following is the best rationale for asking this question?
To determine the clients risk for pressure ulcers Explanation: Older, disabled, or immobile clients who spend long periods of time in one position are at risk for pressure ulcers. Spending long periods of time sitting or lying in one position is not associated with increased risk for skin cancer, dehydration, or herpes zoster.
A client describes headaches as severe and lasting for days. Which question would be most appropriate to use to determine if these headaches are migraines?
"Do you have any visual changes before the headache?" Explanation: A typical migraine headache has prodromal symptoms that may include visual disturbances, vertigo, tinnitus, and/or numbness or tingling of the fingers and toes. <wbr />Asking about being tense or anxious would be appropriate to assess for a tension headache. Asking about alcohol or tearing would be appropriate for a cluster headache.
The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client's ethnicity. What assessment question should the nurse ask?
"Do you take steroid medications on a regular basis?" Explanation: Steroid therapy causes hirsutism. Dietary supplements, diabetes, and skin cancer are unlikely causes of abnormal hair growth.
A nurse is working with a client who has a history of headaches. When preparing to assess the client's temporomandibular joint (TMJ), the nurse should provide what instruction?
"I'm going to put my fingers in front of your ears and ask you to open your mouth wide." Explanation: To assess the TMJ, place your index finger over the front of each ear as you ask the client to open her mouth. None of the other listed instructions facilitates this assessment.
An older client is concerned about new senile keratoses appearing on the skin. What should the nurse respond to this client's concern?
"These are considered a normal age-related change in the skin." Explanation: Older clients may have skin lesions associated with aging which include senile keratoses. These skin lesions are not considered skin cancer. They do not need to be cleansed and bandaged. They are not treated with medication.
A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on a ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of this pressure ulcer?
3 Explanation: A stage III ulcer is a full-thickness skin loss with damage to or necrosis of subcutaneous tissue that may extend to, but not through, the underlying muscle.
Where is the temporal artery palpated?
Above the cheek bone near the scalp line Explanation: The nurse palpates the temporal artery in the space above the cheek bone near the scalp line. The temporal artery is not found at midline at the base of the neck, between the mandibular joint and the base of the ear, or just left or right of the spine at the base of the skull.
A 82 year old female presents with neck pain, decreased strength and sensation of the upper extremities. The nurse identifies that this could be related to what?
Arthritic changes of the cervical spine Explanation: Arthritic changes in cervical spine may present in the older adults as neck pain, decreased strength and sensation of the upper extremities. Bacterial thyroiditis has neck swelling and cranial damage may manifest as headaches or tension of the muscles
A nurse cares for a client with a stage II pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area?
Broken with the presence of a blister Explanation: A stage II pressure ulcer results in a superficial skin loss of the epidermis alone or the dermis also. A stage I pressure ulcer is red in color but without skin breakdown. Stage III pressure ulcers involve the epidermis, dermis, and subcutaneous tissue. In stage IV, the muscle, bone, and other supportive tissue may be involved.
A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process?
Cushing's disease Explanation: Hirsutism, or facial hair on females, is a characteristic of Cushing's disease and results from an imbalance of adrenal hormones. Iron deficiency anemia is associated with spoon-shaped nails but not with excessive hair. Carcinoma of the skin causes lesions but not facial hair. Lupus erythematosus causes patchy hair loss but does not cause excessive facial hair.
A nurse is working with a 13-year-old boy who complains that he has begun to sweat a lot more than he used to. He asks the nurse where sweat comes from. The nurse knows that sweat glands are located in which layer of skin?
Dermis Explanation: The dermis is a well-vascularized, connective tissue layer containing collagen and elastic fibers, nerve endings, and lymph vessels. It is also the origin of sebaceous glands, sweat glands, and hair follicles. The epidermis, the outer layer of skin, is composed of four distinct layers: the stratum corneum, stratum lucidum, stratum granulosum, and stratum germinativum. The outermost layer consists of dead, keratinized cells that render the skin waterproof.
The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions?
Distribution Explanation: The given terms denote anatomic location, or distribution, of skin lesions over the body.
The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching?
Encourage the use of safety equipment Explanation: Nurses encourage use of appropriate safety equipment to reduce risk of head or neck trauma. There is no identified need to encourage proper nutrition to promote healing in this client. There is no identified need to teach proper posture, bending, and lifting with this client. Encouraging the client to take a safety course is not the primary focus of discharge teaching.
The nurse notes a large keloid on the pierced ear of an adolescent. The client asks what caused this finding. Which of the following would the nurse incorporate into the response as the most likely cause?
Excessive collagen formation Explanation: Keloids are caused by excessive collagen formation during the healing process, not from continuous trauma, decreased subcutaneous tissue, or inadequate circulation.
The nurse prepares an educational program for the families of clients recovering from burns. On the diagram provided, select the area where fat cells, blood vessels, and nerves are located.
Explanation: Beneath the dermis lies the subcutaneous tissue, a loose connective tissue containing fat cells, blood vessels, nerves, and the remaining portions of sweat glands and hair follicles.
The nurse prepares to assess the anterior triangle of a client's neck. Where should the nurse palpate this area on the diagram?
Explanation: The anterior triangle is located in the area below the mandible, lateral to the sternocleidomastoid muscle and medial to the midline of the neck.
The nurse is preparing to examine a client's skin. What would the nurse do next?
Expose only the body part that is being examined. Explanation: When preparing to examine a client's skin, the nurse would expose only the body part to be examined to ensure privacy. The room should be at a comfortable temperature, one that is not too warm or too cool. Gloves are needed when palpating any lesions. The client needs to remove all clothing and jewelry and put on an examination gown.
On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems is associated with this finding?
Graves' disease Explanation: Graves' disease is associated with a diffusely enlarged thyroid. This finding is not normally consistent with neoplasm, hypothyroidism, or nephritic syndrome.
The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs?
Have a nurse who is the same sex as the client examine him Explanation: Clients from conservative religious groups (e.g., Orthodox Jews or Muslims) may require that the nurse be the same sex as the client. The client must still undress and put on an examination gown. It is not likely that the client will want to pray before the examination, and it is not necessary to avoid asking questions regarding his lifestyle.
A nurse is performing a head and neck assessment of a client who is newly admitted to the hospital unit. When preparing to assess the client's thyroid gland, what landmarks should the nurse first identify? Select all that apply.
Hyoid bone Cricoid cartilage Explanation: Thyroid assessment begins with the identification of relevant landmarks, including the thyroid cartilage, the hyoid bone, and the cricoid cartilage. The sternocleidomastoid muscle, esophagus, and carotid arteries are not landmarked.
What structure is found midline in the tracheal area just beneath the mandible?
Hyoid bone Explanation: Important landmarks for the head and neck region are in the tracheal area. The usually palpable U-shaped hyoid bone is located midline just beneath the mandible. The large thyroid cartilage consists of two flat, plate-like structures joined together at an angle and with a small, sometimes palpable notch at the superior edge. Usually more prominent in males, the thyroid cartilage is also called the "Adam's apple." The palpable cricoid cartilage is a ringed structure just inferior to the thyroid cartilage.
The nurse notes that a client's capillary refill is 5 seconds. What should this finding indicate to the nurse?
Hypoxia Explanation: When the capillary refill is greater than 2 seconds, a respiratory or cardiovascular disease should be considered as causing hypoxia. This finding does not indicate an infection or a vitamin C deficiency. This is not a normal finding.
The RN should intervene and further educate the nursing assistant when observing which action?
Independently pulling an immobile client up in bed Explanation: Friction/shear forces are risks to breaks in skin integrity that can occur when pulling a client up in bed alone. The nursing assistant needs to ask for assistance when repositioning an immobile client. Assisting with feeding or ambulating, and using pillows under bony prominences to prevent pressure ulcers are all appropriate nursing assistant tasks.
What nursing diagnosis would be most appropriate for a client admitted with heart failure?
Ineffective tissue perfusion Explanation: Heart failure can cause ineffective tissue perfusion which can lead to fatigue, pain and activity intolerance. Impaired gas exchange would be more appropriate for respiratory disorders
What does examination of the skin involve? Select all that apply.
Inspection Palpation Explanation: Examination of the skin involves inspection and palpation. It does not generally involve a nutrition assessment, percussion, or auscultation.`
A nursing educator is evaluating a colleague's examination of a client's thyroid gland. The educator would determine that the nurse needs additional instruction when the nurse demonstrates which technique?
Percussion Explanation: When examining the thyroid gland, the nurse inspects for enlargement and asymmetry; auscultates for bruits; and palpates for tumors, masses, size, and tenderness. Percussion does not provide meaningful data.
While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse should recognize the presence of which of the following?
Petechiae Explanation: Petechiae are small, round, red or purple macules that are secondary to blood extravasation. Purpura refers to hemorrhagic disease that produces ecchymoses and petechiae. Ecchymosis refers to round or irregular macular lesions that are larger than petechiae and are variable in color. A cherry angioma is a papular round red or purple lesion.
A nurse is providing care at an inner-city shelter, and a man who frequents the shelter presents with a significant frontal growth that is located midline at the base of his neck. The nurse should recognize the need for what referral?
Referral for further assessment of thyroid function Explanation: A goiter (an enlarged thyroid gland) may appear as a large swelling at the base of the neck. This growth is not suggestive of impaired cranial nerve or lymphatic function, and it does not normally impair swallowing ability.
The ICU nurse is caring for a trauma victim whose status is critical. On assessment, the nurse notes uremic frost along the client's hairline. What would this indicate to the nurse?
Renal failure Explanation: Uremic frost is a sign of marked renal failure. This appearance results from precipitation of renal urea and nitrogen waste products through sweat onto the skin. Uremic frost is not related to cardiovascular failure, hepatic failure, or respiratory failure.
A nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client's current health status would be reflected in her score on this scale?
The client is consistently incontinent of urine. Explanation: The Braden Scale assesses skin moisture, which is strongly influenced by urinary incontinence. This scale does not specifically address the role of a caregiver, recent surgery, or a vegetarian diet.
A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis?
Tension
An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse notes considerable skin tenting. Why does this finding require further assessment?
Tenting indicates dehydration Explanation: A persistent pinch, or tenting of the skin, indicates dehydration. Tenting would not be present in the condition of malnutrition alone, dramatic weight loss, or vitamin B12 deficiency.
A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?
The client's ability to change position Explanation: The Braden Scale appraises the client's level of mobility but does not directly include data related to medications, history of skin disorders, or pigmentation.
What is the most important focus area for the integumentary system?
UV radiation exposure Explanation: Excessive UV radiation is the most important focus area for the integumentary system, because exposure to it has been shown to cause skin cancers, particularly melanoma. Chemical exposure, moles with defined borders smaller than 6 mm, and hygiene of the face and hands are not the most important focus areas for the integumentary system.`
Mrs. Anderson presents with an itchy raised rash that appears and disappears in various locations. Each lesion lasts for many minutes. Which most likely accounts for this rash?
Urticaria or hives Explanation: This is a typical case of urticaria. The most unusual aspect of this condition is that the lesions move from place to place. This would be distinctly unusual for the other causes listed.
The nurse is assessing a dark-skinned client whose forearms and hands have distinct regions of depigmentation. The nurse should document the presence of what health problem?
Vitiligo Explanation: Vitiligo is characterized by discrete areas of depigmentation. Albinism is a generalized absence of pigment, and striae are often known as stretch marks. Angiomas are small, raised skin lesions.
Hair follicles, sebaceous glands, and sweat glands originate from the
dermis. Explanation: The dermis is a well-vascularized, connective tissue layer containing collagen and elastic fibers, nerve endings, and lymph vessels. It is also the origin of sebaceous glands, sweat glands, and hair follicles.
A female client visits the clinic and complains to the nurse that her skin feels "dry." The nurse should instruct the client that skin elasticity is related to adequate
fluid intake. Explanation: Adequate fluid intake is required to maintain skin elasticity.
Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV.
intact, firm skin with redness ulceration involving the dermis full-thickness skin loss necrosis with damage to underlying muscle
When documenting that a client has freckles, the appropriate term to use is
macules Explanation: Macules are skin discolorations that are flat, circumscribed, discolored, and less than 1 cm in diameter. An example of a macule is a freckle.
The nurse notes that a client's nails are greater than a 160-degree angle. What should the nurse assess as a priority for this client?
pulse oximetry Explanation: A nail angle greater than 160 degrees indicates clubbing which is caused by chronic hypoxia. Measuring the client's pulse oximetry would be a priority. Heart sounds, bowel sounds, and body temperature will not provide information to determine the cause for the clubbed nails.
The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as
stage II. Explanation: Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured, serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising; bruising indicates suspected deep tissue injury. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.
An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for:
symptoms of stress. Explanation: Patchy hair loss may accompany infections, stress, hairstyles that put stress on hair roots, and some types of chemotherapy.
A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing?
tension Explanation: Tension headaches often arise in the temporal areas. Cluster headaches typically occur behind the eyes. A throbbing, severe, unilateral headache that lasts 6-24 hours and is associated with photophobia, nausea, and vomiting suggests a migraine headache. Hypertensive is not a type of headache although individuals with hypertension may experience a headache upon arising in the morning.
An older client visits the clinic accompanied by his daughter. The daughter tells the nurse that her father has been experiencing severe headaches that usually begin in the morning and become worse when he coughs. The client tells the nurse that he feels dizzy when he has the headaches. The nurse refers the client for further evaluation because these symptoms are characteristic of a
tumor-related headache. Explanation: Tumor-related headaches have no prodromal stage; may be aggravated by coughing, sneezing, or sudden movements of the head.
Short, pale, and fine hair that is present over much of the body is termed
vellus. Explanation: Vellus hair (peach fuzz) is short, pale, fine, and present over much of the body.
