assessment( quiz 2 )
What is pitting edema?
"Swelling that leaves an indentation when pressed."
capillary refill means
"The time it takes for color to return to the nail bed after pressure is applied "A quick test to assess peripheral perfusion
a nurse is providing teaching to a client about preventing skin cancer. which of the following client statements indicates a need of further teaching ?
Eating a high fiber diet will reduce my risk for developing skin cancer
a nurse in a community health clinic is caring for a client who reports a headache and stiff neck, which of the following actions should the nurse take first ?
Evaluate the client's neurological status
a nurse is teaching a client about risk factors for skin cancer. Which of the following statements by the client indicates an understanding of the teaching ?
I should apply sunscreen prior to going outside, even in the winter months
a nurse is developing an education program about skin cancer for a community center. which of the following instructions should the nurse plan to include?
Keep a body map of skin lesions
a nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as a indication that the client id dehydrated?
Skin tenting present
which of the following are important considerations when assessing for jugular vein distention ( JVD) ?
Use tangential lighting to observe the neck Assess for bilaterally symmetric distention Position the patient at a 45-degree angle
a nurse is performing an integumentary assessment for a client . Which of the following findings should the nurse identify as possible squamous cell carcinoma?
a firm module with hard crust
which of the following is an example of primary prevention for skin cancer?
applying sunscreen regularly when spending time outdoors
How is skin turgor assessed?
by pinching the skin and observing how quickly it returns to its normal position
which of the following is true regarding capillary refill time?
capillary refill of less than 2 seconds indicates normal peripheral circulation
a nurse is documenting in a client health record using the subjective, objective assessment plan (SOAP) charting model. Which of the following information should be included in the subjective component?
client report chest pain after mowing lawn this morning
during assessment of the respiratory system the nurse inspects and palpates the trachea in order to asses ?
deviation from the midline
a nurse is caring for a client who has a body mas index (BMI) of 18. the nurse should place the client in which of the following BMI categories ?
healthy weight
what are preauricular nodes?
lymph nodes located in front of the ear
Assessment of a patient reveals a flat and nonpalpable skin lesion that is 0.5 cm with a circumscribed border. The nurse documents this lesion as which of the following?
macule
While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects:
melanoma
what is a characteristic of a stage 2 skin ulcer?
shallow open ulcer with red-pink wound bed
a nurse is calculating a client's body mas index (BMI) which of the following information does the nurse require?
the client's height
