PrepU N201 E2

Which vessel is the nurse assessing if the major artery of the neck is being examined?

• Carotid

Why is it important to ask the client regarding discharge or drainage from the eyes?

• Discharge is associated with inflammation or infection

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

• Otoscope

A nurse implements which skin assessment to determine the presence of dehydration in a client?

• Turgor

While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of:

• hypoxia.

The ossicles contained in the middle ear include the malleus, the incus, and the:

• stapes

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's:

vesicles

The nurse tests the distant visual acuity of several clients and records the findings. Which finding indicates that the client with the poorest vision?

• 20/60

A client has sought care because he is concerned that a mole on his scalp may be evidence of skin cancer. Which finding would the nurse identify as being most suggestive of melanoma?

• Asymmetric, irregular borders

A new nurse on the long-term care unit is learning how to assess a patient's risk for skin breakdown. What would be the most likely instrument this nurse would use?

• Braden scale

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

A client visits the health care clinic with reports of itchy and watery eyes for three days. The nurse observes a generalized redness to the conjunctiva. The nurse recognizes this as what condition?

• Conjunctivitis

When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics?

• Consistency, delineation, mobility, tenderness

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.

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

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?

• Extraocular movements

When using the PERRLA acronym, the nurse is assessing which body part(s)?

• Eyes

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?

• Glaucoma

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

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?

• It is likely to be related to her lupus.

Which type of vessels filter pathogens from the body and drain the fluid that has moved outside of the circulation back into the vessels?

• Lymphatic

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?

• Normal tympanic membrane

The clinic nurse is assessing an older adult client who fell. The nurse asks if the client ever feels dizzy or has problems with balance. For what is the nurse assessing?

• Vertigo

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:

• swallow a small sip of water.