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A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse?! Cerebellum Brainstem Extrapyramidal tract Thalamus

Cerebellum

Increased lumbar curvature, which compensates for the enlarging uterus in pregnant women, is called what? Lordosis Kyphosis Scoliosis Keratosis

Lordosis

What instruction should a nurse give a client when having trouble eliciting a response from testing the patellar deep tendon reflex? "Close your eyes and imagine you are somewhere else." "Place your hands together, lock your fingers, and squeeze." "Clench your teeth and breathe slowly and deeply." "Tighten the thigh muscles of the opposite leg."

"Place your hands together, lock your fingers, and squeeze."

A client is brought to the health care facility with a sudden loss of movement on the right side of the body. Upon assessment, the nurse finds that the client has a slight flicker of contraction in the muscles on the right side. What should the nurse document as the muscle strength rating? 4 3 2 1

1

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. Transition from pustules to moles can indicate psoriasis The appearance of new moles is a sign of vitamin D deficiency. Excessive eccrine sweat gland production can cause the emergence of a new mole.

Changes in existing moles or the appearance of new moles can indicate melanoma.

Risk factors in which of the following areas are most readily changed to reduce the potential risk for falls? Social Cognitive Physiological Environmental

Environmental

What factors contribute to the client's individual makeup? (Select all that apply.) Ethnicity of client Nutrition Genetic composition Geographic location Cultural norms

Ethnicity of client Nutrition Genetic composition Geographic location Cultural norms

After testing deep tendon reflexes, the nurse documents 2+. The nurse should evaluate further. True False

False

A nurse is teaching a class on hypertension in a community setting. What risk factor would the nurse be sure to address to the class? Quitting cigarette smoking 5 years ago Loss of 50 pounds within the last 12 months High cholesterol and low triglyceride levels Family history

Family history

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? Around the mouth and lips Chest and abdomen Fingers and toes Nose and earlobes

Fingers and toes

When testing the biceps reflex, what type of response should the nurse expect if normal? Forearm flexes and supinates Elbow extends and muscle contracts Elbow flexes and muscle contracts Forearm adducts and wrist rotates

Forearm flexes and supinates

During the taking of the health history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this finding as: Subjective Vertigo Syncope Seizure Activity Objective Vertigo.

Objective Vertigo.

Which cranial nerve controls pupillary constriction? Optic Oculomotor Trochlear Trigeminal

Oculomotor

The nurse is testing a client for carpal tunnel syndrome. The client flexes the wrists at an angle of 90° and holds the backs of the hands to each other for 60 seconds. The client tells the nurse that he is experiencing a burning pain as a result. Which test is the nurse performing on this client? Phalen's Tinel's Ballottement McMurray's

Phalen's

During general inspection, the examiner: Assesses for pain and functional ability Integrates visual, auditory, and olfactory data Inquires about the client's occupational environment Ensures the client moves from standing to lying positions

Integrates visual, auditory, and olfactory data

A client comes to the clinic and reports nosebleeds. What area of the nose is the bleeding most likely coming from? Thompson plexus Sinuses Kiesselbach plexus Wharton ducts

Kiesselbach plexus

What is the level of the spinal cord associated with the knee (patellar) deep tendon reflex? S1 L2 to L4 T9 and T10 T11 and T12

L2 to L4

A client diagnosed with arthritis has been taking aspirin and now reports experiencing adverse effects. What adverse effect indicates that a decrease in dose may be necessary? Tinnitus Vertigo Nystagmus Otalgia

Tinnitus

The nurse is teaching at a community clinic. She explains to the clients that what increases the risk for head and neck cancer? Select all that apply. Tobacco products Alcohol Mold Pet dander Pollens

Tobacco products Alcohol

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

UV radiation exposure

Upon assessing the skin, the nurse finds pustular lesions on the face. The nurse identifies that these could be what? Acne Psoriasis Varicella Herpes simplex

Acne

A client seeks medical attention for pain when touching the area of the frontal sinuses. Which should the nurse consider as the reason for this client's symptom? Eye infection Oropharyngitis Acute otitis media Acute bacterial rhinosinusitis

Acute bacterial rhinosinusitis

A 35-year-old archaeologist comes to the office for a regular skin examination. She has just returned from her annual dig site in Greece. She has fair skin and reddish-blonde hair. She has a family history of melanoma. She has many freckles scattered across her skin. From this description, which of the following is not a risk factor for melanoma in this client? Age Hair color Actinic lentigines Heavy sun exposure

Age

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. Wear nonslip shoes in the house. Avoid risky activities such as snowboarding. Use of guns should be supervised by an adult.

Always use seat belts.

A nurse has just finished assessing a client's spine and neck muscles. How would the nurse document normal findings? C8 and T1 spinous processes prominent. Paravertebral, sternocleidomastoid, and trapezius muscles fully developed, symmetrical, and nontender All findings within normal limits Neck assessment WNL C7 and T1 spinous processes prominent. Paravertebral, sternocleidomastoid, and trapezius muscles fully developed, symmetrical, and nontender

C7 and T1 spinous processes prominent. Paravertebral, sternocleidomastoid, and trapezius muscles fully developed, symmetrical, and nontender

Which nutrient deficiency should a nurse recognize as placing a client at risk for osteoporosis? Protein Vitamin C Vitamin D Calcium

Calcium

A nurse observes a client's gait and notes it to be wide based and staggering. The Romberg test results were positive. The nurse recognizes this as what type of abnormal gait? Cerebellar ataxia Parkinsonian gait Spastic hemiparesis Foot drop gait

Cerebellar ataxia

Before completing the physical examination, the nurse determines that the client is awake, alert, and oriented. This information would be important for which part of the general survey? Apparent state of health Facial expression Level of consciousness Posture, gait, motor activity, and speech

Level of consciousness

A nurse inspects a client's 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? Nodule Papule Vesicle Macule

Macule

A client has a 7-mm lesion with irregular borders and color variation that has grown over the last several weeks. The nurse knows that this lesion could possibly be what type of cancer? Melanoma Nevus Angioma Dermatoma

Melanoma

A client presents to the health care clinic with a three (3) day history of fever, chills, neck pain and stiffness, and headache. The nurse observes an elevated temperature of 102.5° F and pain with rotation of the head side to side and decrease ability to flex the head forward. The nurse recognizes these findings as most likely the onset of what infectious process? Meningitis Arthritis Spondylitis Bursitis

Meningitis

A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms? Bell's palsy Tension headache Temporal arteritis Migraine headache

Migraine headache

You are using the Braden Scale to measure risk factors for pressure sores. What risk factors will you assess? Select all that apply. Admitting diagnosis Moisture Age Activity Nutrition

Moisture Activity Nutrition

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: Shotty Large, firm, and fixed to the tissue. Rubbery, discrete, and mobile. Nonpalpable.

Nonpalpable

Loss of bone density that occurs with greatest frequency in postmenopausal women is called? Osteoporosis Scoliosis Kyphosis Lordosis

Osteoporosis

A client comes to the clinic and reports pain when he touches his ear. With what is this finding most consistent? Acoustic neuroma Otitis externa Otitis media Meniere disease

Otitis externa

A college student presents with a sore throat, fever, and fatigue for several days. Exudates are on her enlarged tonsils. A careful lymphatic examination reveals some scattered small mobile lymph nodes just behind her sternocleidomastoid muscles bilaterally. What group of nodes is this? Submandibular Tonsillar Occipital Posterior cervical

Posterior cervical

Which terms refers to the progressive hearing loss associated with aging? Presbycusis Exostoses Otalgia Sensorineural hearing loss

Presbycusis

A 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 Difficulty with swallowing Changes in sleeping habits Stiffness in the right shoulder

Previous injuries to the head and neck

The nurse should ask about or assess which associated factors when a client complains of cluster headaches? Select all that apply. rhinorrhea ptosis miosis lacrimation photophobia

rhinorrhea ptosis miosis lacrimation

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 nodules. bullae. vesicles. wheals.

vesicles.

Lifestyle can play a big part in developing risk factors for stroke. Which of the following can greatly reduce a client's risk for stroke? Select all that apply. Quitting smoking Regularly exercising Maintaining a healthy weight Eating a high-sodium diet Following a sedentary lifestyle

Quitting smoking Regularly exercising Maintaining a healthy weight

A new mother is concerned that her child occasionally "turns blue." On further questioning, she mentions that this occurs at the child's hands and feet. She does not remember the child's lips turning blue. The mother says that the child is eating and growing well. What should the nurse do? Reassure the mother that this is normal. Obtain an echocardiogram to check for structural heart disease and consult cardiology. Admit the child to the hospital for further observation. Question the validity of the mother's story.

Reassure the mother that this is normal.

Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media? Pearly, translucent, with no bulging Yellowish, bulging, with fluid bubbles Gray, translucent, with no retraction Red, bulging, with an absent light reflex

Red, bulging, with an absent light reflex

While obtaining a health history of a 3-month-old infant from the mother, the nurse asks about the infant's ability to suck and grasp the mother's finger. What is the nurse assessing? Intelligence Reflexes Cranial nerves Cerebral cortex function

Reflexes

A client's patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding? Right knee +1; Left knee 0 Right knee +2; Left knee +1 Right knee +3; Left knee +2 Right knee +4; Left knee +3

Right knee +2; Left knee +1

x A client presents at the clinic complaining of a loss of balance. What test should the nurse expect the physician to carry out on a client with a loss of balance? Audiometric test Romberg test Weber test Rinne test

Romberg

A nurse is inspecting a client's gait. Which of the following would indicate an abnormal finding? Toes point out Posture is erect Arms swing in opposition Weight is evenly distributed

Toes point out

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

Turgor

A nurse is testing the range of motion of a client's wrist for supination. Which movement will this involve? Turning the palm of the hand upward Turning the palm of the hand downward Moving the tips of the fingers toward the forearm Moving the tips of the fingers away from the forearm

Turning the palm of the hand upward

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? Insect bites Urticaria or hives Psoriasis Purpura

Urticaria or hives

A family member of a client recovering from a traumatic brain injury asks the nurse what safeguards can be put in place at home to prevent future head injuries. What should the nurse instruct this family member? (Select all that apply.) Use rails on stairs Remove extension cords from high traffic areas Avoid the use of throw rugs Always sit to have a shower Avoid taking medications that cause faintness

Use rails on stairs Remove extension cords from high traffic areas Avoid the use of throw rugs

Which action by a nurse demonstrates the correct technique to use the reflex hammer? Strike the tendon then palpate for a response Instruct the client to tense the muscles before striking Tap the tendon gently to avoid pain and tingling Use rapid wrist movement and strike the tendon

Use rapid wrist movement and strike the tendon

Which cranial nerve is associated with the movement of the uvula? Vagus (CN X) Glossopharyngeal (CN IX) Trigeminal (CN V) Facial (CN VII)

Vagus

A client presents to the health care clinic with reports of difficulty swallowing. Which cranial nerves will provide the nurse with information related to the problem? Select all that apply. Vagus Abducens Trochlear Hypoglossal Spinal accessory Glossopharyngeal

Vagus Hypoglossal Glossopharyngeal

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 Otalgia Tinnitus Otorrhea

Vertigo

Upon examination of a client, the nurse finds a circumscribed elevated, palpable mass containing serous fluid. How should the nurse properly document this finding? Vesicle Papule Wheal Cyst

Vesicle

Which area of the brain integrates the understanding of spoken and written words? Wernicke's area Broca's area Basal ganglia Cerebrum

Wernicke's area

The nurse should make it a priority to assess which client for papilledema? a 45-year-old suspected of experiencing a subarachnoid hemorrhage an 80-year-old diagnosed with chronic open-angle glaucoma a 12-year-old demonstrating a deviated left eye a 56-year-old reporting double vision

a 45-year-old suspected of experiencing a subarachnoid hemorrhage

The nurse is speaking to a group of seniors about health promotion and is preparing to discuss the ABCDEs of melanoma. Which of the following descriptions is correct for the ABCDEs? a = actinic; b = basal cell; c = color changes, esp. blue; d = diameter; 6 mm; e = evolution a = asymmetry; b = irregular borders; c = color changes, esp. blue; d = diameter greater than 6 mm; e = evolution a = actinic, b = irregular borders, c = keratoses, d = dystrophic nails, e = evolution a = asymmetry; b = regular borders; c = color changes, especially orange; d = diameter greater than 6 mm; e = evolution

a = asymmetry; b = irregular borders; c = color changes, esp. blue; d = diameter greater than 6 mm; e = evolution

The nurse is assessing a dark-skinned client who has been transported to the emergency room by ambulance. When the nurse observes that the client's skin appears pale, with blue-tinged lips and oral mucosa, the nurse should document the presence of a great degree of cyanosis. a mild degree of cyanosis. lupus erythematosus. hyperthyroidism.

a great degree of cyanosis.

The nurse has performed the Rinne test on an older adult client. After the test, the client reports that her bone conduction sound was heard longer than the air conduction sound. The nurse determines that the client is most likely experiencing normal hearing. sensorineural hearing loss. conductive hearing loss. central hearing loss.

conductive hearing loss.

A client is concerned because the sclera of the right eye has been pink in color for several days and tearing. What should the nurse suspect is occurring with this client? hyphema anisocoria conjunctivitis exophthalmos

conjunctivitis

The nurse notes that the pupil of a client's left eye constricts when a light is shined into the right eye. How should the nurse document this finding? direct light response present in left eye pupils equal and react to accommodation consensual light response present in left eye consensual light response present in right eye

consensual light response present in left eye

What abnormal physical response should the nurse be prepared to manage after noting pallor in a client? fainting vomiting diarrhea diaphoresis

fainting

When assessing the fundus of the eye, the nurse recognizes which normal characteristic represented in dark-skinned individuals? slightly darker fovea is just discernible no light reflex is visible fundus is grayish brown with a purplish cast the lower field of the fundus has characteristic stripe

fundus is grayish brown with a purplish cast

The nurse would expect to assess which symptoms in a client complaining of migraine headaches? Select all the apply. throbbing photophobia recurrent muscle tension continuous

throbbing photophobia recurrent

Short, pale, and fine hair that is present over much of the body is termed vellus. dermal. lanugo. terminal.

vellus

Which question asked by the nurse is assessing problems with tinnitus? "Do you experience buzzing in your ears?" "Do you ever have problems with balance?" "Have you ever had drainage from your ears?" "In what situations is it hard for you to hear?"

"Do you experience buzzing in your ears?"

A mother brings her 2-month-old daughter in for an examination and says, "My daughter rolled over against the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is something terribly wrong?" The nurse's best response would be: "Your baby may have craniosynostosis, a disease of the sutures of the brain." "That 'soft spot' may be an indication of cretinism or congenital hypothyroidism." "Perhaps that could be a result of your dietary intake during pregnancy." ! "That 'soft spot' is normal, and actually allows for growth of the brain during the first year of your baby's life."

"That 'soft spot' is normal, and actually allows for growth of the brain during the first year of your baby's life."

How many pairs of cranial nerves exit from the brain?

12

The nurse is performing a Braden assessment on a 62-year-old retired man. The nurse documents no impairment in sensory perception, skin usually dry, sitting in chair most of the day with ambulation short distances outside the room three times a day, and making frequent changes in position. The nurse would record those portions of the Braden score as 15 13 11 9

15

Which of the following ratings indicates Poor ROM (range of motion)? 2/5 5/5 1/5 3/5

2/5

A client is able to actively move the right arm against gravity. How should the nurse document this finding using the muscle strength grading scale? 1 2 3 4

3

The nurse recognizes that which client is at greatest risk for the development of skin cancer? 28-year-old Caucasian male who works in a paper mill 45-year-old female with 10 year history of cigarette smoking 15-year-old female with facial freckles 55-year-old male who lived in California for 20 years

55-year-old male who lived in California for 20 years

When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as being at highest risk? 42-year-old Caucasian woman who smokes 68-year-old African American male with hypertension 55-year-old Caucasian male who has two beers a week 35-year-old African American who has sleep apnea

68-year-old African American male with hypertension

Jacob, a 33-year-old construction worker, complains of a "lump on his back" over his scapula. It has been there for about 1 year and is getting larger. He says his wife has been able to squeeze out a cheesy textured substance on occasion. He worries this may be cancer. When gently pinched from the side, a prominent dimple forms in the middle of the mass. What is most likely? An enlarged lymph node A sebaceous cyst An actinic keratosis A malignant lesion

A sebaceous cyst

After a physical assessment, the nurse determines that a client has full range of motion of the temporomandibular joint. Which of the following assessments did the nurse complete with the client? Select all that apply. Asked the client to open and close the mouth Asked the client to jut the jaw forward Asked the client to rock the jaw laterally Asked the client to swallow Asked the client to extend the tongue

Asked the client to open and close the mouth Asked the client to jut the jaw forward Asked the client to rock the jaw laterally

The nursing instructor is discussing the function of sebaceous glands in the body. What would the teacher explain as the purpose of sebum to the students? Assists in keeping the skin intact Assists in friction protection Assists in protection from infection Assists in keeping skin dry

Assists in friction protection

A nurse is teaching a client how to assess her own skin for possible signs of malignant melanoma. Which of the following should the nurse point out as danger signs associated with skin lesions indicating this disease? Select all that apply. Asymmetrical Flat Change in size Itching Bleeding of a mole Regular borders

Asymmetrical Change in size Itching Bleeding of a mole

The nurse is beginning examination of the client. All the following areas are important to observe as part of the general survey except: Apparent age Signs of distress Dress, grooming, and personal hygiene Blood pressure

Blood pressure

During the physical assessment of a client, a nurse observes that the client tends to lean forward, using the arms to support the upper body. The nurse recognizes this as a sign of what disease process? Parkinson disease Osteoporotic thinning Chronic obstructive pulmonary disease Rheumatoid arthritis

Chronic obstructive pulmonary disease

A nurse has completed the general survey of a client who has been transferred to the unit. The information gathered during the general survey primarily provides the nurse with which of the following? Select the 3 answers that apply. A direct link to the client's medical diagnosis Clues about the overall health of the client An indication of the level of physical distress experienced by the client Indications about normal variations in the status of body systems Data relating to the patient's level of social support

Clues about the overall health of the client An indication of the level of physical distress experienced by the client Indications about normal variations in the status of body systems

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? Border regularity Diameter of less than 6 mm Color variation Symmetry of lesions

Color variation

A client has sustained an injury to the cerebellum. Which area would be the primary area for assessment? Vital signs Neurologic system Cardiac function Coordination

Coordination

Which of these medications should a nurse ask a client if they are taking when assessing the risk for osteoporosis? Select all that apply. Corticosteroids Antihypertensives Estrogen replacement therapy Thyroid replacement drugs Rescue inhaler for asthma

Corticosteroids Thyroid replacement drugs

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

Damage to the trigeminal nerve

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands? Dermis Epidermis Subcutaneous layer Connective layer

Dermis

The client has experienced a stroke and has dysphagia. The nurse knows this is what? Difficulty swallowing Painful swallowing Lack of gag reflex Difficulty talking

Difficulty swallowing

An African American client appears to have lumbar lordosis present upon examination of the thoracic and lumbar spine. What should the nurse do in relation to this finding? Report this to the health care provider for possible surgery Document this as a normal variation Ask the client about previous injuries to the spinal area Check to see if the curve lengthens when the client bends forward

Document this as a normal variation

A nurse cares for a client diagnosed with cranial nerve III disorder. What should the nurse expect to find in the client? Inability to close eyes Drooping of eyelids Loss of visual field Swelling of the optic nerve

Drooping of eyelids

The nurse is performing an assessment of a client's musculoskeletal system. What would the nurse examine first? Leg length Cervical range of motion Gait Lateral bending ability

Gait

A six-month old male infant is brought to the emergency department by his parents for inconsolable crying and pulling at his right ear. When assessing this infant the nurse is aware that the tympanic membrane should be what color in a healthy ear? Yellowish-white Red Gray Bluish-white

Gray

What information, acquired during an eye assessment and history, would the nurse document as lifestyle habits? Select all that apply. Has smoked for last 12 years Uses sunglasses when outdoors Uses protective eyewear when appropriate Wears disposable contact lens Eyes itch when in a smoky environment

Has smoked for last 12 years Uses sunglasses when outdoors Uses protective eyewear when appropriate

Which finding should a nurse recognize as normal when assessing the ears of an elderly client? Decrease in cerumen production Shortened earlobes High-tone frequency loss Bulging tympanic membrane

High-tone frequency loss

test for gross motor skill and coordination of a 6-year-old child, which of these techniques would be appropriate? Ask the child to: Touch his finger to his nose Stand on his head Make "funny" faces at the nurse. ! Hop on one foot.

Hop on one foot.

When identifying the midline structures of the neck from the mandible to the sternal notch, the nurse notes the structures in what order? Cricoid cartilage, hyoid bone, tracheal rings, thyroid isthmus Thyroid cartilage, thyroid isthmus, cricoid cartilage, hyoid bone Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid Hyoid bone, tracheal rings, cricoid cartilage, lobes of the thyroid gland

Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid

Which part of the brain controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions and maintains overall autonomic control? Hypothalamus Brain stem Cerebral cortex Medulla

Hypothalamus

The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes? Superficial to the sternomastoid In front of the ear In the midline, a few centimeters behind the tip of the mandible At the angle of the mandible

In the midline, a few centimeters behind the tip of the mandible

A 58-year-old gardener comes to the office for evaluation of a new lesion on her upper chest. The lesion appears to be "stuck on" and is oval, brown, and slightly elevated with a flat surface. It has a rough, wart-like texture on palpation. Based on this description, what diagnosis is most likely? Actinic keratosis Seborrheic keratosis Basal cell carcinoma Squamous cell carcinoma

Seborrheic keratosis

An older adult client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what? Sebum production Sweat glands Subcutaneous tissue Squamous cells

Sebum production

The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition? Severe dehydration Connective tissue disorders such as scleroderma Childhood growth spurts Severe obesity

Severe dehydration

A client presents to the clinic and reports numerous skin tags in the left axillary area. The client is worried about skin cancer. What can the nurse tell the client about skin tags to alleviate fear of cancer? Skin tags are common benign skin lesions Skin tags can turn into skin cancer if they are not removed Skin tags are an early precursor to more serious skin cancer conditions Skin tags need to be removed as soon as possible or they will keep growing

Skin tags are common benign skin lesions

A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis? Tension Migraine Cluster Analgesic rebound

Tension

The nurse is caring for a newly admitted adult client. When performing the general survey of this client, the nurse knows that accurate measurements provide critical information about what? Safety State of health Growth pattern Past surgeries

State of health

During eye examinations, the nurse keeps in mind that movement of the extraocular muscles is: Decreased in the older adult. Stimulated by cranial nerves (CN) III, IV, and VI. Impaired in a patient with cataracts. Stimulated by cranial nerves (CN) I and II

Stimulated by cranial nerves (CN) III, IV, and VI.

Mrs. Fletcher presents to the office with chronic unilateral pain when chewing. She does not have facial or scalp tenderness. Which of the following is the most likely cause of her pain? Trigeminal neuralgia Temporomandibular joint syndrome Temporal arteritis Tumor of the mandible

Temporomandibular joint syndrome

The nurse is preparing to test the sensory cranial nerves. The nerves being tested include (Select all that apply.) olfactory optic acoustic trochlear hypoglossal

olfactory optic acoustic

An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse? The client has chronic hypoxia The client has melanoma The client has COPD The client has asthma

The client has chronic hypoxia

During a general survey, the nurse asks if the client is feeling cold. What did the nurse most likely observe in the client? The client is wearing clothing that is inconsistent with warm weather. The client is bouncing both legs up and down while seated. The client has an oral temperature of 37°C (98.6°F). The client's lips are bluish in color.

The client is wearing clothing that is inconsistent with warm weather

When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources? Noted anatomists The underlying bones Their anatomical positions The underlying vascular network

The underlying bones

On inspection of the spine of a 79-year-old man, the nurse might expect to find a(n) increased thoracic curve increased cervical curve decreased lumbar curve decreased cervical curve

increased thoracic curve

An older client asks why vision is not as sharp as it used to be when the eyes are focused forward. What should the nurse realize this client is describing? cataracts glaucoma detached retina macular degeneration

macular degeneration

A client visits the clinic for a routine physical examination. The nurse prepares to assess the client's skin. The nurse asks the client if there is a family history of skin cancer and should explain to the client that there is a genetic component with skin cancer, especially basal cell carcinoma. actinic keratoses. squamous cell carcinoma. malignant melanoma.

malignant melanoma.

The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses, the nurse should proceed to examine the ethmoidal sinuses. laryngeal sinuses. maxillary sinuses. sphenoidal sinuses.

maxillary sinuses.

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.) notched border diameter great than 6 mm asymmetry pink color

notched border diameter great than 6 mm asymmetry

A dark-skinned client visits the clinic because he "hasn't been feeling well." To assess the client's skin for jaundice, the nurse should inspect the client's abdomen. arms. legs. sclera.

sclera

What task should a nurse ask a client to perform to assess the function of cranial nerve XI? shrug shoulders against resistance move tongue side to side swallow water walk in heel-to-toe fashion

shrug shoulders against resistance

The nurse is going to test range of motion in a client. To test extension of the triceps muscle, the nurse would instruct the client to straighten the elbow bend the elbow turn the palm up turn the palm down

straighten the elbow

What should the nurse assess to test the function of the parietal lobe? impulses from the ear communication tactile sensation ability to read

tactile sensation