health assessment final

During a prenatal class, a nurse teaches a client how to measure the frequency of contractions. The client demonstrates understanding with which statement? A) "I should time from when I feel the contraction to the end of the contraction." B) "I'll start timing when I feel one starting until I feel another one starting." C) "I should start timing when the contraction is the strongest until it subsides." D) "I should time from when one contraction ends and another one starts."

B) "I'll start timing when I feel one starting until I feel another one starting."

The clinic nurse is assessing a client who is pregnant at 18 weeks' gestation. The nurse is obtaining a fetal heart rate using Doppler ultrasound. What fetal heart rate represents an expected finding? A) 90 beats per minute B) 130 beats per minute C) 175 beats per minute D) 225 beats per minute

B) 130 beats per minute

Chapter 32 Geriatric/Polypharmacy When examining the skin of an elderly client, the presence of which skin lesions should indicate a need for referral? A) Cherry angioma B) Actinic keratosis C) Seborrheic keratosis D) Acrochordons

B) Actinic keratosis

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

B) Acute illness

A client at 32 weeks' gestation, who has had regular prenatal care, is found to have gained 6 pounds in 1 week. Which of the following would be most appropriate for the nurse to do next? A) Ask for 24-hour diet recall. B) Assess the legs for edema. C) Collect a urine culture. D) Check fundal height.

B) Assess the legs for edema.

A client's bladder is found to be distended. At which location should the nurse begin palpating? A) At the umbilicus B) At the symphysis pubis C) In the right lower quadrant D) In the left lower quadrant

B) At the symphysis pubis

Assessment of a client's nails reveals brownish-black discoloration and crumbling of the nail plate. The nurse should suspect which of the following etiologies? A) Fungal infection B) Bacterial infection C) Yeast infection D) Circulatory disorder

B) Bacterial infection

A home care nurse is assessing an older adult's functional status. The nurse should identify which of the following as an instrumental activity of daily living? A) Bathing B) Cooking C) Toileting D) Eating

B) Cooking

The nurse is preparing to assess the size of the client's aorta. The nurse should palpate at which location? A) Midline at the umbilicus B) Deep epigastrium to the left of midline C) Slightly above the suprapubic area D) Between the umbilicus and the symphysis pubis

B) Deep epigastrium to the left of midline

A nurse is using the Katz Activities of Daily Living tool to assess an older adult's functional status. What question will the nurse include in this assessment? A) ìWho generally prepares your meals and snacks?î B) ìDo you require any assistance when showering or bathing?î C) ìDo you feel like you have enough support from your family?î D) ìAre you able to shop for your own groceries?î

B) Do you require any assistance when showering or bathing?

Chapter 23 The nurse is percussing a client's liver and is assessing liver descent. The nurse should have the client do which of the following? A) Cough forcefully B) Hold the breath C) Breathe in and out deeply D) Perform the Valsalva maneuver

B) Hold the breath

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. A) Sternocleidomastoid muscle B) Hyoid bone C) Cricoid cartilage D) Carotid artery E) Esophagus

B) Hyoid bone C) Cricoid cartilage

During an integumentary assessment, the nurse notes that the client's fingernails are very thin and concave. The nurse knows the client needs medical follow-up for further assessment to rule out which condition? A) Diabetes mellitus B) Iron deficiency anemia C) Vitamin A deficiency D) Peripheral vascular disease

B) Iron deficiency anemia

A nurse is conducting a focused head and neck assessment of a client. When preparing to assess the client's thyroid gland, the nurse should be aware of which of the following principles? A) The thyroid gland is not normally palpable in female clients. B) Many clients have an additional (third) thyroid lobe. C) The thyroid gland is not normally palpable until clients are in their thirties or forties. D) Palpation creates a risk of rupturing the thyroid gland in some older adult clients.

B) Many clients have an additional (third) thyroid lobe.

An older adult client has been admitted to the intensive care unit after experiencing a serious decline in health due to influenza. The client's family is surprised that influenza could have such serious health consequences. When educating the family about this phenomenon, what should the nurse describe? A) Older adults' immune systems cannot produce new antibodies. B) Older adults have a diminished physiologic reserve. C) Older adults lack resistance to many common viruses. D) Older adults cannot tolerate antibiotics used to treat influenza.

B) Older adults have a diminished physiologic reserve.

A 15-year-old boy shows the school nurse a "bump" on his neck. The nurse observes a raised, erythematous, solid, 0.3-cm by 0.2-cm mass. The nurse would document the presence of which of the following? A) Macule B) Papule C) Nodule D) Pustule

B) Papule

A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. Which of the following should the nurse do next? A) Document the benign findings. B) Perform a random blood sugar test. C) Ask the client about a family history of cancer. D) Refer the client for medical follow-up.

B) Perform a random blood sugar test.

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? A) Purpura B) Petechiae C) Ecchymosis D) Cherry angioma

B) Petechiae

A client comes to the prenatal clinic for a follow-up examination. When assessing the client's breasts, which of the following should the nurse expect to find? Select all that apply. A) Pallor of the areolae B) Prominent veins C) Nodular breasts D) Warmth E) Increased sensitivity

B) Prominent veins C) Nodular breasts E) Increased sensitivity

The nurse is assessing an elderly client who is receiving tube feedings via a nasogastric tube. The nurse should assess the client for signs and symptoms of which of the following? A) Gingivitis B) Sinusitis C) Epiglottitis D) Cellulitis

B) Sinusitis

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? A) Stage I B) Stage II C) Stage III D) Stage IV

B) Stage II

The nurse is assessing a client who is in liver failure and who has developed ascites. When measuring the client's abdominal girth, the nurse should place the client in which position? A) Sitting B) Standing C) Supine D) Prone

B) Standing

A nurse is palpating the position of the client's trachea. At which anatomic site would the nurse first position a finger for palpation? A) Sternocleidomastoid muscle B) Sternal notch C) Submental space D) Supraclavicular space

B) Sternal notch

The nurse can best palpate the superficial cervical nodes, the deep cervical chain, and the supraclavicular nodes by first locating which muscle? A) Infraspinous B) Sternomastoid C) Trapezius D) Platysma

B) Sternomastoid

An older adult client has been admitted for assessment related to decreased cognition. What assessment finding is most suggestive of delirium as the cause of the client's cognitive changes? A) The client has a family history of cognitive disorders. B) The client recently began a new medication regimen. C) The client has been under significant psychosocial stress. D) The client's cognition has declined over several months.

B) The client recently began a new medication regimen.

The nurse assesses the uterine fundus and finds it to be halfway between the symphysis pubis and the umbilicus. The nurse knows that this is an expected finding at how many gestational weeks? A) 6 B) 12 C) 16 D) 20

C) 16

Chapter 29 Women's Health A newly pregnant client says that she has heard that her nipples will leak milk during the pregnancy. The nurse should tell the client that she should expect to be able to express colostrum from her nipples beginning at how many weeks' gestation? A) 6 to 8 B) 12 to 14 C) 24 to 28 D) 34 to 36

C) 24 to 28

The nurse is measuring the fundal height of a woman who is at 28 weeks' gestation. Which measurement would the nurse expect? A) 12 cm B) 18 cm C) 28 cm D) 32 cm

C) 28 cm

A client's recent weight loss and diarrhea has been attributed to hyperthyroidism. When auscultating the client's thyroid gland, what assessment finding is most consistent with this diagnosis? A) Audible referred breath sounds at the site of the thyroid B) An audible S3 sound at the site of the thyroid C) A sound of turbulent blood flow in the thyroid D) Irregular S1 and S2 rhythms in the thyroid

C) A sound of turbulent blood flow in the thyroid

The nurse is assessing the head and neck of a 51-year-old male client. Following inspection and palpation of the client's thyroid gland, the nurse determines that the gland is enlarged. What is the next action that the nurse should perform? A) Obtain a full set of vital signs. B) Percuss the client's thyroid. C) Auscultate the client's thyroid. D) Perform a swallowing assessment.

C) Auscultate the client's thyroid.

During an assessment of an elderly client, the nurse notes a decrease in pupil size and a slowed reaction of the pupil to light. Accommodation and convergence are normal. Based on these findings, which of the following should the nurse emphasize with client education? A) Use drops to prevent dryness B) Wear sunglasses outdoors C) Avoid driving at night D) Obtain an eye examination

C) Avoid driving at night

The nurse is preparing to perform Leopold's maneuvers. During the first maneuver, the nurse palpates a soft mass in the upper quadrant of the abdomen. The nurse interprets this as which fetal part? A) Back B) Head C) Buttocks D) Feet

C) Buttocks

An elderly client's history reveals the use of antihistamines. When inspecting the client's mouth, which of the following would the nurse expect to find? A) Resorption of the gum ridge B) Swollen, red tongue C) Decreased saliva production D) Pocketing of food

C) Decreased saliva production

A nurse has completed the assessment of an older adult client's head and neck and is now analyzing the assessment findings. Which of the following findings should the nurse attribute to age-related physiological changes? A) Increased size of a single thyroid nodule B) A nonpalpable carotid pulse C) Decreased strength of temporal artery pulsations D) Tenderness of lymph nodes on palpation

C) Decreased strength of temporal artery pulsations

The nurse is interviewing an 82-year-old client who is accompanied by her daughter. The daughter states that her mother is ìunable to hold her urine,î and the client attests that this is true. What question should the nurse prioritize when assessing the client's urinary incontinence? A) ìDid you deliver your children vaginally or by cesarean section?î B) ìHave you been prone to urinary tract infections in the past?î C) Is this something that has begun to happen just recently? D) ìHave you noticed any change in your bowel function?î

C) Is this something that has begun to happen just recently?

A nurse is attempting to auscultate fetal heart tones after determining that the fetus is in a longitudinal lie, cephalic presentation, and left occiput anterior position. The nurse would auscultate them at which area? A) Left upper quadrant B) Right upper quadrant C) Left lower quadrant D) Right lower quadrant

C) Left lower quadrant

6. A nurse is preparing a health education class for a group of older adult clients at a local senior center. The nurse is focusing on health promotion and disease prevention. Which condition would the nurse cite as a common cause of infection-related deaths in the elderly? A) Pyelonephritis B) Cellulitis C) Pneumonia D) Meningitis

C) Pneumonia

Chapter 15 Which factor, if present in a client's lifestyle and health practices assessment, would alert the nurse to the need for performing a more thorough head and neck assessment? A) Alcohol abuse B) Recreational drug use C) Smokeless tobacco use D) Multiple sex partners

C) Smokeless tobacco use

The nurse is percussing a client's abdomen. What predominant sound should the nurse expect to hear over the majority of the abdomen? A) Accentuated tympany B) Hyperresonance C) Tympany D) Dullness

C) Tympany

A patient will be ready to be discharged from the hospital soon, and the patient's family members are concerned about whether the patient is able to walk safely outside alone. The nurse will perform which test to assess this? a. Get Up and Go Test b. Performance ADLs c. Physical Performance Test d. Tinetti Gait and Balance Evaluation

a. Get Up and Go Test

An older patient has been admitted to the intensive care unit (ICU) after falling at home. Within 8 hours, his condition has stabilized and he is transferred to a medical unit. The family is wondering whether he will be able to go back home. Which assessment instrument is most appropriate for the nurse to choose at this time? a. Lawton IADL instrument b. Hospital Admission Risk Profile (HARP) c. Mini-Cog d. NEECHAM Confusion Scale

b. Hospital Admission Risk Profile (HARP)

The nurse is assessing the abilities of an older adult. Which activities are considered IADLs? Select all that apply. a. Feeding oneself b. Preparing a meal c. Balancing a checkbook d. Walking e. Toileting f. Grocery shopping

b. Preparing a meal c. Balancing a checkbook f. Grocery shopping

A patient's pregnancy test is positive, and she wants to know when the baby is due. The first day of her last menstrual period was June 14, and that period ended June 20. Using the Nägele rule, what is her expected date of delivery? a. March 7 b. March 14 c. March 21 d. March 27

c. March 21

During a morning assessment, the nurse notices that an older patient is less attentive and is unable to recall yesterday's events. Which test is appropriate for assessing the patient's mental status? a. Geriatric Depression Scale, short form b. Rapid Disability Rating Scale-2 c. Mini-Cog d. Get Up and Go Test

c. Mini-Cog

When examining the face of a patient, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the ___________ and ___________ glands. a. Occipital; submental b. Parotid; jugulodigastric c. Parotid; submandibular d. Submandibular; occipital

c. Parotid; submandibular

A man has come in to the clinic for a skin assessment because he is worried he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and "stuck on" his skin. Which is the best prediction? a. Senile lentigines, which do not become cancerous b. Actinic keratoses, which are precursors to basal cell carcinoma c. Acrochordons, which are precursors to squamous cell carcinoma d. Seborrheic keratoses, which do not become cancerous

d. Seborrheic keratoses, which do not become cancerous

The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an ìitching rash.î Which question would be most important for the nurse to ask? A) ìAre you allergic to foods, medications, or other substances?î B) ìDoes anyone else in your family have a rash like this?î C) ìHow painful is your rash?î D) ìWhat have you been doing to control the itching?î

A) Are you allergic to foods, medications, or other substances?

The nurse is performing light palpation of the client's abdomen. How can the nurse best prevent voluntary guarding during this phase of assessment? A) Ask the client to breathe slowly and deeply. B) Perform auscultation prior to palpation. C) Explain the procedure to the client before palpating. D) Position the client sitting upright.

A) Ask the client to breathe slowly and deeply.

When auscultating the heart of an elderly client, the nurse detects a soft systolic murmur at the base of the heart. The nurse understands that this is most likely the result of which of the following? A) Calcification of the aortic and mitral valves B) Accumulation of amyloid in the pacemaker cells C) Enlargement of the heart muscle D) Regurgitation through a stenotic valve

A) Calcification of the aortic and mitral valves

Assessment of a client's skin reveals several individual and distinct 2-mm lesions on the client's back. The nurse would document the configuration as which of the following? A) Discrete B) Linear C) Annular D) Confluent

A) Discrete

A nurse is providing a client with instructions on how to perform self-examination of the skin. The nurse would encourage the client to perform this examination at which frequency? A) Monthly B) Bimonthly C) Quarterly D) Yearly

A) Monthly

Which of the following findings should the nurse document after assessing the thyroid gland of an older adult without abnormalities? A) Nodularity B) Tenderness C) Enlargement D) Bruits

A) Nodularity

During a health history, a client reports complaints of headaches. Which of the following would lead the nurse to suspect that the client is experiencing cluster headaches? A) Pain radiating from eye to temporal region B) Throbbing and severe pain C) Report of ringing in the ears prior to headache D) Complaint of sensitivity to light

A) Pain radiating from eye to temporal region

A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present, and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. The nurse should document which of the following? A) Positive Rovsing's sign B) Psoas sign present C) Obturator sign positive D) Positive skin hypersensitivity test

A) Positive Rovsing's sign

The nurse has assessed the thorax and lungs of an elderly client, as well as reviewing the results of lung function testing. Which of the following findings should the nurse attribute to possible pathology rather than expected, age-related changes? A) Respiratory rate of 30 breaths per minute B) Decreased vital capacity C) Increased residual volume D) Presence of a slight barrel chest

A) Respiratory rate of 30 breaths per minute

The gerontologic nurse is using the SPICES screening tool to assess an older adult's health status. The nurse will assess for which of the following health problems? Select all that apply. A) Sleep disturbances B) Infection C) Poor nutrition D) Falls E) Pain

A) Sleep disturbances C) Poor nutrition D) Falls

The nurse is assessing the gastrointestinal system of an 81-year-old client. What agerelated change should the nurse consider when collecting and analyzing assessment data? A) The client is more vulnerable to impaired nutrition due to decreased appetite. B) The client derives less nutritional value from food because of decreased enzyme production. C) The client's liver will be significantly larger than that of a younger client. D) The client will have greater bowel motility than a younger adult.

A) The client is more vulnerable to impaired nutrition due to decreased appetite.

The nurse is conducting an assessment of an adult client who describes herself as being in good health. Inspection of the client's nail beds reveals the presence of a bluish tone. The nurse should recognize that this finding is most likely attributable to what phenomenon? A) Vasoconstriction B) Hyperglycemia C) Hypoxemia D) Cardiopulmonary insufficiency

A) Vasoconstriction

Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites? a. Dullness across the abdomen b. Flatness in the right upper quadrant c. Hyperresonance in the left upper quadrant d.. Tympany in the right and left lower quadrants

ANS: A A large amount of ascitic fluid produces a dull sound to percussion.

The nurse is assessing an older adult's advanced activities of daily living (AADLs), which would include: a. Recreational activities. b. Meal preparation. c. Balancing the checkbook. d. Self-grooming activities.

ANS: A AADLs are activities that an older adult performs such as occupational and recreational activities. Self-grooming activities are basic ADLs; meal preparation and balancing the checkbook are considered IADLs.

A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding? a. Color variation b. Border regularity c. Symmetry of lesions d. Diameter of less than 6 mm

ANS: A Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.

The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. These findings are characteristic of: a. Allergies. b. Sinus infection. c. Nasal congestion. d. Upper respiratory infection.

ANS: A Chronic allergies often develop chronic facial characteristics and include blue shadows below the eyes, a double or single crease on the lower eyelids, open-mouth breathing, and a transverse line on the nose.

The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find: a. Lesions that run together. b. Annular lesions that have grown together. c. Lesions arranged in a line along a nerve route. d. Lesions that are grouped or clustered together.

ANS: A Confluent lesions (as with urticaria [hives]) run together. Grouped lesions are clustered together. Annular lesions are circular in nature. Zosteriform lesions are arranged along a nerve route.

The nurse is examining a patient who tells the nurse, "I sure sweat a lot, especially on my face and feet but it doesn't have an odor." The nurse knows that this condition could be related to: a. Eccrine glands. b.. Apocrine glands. c. Disorder of the stratum corneum. d. Disorder of the stratum germinativum.

ANS: A The eccrine glands are coiled tubules that directly open onto the skin surface and produce a dilute saline solution called sweat. Apocrine glands are primarily located in the axillae, anogenital area, nipples, and naval area and mix with bacterial flora to produce the characteristic musky body odor. The patient's statement is not related to disorders of the stratum corneum or the stratum germinativum.

The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? a. Dullness b. Tympany c. Resonance d. Hyperresonance

ANS: A The liver is located in the right upper quadrant and would elicit a dull percussion note.

When examining a patient's CN function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the: a. Sternomastoid and trapezius. b. Spinal accessory and omohyoid. c. Trapezius and sternomandibular. d. Sternomandibular and spinal accessory.

ANS: A The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory.

A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. His hair seems to be breaking off in patches, and he notices some scaling on his head. The nurse begins the examination suspecting: a. Tinea capitis. b. Folliculitis. c. Toxic alopecia. d. Seborrheic dermatitis.

ANS: A Tinea capitis is rounded patchy hair loss on the scalp, leaving broken-off hairs, pustules, and scales on the skin, and is caused by a fungal infection. Lesions are fluorescent under a Wood light and are usually observed in children and farmers; tinea capitis is highly contagious.

When examining children affected with Down syndrome (trisomy 21), the nurse looks for the possible presence of: a. Ear dysplasia. b. Long, thin neck. c. Protruding thin tongue. d. Narrow and raised nasal bridge.

ANS: A With the chromosomal aberration trisomy 21, also known as Down syndrome, head and face characteristics may include upslanting eyes with inner epicanthal folds, a flat nasal bridge, a small broad flat nose, a protruding thick tongue, ear dysplasia, a short broad neck with webbing, and small hands with a single palmar crease.

During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is: a. Xerosis. b. Pruritus. c. Alopecia. d. Seborrhea.

ANS: A Xerosis is the term used to describe skin that is excessively dry. Pruritus refers to itching, alopecia refers to hair loss, and seborrhea refers to oily skin.

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.

A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. The nurse suspects that this coloring is due to: a. Polycythemia. b. Carbon monoxide poisoning. c. Carotenemia. d. Uremia.

ANS: B A bright cherry-red coloring in the face, upper torso, nail beds, lips, and oral mucosa appears in cases of carbon monoxide poisoning.

A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition? a.. Acne b.. Basal cell carcinoma c. Melanoma d. Squamous cell carcinoma

ANS: B Basal cell carcinoma usually starts as a skin-colored papule that develops rounded, pearly borders with a central red ulcer. It is the most common form of skin cancer and grows slowly. This description does not fit acne lesions.

A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: a. Bell palsy. b. Damage to the trigeminal nerve. c. Frostbite with resultant paresthesia to the cheeks. d. Scleroderma.

ANS: B Facial sensations of pain or touch are mediated by CN V, which is the trigeminal nerve. Bell palsy is associated with CN VII damage. Frostbite and scleroderma are not associated with this problem.

An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to: a. Increased gastric acid secretion. b. Decreased gastric acid secretion. c. Delayed gastrointestinal emptying time. d. Increased gastrointestinal emptying time.

ANS: B Gastric acid secretion decreases with aging and may cause pernicious anemia (because it interferes with vitamin B12 absorption), iron-deficiency anemia, and malabsorption of calcium.

A mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects: a. Eczema. b. Impetigo. c. Herpes zoster. d. Diaper dermatitis.

ANS: B Impetigo is moist, thin-roofed vesicles with a thin erythematous base and is a contagious bacterial infection of the skin and most common in infants and children. Eczema is characterized by erythematous papules and vesicles with weeping, oozing, and crusts. Herpes zoster (i.e., chickenpox or varicella) is characterized by small, tight vesicles that are shiny with an erythematous base. Diaper dermatitis is characterized by red, moist maculopapular patches with poorly defined borders

The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally: a. Shotty. b. Nonpalpable. c. Large, firm, and fixed to the tissue. d. Rubbery, discrete, and mobile.

ANS: B Most lymph nodes are nonpalpable in adults. The palpability of lymph nodes decreases with age. Normal nodes feel movable, discrete, soft, and nontender.

A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition? a. Obturator test b.. Test for Murphy sign c. Assess for rebound tenderness d. Iliopsoas muscle test

ANS: B Normally, palpating the liver causes no pain. In a person with inflammation of the gallbladder, or cholecystitis, pain occurs as the descending liver pushes the inflamed gallbladder onto the examining hand during inspiration (Murphy test). The person feels sharp pain and abruptly stops midway during inspiration.

A patient says that she has recently noticed a lump in the front of her neck below her "Adam's apple" that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule): a. Is tender. b. Is mobile and not hard. c. Disappears when the patient smiles. d. Is hard and fixed to the surrounding structures.

ANS: B Painless, rapidly growing nodules may be cancerous, especially the appearance of a single nodule in a young person. However, cancerous nodules tend to be hard and fixed to surrounding structures, not mobile.

A patient has come in for an examination and states, "I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is?" The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his: a. Thyroid gland. b. Parotid gland. c. Occipital lymph node. d. Submental lymph node.

ANS: B Swelling of the parotid gland is evident below the angle of the jaw and is most visible when the head is extended. Painful inflammation occurs with mumps, and swelling also occurs with abscesses or tumors. Swelling occurs anterior to the lower ear lobe.

The nurse is preparing to use the Lawton IADL instrument as part of an assessment. Which statement about the Lawton IADL instrument is true? a. The nurse uses direct observation to implement this tool. b. The Lawton IADL instrument is designed as a self-report measure of performance rather than ability. c. This instrument is not useful in the acute hospital setting. d. This tool is best used for those residing in an institutional setting.

ANS: B The Lawton IADL instrument is designed as a self-report measure of performance rather than ability. Direct testing is often not feasible, such as demonstrating the ability to prepare food while a hospital inpatient. Attention to the final score is less important than identifying a person's strengths and areas where assistance is needed. The instrument is useful in acute hospital settings for discharge planning and continuously in outpatient settings. It would not be useful for those residing in institutional settings because many of these tasks are already being managed for the resident.

A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN ______ and proceeds with the examination by _____________. a. XI; palpating the anterior and posterior triangles b. XI; asking the patient to shrug her shoulders against resistance c. XII; percussing the sternomastoid and submandibular neck muscles d. XII; assessing for a positive Romberg sign

ANS: B The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory. The innervated muscles assist with head rotation and head flexion, movement of the shoulders, and extension and turning of the head.

The nurse is assessing a patient who has liver disease for jaundice. Which of these assessment findings is indicative of true jaundice? a. Yellow patches in the outer sclera b. Yellow color of the sclera that extends up to the iris c. Skin that appears yellow when examined under low light d. Yellow deposits on the palms and soles of the feet where jaundice first appears

ANS: B The yellow sclera of jaundice extends up to the edge of the iris. Calluses on the palms and soles of the feet often appear yellow but are not classified as jaundice. Scleral jaundice should not be confused with the normal yellow subconjunctival fatty deposits that are common in the outer sclera of dark-skinned persons.

A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer. Which of these findings are characteristic of a stage II pressure ulcer? Select all that apply. a. Intact skin appears red but is not broken. b.. Partial thickness skin erosion is observed with a loss of epidermis or dermis. c. Ulcer extends into the subcutaneous tissue. d. Localized redness in light skin will blanch with fingertip pressure. e. Open blister areas have a red-pink wound bed. f. Patches of eschar cover parts of the wound.

ANS: B, E

The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is very concerned. She tells the nurse that she noticed the lump approximately 8 hours after her baby's birth and that it seems to be getting bigger. One possible explanation for this is: a. Hydrocephalus. b. Craniosynostosis. c. Cephalhematoma. d. Caput succedaneum.

ANS: C A cephalhematoma is a subperiosteal hemorrhage that is the result of birth trauma. It is soft, fluctuant, and well defined over one cranial bone. It appears several hours after birth and gradually increases in size.

A patient comes in for a physical examination and complains of "freezing to death" while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to: a. Venous pooling. b. Peripheral vasodilation. c. Peripheral vasoconstriction. d. Decreased arterial perfusion.

ANS: C A chilly or air-conditioned environment causes vasoconstriction, which results in false pallor and coolness

During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be: a. Clumped. b. Unilateral. c. Firm but freely movable. d. Firm and nontender.

ANS: C Acutely infected lymph nodes are bilateral, enlarged, warm, tender, and firm but freely movable. Unilaterally enlarged nodes that are firm and nontender may indicate cancer.

The nurse is assessing for inflammation in a dark-skinned person. Which technique is the best? a. Assessing the skin for cyanosis and swelling b. Assessing the oral mucosa for generalized erythema c. Palpating the skin for edema and increased warmth d. Palpating for tenderness and local areas of ecchymosis

ANS: C Because inflammation cannot be seen in dark-skinned persons, palpating the skin for increased warmth, for taut or tightly pulled surfaces that may be indicative of edema, and for a hardening of deep tissues or blood vessels is often necessary.

A 42-year-old woman complains that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse expects that the spots are probably: a. Anasarca. b. Scleroderma. c... Senile angiomas. d. Latent myeloma.

ANS: C Cherry (senile) angiomas are small, smooth, slightly raised bright red dots that commonly appear on the trunk of adults over 30 years old.

A woman who is 8 weeks' pregnant is visiting the clinic for a checkup. Her systolic blood pressure is 30 mm Hg higher than her prepregnancy systolic blood pressure. The nurse should: a. Consider this a normal finding. b. Expect the blood pressure to decrease as the estrogen levels increase throughout the pregnancy. c. Consider this an abnormal finding because blood pressure is typically lower at this point in the pregnancy... d. Recommend that she decrease her salt intake in an attempt to decrease her peripheral vascular resistance.

ANS: C During the seventh gestational week, blood pressure begins to drop as a result of falling peripheral vascular resistance. Early in the first trimester, blood pressure values are similar to those of prepregnancy measurements. In this case, the woman's blood pressure is higher than it should be.

The nurse notices that a patient's palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)? a. III b. V c. VII d. VIII

ANS: C Facial muscles are mediated by CN VII; asymmetry of palpebral fissures may be attributable to damage to CN VII (Bell palsy).

A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During the assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment aware that another finding may be: a. Keratoses. b. Xerosis. c. Chloasma. d. Acrochordons.

ANS: C In pregnancy, skin changes can include striae, linea nigra (a brownish-black line down the midline), chloasma (brown patches of hyperpigmentation), and vascular spiders. Keratoses are raised, thickened areas of pigmentation that look crusted, scaly, and warty. Xerosis is dry skin. Acrochordons, or skin tags, occur more often in the aging adult.

A black patient is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patient's skin? a. Ruddy blue. b. Generalized pallor. c. Ashen, gray, or dull. d... Patchy areas of pallor.

ANS: C Pallor attributable to shock, with decreased perfusion and vasoconstriction, in black-skinned people will cause the skin to appear ashen, gray, or dull (see Table 12-2).

While performing a well-child assessment on a 5 year old, the nurse notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5 cm in size, round, mobile, and nontender. The nurse suspects that this child: a. Has chronic allergies. b. May have an infection. c. Is exhibiting a normal finding for a well child of this age. d. Should be referred for additional evaluation.

ANS: C Palpable lymph nodes are normal in children until puberty when the lymphoid tissue begins to atrophy. Lymph nodes may be up to 1 cm in size in the cervical and inguinal areas but are discrete, movable, and nontender.

The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include: a. Flatness, resonance, and dullness. b. Resonance, dullness, and tympany. c. Tympany, hyperresonance, and dullness. d. Resonance, hyperresonance, and flatness.

ANS: C Percussion notes normally heard during the abdominal assessment may include tympany, which should predominate because air in the intestines rises to the surface when the person is supine; hyperresonance, which may be present with gaseous distention; and dullness, which may be found over a distended bladder, adipose tissue, fluid, or a mass.

A patient has been admitted for severe psoriasis. The nurse expects to see what finding in the patient's fingernails? a. Splinter hemorrhages b. Paronychia c. Pitting d. Beau lines

ANS: C Sharply defined pitting and crumbling of the nails, each with distal detachment characterize pitting nails and are associated with psoriasis. (See Table 12-13 for descriptions of the other terms.)

A patient who is in her first trimester of pregnancy tells the nurse that she is experiencing significant nausea and vomiting and asks when it will improve. The nurse should reply: a. "Did your mother have significant nausea and vomiting?" b. "Many women experience nausea and vomiting until the third trimester." c. "Usually, by the beginning of the second trimester, the nausea and vomiting improve." d. "At approximately the time you begin to feel the baby move, the nausea and vomiting will subside."

ANS: C The nausea, vomiting, and fatigue of pregnancy improve by the 12th week. Quickening, when the mother recognizes fetal movement, occurs at approximately 18 to 20 weeks.

A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors? a. Subcutaneous fat deposits are high in the newborn. b. Sebaceous glands are overproductive in the newborn. c. The newborn's skin is more permeable than that of the adult. d. The amount of vernix caseosa dramatically rises in the newborn.

ANS: C The newborn's skin is thin, smooth, and elastic and is relatively more permeable than that of the adult; consequently, the infant is at greater risk for fluid loss. The subcutaneous layer in the infant is inefficient, not thick, and the sebaceous glands are present but decrease in size and production. Vernix caseosa is not produced after birth.

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a: a. Bulla. b. Wheal. c. Nodule. d. Papule.

ANS: D A papule is something one can feel, is solid, elevated, circumscribed, less than 1 cm in diameter, and is due to superficial thickening in the epidermis. A bulla is larger than 1 cm, superficial, and thin walled. A wheal is superficial, raised, transient, erythematous, and irregular in shape attributable to edema. A nodule is solid, elevated, hard or soft, and larger than 1 cm.

A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition is due to hyperemia and knows that it can be caused by: a... Decreased amounts of bilirubin in the blood b. Excess blood in the underlying blood vessels c. Decreased perfusion to the surrounding tissues d. Excess blood in the dilated superficial capillaries

ANS: D Erythema is an intense redness of the skin caused by excess blood (hyperemia) in the dilated superficial capillaries.

The nurse is palpating the abdomen of a woman who is 35 weeks' pregnant and notices that the fetal head is facing downward toward the pelvis. The nurse would document this as fetal: a. Lie. b. Variety. c. Attitude. d. Presentation.

ANS: D Fetal presentation describes the part of the fetus that is entering the pelvis first. Fetal lie is orientation of the fetal spine to the maternal spine. Fetal attitude is the position of fetal parts in relation to each other, and fetal variety is the location of the fetal back to the maternal pelvis.

During the assessment of a woman in her 22nd week of pregnancy, the nurse is unable to hear fetal heart tones with the fetoscope. The nurse should: a. Immediately notify the physician, then wait 10 minutes and try again. b. Ask the woman if she has felt the baby move today. c.. Wait 10 minutes, and try again. d. Use ultrasound to verify cardiac activity.

ANS: D If no fetal heart tones are heard during auscultation with a fetoscope, then the nurse should verify cardiac activity using ultrasonography. An ultrasound should be immediately done and before notifying the physician or causing the woman distress by asking about fetal movement.

A patient has had a "terrible itch" for several months that he has been continuously scratching. On examination, the nurse might expect to find: a. A keloid. b. A fissure. c. Keratosis. d. Lichenification.

ANS: D Lichenification results from prolonged, intense scratching that eventually thickens the skin and produces tightly packed sets of papules. A keloid is a hypertrophic scar. A fissure is a linear crack with abrupt edges, which extends into the dermis; it can be dry or moist. Keratoses are lesions that are raised, thickened areas of pigmentation that appear crusted, scaly, and warty.

A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration. The nurse should test skin mobility and turgor over the infant's: a. Sternum. b. Forehead. c. Forearms. d. Abdomen.

ANS: D Mobility and turgor are tested over the abdomen in an infant. Poor turgor, or tenting, indicates dehydration or malnutrition. The other sites are not appropriate for checking skin turgor in an infant.

The nurse is aware that the four areas in the body where lymph nodes are accessible are the: a. Head, breasts, groin, and abdomen. b. Arms, breasts, inguinal area, and legs. c. Head and neck, arms, breasts, and axillae. d. Head and neck, arms, inguinal area, and axillae.

ANS: D Nodes are located throughout the body, but they are accessible to examination only in four areas: head and neck, arms, inguinal region, and axillae.

A newborn infant has Down syndrome. During the skin assessment, the nurse notices a transient mottling in the trunk and extremities in response to the cool temperature in the examination room. The infant's mother also notices the mottling and asks what it is. The nurse knows that this mottling is called: a. Café au lait. b. Carotenemia. c... Acrocyanosis. d. Cutis marmorata.

ANS: D Persistent or pronounced cutis marmorata occurs with infants born with Down syndrome or those born prematurely and is a transient mottling in the trunk and extremities in response to cool room temperatures. A café au lait spot is a large round or oval patch of light-brown pigmentation. Carotenemia produces a yellow-orange color in light-skinned persons. Acrocyanosis is a bluish color around the lips, hands and fingernails, and feet and toenails.

A female patient has nausea, breast tenderness, fatigue, and amenorrhea. Her last menstrual period was 6 weeks ago. The nurse interprets that this patient is experiencing __________ signs of pregnancy. a. Positive b. Possible c. Probable d. Presumptive

ANS: D Presumptive signs of pregnancy are those that the woman experiences and include amenorrhea, breast tenderness, fatigue, nausea, and increased urinary frequency. Probable signs are those that are detected by the examiner, such as an enlarged uterus or changes in the cervix. Positive signs of pregnancy are those that document direct evidence of the fetus such as fetal heart tones or positive cardiac activity on ultrasound.

Which of these statements best describes the action of the hormone progesterone during pregnancy? a. Progesterone produces the hormone human chorionic gonadotropin. b. Duct formation in the breast is stimulated by progesterone. c. Progesterone promotes sloughing of the endometrial wall. d. Progesterone maintains the endometrium around the fetus.

ANS: D Progesterone prevents the sloughing of the endometrial wall and maintains the endometrium around the fetus. Progesterone increases the alveoli in the breast and keeps the uterus in a quiescent state. The other options are not correct.

A nurse is preparing to palpate a client's submental lymph nodes. At what anatomic location should the nurse position his or her hands? A) At the angle of the client's mandible B) At the base of the client's skull C) On the area behind the client's ears D) Behind the tip of the client's mandible

D) Behind the tip of the client's mandible

When examining the eyes of an elderly client, the nurse observes a brownish discoloration of the lens. The nurse interprets this finding as being suggestive of what health problem? A) Conjunctivitis B) Presbyopia C) Glaucoma D) Cataracts

D) Cataracts

An older adult male client states that he has trouble cutting his toenails because they are hard and thick, and the nurse notes that they are very long and unkempt. Which system would be most important for the nurse to assess? A) Integumentary B) Digestive C) Neurologic D) Circulatory

D) Circulatory

The nurse is palpating the uterus of a woman who is 8 weeks' pregnant. Which finding would be considered to be most consistent with this stage of pregnancy? a. The uterus seems slightly enlarged and softened. b. It reaches the pelvic brim and is approximately the size of a grapefruit. c. The uterus rises above the pelvic brim and is approximately the size of a cantaloupe. d. It is about the size of an avocado, approximately 8 cm across the fundus.

ANS: D The 8-week pregnant uterus is approximately the size of an avocado, 7 to 8 cm across the fundus. The 6-week pregnant uterus is slightly enlarged and softened. The 10-week pregnant uterus is approximately the size of a grapefruit and may reach the pelvic brim. The 12-week pregnant uterus will fill the pelvis. At 12 weeks, the uterus is sized from the abdomen.

The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis: a. Contains mostly fat cells. b. Consists mostly of keratin. c. Is replaced every 4 weeks. d. Contains sensory receptors.

ANS: D The dermis consists mostly of collagen, has resilient elastic tissue that allows the skin to stretch, and contains nerves, sensory receptors, blood vessels, and lymphatic vessels. It is not replaced every 4 weeks.

The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is: a. Highly vascular. b. Thick and tough. c... Thin and nonstratified. d. Replaced every 4 weeks.

ANS: D The epidermis is thin yet tough, replaced every 4 weeks, avascular, and stratified into several zones.

A client's medical assessment reveals no heart disease. An electrocardiogram is performed and a dysrhythmia is noted. The nurse interprets this finding as most likely reflecting which of the following age-related changes? A) Decreased ventricular compliance B) Peripheral vascular disease C) Widening pulse pressure D) Collagen deposits around pacemaker cells

D) Collagen deposits around pacemaker cells

When preparing to assess a client's thyroid gland, the nurse should ensure that which piece of equipment is readily available? A) Penlight B) Tongue depressor C) Centimeter-scale ruler D) Cup of water

D) Cup of water

A nurse is assessing an adult client's neck. Which of the following would be most appropriate when auscultating the client's thyroid gland for bruits? A) Hyperextend the client's neck. B) Turn the client's head to the right. C) Have the client swallow water. D) Have the client hold his or her breath.

D) Have the client hold his or her breath.

A mother brings her child into the clinic for an examination of the scalp and hair. She states that the child has developed irregularly shaped patches with broken-off, stublike hair in some places; she is worried that this condition could be some form of premature baldness. The nurse tells her that it is: a. Folliculitis that can be treated with an antibiotic. b... Traumatic alopecia that can be treated with antifungal medications. c. Tinea capitis that is highly contagious and needs immediate attention. d. Trichotillomania; her child probably has a habit of absentmindedly twirling her hair.

ANS: D Trichotillomania, self-induced hair loss, is usually due to habit. It forms irregularly shaped patches with broken-off, stublike hairs of varying lengths. A person is never completely bald. It occurs as a child absentmindedly rubs or twirls the area while falling asleep, reading, or watching television.

A client has sought care because of the development of pruritic lesions between her toes, which the nurse suspects are attributable to a fungal etiology. How can the nurse best corroborate this suspicion? A) Test whether gentle abrasion with an emery board is painful. B) Apply hydrogen peroxide to see whether the client's pruritus is relieved. C) Perform a trial with a topical antibiotic. D) Illuminate the area using a Wood's light.

D) Illuminate the area using a Wood's light.

During a woman's 34th week of pregnancy, she is told that she has preeclampsia. The nurse knows which statement concerning preeclampsia is true? a. Preeclampsia has little effect on the fetus. b. Edema is one of the main indications of preeclampsia. c... Eclampsia only occurs before delivery of the baby. d. Untreated preeclampsia may contribute to restriction of fetal growth.

ANS: D Untreated preeclampsia may progress to eclampsia, which is manifested by generalized tonic-clonic seizures. Eclampsia may develop as late as 10 days postpartum. Before the syndrome becomes clinically manifested, it is affecting the placenta through vasospasm and a series of small infarctions. The placenta's capacity to deliver oxygen and nutrients may be seriously diminished, and fetal growth may be restricted. Edema is common in pregnancy and is not an indicator of preeclampsia.

The nurse notices that a patient's submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the patient's: a. Infraclavicular area. b. Supraclavicular area. c. Area distal to the enlarged node. d. Area proximal to the enlarged node.

ANS: D When nodes are abnormal, the nurse should check the area into which they drain for the source of the problem. The area proximal (upstream) to the location of the abnormal node should be explored.

Ch 14 The nurse is performing an assessment of a client admitted to the emergency department in status asthmaticus. The nurse should carefully inspect which part of the body in an effort to differentiate central cyanosis from peripheral cyanosis? A) Nail beds B) Sclerae C) Palms D) Oral mucosa

D) Oral mucosa

The nurse is assessing a pregnant client and is performing Leopold's maneuvers. For the first two maneuvers, the nurse will perform which of the following actions? A) Palpate the client's midline abdomen and then the region of the symphysis pubis. B) Palpate the client's abdomen beginning with the left flank and then moving to the right flank. C) Palpate the client's floating ribs and then gradually palpate to the level of the ischial spines. D) Palpate the client's fundal region and then the lateral sides of the abdomen.

D) Palpate the client's fundal region and then the lateral sides of the abdomen.

A nurse is preparing to palpate a client's spleen. Which position should the nurse use to best facilitate palpation? A) Sitting upright B) Prone C) Semi-Fowler's D) Right side-lying

D) Right side-lying

During palpation of the client's abdomen, the nurse feels a prominent, nontender, pulsating 6-cm mass above the umbilicus. What action should the nurse take? A) Refer the client to an oncologist. B) Provide a dietician consult for the client. C) Counsel the client regarding hernia repair. D) Stop palpating and get medical assistance.

D) Stop palpating and get medical assistance.

A nurse is preparing for an assessment by reviewing a new client's electronic health record, which documents the presence of macules on the client's left flank and mid-back regions. The nurse should recognize what characteristic of these skin lesions? A) The lesions will be raised and have irregular borders. B) The lesions will be acutely painful. C) The lesions will produce eschar. D) The lesions will not be palpable.

D) The lesions will not be palpable.

The nurse assesses a client and palpates a temporal artery that is hard, thick, and tender with absent pulsations. The nurse would gather additional information related to which aspect of health? A) Mental status B) Hearing C) Neurologic status D) Vision

D) Vision

The nurse is reviewing an older adult's recent laboratory values prior to performing a physical assessment. What value would most clearly indicate the need for further nutritional assessment? A) Hemoglobin 12.2 g/dL B) Hematocrit 40% C) Serum albumin 3.9 g/dL D) Vitamin B12 91 μg/ml

D) Vitamin B12 91 μg/ml

The nurse notices that a school-aged child has bluish-white, red-based spots in her mouth that are elevated approximately 1 to 3 mm. What other signs would the nurse expect to find in this patient? a. Pink, papular rash on the face and neck b. Pruritic vesicles over her trunk and neck c. Hyperpigmentation on the chest, abdomen, and back of the arms d. Red-purple, maculopapular, blotchy rash behind the ears and on the face

ANS: D With measles (rubeola), the examiner assesses a red-purple, blotchy rash on the third or fourth day of illness that appears first behind the ears, spreads over the face, and then over the neck, trunk, arms, and legs. The rash appears coppery and does not blanch. The bluish-white, red-based spots in the mouth are known as Koplik spots.