200 module 3 & 4

The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. what should be included in these instructions?

Always use seat belts.

An 82-year-old female presents with neck pain, decreased strength and sensation of the upper extremities. The nurse identify is that this could be related to what?

Arthritic changes of the cervical spine

The nurse is preparing to perform a head and neck assessment of an adult client who has immigrated to the United States from Cambodia. The nurse should first

Ask the client if touching the head is permissible Some cultures such as Southeast Asian, prohibit touching the head or touching the feet before touching the head.

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

A new nurse on the long-term care unit is learning how to assess a clients 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

The nurse practitioner auscultate both lobes of a clients enlarged thyroid gland. Identification of what sound would tend to confirm a diagnosis of a toxic goiter?

Bruit

The nurse is palpating a clients cervical vertebrae. Which vertebra can be easily palpated when the neck is flexed and should help the nurse locate the other vertebrae?

C7

And adult client comes to the ED with new onset of pain in his neck and jaw. What system requires emergency assessment?

Cardiovascular Neck pain may be cardiac

A nurse asked the client to describe the pain associated with a headache by reading the pain on a scale from 1 to 10. This subjective data should be documented in which section of the assessment?

Characteristic symptoms

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 asked the nurse where Sweat comes from. The nurse knows that sweat glands are located in which layer of skin?

Dermis

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

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 chemo therapy, the nurse should further assess the client for signs and symptoms of

Hypothyroidism

A client diagnosed with goiter has undergone a thyroid ectomy. Which statement from the client indicates understanding of postoperative care teaching?

I must take thyroid hormone replacement medication for the rest of my life

During your physical examination of the client you note an enlarged tender tonsillar lymph node. What would you do?

Look for a source, such as infection in the area that it drains

A 38 year old accountant comes to the clinic for evaluation of a headache. The throbbing sensation is located in the right temporal region, and is an eight on a pain scale of 1 to 10. It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an over-the-counter analgesic, which results in the resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache?

Migraine

A clients risk for pressure sore development according to the Braden scale is as follows: sensory perception 4, moisture 4, activity 2, mobility 2, nutrition 1, friction and sheer 3. From this assessment, the nurse determines that the clients risk for pressure sore development is

Mild risk.

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 nurses next action?

Notify the healthcare provider immediately.

Why is it important for the nurse to ask the client what they think caused a skin condition?

The client's perception affects the approach and effectiveness in treating the skin condition

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.

The nurse is assessing a client complaining of swelling in the neck. Well palpating the neck, the nurse find a 2 cm lump that is fixed and hard. Why does this finding require emergency investigation?

This could be a sign of cancer

When assessing for apocrine gland function, the nurse would assess for moisture where on the clients body?

Under arms

During the physical examination of a client, a nurse notes that a clients 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

A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what?

carotene

The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions?

distribution The given terms denote anatomic location, or distribution, of skin lesions over the body

To assess an adult clients skin turgor, the nurse should

use two fingers to pinch the skin under the clavicle

A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for six weeks. She was treated for sepsis and respiratory failure and had to be on a ventilator for three weeks. The nurse is completing an initial assessment and evaluating the clients skin condition. On her sacrum there is a 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

A nurse is preparing to examine a client from southeast east Asia who has been experiencing chronic headaches. Which of the following should the nurse do in light of this clients cultural background?

Ask permission before palpating the head and neck

When assessing an adult client experiencing diarrhea, the nurse notes a round moon face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What is the possible cause of these signs?

Cushing's syndrome

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

A nurse visits an older adult client at home in order to conduct a risk assessment for falls. Which factors would most likely increase the risk for falls for this client? SATA

A throw rug in the dining room Bathtubs in all bathrooms A television cord runs across the floor

Where is the temporal artery palpated?

Above the cheek bone near the scalp line

Client reports using pain medication and sitting in a dark room on the onset of a migraine headache. In which part of the subjective section of the physical examination should the nurse document this information?

Relieving factors

A nurse inspects a clients skin and notices several flat, brown color change areas on the forearms. What is the proper term for documentation of this finding by the nurse?

macule A macule is a flat, non-palpable skin color change that may manifest as brown, white, tan, red, or purple. Freckles and port wine birthmarks are examples of a macule.

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 Hirsutism, or facial hair on females, is a characteristic of Cushing's disease and results from an imbalance of adrenal hormones.

And adult female client visits the clinic for the first time. The client has many bruises around her neck and face, and she tells the nurse that the bruises are the result of an accident. The nurse suspects that the client may be experiencing

Domestic abuse

Teenagers doing community service following arrest for driving under the influence are working at the rehabilitation hospital with clients who have paraplegia. These clients have been paralyzed by drunk drivers. How are the nurses who care for these clients best use the time spent with these teenagers?

Educating them about not drinking and driving

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

A client presents at the clinic for a routine check up. The nurse notes that she is dressed and warm clothing even though the temperature outside is 73°. The nurse also notes that the client has gained 10 pounds since her last visit 9 months ago. What might the nurse suspect?

Hypothyroidism

Which of the following assessment findings most likely constitutes a secondary skin lesion?

Keloid formation at the site of an old incision A secondary lesion emerges from an existing primary lesion

When assessing a clients terminal hair distribution, the nurse inspects all of the following areas except

Palmer surfaces

A client complains of recurring headaches that are worse when first waking in the morning and with coughing or sneezing. What would be the nurses most appropriate action?

Perform a focused assessment

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the

areola of the breast. Apocrine glands are small and non-functional until puberty at which time they are activated and secrete a milky sweat

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

Client reports severe pain in the posterior region of the neck and difficulty turning the head to the right. What additional information should the nurse collect?

Previous injuries to the head and neck

A client reports using pain medication and sitting in a dark room on the onset of a migraine headache. In which part of the subjective section of the physical examination should the nurse document this information?

Relieving factors

Connecting the skin to underlying structures is the

Subcutaneous tissue

The nurse is preparing to assess the neck of an adult client. To inspect movement of the clients thyroid gland, the nurse should ask the client to

Swallow a small sip of water

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

Short, pale, and find hair that is present over much of the body is termed

Vellus