BHA Exam 2 Review Questions

How should the pt be positioned for an assessment using a snellen chart?

20ft away from the chart

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands? A.) Dermis B.) Epidermis C.) Subcutaneous layer D.) Connective layer

A, dermis

How should you teach adolescents to prevent head injury?

Always wear seatbelt

Cataract lens on the eye

Appears cloudy

Central cyanosis

Around the core, lips, and tongue

What are the ABCDEs of assessing the skin for melanoma?

Asymmetrical Irregular borders Change in color Diameter greater than or equal to 6mm Evolution of lesions over time (change)

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 pathophysiologic cause for this finding is related to what disease process?

Atelectasis

During the physical examination of a patient's eyes, the nurse asks the patient to follow the tracing of a giant H with the eyes. What function is the nurse assessing in this patient? A.) Pupil reaction to light B.) Extraocular movements C.) Convergence D.) Corneal light reflex

B, Extraocular movements

Assessment of a client's nails reveals Beau's lines. The nurse interprets this finding as indicating which of the following? A.) Oxygen deficiency B.) Acute illness C.) Psoriasis D.) Trauma

B, acute illness

The student nurse learns that examining the skin can do all of the following except? A.) Reveal overhydration B.) Allow early identification of neurologic deficits C.) Identify physical abuse D.) Allow early identification of potentially cancerous lesions

B, allow early identification of neurological deficits

An African American female client visits the clinic. She tells the nurse that she had her ears pierced several weeks ago, and an elevated, irregular, reddened mass has now developed at the ear lobe. The nurse should document a A.) cyst B.) keloid C.) lichenification D.) bulla

B, keloid

A nurse is collecting a thorough and accurate subjective history of a client's nail problems. The client asks why this is necessary. Which of the following should the nurse mention in response? A.) Nail problems may affect a person's body image negatively. B.) Nail problems can be caused by an underlying systemic illness. C.) Local irritation can cause damage to the nail bed. D.) Abnormalities may be a sign of poor hygiene.

B, nail problems can be caused by an underlying systemic illness

Where should you stand when assessing a pt's thyroid?

Behind them

When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics? A.) Congruency, induration, size, turgor B.) Delineation, integrity, shape, colour C.) Consistency, delineation, mobility, tenderness D.) Configuration, discreteness, temperature, colour

C, Consistency, delineation, mobility, tenderness

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? A.) Acne is caused by the apocrine glands B.) Acne is caused by decreased activity of the sebaceous glands C.) Acne is caused by the impedance of sebum secretion onto the skin's surface D.) Acne is caused by enlarged epocrine glands

C, acne is caused by the impedance of sebum secretion onto the skin's surface

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? A.) Around the mouth and lips B.) Chest and abdomen C.) Fingers and toes D.) Nose and earlobes

C, fingers and toes

Golden/yellow pigmented, found in the subcutaneous fat

Carotene

When documenting a pt's lesion, what should you record?

Color Location/distribution Elevation

What is the mucous membrane that covers the sclera?

Conjunctiva

The nurse tests the distant visual acuity of several clients and records the findings. Which finding indicates that the client with the poorest vision? A.) 20/30 B.) 20/40 C.) 20/50 D.) 20/60

D, 20/60

When assessing risk factors for eye and vision problems, the nurse knows that genetics can play a role. What major eye problem are clients most likely at increased risk for if a first-degree relative has it? A.) Retinoblastoma B.) Strabismus C.) Retinitis pigmentosa D.) Glaucoma

D, Glaucoma

Hair follicles, sebaceous glands, and sweat glands originate from the A.) epidermis B.) eccrine glands C.) keratinized tissue D.) dermis

D, dermis

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin A.) A B.) B12 C.) C D.) D

D, vitamin d

Acromegaly

Enlarged features

Examining the pt's eye trace is what type of movement?

Extraocular movement

Head pain around the eyes

HA from eye disorder

Peripheral cyanosis

In the extremities or fingers

Where is Vitamin D synthesized?

In the skin

With Esotropia the eyes move in which direction?

Inwards "Cross-eyed"

Why do older pts complain of frequent dry mouth?

It's a side effect of medication use

Where do you palpate the thyroid?

Just below the cricoid cartilage

Why does skin tend to get dry in older pts?

Lack of sebum

What color should the tympanic membrane be?

Light grey

When doing a head and neck assessment, you're palpating the ______________.

Lymph node, make sure moves left to right, up and down

If the thyroid gland is not palpable, you should document that as a _____________ finding.

Normal

What should you do if your pt has sudden vision loss in one eye?

Notify health provider immediately

What is the proper way to assess the carotid artery?

One at a time to avoid cutting off blood flow

Ptosis

One lazy eye

The nurse is preparing to examine a client's internal ear. Which equipment would be necessary?

Otoscope

Head pain from mental/physical exercion

Post traumatic HA

How do you properly assess a pt's sinuses?

Press on frontal brow Press up on maxillary sinuses

PERRLA

Pupils equal, round, reactive to light, accomodation

What interventions should be taken prior to assessing a pt's skin?

Put on gloves Give the pt privacy Give the pt a gown

What are some ways to prevent future head injuries?

Reduce the use of throw rugs in the home No drinking and driving Wear helmets with contact sports

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

What do you ask a pt to do when assessing the thyroid gland?

Swallow

As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test?

The client and the examiner see the examiner's finger at the same time

Where are blood vessels found in the skin?

The dermis

What is the bone under scalp and above the cheek bone?

Tympanic bone

What do you use an otoscope to assess?

Tympanic membrane

What it the short, pale, and fine hair found all over the body?

Villus

The nurse is assessing a dark-skinned client whose forearms are hands have distinct regions of depigmentation. The nurse should document the presence of what health problem?

Vitiligo

Pt teaching regarding contact lenses

Wash hands Don't share lenses Keep lenses clean Discard contact solution fluid

If a pt comes in with a large keloid/haloid, the nurse would know it's most likely caused by excessive _____________ formation.

collagen

Vessels that move toxins outside the body

lymphatic

Throbbing head pain for 8 hours would be considered a ______________.

migraine

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 "ABCD" characteristic of malignant melanoma? A.) Asymmetrical shape B.) Borders well demarcated C.) Color is uniform D.) Diameter less than 6mm

A, Asymmetrical shape

Which vessel is the nurse assessing if the major artery of the neck is being examined? A.) Carotid B.) Jugular C.) Temporal D.) Radial

A, Carotid

Which type of vessels filter pathogens from the body and drain the fluid that has moved outside of the circulation back into the vessels? A.) Lymphatic B.) Arteries C.) Aortic D.) Veins

A, Lymphatic

What is the most important focus area for the integumentary system? A.) UV radiation exposure B.) Chemical exposure C.) Moles with defined borders smaller than 6mm D.) Washing the face and hands

A, UV radiation exposure

What is the rationale for asking the client whether he or she has noticed any new or changed moles? A.) Changes in existing moles or the appearance of new moles can indicate melanoma. B.) Transition from pustules to moles can indicate psoriasis C.) The appearance of new moles is a sign of vitamin D deficiency. D.) Excessive eccrine sweat gland production can cause the emergence of a new mole.

A, changing in existing moles or the appearance of new moles can indicate melanoma

The nurse is using the mnemonic ABCDE to assess a client's mole. What should the nurse document for the C? A.) Color B.) Category C.) Consistency D.) Characteristics

A, color

The apocrine glands are stimulated by what? A.) Emotional stress B.) Temperature C.) Physical stress D.) Overhydration

A, emotional stress

A 20-year-old client visits the outpatient center and tells the nurse that he has been experiencing sudden generalized hair loss. After determining that the client has not received radiation or chemotherapy, the nurse should further assess the client for signs and symptoms of A.) hypothyroidism. B.) hyperthyroidism. C.) infectious conditions. D.) hypoparathyroidism.

A, hypothyroidism

Mrs. Hill is a 28-year-old woman of African ancestry with a history of systemic lupus erythematosis (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? A.) It is likely to be related to her lupus. B.) It is likely to be related to an exposure to a chemical. C.) It is likely to be related to an allergic reaction. D.) It should not cause any problems.

A, it is likely to be related to her lupus

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? A.) Tenting indicates dehydration B.) Tenting indicates malnutrition C.) Tenting indicates dramatic weight loss D.) Tenting indicates vitamin B12 deficiency

A, tenting indicates dehydration

The nurse is preparing to assess the neck of an adult client. To inspect movement of the client's thyroid gland, the nurse should ask the client to? A.) Inhale deeply B.) Swallow a small sip of water C.) Cough deeply D.) Flex the neck to each side

B, swallow a small sip of water

While inspecting the tympanic membrane, the nurse notes a pearly gray and shiny appearance. The nurse would interpret this finding as which of the following? A.) Scarring from previous infection B.) Serous otitis media C.) Normal tympanic membrane D.) Acute otitis media

C, normal tympanic membrane

The ossicles contained in the middle ear include the malleus, the incus, and the________ A.) pars flaccida B.) umbo C.) stapes D.) pars tena

C, stapes

A client tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the patient's oxygenation level is within normal levels. The nurse knows that the blue color the patient described is caused by what? A.) Reynaud disease B.) Central cyanosis C.) Neurofibromatosis D.) Peripheral cyanosis

D, peripheral cyanosis

What does virtuous humor in the eye cause?

Floaters

Hair growth on a burnt pt

Hair will no longer grow due to the dermis being damaged

What should you have the pt do to assess their sclera and conjunctiva?

Have them look up

When assessing the head and neck, you're looking at which 3 parts of the body?

Head Neck Lymph

When assessing the lymph nodes, how should you ask the pt to sit?

In an upright position

N/V, loss of consciousness, neck pain

Subarachnoid hemorrhage

Head pain thats usually temporal, but also occipital

tension headache