Family Health Assessment 1 PREP U (chapters 11,12,13.)

Which of the following scores on the Braden Scale signifies that the client is not at risk for a pressure sore?

- 19 to 23 Levels of risk for developing pressure ulcers are rated according to the following scores: • 19 to 23: not at risk • 15 to 18: mild risk • 13 to 14: moderate risk • 10 to 12: high risk • 9 or lower: very high risk

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

- Acne Pustular lesions include acne, furuncles and carbuncles. Varicella and herpes simplex are vesicular lesions and psoriasis are plaque lesions.

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?

- Auscultate the client's thyroid. The nurse should auscultate the thyroid only if an enlarged thyroid gland is identified during inspection or palpation. Vital signs are not indicated, and the thyroid is never percussed. A swallowing assessment is not likely necessary.

While assessing an adult client's feet for fungal disease using a Wood light, the nurse documents the presence of a fungus when the fluorescence is...

- Blue. Blue-green fluorescence indicates fungal infection.

A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated?

- Compressing the arteries bilaterally The nurse needs to avoid bilateral compression of the carotid blood vessels to prevent reducing the blood supply to the brain. The nurse does not need to avoid having the client flex the neck, ask the client to swallow water, or perform the exam while the client is seated.

A nurse has performed a head and neck assessment of an adult client and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?

- Document this as an expected assessment finding. It is not unusual for the thyroid lobes to be non-palpable using the posterior approach.

The nurse is preparing to test a client's eyes for accommodation. The nurse would have the client focus on an object in which sequence for this test?

- Far, then near. When testing accommodation, the nurse would ask the client to focus on a distant object such as a finger or pencil and to remain focused on that object as the nurse moves it closer to the eyes.

A nurse assesses the parallel alignment of a client's eyes by testing the corneal light reflex. Where should the nurse shine the penlight to obtain an accurate result?

- Focused on the bridge of the nose. When testing the corneal light reflex, the nurse should shine the light toward the bridge of the nose. At the same time, the client is instructed to stare straight ahead. This facilitates a parallel image on the cornea. The eye response upon shining the light toward the eye may interfere with the assessment. The light should not be shined toward the forehead or on an object on the wall.

A client presents to the emergency department after being hit in the head with a baseball bat during a game. The nurse should assess for which condition?

- Hyphema Hyphema is blood in the anterior chamber of the eye, usually caused by blunt trauma. Blepharitis is inflammation of the margin of the eyelid. Chalazion is a cyst in the eyelid. Iris nevus is a rare condition affecting one eye. The latter 3 conditions are not commonly attributed to blunt force trauma to the head as hyphema is.

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, such as the keloids that can emerge from the site of a healed wound.

The nurse is assessing the face of a client with a diagnosis of Parkinson's disease. What would the nurse most likely assess?

- Masklike expression A client with Parkinson's disease often exhibits a masklike face. A sunken face with depressed eyes and hollow cheeks is typical of cachexia. Drooping of one side may suggest a stroke or Bell's palsy. Asymmetry of the earlobes occurs with parotid gland enlargement from an abscess or tumor.

The nurse is performing an assessment of the neck and identifies tracheal deviation. What is the most appropriate response of the nurse?

- Notify the health care provider Tracheal deviation is an emergency and the health care provider should be notified immediately. The client should be provided nursing care and further head and neck assessment along documentation can occur once emergency has subsided.

When testing the near reaction, an expected finding includes which of the following?

- Pupillary constriction on near gaze; dilation on distant gaze. During accommodation, pupils constrict with near gaze and dilate with far gaze.

A nurse is providing care at an inner-city shelter, and a man who frequents the shelter presents with a significant frontal growth that is located midline at the base of his neck. The nurse should recognize the need for what referral?

- Referral for further assessment of thyroid function. A goiter (an enlarged thyroid gland) may appear as a large swelling at the base of the neck. This growth is not suggestive of impaired cranial nerve or lymphatic function, and it does not normally impair swallowing ability.

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?

- Smokeless tobacco use Tobacco use increases the risk of head and neck cancer. The nurse would need to perform a thorough head and neck examination. Alcohol abuse, recreational drug use, or multiple sex partners are not risk factors associated with head and neck cancer.

A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches?

- Stiff neck. Limitation of neck mobility may be from muscle tension/strain or cervical vertebral joint dysfunction.

When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?

- The underlying bones. Regions of the head take their names from the underlying bones of the skull, not from the names of anatomists, anatomical positions, or vasculature.

A nurse is providing care for a client who has decreased mobility secondary to a recent stroke. Which assessment finding would be indicative of a stage I pressure ulcer?

- There is a non-blanching reddened area on the client's coccyx region. Non-blanching erythema is characteristic of a stage I pressure ulcer. Bruising and bleeding are not associated with this stage, and a rash is not normally associated with pressure ulcer development.

A client seeks medical attention for sharp, shooting facial pain that lasts for several minutes at a time. For which health problem should the nurse assess this client?

- Trigeminal neuralgia. Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pain that lasts from seconds to minutes. The pain occurs over the divisions of the fifth trigeminal cranial nerve. A headache associated with a fever or high blood pressure is a cluster headache. Tension headaches are caused by tightening of facial and neck muscles. Migraine headaches are provoked by hormone fluctuations.

meningitis

- inflammation of the meninges of the brain and spinal cord - Dangerous infection of the outer lining of the brain

Chapter 12: Head and Neck, with Basic Vision and Hearing Basics

...

Chapter 13: Eye Assessment for Advanced and Specialty

...

Hypothyroidism in the older adult can be difficult to diagnose. What are some of the reasons it is difficult to diagnose? Select all that apply.

- 1. Subtle onset., 2. Symptoms attributed to the aging process., 3. Chronic diseases.

What medical outcomes are directly associated with a nursing observation made during an integumentary systems assessment? Select all that apply.

- 1. a cancerous skin lesion located on the back, 2. presence of a systemic disease like measles, 3. a rash triggered by taking the medication ibuprofen., 4. A reddened area on the heel that indicates a potential risk for pressure ulcer formation. For the nurse, assessment of the skin is much more than discovering skin lesions or diseases. Examination of the skin can reveal signs of systemic diseases, medication side effects, dehydration, overhydration, or physical abuse; allow early identification of potentially cancerous lesions and risk factors for pressure ulcer formation. The loss of skin turgor attributed to aging is not considered a medical outcome or disease.

The nurse measures a client's pupils and documents the size. Which size would the nurse document as normal?

- 4mm. Pupils are normally equal in size and range from 3 to 5 mm. Size outside this range are considered abnormal.

Braden Scale

- A tool for predicting pressure ulcer risk - sensory perception, moisture, activity, mobility, nutrition, friction and shear - Pressure ulcers lower the number, higher the risk 4-23 less than 17 = risk for pressure ulcers

A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition?

- Corrective lenses. Astigmatism is corrected with a cylindrical lens that has more focusing power in one access than the other. These corrective lenses can and should be worn while driving at night. Eye drops and surgery are not usual treatments for this condition.

A nurse documents which of the following as a normal finding when examining the thyroid gland of an older adult client?

- Nodularity. If palpable, the older adult's thyroid gland may feel more nodular or irregular because of fibrotic changes that occur with aging. The thyroid also may be felt lower in the neck because of age-related structural changes.

A nursing educator is evaluating a colleague's examination of a client's thyroid gland. The educator would determine that the nurse needs additional instruction when the nurse demonstrates which technique?

- Percussion. When examining the thyroid gland, the nurse inspects for enlargement and asymmetry; auscultates for bruits; and palpates for tumors, masses, size, and tenderness. Percussion does not provide meaningful data.

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. Previous head or neck injuries may cause limitations in movement and chronic pain. Change in sleeping habits is too vague to be correct. The other two options may produce pain but not necessarily limit functioning.

What part of the eye receives and transmits visual stimuli to the brain for processing?

- Retina. The retina, which is the innermost layer of the eye, receives and transmits visual stimuli to the brain for processing. The posterior and vitreous chambers of the eye contain aqueous and vitreous humor of the eye. The optic disc, a well-defined round or oval area, is the opening for the optic nerve head.

The nurse is caring for a 63-year-old client who can neither read nor speak English. What would be the appropriate chart to use to assess this client's vision?

- Snellen E. The Snellen E chart can be used for people who cannot read or speak English.

A nurse is palpating the position of the client's trachea. At which anatomic site would the nurse first position a finger for palpation?

- Sternal notch. (a large, visible dip in between the neck in humans, between the clavicles, and above the manubrium of the sternum.) To palpate the trachea, the nurse would first place a finger in the sternal notch and then feel each side of the notch and palpate the tracheal rings.

The middle layer of the eye is known as the

- choroid layer. The middle layer contains both an anterior portion, which includes the iris and the ciliary body, and a posterior layer, which includes the choroid.

While assessing the eye of an adult client, the nurse observes an inward turning of the client's left eye. The nurse should document the client's

- esotropia. Esotropia is an inward turn of the eye.

A client has conjunctivitis. The nurses understand that conjunctivitis differs from conjunctival hemorrhage in that conjunctivitis

- has a watery, mucoid discharge.

A client complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent...

- macular degeneration. Macular degeneration causes deterioration in the center of the retina, which leads to a gradual loss of central vision.

Chapter 11: Skin, Hair, and Nails.

...

An older client is concerned about new senile keratoses appearing on the skin. What should the nurse respond to this client's concern?

- "These are considered a normal age-related change in the skin." Older clients may have skin lesions associated with aging which include senile keratoses. These skin lesions are not considered skin cancer. They do not need to be cleansed and bandaged. They are not treated with medication.

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.)

- 1. asymmetry, 2. diameter greater than 6mm, 3. notched border

The nurse notes that a client has the rash shown on the forearm What should the nurse suspect as the cause for this client's rash?

- Allergic reaction Contact dermatitis occurs as an inflammatory response to an antigen. Contact dermatitis is not caused by low fluid volume, high blood pressure, or an insufficient intake of protein.

A client has anisocoria on examination. Pathological causes of this include which of the following?

- Horner's syndrome. Anisocoria can be associated with serious pathology. Remember to exclude benign causes before embarking on an intensive follow-up. Testing the near reaction in this case may help locate an Argyll-Robertson or tonic (Adie's) pupil.

A mother brings her 4-year-old daughter to the clinic and reports that the child has developed a rash that she is constantly scratching on her abdomen. On examination, the nurse finds that the rash is serpiginous. The nurse would know that the rash is most probably caused by

- Scabies A serpiginous rash is snaking. This type of rash can be caused by scabies.

The nurse should implement which technique when assessing for jaundice in a dark-skinned client diagnosed with liver disease?

- assessing the client's hard palate with a bright light. The nurse should not confuse a normal scleral yellow pigmentation in dark-skinned individuals with jaundice. Rather, the nurse should observe the hard palate with a bright light for jaundice. While it is appropriate to assess for jaundice in the locations identified by the other options, the techniques described are incorrect.

Hair follicles, sebaceous glands, and sweat glands originate from

- dermis The dermis is a well-vascularized, connective tissue layer containing collagen and elastic fibers, nerve endings, and lymph vessels. It is also the origin of sebaceous glands, sweat glands, and hair follicles.

A nurse is caring for a client admitted with neck pain. The client is febrile (having or showing the symptoms of a fever). What is the most likely medical diagnosis for this client?

- meningitis Neck pain associated with fever and headache may signify serious illness such as meningitis and should be carefully evaluated.

Photoreceptors of the eye are located in the eye's

- retina. The innermost layer, the retina, extends only to the ciliary body anteriorly. It receives visual stimuli and sends it to the brain. The retina consists of numerous layers of nerve cells, including the cells commonly called rods and cones. These specialized nerve cells are often referred to as "photoreceptors" because they are responsive to light.

A client tells the nurse that she has difficulty seeing while driving at night. The nurse should explain to the client that night blindness is often associated with

- vitamin A deficiency. Night blindness is associated with optic atrophy, glaucoma, and vitamin A deficiency.

A client describes their frequent headaches as being severe and lasting for days. The client's positive response to what question would most clearly suggest to the nurse that these headaches are migraines?

- "Do you have any visual changes before the headache?" A typical migraine headache has prodromal symptoms that may include visual disturbances, vertigo, tinnitus, and/or numbness or tingling of the fingers and toes. Asking about being tense or anxious would be appropriate to assess for a tension headache. Asking about alcohol or tearing would be appropriate for a cluster headache.

CRANIAL NERVES

- 12 pairs of nerves arising from the brain. - 12 pairs of nerves that carry messages to and from the brain.

A group of students are reviewing the structures of the head and neck in preparation for an examination. The students demonstrate understanding of the material when they identify that the face has how many bones?

- 14 bones. The face has 14 bones: 2 maxilla, 2 zygomatic, 2 inferior conchae, 2 nasal, 2 lacrimal, 2 palatine, 1 vomer, and 1 mandible. The cranium has 8 bones.

Which of the following statements most accurately describes the maintenance of normal intraocular pressure?

- Aqueous humor is continuously circulating through the eye with production equaling drainage. Aqueous humor, produced by the ciliary body, maintains intraocular pressure with production equaling drainage. It is not a closed system, and pressure is not adjusted through muscular control of eye volume.

Recommended protective measures to avoid skin cancer include which of the following?

- Avoiding sun exposure While monthly self-examination and awareness of signs of skin cancer may aide in early detection, only avoiding sun will prevent and protect against skin cancer. Clinical examinations are recommended annually.

An adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses can lead to...

- Corneal damage. Improper cleaning or prolonged wearing of contact lenses can lead to infection and corneal damage

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. A client with hypothyroidism is expected to have dry and rough skin. This is a good example of how the skin can give clues to systemic diseases.

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?

- consensual light response present in left eye. The consensual light response occurs when one eye is exposed to light and the pupil of the other eye constricts. Since the light was shined in the right eye, the left pupil constricted. The left eye was not exposed to direct light. There is not enough information to determine if the pupils are equal or reacting to accommodation.

A client who is an active outdoor swimmer recently received a diagnosis of discoid systemic lupus erythematosus. The client visits the clinic for a routine examination and tells the nurse that she continues to swim in the sunlight three times per week. She has accepted her patchy hair loss and wears a wig on occasion. A priority nursing diagnosis for the client is

- risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions. Because the client has the diagnosis of discoid systemic lupus erythematosus and continues to swim in the sunlight three times per week she is at risk for a health problem. The diagnosis risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions is the most accurate for this client.

The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that..

- squamous cell carcinomas are most common on body sites with heavy sun exposure. Squamous cell carcinoma is most common on body sites with very heavy sun exposure.

A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis( the body's extreme response to an infection.) and respiratory failure and had to be on a ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is 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?

- stage 3 A stage III ulcer is a full-thickness skin loss with damage to or necrosis of subcutaneous tissue that may extend to, but not through, the underlying muscle.

A client reports sharp, shooting, piercing facial pains that last from seconds to minutes. The nurse identifies these as signs and symptoms of which of the following disorders?

- tic douloureux, (also known as trigeminal neuralgia). Trigeminal neuralgia (tic douloureux) is manifested by sharp, shooting, piercing facial pains that last from seconds to minutes. Pain occurs over the divisions of the fifth trigeminal cranial nerve (the ophthalmic, maxillary, and mandibular areas). Signs and symptoms of hyperthyroidism include goiter, increased heart rate and blood pressure, increased appetite, loss of weight, heat intolerance. Bell palsy affects cranial nerve VII, affects one side of the face, and is not painful. A stroke may cause a facial droop that is not painful.

To assess an adult client's skin turgor, the nurse should

- use two fingers to pinch the skin under the clavicle. To assess turgor, gently pinch the skin over the clavicle with two fingers.

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

- vellus. Vellus hair (peach fuzz) is short, pale, fine, and present over much of the body.

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. Vesicles are circumscribed elevated, palpable masses containing serous fluid. Vesicles are less than 0.5 cm. Examples of vesicles include herpes simplex/zoster, varicella (chickenpox), poison ivy, and second-degree burn.

A nurse is teaching a group of 5th grade children about characteristics of the skin. Which of the following should she mention? Select all that apply.

- • Largest organ of the body • Protects against damage to the body from sunlight • Helps make vitamin D in the body • Aids in maintaining body temperature The skin is the largest organ of the body. The skin is a physical barrier that protects the underlying tissues and organs from microorganisms, physical trauma, ultraviolet radiation, and dehydration. It plays a vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis. The heart, not the skin, circulates blood throughout the body. The digestive system, not the skin, is involved in digestion of food

A female client asks a nurse why it seems like her headaches are more severe and longer in duration than male friends who also have migraines. What is the best response by the nurse?

- "Hormones affect the severity of migraine headaches." Women's migraines are often longer in duration than men's, and women report chronic pain more often. These differences can be caused by menstruation, hormonal changes, pregnancy, and menopause (Migraine Research Foundation, 2020). Although people experience different symptoms with migraines, this is not the best response to the client's question. Migraine severity is not related to genetics.

A nurse is working with a client who has a history of headaches. When preparing to assess the client's temporomandibular joint (TMJ), the nurse should provide what instruction?

- "I'm going to put my fingers in front of your ears and ask you to open your mouth wide." To assess the TMJ, place your index finger over the front of each ear as you ask the client to open her mouth. None of the other listed instructions facilitates this assessment.

A 52-year-old client with documented myopia presents to the emergency department because of "spots" floating in their line of vision. What should the nurse respond to the client about this symptom?

- "It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." - "This is a normal change in the eye associated with aging." The nurse should respond with the statement "This is a normal change in the eye associated with aging" because spots or floaters are common among clients with myopia or clients over age 40. These findings are not consistent with cataracts, detached retina, or glaucoma.

A nurse is teaching nursing students about the risks associated with developing head and neck cancers. The nurse determines student understanding when the students make which of the following statements?

- "Most head and neck cancers are linked to smoking." Tobacco use increases the risk of head and neck cancer. Eighty-five percent of head and neck cancers are linked to tobacco use (smoking and smokeless tobacco). Alcohol use is also a risk factor for some head and neck cancers, but this is not the best option. Asbestosis has been found to contribute to head and neck cancers. Chewing tobacco can cause oral, throat cancers.

A client asks, "What does SPF 15 mean when considering a sunscreen?" What information should the nurse use to base the response to this client's question?

- "SPF 15 is the ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B rays." The sun protective factor or SPF is a ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B sunrays. None of the other options present correct information regarding the meaning of SPF 15.

A mother brings her 5-year-old son who is of African descent to the clinic. The mother is concerned about recent changes in her child's hair color from black to a copper-red. What is the best response by the nurse?

- "This could be a sign of malnutrition." Copper-red hair in children of African descent may be a sign of severe protein malnutrition. Changes in hair color from black to copper-red hair in children of African descent is not a normal finding. Hypothyroidism causes patchy, thin hair, not a change in hair color. Folliculitis is an infection of the follicle causing pustules and erythema.

The nurse should make it a priority to assess which client for papilledema?

- -a 45-year-old suspected of experiencing a subarachnoid hemorrhage. Papilledema describes swelling of the optic disc and anterior bulging of the physiologic cup. Increased intracranial pressure is transmitted to the optic nerve, causing edema of the optic nerve. Papilledema often signals serious disorders of the brain, such as meningitis, subarachnoid hemorrhage, trauma, and mass lesions. An enlarged physiological cup suggests chronic open-angle glaucoma. If cranial nerve IV is paralyzed, the left eye will deviate from its normal position in that direction of gaze, and the eyes will no longer appear conjugate, or parallel. Diplopia in adults may arise from a lesion in the brainstem or cerebellum, or from weakness or paralysis of one or more extraocular muscles, as in horizontal diplopia from palsy of cranial nerve (CN) III or VI, or vertical diplopia from palsy of CN III or IV.

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.

- 1. Hyoid bone, 2. Cricoid cartilage Thyroid assessment begins with the identification of relevant landmarks, including the thyroid cartilage, the hyoid bone, and the cricoid cartilage. The sternocleidomastoid muscle, esophagus, and carotid arteries are not landmarked.

What information should the nurse include when documenting the data associated with the physical examination of a client's eyes? Select all that apply.

- 1. Shape and size of the pupils., 2.Appearance of the optic disc. The shape and size of the pupils and appearance of the optic disc should be included when documenting the physical examination of a client's eyes. The presence of double vision, eye trauma, and diagnosis of chronic illnesses should be documented within the eye history.

A comprehensive physical examination of the eye includes tests for which of the following? Select all that apply.

- 1. Visual acuity., 2.Eye muscle function., 3. Internal ocular structures., 4. The external eye A comprehensive physical examination of the eye involves assessment of visual acuity, the external eye, eye muscle function, external ocular structures (including pupil reflexes), and internal ocular structures. The Rinne test is a type of hearing exam.

A nurse is providing care to an 86-year-old client. The nurse identifies which of the following finding(s) as a normal age-related head and neck change? Select all that apply.

- 1. decreased range of motion of the neck, 2. cervical curvature of the spine, 3. Decreased temporal pulse. Normal age-related changes in older clients include decreased range of motion in the neck due to arthritis, increased cervical curvature, decreased temporal pulse, and nodular (not smooth) thyroid. The lumbar is the lower back and is not related to changes in the neck and head.

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV.

- 1.intact, firm skin with redness., 2. ulceration involving dermis., 3. full thickness skin loss., 4. necrosis with damage to underlying muscle.

Which of the following assessment findings suggests a problem with the client's cranial nerves?

- A client's extraocular movements are asymmetrical and she complains of diplopia. Deficits in cranial nerves III, IV, and VI can manifest as impaired extraocular movements or diplopia. Flashes of light are associated with retinal detachment, while intraocular bleeding and cataracts do not have a neurological etiology.

You are assessing visual fields on a client newly admitted for eye surgery. The client's left eye repeatedly does not see your fingers until they have crossed the line of gaze. You would document that the client has what?

- A left temporal hemianopsia. When the client's left eye repeatedly does not see your fingers until they have crossed the line of gaze, a left temporal hemianopsia is present.

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 sound of turbulent blood flow in the thyroid A soft, blowing, swishing sound auscultated over the thyroid lobes is often heard in hyperthyroidism because of an increase in blood flow through the thyroid arteries. Breath sounds and heart sounds are atypical

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 sound of turbulent blood flow in the thyroid. A soft, blowing, swishing sound auscultated over the thyroid lobes is often heard in hyperthyroidism because of an increase in blood flow through the thyroid arteries. Breath sounds and heart sounds are atypical.

A male client can neither turn his head against resistance nor shrug his shoulders. The nurse documents a deficit in the functioning of which cranial nerve?

- Accessory (XI) The eleventh cranial nerve is responsible for muscle movement that permits shrugging of the shoulders by the trapezium muscles and turning the head against resistance by the sternomastoid muscle. The abducens (VI) and trochlear (IV) are involved with eye muscle movement. The hypoglossal (XII) is involved with tongue muscles.

Upon examination of the head and neck of a client, a nurse notes that the submandibular nodes are tender and enlarged. The nurse should assess the client for further findings related to what condition?

- Acute infection. The lymph nodes are enlarged and tender in acute infections. Normally, lymph nodes are not sore or tender and are usually not palpable. Chronic infection causes the nodes to become confluent. In metastatic disease, the nodes enlarge and become fixed in place and are nontender. The lymph node findings may vary in Cushing's disease.

The nurse is inspecting the cornea and lens of an elderly client and notices a white arc around the limbus of the client's eye. The nurse recognizes this condition, common in older adults, as which of the following?

- Arcus senilis. Arcus senilis, a normal condition in older clients, appears as a white arc around the limbus. The condition has no effect on vision. Presbyopia, which is impaired near vision, is caused by decreased accommodation and is a common condition in clients over 45 years of age. Ectropion is when the lower eyelids evert, causing exposure and drying of the conjunctiva. This is a normal finding in the older client. Myopia is impaired far vision. (less)

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

- Arthritic changes of the cervical spine. Arthritic changes in cervical spine may may present in the older adults as neck pain, decreased strength and sensation of the upper extremities. Bacterial thyroiditis has neck swelling and cranial damage may manifest as headaches or tension of the muscles.

An 81-year-old client complains of neck pain and demonstrates decreased range of motion on examination. Which of the following causes should the nurse most suspect in this client?

- Arthritis. Older clients who have arthritis or osteoporosis may experience neck pain and a decreased range of motion. Sudden head and neck pain seen with elevated temperature and neck stiffness may be a sign of meningeal inflammation. Stress and tension may increase neck pain. Neck pain may accompany muscular problems or cervical spinal cord problems.

A nurse assesses a client's pupils for the reaction to light and observes that the pupils are of unequal size. What should the nurse do next in relation to this finding?

- Ask the client about previous trauma to the eyes. Unequal pupil size is termed anisocoria. Often it is a normal finding but it can indicate trauma to the parasympathetic nerve supply to the iris. The nurse should ask the client about previous trauma to the eye to determine whether this is a new finding or new onset. All other options the nurse can do after this is determined.

A nurse palpates a client's cervical lymph nodes and notes the following findings: cervical lymph nodes .6 inches (1.5 cm) in diameter (enlarged), painful, and mobile. What is the best action of the nurse?

- Ask the client if they have experienced any other signs or symptoms. Normally, lymph nodes are either not palpable or they may feel like very small beads. If the nodes become overwhelmed by microorganisms, as happens with an infection such as mononucleosis, they swell and become painful. Lymph nodes greater than 6 inches (1.5 cm) in diameter is an abnormal finding and requires further assessment. If cancer metastasizes to the lymph nodes, they may enlarge but will not be painful. The nurse would further assess the client for other signs or symptoms before notifying the health care provider.

A client reports, "There is something in my left eye that is causing me considerable discomfort." What initial step should the nurse take when everting the client's upper eyelid in order to search for the foreign body?

- Ask the client to look down toward the left cheek. Adequate examination of the eye in search of a foreign body requires eversion of the upper eyelid. The nurse should follow these steps: Instruct the client to look down; get the client to relax the eyes (by reassurance and by gentle, assured, and deliberate movements); raise the upper eyelid slightly so that the eyelashes protrude, and then grasp the upper eyelashes and pull them gently down and forward; place a small stick such as an applicator or a tongue blade at least 1 cm above the lid margin (and therefore at the upper border of the tarsal plate); push down on the stick as you raise the edge of the lid, thus everting the eyelid or turning it "inside out." Do not press on the eyeball itself.

A nurse is preparing to assess the distant visual acuity of a client who wears reading glasses. Which of the following would be most appropriate?

- Ask the client to remove the glasses before testing. When testing distant visual acuity, the nurse should have the client remove the reading glasses, because they blur distant vision. The client would wear his or her glasses during the test if they were not reading glasses. The nurse would still test the client's distant visual acuity. The E chart would be appropriate if the client could not read or has a handicap that prevents verbal communication.

The nurse suspects an enlarged thyroid in a client during the physical examination of the head and neck. What should the nurse do first?

- Ask the client to sip and swallow water. In order to determine if the thyroid gland is enlarged, the first step in the physical assessment is to ask the client to sip some water, extend the neck and swallow. By doing so, the nurse can watch for upward movement of the thyroid gland and determine if the gland is enlarged. Once it confirmed that the thyroid gland is enlarged, it would be the next step for the nurse to listen over the lateral lobes with a stethoscope to detect a bruit. Displacing the trachea would not be part of the assessment; however, the nurse would need to inspect the trachea for deviations that may push it to one side. Assessment of the thyroid gland can be done while the client is sitting up from either an anterior or posterior approach. The assessment cannot be effectively done with the client lying down.

Which technique by the nurse demonstrates proper use of the ophthalmoscope?

- Asks the client to fix the gaze upon an object and look straight ahead. After turning on the ophthalmoscope, the nurse should ask the client to gaze straight ahead and slightly upward. Ask the client to remove glasses but keep contact lens in place. The nurse should use the right eye to examine the right eye & left eye to examine the client's left eye. This allows the nurse to get as close as possible to the client's eye. Begin about 10-15 inches from the client at a 15 degree angle. The nurse should keep the ophthalmoscope still & ask the client to look into the light to view the fovea and macula.

A client complains of excessive tearing of the eyes. Which assessment would the nurse do next?

- Assess the nasolacrimal sac. Excessive tearing is caused by exposure to irritants or obstruction of the lacrimal apparatus. Therefore the nurse should assess the nasolacrimal sac. Inspecting the palpebral conjunctiva would be done if the client complains of pain or a feeling of something in the eye. The client is not exhibiting signs of problems with muscle strength such as drooping, so performing the eye position test, which assesses eye muscle strength and cranial nerve function, is not necessary. Testing the pupillary reaction to light evaluates pupillary response and function of the oculomotor nerve.

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. Fatigue, weakness, and cold sensitivity are symptoms of hypothyroidism. These symptoms are not associated with Cushing's syndrome, hyperthyroidism, or any of the disorders that result in parotid gland enlargement.

A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding?

- At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet. The Snellen chart tests distant visual acuity by seeing how far the client can read the letters standing 20 feet from the chart. The top number is how far the client is from the chart and the bottom number refers to the last line the client can read. A reading of 20/50 means the client sees at 20 feet what a person with normal vision can see at 50 feet. The minus number is the number of letters missed on the last line the client can distinguish.

During the physical examination of a client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiologic cause for this finding is related to what disease process?

- Atelectasis (a complete or partial collapse of the entire lung or area (lobe) of the lung). Atelectasis can cause the trachea to be pushed to one side from its midline position. Endocarditis is an infection in the muscle of the heart, which does not cause the trachea to shift. Bronchitis is an inflammation of the mucous membrane of the bronchial tubes. Tuberculosis is an infection in the lungs. Neither bronchitis nor tuberculosis is responsible for the tracheal shift.

When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles?

- Attempting to roll the structure up and down and side to side. While lymph nodes may be rolled both up and down and side to side, muscles will not move in this manner. The other cited techniques do not differentiate between lymph nodes and muscles.

A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?

- Auscultate with the bell over the lateral lobes. If a nurse palpates an enlargement of the thyroid, auscultation should be performed with the bell of the stethoscope to assess for the presence of a bruit. A bruit is a soft, swishing sound produced because of an increase in blood flow through the thyroid arteries. The nurse should also ask the client about past history of thyroid problems, the findings must be documented, then the health care provider notified once assessment is complete to obtain further orders.

Which assessment technique should a nurse use to assess for the presence of a bruit (vascular sounds resembling heart murmurs.) in a client with hyperthyroidism?

- Auscultation A bruit is a soft, blowing, swishing sound auscultated over the thyroid lobes with the bell of the stethoscope that is often heard in hyperthyroidism because of an increase in blood flow through the thyroid arteries. A bruit can be elicited through auscultation in a client with hyperthyroidism. A bruit cannot be elicited through inspection, palpation, and percussion. Inspection can only reveal swelling of the neck and palpation can indicate only the enlarged mass.

A nurse is preparing to palpate a client's submental lymph nodes. At what anatomic location should the nurse position his or her hands?

- Behind the tip of the client's mandible. The submental lymph nodes are located a few centimeters behind the tip of the mandible. The tonsillar nodes are located at the angle of the mandible, at the anterior edge of the sternomastoid muscle. The occipital nodes are at the posterior base of the skull. The postauricular nodes are behind the ears.

A client presents to a primary care office with a complaint of double vision (diplopia). On questioning, the client claims to have not suffered any head injuries. Which of the following underlying conditions should the nurse most suspect in this client?

- Brain tumor. Double vision (diplopia) may indicate increased intracranial pressure due to injury or a tumor. Vitamin A deficiency is a cause of night blindness. Allergies are usually indicated by burning or itching pain in the eye. Viral infection is usually indicated by redness or swelling of the eye.

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

- C7 The cervical vertebrae (C1 through C7) are located in the posterior neck and support the cranium. The vertebra prominens is C7, which can easily be palpated when the neck is flexed. Using C7 as a landmark will help you to locate other vertebrae.

A nurse is collecting subjective data during a client's eye and vision assessment. When asking the question, "Do you wear sunglasses during exposure to the sun?" the nurse is addressing a known risk factor for what health problem?

- Cataracts. Sun exposure is a risk factor for cataracts but is not noted to influence the development of presbyopia, nystagmus, or glaucoma.

A nurse shines a light into one eye during ocular exam and the pupil of the other constricts. The nurse interprets this as which of the following?

- Consensual response. When a light is shone in one eye, that eye will constrict and the opposite (consensual) eye will also constrict. Shining a light on one eye with the resulting constriction of that eye demonstrates the direct reflex. The optic chiasm is the point where the optic nerves from each eyeball cross. Accommodation occurs when the client moves the focus of vision from a distant point to a near object, causing the pupils to constrict.

A nurse has completed the assessment of an older adult client's head and neck and is now analyzing the assessment findings. Which finding should the nurse attribute to age-related physiological changes?

- Decreased strength of temporal artery pulsations. The strength of the pulsation of the temporal artery may be decreased in the older client. Enlargement of a single thyroid nodule suggests a malignancy and must be evaluated further. Carotid pulses should always be palpable in healthy clients, and tender lymph nodes are a pathologic finding in clients of any age.

A client asks a nurse if any foods promote eye health. What food would the nurse include as a response?

- Deep-water fish. Foods that promote eye health include deep-water fish, fruits, and vegetables (e.g., carrots, spinach).

A nurse examines a client's retina during the ophthalmic examination and notices light-colored spots on the retinal background. The nurse should ask the client about a history of what disease process?

- Diabetes. Exudates appear as light-colored spots on the retinal background and occur in individuals with diabetes or hypertension. Anemia, renal insufficiency, and retinal detachment do not cause this appearance on the retina.

A nurse is inspecting a client's eyelids and eyelashes. Which of the findings would the nurse document as abnormal?

- Drooping of the upper lid. Drooping of the upper lid is ptosis and may be attributed to oculomotor nerve damage, myasthenia gravis, weakened muscle or tissue, or a congenital disorder. It is an abnormal finding. Raised yellow plaques near the inner canthus are a normal variation associated with increasing age and high lipid levels. An upright lower eyelid and white sclera that is not visible above or below the iris are normal findings.

A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis?

- Exophthalmos. In exophthalmos, the eyeball protrudes forward. If it is bilateral, it suggests the presence of Graves' disease, although unilateral exophthalmos could still be caused by Graves' disease. Alternative causes include a tumor and inflammation in the orbit.

When performing the cover test, a nurse notices that the client's left eye turns outward. How should the nurse document this finding in the client's record?

- Exotropia With the cover test, the eyes of the client should remain fixed straight ahead. If the covered eye moves when uncovered to reestablish focus, it is abnormal. If the eye turns outward it is called exotropia. If the uncovered eye turns inward, it is called esotropia. Strabismus is constant malalignment of the eyes. Presbyopia is impaired near vision.

A client's history suggests a need to assess eye muscle strength and cranial nerve function. What assessment should the nurse consequently perform?

- Eye position tests. The eye positions tests evaluates eye muscle strength and cranial nerve function. The corneal light reflex test evaluates muscle weakness. The cover test detects deviations in alignment or strength of the eye. The visual fields test evaluates gross peripheral vision.

Which of the following would a nurse expect to assess in a client with esotropia? (an eye misalignment in which one eye is deviated inward, or nasally)

- Eye turning inward. Esotropia is a term used to describe eyes that turn inward. Exotropia refers to an outward turning of the eyes. Strabismus refers to a constant malalignment of the eyes. Nystagmus refers to oscillating or shaking movement of the eye.

A nurse is preparing a presentation for a local community group about preventing traumatic brain injury. The nurse would discuss which measure as prevention of the leading cause?

- Fall prevention. The leading causes of traumatic brain injury are falls, motor vehicle accidents, strikes by or against objects, and assaults. Therefore the nurse would address measures related to fall prevention.

After teaching a group of students about risk factors for traumatic brain injury, the instructor determines that additional teaching is needed when the students identify which of the following?

- Female gender Risk factors for traumatic brain injury include transportation accidents, violence (often firearms related), falls, male gender, failure to use protective equipment, and participation in contact sports.

What is the most common type of hyperthyroidism?

- Graves disease: is the most common cause; it is an autoimmune disorder in which thyroid-stimulating antibodies cause the thyroid gland to make too much TH (thyroid hormone). Graves' disease, the most common type of hyperthyroidism, is autoimmune and may also be genetic. Cushing's syndrome, moon face, and thyroid cancer are not the most common types of hyperthyroidism.

A nurse begins the eye examination on a client who presents to the health care clinic for a routine examination. What is the correct action by the nurse to perform the test for near visual acuity?

- Have the client hold the Jaeger card 14 inches from the face and read with one eye at a time. Near vision is tested with a Jaeger card, Snellen card, or comparable card), held 14 inches from the face. Have the client cover one eye with an opaque card before reading from top to bottom. Sitting the client in front of the examiner, extending one arm, and slowly move one finger upward until it is seen by both the client and the examiner is a test for gross peripheral vision. If the client wears glasses, they should be left on for the test. Placing the client 20 feet from the chart and record the smallest line the client can read is the test for distant acuity.

A client presents to the health care clinic with reports of a stiff neck for the past 3 days. What objective information can the nurse obtain during the health history using inspection?

- Head position. While collecting history, the nurse would be able to inspect the client to see in what position the head was being held. Range of motion would require the nurse to give the client commands and would be performed during the physical assessment. Neck tenderness and thyroid size would require the use of palpation, not inspection, and would also be covered in the physical assessment portion of the examination.

A nurse needs to assess a client who is experiencing chronic headache to determine how it is affecting her activities of daily living. Which of the following interventions should the nurse implement?

- Headache Impact Test The Headache Impact Test may be used to assess the impact of headache on a client's activities of daily living. A mnemonic assessment tool is used to assess for the character, onset, location, duration, severity, pattern, and associated factors of pain. It does not assess for the effect of pain on the client's activities of daily living. Auscultation is use of a stethoscope to assess the client's blood pressure, heart sounds, or respiration. The family health history portion of the interview is used to assess for health conditions of family members that might help shed light on the client's chief complaint.

What is vital in maintaining vision and a healthy outlook for clients?

- Health education. Nursing education is vital in maintaining vision and a healthy outlook for clients.

When talking to a client before starting the physical exam, the nurse notes that the client consistently tilts her head to one side. What would the nurse examine first?

- Hearing acuity. A head tilted to one side may indicate unilateral vision or hearing deficiency, which should be ruled out before proceeding with the examination. The nurse would not need to evaluate the thyroid gland, mental status, or lymph nodes based on this finding.

When identifying the midline structures of the neck from the mandible to the sternal notch, the nurse notes the structures in what order?

- Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid. The midline structures of the neck include (1) the mobile hyoid bone just below the mandible; (2) the thyroid cartilage, readily identified by the notch on the superior edge (larger in males than in females); (3) the cricoid cartilage; (4) the tracheal rings; and (5) the thyroid gland.

While the nurse is assessing a client for an unrelated health concern, the client experiences a sudden, severe headache with no known cause. He also complains of dizziness and trouble seeing out of one eye. What associated condition should the nurse suspect in this client?

- Impending stroke. A sudden, severe headache with no known cause may be a sign of impending stroke, particularly if accompanied by sudden trouble seeing in one or both eyes or sudden trouble walking, dizziness, and loss of balance or coordination. Only impending stroke is associated with all of these symptoms. Diabetes is not associated with headache or the other symptoms. A tumor-related headache is aching and steady and not necessarily associated with sudden onset. Hyperthyroidism is associated with goiter, bruit, and sudden weight loss, but not with any of the symptoms listed.

The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes?

- In the midline, a few centimeters behind the tip of the mandible The submental lymph nodes are located near the midline, a few centimeters behind the tip of the mandible. Superficial cervical lymph nodes are located superficial to the sternomastoid. The preauricular lymph nodes are located in front of the ear. The tonsillar lymph nodes are located near the mandible.

The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes?

- In the midline, a few centimeters behind the tip of the mandible. The submental lymph nodes are located near the midline, a few centimeters behind the tip of the mandible. Superficial cervical lymph nodes are located superficial to the sternomastoid. The preauricular lymph nodes are located in front of the ear. The tonsillar lymph nodes are located near the mandible.

A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test near visual acuity using a Jaeger reading card?

- Instruct the client hold the chart 14 inches from the eyes. To test near visual acuity, the nurse should have the client hold the chart 14 inches from the eyes. The Snellen chart should be kept at eye level, 20 feet away on the wall when testing for distant vision. An arms length is an arbitrary length depending on the size of the client and is not an accurate method for testing. The chart should not be placed on a table 17 inches away from the client.

A nurse is presenting a class to a local community about vision and eye health. As part of the presentation the nurse explains how visual perception occurs. Which of the following would the nurse include in the explanation?

- Involves light rays striking the retina. Visual perception occurs as light rays strike the retina, where they are transformed into nerve impulses, conducted to the brain through the optic nerve, and interpreted. Visual fields refer to what a person sees with one eye. The pupillary light reflex is a protective reflex that prevents damage to the delicate photoreceptors by excessive light. Accommodation is the process that allows the eyes to focus on near objects.

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?

- Iron deficiency anemia. Spoon nails or nails that are thin and concave are associated with iron deficiency, not vitamin A deficiency, peripheral vascular disease, or diabetes mellitus.

A client reports an area of distortion when looking at the Amsler chart. What does this finding indicate to the nurse?

- Macular degeneration, The Amsler chart is used to assess for macular degeneration. Any areas of distortion should be marked on the chart and reported to the health care provider. This chart is not used to assess for glaucoma, a detached retina, or cataract formation.

As the nurse palpates the lymph nodes of the neck, hard and fixed nodes are noted in the supra-clavicular region. This finding is consistent with which condition?

- Malignancy (the state or presence of a malignant tumor; cancer). Hard or fixed nodes, particularly in the supra-clavicular region of the neck, suggest a malignancy. This could even be a possible metastasis of a thoracic or abdominal malignancy. Although inflamed or enlarged nodes may be tender on palpation, the node should still be mobile. In hypothyroidism, the thyroid gland may be enlarged, but discovering hard or fixed nodes warrants further assessment for malignancy.

A client presents to the emergency department with reports of neck pain and a sudden onset of a headache. Upon examination, the nurse finds that the client has an increased temperature and neck stiffness. The nurse recognizes these findings as most likely to be caused by what condition?

- Meningeal inflammation. Meningeal inflammation is a likely cause of this condition, which manifests as sudden headache, neck pain with stiffness, and fever. Migraine headaches are accompanied by nausea, vomiting, and sensitivity to noise or light, not by fever and neck stiffness. Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pains that last from seconds to minutes. Parkinson's disease is not manifested by headache and neck pain.

A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms?

- Migraine headache. Migraine headaches are usually located around the eyes, temples, cheeks, and forehead. They are often accompanied by nausea and vomiting. Bell's palsy is a one sided facial paralysis caused by inflammation of the facial nerve. A tension headache usually presents with stress, anxiety, or tension and is located in the frontal, temporal, or occipital region. Temporal arteritis produces pain around the temple but no nausea or vomiting.

When preparing to provide education regarding the prevention of head injuries from motor vehicle accidents, the nurse should be sure to include which point?

- Mobile phones should only be used if there is a hands-free option available. Only hands-free mobile phones can be used when driving, and text messaging is prohibited due to the risk for distraction. Small children should only sit in the back of the motor vehicle, especially if there is a passenger side airbag. Only medications with side effects such as fainting or dizziness should be avoided. Helmets should always be worn when riding motorcycles, all-terrain vehicles, motorized scooters, bicycles, horses, and snowmobiles.

Which risk factor for traumatic brain injury should a nurse include in a discussion about prevention for a group of adolescents?

- Modes of transportation are the leading cause. All modes of transportation, such as motor vehicle & bicycles, are the leading cause of traumatic brain injuries for people age 5 to 64 years. Males have twice the risk of females. Firearm injuries are high in the violence category and two thirds are suicidal in intent. Fall occur most frequently in the over 65 years of age population.

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?

- Monthly Coupled with a yearly skin examination by a doctor, a client should examine his or her skin every month to detect early warning signs of the three main types of skin cancer.

The nurse observes a young client holding a newspaper up close to read. Which condition does the nurse suspect this client suffers from?

- Myopia. Myopia is nearsightedness, meaning the client can see objects better up close. Asthenopia is eye strain, and symptoms include fatigue, red eyes, eye pain, blurred vision, and headaches. Hyperopia is farsightedness. Presbyopia commonly occurs naturally due to the aging process; therefore it's rare to observe this condition in young adults.

A nurse assesses a client's pupillary reaction and observes pinpoint pupils. The nurse interprets this finding as suggesting which of the following?

- Narcotic use. Pinpoint pupils suggest narcotic use or brain damage. Hyphema would suggest recent eye trauma. Dilated and fixed pupils typically result from central nervous system injury, circulatory collapse, or deep anesthesia.

During adolescence, what vision change is common?

- Nearsightedness. Vision changes, such as nearsightedness, are common in adolescents. Amblyopia is also known as "lazy eye". This is more common in young children. Presbyopia is the decreased ability for one to focus on near objects and is more common in the adult as they age. Color blindness is a genetic condition and not impacted by the age of the client.

A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes?

- Nonreaction of the opposite pupil to light. When a light is shone into the eyes, both the pupil that receives direct light and the consensual (opposite) pupil should constrict. An abnormal response to this test is if wither or both pupils do not constrict in response to light. Pupils do not dilate in response to light shone into them. Convergence of the eyes is called accommodation & occurs when a person moves his focus of vision from a far object to a close object.

A client reports sudden head and neck pain with stiffness, a new sensitivity to light, and has developed a fever. What is a priority action of the nurse?

- Notify the health care provider. Sudden head and neck pain seen with elevated temperature and neck stiffness may be a sign of meningeal inflammation. These findings need to be reported to the health care provider immediately in order for steps to be taken that will determine the cause of the meningeal inflammation, for example, bacterial or viral meningitis. The nurse may administer acetaminophen for the pain, but this is not a priority. The nurse will document the findings and continue to monitor the client but notifying the health care provider is the priority action that is needed to ensure the safety of the client and others.

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 nurse's next action?

- Notify the healthcare provider immediately. Temporal arteritis is a painful inflammation of the temporal artery. Clients report severe unilateral headache sometimes accompanied by visual disturbances. This condition needs immediate care

The nurse is performing a cardinal fields of gaze test on a client who has an inner ear infection. What would be an expected finding?

- Nystagmus. Nystagmus may be associated with an inner ear disorder. Strabismus or tropia would refer to a constant malalignment of the eyes due to a muscle weakness detected with the corneal light reflex test. Phoria describes a drifting of the eyes due to a mild muscle weakness and is detected only with the cover test.

A nurse has completed the assessment of a client's direct pupillary response and is now assessing consensual response. This aspect of assessment should include which action?

- Observing the eye's reaction when a light is shone into the opposite eye. The nurse assesses consensual response at the same time as direct response by shining a light obliquely into one eye and observing the pupillary reaction in the opposite eye. This does not involve a comparison between maximum and minimum pupil size, however. Neither eye is covered, and peripheral vision is not relevant to this assessment.

The nurse performs the action shown when assessing a client's eyes. What is the nurse assessing?

- Ocular alignment. The assessment pictured is the cover test. The cover test assesses ocular alignment. The Jaeger chart is used to assess near vision. The Snellen chart is used to assess distant vision. Ishihara cards are used to assess color discrimination.

The nurse is preparing to palpate a client's temporal artery. The nurse would place the hands at which location?

- On each side between the top of the ear and the eye. The temporal artery is located between the top of the ear and the eye. The submandibular glands are located inferior to the mandible, underneath the base of the tongue. The parotid glands are located on each side of the face, anterior and inferior to the ears. The internal jugular and carotid arteries are located bilaterally, parallel and anterior to the sternomastoid muscle.

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse?

- Open the mouth While performing the assessment of the temporomandibular joint, the nurse should ask the client to open the mouth. This gives an easy access to the joint. Telling the client to sit upright and not move helps in performing the overall examination; however, it does not contribute to the examination of the temporomandibular joint. Telling the client to perform a chewing action is not appropriate.

When performing a client's ophthalmoscopic exam, the nurse observes a round shape with distinct margins. How would the nurse document this finding?

- Optic disc. The optic disc is round to oval with sharp, well-defined borders. The physiologic cup appears on the optic disc as slightly depressed and a lighter color than the disc. Arteriole retinal vessels appear bright red, and venules appear darker red and larger, with both progressively narrowing as they move away from the optic disc. The fovea is a small area of the retina that provides acute vision.

When performing an ophthalmoscopic exam, a nurse observes a round shape with distinct margins. The nurse would document this as which of the following?

- Optic disc. The optic disc is round to oval with sharp, well-defined borders. The physiologic cup appears on the optic disc as slightly depressed and a lighter color than the disc. Arteriole retinal vessels appear bright red, and venules appear darker red and larger, with both progressively narrowing as they move away from the optic disc. The fovea is a small area of the retina that provides acute vision.

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?

- Oral mucosa Central cyanosis results from a cardiopulmonary problem. The oral mucosa is normally pink. When a bluish discoloration exists, it may indicate systemic hypoxemia. Peripheral cyanosis that results from vasoconstriction would most likely be noted in the nail beds and conjunctival areas. Central cyanosis cannot be determined by inspection of the sclerae or palms.

An adolescent shows the nurse a "bump" on his neck. The nurse observes a raised, erythematous, solid 0.3-cm by 0.2-cm mass. How would the nurse document this finding?

- Papule A papule is a solid, elevated, circumscribed skin lesion that does not contain serous or purulent fluid. A macule is a flat nonpalpable skin color change usually less than 1 cm in size. A nodule is an elevated solid palpable mass between 0.5 to 2 cm in size. A pustule is pus-filled vesicle or bulla (circumscribed elevated mass).

A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client's symptoms?

- Parkinson's disease. This is a typical description for a client with Parkinson's disease. Facial mobility is decreased, which results in a blunt expression or a "masked" appearance. The client also has decreased blinking and a characteristic stare with an upward gaze. Combined with the findings of slow movements and a shuffling gait, the diagnosis of Parkinson's is highly likely.

On a health history, a client reports no visual disturbances, last eye exam being 2 years ago, and not wearing glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next?

- Perform both the distant and near visual acuity tests. The first thing the nurse should do is perform both the distant and near visual acuity exams to assess for loss of far and near vision. Testing the pupil is important to assess reaction to light. The findings must be documented in the client's record. If abnormalities are found upon assessment, the client should be referred for a complete eye examination.

A nurse assesses the pupillary reaction to light for a client who has lost vision in one eye. Which precaution should the nurse follow to get an accurate result of consensual response?

- Place an opaque card in between the eyes of the client. The nurse should place an opaque card in between the eyes of the client when assessing the client for consensual response to avoid inaccurate results. The light should not be focused directly into the eye to be tested; it should be focused obliquely into one eye, and the response should be checked in the other eye. The client should not be instructed to close the other eye not focused with light because the response is checked in the other eye.

The nurse observes a middle-aged colleague fully extending her arm to read the label on a vial of medication. Which of the following age-related changes is the nurse likely to have observed?

- Presbyopia. Presbyopia denotes an age-related deficit in close vision. It is less likely that cataracts, macular degeneration, or loss of convergence underlie the colleague's visual changes.

During a health history, a 48-year-old client states, "I've noticed that I need to hold my newspaper farther away so that I can read it." Which of the following would the nurse suspect?

- Presbyopia. Presbyopia is indicated when the client moves an object away from the eyes to focus. It is a common condition in clients over age 45. Myopia is impaired far vision. Cataracts typically are associated with painless blurring, light sensitivity, poor night vision, and a need for a brighter light to read. Tropia refers to a misalignment of the eyes.

A nurse notices a middle-aged client in the waiting room pick up a magazine to read while she waits to be seen. She opens the magazine and then extends her arms to move it further from her eyes. Which condition does the nurse most suspect in this client?

- Presbyopia. Presbyopia, which is impaired near vision, is indicated when the client moves a reading chart or other reading material away from the eyes to focus on the print. It is caused by decreased accommodation and is a common condition in clients over 45 years of age. With the cover test, the eyes of the client should remain fixed straight ahead. If the covered eye moves when uncovered to reestablish focus, it is abnormal. If the eye turns outward it is called exotropia. If the uncovered eye turns inward, it is called esotropia. Strabismus is constant malalignment of the eyes.

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions?

- Psoriasis, fungal infections, trauma Additional nail problems include psoriasis, fungal infections, and trauma. Vitiligo, vitamin deficiency, eczema, melanoma, and herpes zoster are skin conditions. Hirsutism and alopecia are hair conditions. Vitamin deficiencies and chemotherapy can cause problems with many body systems.

A young adult client has just had X-rays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for ne328xt?

- Range of motion of the neck. Musculoskeletal injury or disease can be confirmed with an X-ray, CT, or MRI. If test results are negative, the nurse should assess for complete range of motion of the neck, looking for any muscle tension, loss of mobility, or pain. According to the scenario, the nurse would not assess for headache, shortness of breath, or ROM of the arms and shoulders next.

The nurse suspects that a client has Cushing's syndrome. What assessment finding did the nurse use to make this clinical determination?

- Red cheeks. The increased adrenal cortisol production of Cushing syndrome produces a round or "moon" face with red cheeks. A mask-like face is associated with Parkinson's disease. Swelling around the eyes is associated with nephrotic syndrome. An elongated prominent forehead is associated with acromegaly.

A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. The client states that he almost ran into a parked car yesterday because he misjudged the distance from the bumper of his own car. He works for a computer software company and has noticed he is experiencing difficulty reading the manuals that accompany the software he installs for companies. What nursing diagnosis can the nurse confirm based on this data?

- Risk for Injury. The only nursing diagnosis that can be confirmed with these data is Risk for Injury. The client is aware of the dangers of driving due to changes in his vision. There is not enough data to support the other diagnoses.

A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved?

- Sternocleidomastoid The sternomastoid muscle rotates and flexes the head, whereas the trapezius muscle extends the head and moves the shoulders. The masseter and temporalis muscles are involved in raising and lowering the mandible during mastication (chewing).

A 15-year-old high school student presents to the emergency department with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On physical examination, the pupils are equal, round, and reactive to light with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. Based on this description, what is the most likely diagnosis?

- Subconjunctival hemorrhage. A subconjunctival hemorrhage is a leakage of blood outside of the vessels, which produces a homogenous, sharply demarcated bright red area; it fades over several days, turns yellow, then disappears. There is no associated eye pain, ocular discharge, or changes in visual acuity; the cornea is clear. Many times it is associated with severe cough, choking, or vomiting, which increase venous pressure. It is rare for a serious condition to cause it, so reassurance is usually the only treatment necessary.

A nurse has completed an assessment of a client's lymph nodes. Which of the following data would the nurse document as an abnormal finding?

- Tender. A lymph node that is tender is an abnormal finding suggesting acute infection. Size less than 1 cm, mobile, and discrete indicate normal findings.

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 Headache. This is a description of a typical tension headache.

The nurse prepares to assess the anterior triangle of a client's neck. Where should the nurse palpate this area on the diagram?

- The anterior triangle is located in the area below the mandible, lateral to the sternocleidomastoid (each of a pair of long muscles that connect the sternum, clavicle, and mastoid process of the temporal bone and serve to turn and nod the head.) muscle and medial to the midline of the neck.

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

- The client and the examiner see the examiner's finger at the same time. The observation that the client and examiner see the examiner's finger at the same time indicates normal peripheral vision. The client not seeing the examiner's finger and a delay in seeing indicates reduced peripheral vision. Client's consensual pupils constrict in response to indirect light as well as direct light shown into the client's pupils resulting in constriction is observed when testing the pupils for reaction to light. Eyes converge on an object as it is moved towards the nose tests for accommodation.

A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?

- The lacrimal apparatus: (which consists of the lacrimal gland, punctum, lacrimal sac, and nasolacrimal duct) protects and lubricates the cornea and conjunctiva by producing and draining tears.

The nurse is caring for a client who comes to the clinic reporting a lump by her ear. What are the symptoms of a cancerous lymph node?

- The node is fixed and rubbery Lymph nodes larger than 1 cm, fixed, irregular, hard, or rubbery require emergency investigation. Such signs raise the possibility of cancer.

The nurse is assessing a client's thyroid by having the client swallow a small sip of water. What will the nurse document as an expected finding?

- The thyroid cartilage and cricoid cartilage move upward symmetrically. When inspecting movement of the neck structures, the nurse will ask the client to swallow a small sip of water. The thyroid cartilage and cricoid cartilage should move upward symmetrically while the client swallows. Asymmetry in the movement of the neck structures, the appearance of asymmetry, and difficulty swallowing during the exam are abnormal findings.

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. Whenever a lymph node is enlarged or tender, the nurse should assess for infection in the area that the particular nodes drain. Thyroid or muscular involvement is less likely, and infection does not likely underlie the nodes directly.

A nurse assesses the vision of an older adult client with a long history of uncontrolled type 2 diabetes. The nurse determines the client's vision with corrective lenses is 20/200. How should the nurse interpret these findings?

- These findings indicate the client is legally blind. A client is considered legally blind when vision in the better eye with corrective lenses is 20/200 or less. In this case the client has to be only 20 feet away from an object to see it when others can see the same object from 200 feet. The Snellen chart is used to test distant visual acuity; the higher the second number the more impaired the vision. Even though vision does decrease as people age, 20/200 is not a normal finding. The client may need a new pair of glasses but this is not the best response. Because the client is an older adult and diabetic, they are at higher risk for macular degeneration, but this is not the best option. Macular degeneration causes a loss of central vision; it does not necessarily affect distant visual acuity.

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

- This could be a sign of cancer. Lymphatics larger than 1 cm, fixed, irregular, or hard or rubbery require emergency investigation. Such signs raise the possibility of cancer. The signs and symptoms cited in the scenario do not indicate pneumothorax, embolus, or parotid stone.

During the health history, a client describes recent episodes of intermittent facial pain lasting several minutes. The nurse should recognize that this complaint is suggestive of what health problem?

- Trigeminal neuralgia. Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pain that lasts from seconds to minutes. Migraine headache is characterized by pain around the eyes, temples, cheeks, or forehead. Meningitis would be manifested by sudden head and neck pain, with fever and neck stiffness. Temporomandibular joint dysfunction is manifested by limited range of motion, swelling, tenderness, or crepitation in the jaw area.

A nurse is going to inspect and palpate a client's head and neck. After asking the client to remove the wig, what should the nurse do next?

- Wash hands. If the client is wearing a wig or hairpiece, the nurse asks him or her to remove it. The nurse then washes the hands. The client is usually seated, facing the examiner. The nurse can instruct the client to report any discomfort as the nurse performs the different parts of the head and neck examination. The nurse would don gloves if the client has an open lesion or wound.

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?

- Wood's light. The nurse should inspect the lesion under Wood's light to confirm the presence of fungus on the lesion. Wood's light is an ultraviolet light filtered through a special glass that shows a blue-green fluorescence if the lesion is due to fungal infection. The lesion can be inspected in sunlight and artificial light, but it may not indicate the type of infection in the lesion. Lesions cannot be inspected properly using a flashlight.

The nurse is performing a physical examination and notes an enlarged left supraclavicular lymph node. The nurse understands that this could be indicative of...

- a metastasis (The spread of cancer cells from the place where they first formed to another part of the body).

The functional reflex that allows the eyes to focus on near objects is termed...

- accommodation reflex Accommodation is a functional reflex allowing the eyes to focus on near objects. This is accomplished through movement of the ciliary muscles, causing an increase in the curvature of the lens.

A nurse performs a comprehensive assessment on a client. The nurse observes the following findings: enlarged hands, feet, and facial features (nose, ears). Which of the following disorders do these findings indicate?

- acromegaly Acromegaly is characterized by enlargement of the facial features (nose, ears) and the hands and feet. Parkinson disease is caused by decreased dopamine manifests with rigidity, bradykinesia, postural instability (slow, jerky movements), cogwheel gait, shuffling, and mask-like facies. Cushing syndrome may present with a moon-shaped face, reddened face, and increased facial hair. Scleroderma is an autoimmune disorder that can cause changes in the skin, blood vessels, muscles, and internal organs; skin may be tight and hard on the face and hands.

The nurse is planning to assess an adult client's thyroid gland. The nurse should plan to

- approach the client posteriorly. To palpate the thyroid, use a posterior approach. Stand behind the client and ask the client to lower the chin to the chest and turn the neck slightly to the right.

A factory worker has presented to the occupational health nurse with a small wood splinter in his left eye. The nurse has assessed the affected eye and irrigated with warm tap water, but the splinter remains in place. What should the nurse do next?

- arrange for the worker to be promptly assessed by an eye specialist. The nurse should refer the client to an eye doctor immediately if a foreign body cannot be removed with gentle washing. Optometrists are specialists in primary vision care and do not normally treat eye trauma. Irrigation with hydrogen peroxide or attempted removal using instruments would be contraindicated and potentially dangerous.

A client is brought to the emergency department via ambulance after experiencing difficulty speaking and weakness in the left arm and leg. The nurse understands that the client is most likely experiencing which of the following disorders?

- cerebrovascular accident. Sudden trouble seeing or visual disturbances in one or both eyes or sudden trouble walking, dizziness, or loss of balance or coordination may be a sign of an impending stroke. Sudden weakness or numbness in the face, arms, or legs—especially on one side of the body—may indicate an impending stroke. Bell palsy affects cranial nerve VII, affects one side of the face, and is not painful. Temporal arteritis is an acute urgent condition seen when the temporal artery is hard, thick, and tender with inflammation, as seen with temporal arteritis (inflammation of the temporal arteries that may lead to blindness). Trigeminal neuralgia (tic douloureux) is manifested by sharp, shooting, piercing facial pains that last from seconds to minutes.

A nurse is performing a focused visual assessment on a client. The nurse assesses the pupillary response with a pen light. Both of the client's pupils immediately constrict when the light is shone into the right pupil. How should the nurse document this finding?

- consensual reflexes observed. When exposed either directly or indirectly to light, pupils will constrict; the term consensual means that constriction occurs in both eyes when light is only shown into one eye. Oscillating or shaking of an eye is referred to as nystagmus. Accommodation is tested by having the client focus their vision on something distant and then a near object, which causes the pupils to constrict. A wisp of cotton is used to test corneal reflex, which stimulates a blink in both eyes when the cotton touches the eye.

A nurse inspects the eyes of a young child and notices the inward turning of the eyes. What test should the nurse perform to assess whether this finding is normal or abnormal?

- corneal light reflex In young children the pupils will often appear at the inner canthus due to the epicanthic fold. To test for corneal light reflex the nurse shines a penlight about 12 inches from the face, directing it towards the bridge of the nose. The reflection of light on the cornea should be in the exact same spot on each eye. If not, this is considered abnormal & requires further assessment. The cover test does not test extraocular muscle function. The confrontation test examples peripheral vision. Pupillary reaction to light test constriction of pupil, not alignment

The nurse has tested the near visual acuity of a 45-year-old client. The nurse explains to the client that the client has impaired near vision and discusses a possible reason for the condition. The nurse determines that the client has understood the instructions when the client says that presbyopia is usually due to

- decreased accommodation. Presbyopia (impaired near vision) is indicated when the client moves the chart away from the eyes to focus on the print. It is caused by decreased accommodation.

A client reports slight swelling and tightness at the base of their neck. The nurse palpates the client's throat and neck and determines the thyroid gland is enlarged. What medical term will the nurse use when charting this finding?

- goiter explanation: The term used to describe an enlarged thyroid gland is goiter. A goiter may be seen in hyperthyroidism and hypothyroidism. Additional assessments will be required to determine the client's underlying condition causing the goiter, so it is not appropriate for the nurse to chart this finding as hyperthyroidism or hypothyroidism until further assessments are completed. Iodine deficiency is the primary cause of an enlarged thyroid gland, but such a deficiency has not yet been established, so it is not appropriate for the nurse to chart the finding as iodine deficiency.

A client presents at the clinic for a routine check-up. The nurse notes that she is dressed in warm clothing even though the temperature outside is 73°F (22.8°C). The nurse also notes that the client has gained 10 pounds (4.5 kg) since her last visit 9 months ago. What might the nurse suspect?

- hypothyroidism Intolerance to cold, preference for warm clothing and many blankets, and decreased sweating suggest hypothyroidism; the opposite symptoms, palpitations, and involuntary weight loss suggest hyperthyroidism.

The nurse is using the ophthalmoscope to examine the client's eyes. The nurse holds the scope

- in the right hand for the right eye and in the left hand for the left eye.

A client with a zosteriform rash has a rash that...

- is distributed along a dermatome A zosteriform rash is distributed along a dermatome (an area of skin that is mainly supplied by a single spinal nerve).

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?

- macular degeneration Macular degeneration causes a loss of central vision. Risk factors for macular degeneration are age, smoking history, obesity, family history, and female gender. Cataracts are characterized by cloudiness of the eye lenses. Glaucoma is an increase in intraocular pressure that places pressure on eye structures and affecting vision. A detached retina is the sudden loss of vision in one eye. This health problem may be precipitated by the appearance of blind spots.

A client reports having a headache. The nurse performs a specialized focused assessment and notes the following: client rates pain 10 on a scale of 1 to 10 (10 being the worst), nauseated and vomited, reporting sensitivity to noise and light. The nurse determines that the client is most likely experiencing which of the following types of headache?

- migraine Migraine headaches are accompanied by nausea, vomiting, and sensitivity to noise or light. A sinus headache is deep, constant, throbbing pain, with pressure-like pain in one specific area of face or head (e.g., behind eyes) and the face being tender to the touch. A cluster headache has stabbing pain and may be accompanied by tearing, eyelid drooping, reddened eye, or runny nose. A tension headache is dull, tight, and diffuse.

The optic nerves from each eyeball cross at the

- optic chiasma At the point where the optic nerves from each eyeball cross—the optic chiasma—the nerve fibers from the nasal quadrant of each retina (from both temporal visual fields) cross over to the opposite side.

The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first?

- preauricular. The lymph nodes in front of the ear, or preauricular, are usually palpated first. The submental nodes are under the chin. The supraclavicular nodes are located near the clavicle and sternocleidomastoid muscle. The superficial cervical nodes are located superficial to the sternocleidomastoid muscle.

A client has tested 20/40 on the distant visual acuity test using a Snellen chart. The nurse should...

- refer the client to an optometrist. Myopia (impaired far vision) is present when the second number in the test result is larger than the first (20/40). The higher the second number, the poorer the vision.

The nurse is examining an adult client's eyes. The nurse has explained the positions test to the client. The nurse determines that the client needs further instructions when the client says that the positions test

- requires the covering of each eye separately. Perform the positions test, which assesses eye muscle strength and cranial nerve function. Instruct the client to focus on an object you are holding (approximately 12 inches from the client's face). Move the object through the six cardinal positions of gaze in a clockwise direction, and observe the client's eye movements.

An older client visits the clinic accompanied by his daughter. The daughter tells the nurse that her father has been experiencing severe headaches that usually begin in the morning and become worse when he coughs. The client tells the nurse that he feels dizzy when he has the headaches. The nurse refers the client for further evaluation because these symptoms are characteristic of a...

- tumor-related headache. Tumor-related headaches have no prodromal stage; may be aggravated by coughing, sneezing, or sudden movements of the head.

A client is diagnosed with an obstruction of the canal of Schlemm affecting the left eye. What assessment data concerning the left eye noted in the client's medical record supports this diagnosis?

-Increased intraocular pressure. Aqueous humor is produced by the ciliary body, circulates from the posterior chamber through the pupil into the anterior chamber, and drains out through the canal of Schlemm. This system controls the pressure within the eye. If there is an obstruction of the canal of Schlemm, aqueous humor will not drain, increasing pressure within the eye. An obstruction of the canal of Schlemm will not displace the optic nerve because the optic nerve is located within the posterior portion of the eye. An opaque lens is a cataract, which is not caused by an obstruction of the canal of Schlemm. Pupil reaction is a neurological function not affected by intraocular pressure.

A nurse performs the Snellen test on a client and obtains these results: OD 20/40, OS 20/30. What conclusion can the nurse make in regards to the client's vision based on these results?

-The larger the bottom number, the worse the visual acuity. OD = right eye, OS = left eye. Therefore, the client has worse vision in the right eye because the larger the number on the bottom, the worse the visual acuity. A client is considered legally blind when the vision in the better eye with corrective lens is 20/200 or less. Snellen test is to test for distant vision (far) not near vision.

A nurse performs a focused assessment on a new client. The nurse observes that the client's nails are extremely short and jagged. The client states they have a tendency to bite their nails. What is the best response by the nurse?

- "Do you feel anxious at times?" Excessive nail biting may be a sign of anxiety. Although anxiety and depression can occur at the same time, nail biting is a sign of anxiety. While the nurse may want to find out if the nail biting is new, and while nail biting may run in the family, these are not the priority in this situation.

A nurse is assessing a 49-year-old client who questions the nurse's need to know about sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment?

- "Having bad sunburns when you're a child puts you at risk for skin cancer later in life." Experiencing severe sunburns as a child is a risk factor for skin cancer. The nurse is not directly assessing the client's pattern of moles in this way, nor the skin's ability to heal. The nurse is not assessing the parents' care of their child's overall skin health by asking this question.

ABCDE criteria

Asymmetry, Border irregularity, Color, Diameter, Evolution.

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider?

- Fixed to underlying tissue Normally lymph nodes are round and soft, less than 1 cm in size, mobile from side to side, soft in consistency, and nontender. A fixed lymph node may be seen in metastatic disease.

While assessing an adult client's skull, the nurse observes that the client's skull and facial bones are larger and thicker than usual. The nurse should assess the client for...

- acromegaly. The skull and facial bones are larger and thicker in acromegaly.

An adult client tells the nurse that she frequently experiences burning and itching of both eyes. The nurse should assess the client for...

- allergies. Burning or itching pain is usually associated with allergies or superficial irritation.

The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an "itching rash." Which question would be most important for the nurse to ask?

- "Are you allergic to foods, medications, or other substances?" The lesions most likely appear to be urticaria, which is caused by capillary dilatation in response to an allergic reaction. Asking about anyone else in the family with a similar rash might be appropriate if the lesions were vesicles or pustules. Once the nurse determines the possible cause of the rash, it would be appropriate to gather additional information, such as a history of a previous or similar rash, pain, and measures taken to address the itching.

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.

Amsler chart

This grid-like test is used to check for signs of macular degeneration or worsening of such

Medial

Toward the midline of the body

Hirsutism (hypertrichosis)

abnormal hairiness, especially in women.

Lateral

away from the midline

senile keratoses

small yellow or brown raised lesions that may appear on the face and trunk with aging

wheal lesion

solid, elevated, firm, round with swelling ex: hives, insect bites

A nurse is completing a comprehensive health history of a 69-year-old woman who is a new client of the clinic. Which of the nurse's interview questions most directly addresses the client's risk for developing cataracts?

- "Have you ever been tested for diabetes?" Diabetes is a significant risk factor for cataracts, especially those with an early onset. Exercise, use of pain medications, and visual acuity are not closely correlated with the development of cataracts.

What features would most likely be noted on fundoscopic examination of someone with glaucoma?

- Increased cup-to-disc ratio. It is important to screen for glaucoma on fundoscopic examination. The cup and disc are among the easiest features to find. AV nicking and cotton wool spots are seen in hypertension. Microaneurysms are seen in diabetes.

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

- hypothyroidism. Generalized hair loss may be seen in various systemic illnesses such as hypothyroidism and in clients receiving certain types of chemotherapy or radiation therapy.

The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client's ethnicity. What assessment question should the nurse ask?

- "Do you take steroid medications on a regular basis?" Steroid therapy causes hirsutism. Dietary supplements, diabetes, and skin cancer are unlikely causes of abnormal hair growth.

While performing a focused skin assessment on a new client, the client reports "the mole on my neck seems different." What is the best response by the nurse?

- "How has it changed?" Asking an open-ended question will elicit a more complete response, such as how the mole has changed for example, diameter, color, shape). The other options will not elicit the information needed to direct next priority actions. Telling the client that moles change as we age is not an appropriate response; further assessment is needed. Asking if the client knows how to check for signs of skin cancer and about when they noticed the change are close-ended questions that will not provide the information needed.

A client comes to the clinic due to losing a fingernail while doing construction on their home. The client asks the nurse how long it will take for the fingernail to regrow. What is the best response by the nurse?

- "It takes about 6 months to totally replace a fingernail." It takes 6 months to totally replace a fingernail and 12 months to totally replace a toenail. A week is too short for nail regrowth. Telling the client that the nail will never be the same is not providing accurate information or therapeutic communication.

Which statement by a client about the skin needs validation by the collection of objective data by the nurse?

- "My feet hurt and are always cold to the touch" A nurse needs to validate any subjective information that either does not fit with the rest of the information supplied by the client or any information that may indicate a problem exists. Cold feet that are painful need to be validated by careful assessment of the client's circulation. Dry and itchy skin is expected in the winter when the air is dry. Previous history of cancer and a port wine spot are past of the past medical history.

The nurse is teaching a client about the use of sunscreen. What should the nurse include in the teaching? Select all that apply.

- 1. Apply sunscreen again every 2 hours while in the sun., 2. Sunscreen should be applied again after sweating or swimming., 3. Water-resistant sunscreen may be used during activities such as swimming., 4. Regular use of sunscreen has been found to reduce the incidence of melanoma. The nurse should teach the client to use SPF 30, not SPF 20, sunscreen with broad-spectrum protection. Sunscreen should be applied again every 2 hours while in the sun. Sweating or swimming creates the need for sunscreen reapplication. Water-resistant sunscreen may be used during activities such as swimming. A landmark study in 2011 demonstrated that the regular use of sunscreen decreases the incidence of melanoma.

A nurse is preparing a client for a physical examination of his skin, hair, and nails. Which of the following interventions should the nurse implement? Select all that apply.

- 1. Wear gloves when palpating lesions., 2. Use sunlight, if possible, to inspect the skin., 3. Have the client remove his toupee (a small wig or artificial hairpiece worn to cover a bald spot.), 4. Keep the room door closed. To prepare for the skin, hair, and nail examination, ask the client to remove all clothing and jewelry and put on an examination gown. In addition, ask the client to remove nail enamel, artificial nails, wigs, toupees, or hairpieces as appropriate. The client may remain in a sitting position for most of the examination. If available, sunlight is best for inspecting the skin. Wear gloves when palpating any lesions because you may be exposed to drainage. Keep the room door closed or the bed curtain drawn to provide privacy as necessary.

Which situations should the nurse identify as being risk factors of the development of pressure sores? Select all that apply.

- 1. pressure that impairs capillary blood flow to the skin., 2. friction created by dragging the skin against bedlinen., 3. shearing that occurs when sliding down in bed., 4. moisture being allowed to accumulate on the skin Pressure sores result when sustained compression obliterates arteriolar and capillary blood flow to the skin. Sores may also result from the shearing forces created by bodily movements. When a person slides down in bed from a partially sitting position or is dragged rather than lifted up from a supine position, for example, the movements may distort the soft tissues of the buttocks and close off the arteries and arterioles. Friction and moisture further increase the risk. Changing position frequently will assist in preventing pressure sores.

A nurse has been assigned a group of clients. Which client is at highest risk for developing skin cancer?

- 67-year-old White female. Fair-skinned people are at higher risk of developing skin cancer, especially those with light eyes and freckles and people who live far from the equator. However, high levels of sunlight exposure places all people at risk. Clients of African descent, Native American/First Nations heritage, Asians, and Latinos or Hispanics are generally darker-skinned people. Even though darker-skinned people are not as susceptible to skin cancers, they have a poorer prognosis because they are often diagnosed late.

The nurse is teaching an older adult diagnosed with diabetes about the skin. Which of the following should be emphasized?

- A neuropathic ulcer can develop without feeling it. While all options are true of older adults' skin, it is most important to emphasize to a client with diabetes that a neuropathic ulcer can develop without the client feeling it. People with diabetes are more likely to experience decreased sensation in the feet. The slowing of the healing process that comes with aging is also exacerbated by diabetes, as circulation may be slowed and the rate in which nutrients are delivered to wounds becomes decreased. Therefore, to reduce the risk of client injury, the nurse should emphasize that the client with diabetes checks their feet on a regular basis.

A client has a circumscribed, elevated, palpable mass containing serous fluid on the forearm. Which diagram should the nurse use to explain this mass to the client? - (Circumscribed: confined to a limited area. ex: circumscribed patches of hair loss.)

- A vesicle is a circumscribed elevated, palpable mass containing serous fluid that is less than 0.5 cm. A plaque is an elevated, palpable, and solid mass that is greater than 0.5 cm and may be coalesced papules with a flat top. A tumor is an elevated, solid, palpable mass that extends deeper into dermis than a papule. Tumors are greater than 1-2 cm and do not always have sharp borders292. A wheal is an elevated mass with transient borders that is often irregular.

A nurse notes that a client looks much older than his chronologic age. Which of the following conditions would most likely contribute to this appearance?

- Alcoholism A client may appear older than actual chronologic age due to a hard life, manual labor, chronic illness, alcoholism, or smoking. Parkinson's disease is associated with stiff, rigid movements. Marfan syndrome is associated with arm span being greater than height and pubis to sole measurement exceeding pubis to crown measurement. Cushing syndrome is associated with central body weight gain with excessive cervical obesity (Buffalos hump).

An 8-year-old girl comes with her mother for evaluation of hair loss. The girls denies pulling or twisting her hair, and her mother has not noted this behavior at all. She does not put her daughter's hair in braids. Physical examination reveals a clearly demarcated, round patch of hair loss without visible scaling or inflammation. No hair shafts are visible. Based on this description, what is the most likely diagnosis?

- Alopecia areata. This is a typical description for alopecia areata. There are no risk factors for trichotillomania or traction alopecia. The physical examination is not consistent with tinea capitis, because the skin is intact.

A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCDE" characteristic of malignant melanoma?

- Asymmetrical shape Malignant melanomas are evaluated according to the mnemonic ABCDE: A for asymmetrical, B for irregular borders, C for color variations, D for diameter exceeding 1/8 to 1/4 of an inch, and E for elevated.

A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCD" characteristic of malignant melanoma?

- Asymmetrical shape Malignant melanomas are evaluated according to the mnemonic ABCDE: A for asymmetrical, B for irregular borders, C for color variations, D for diameter exceeding 1/8 to1/4 inch (3-4mm), and E for elevated.

The nurse prepares an educational program for the families of clients recovering from burns. On the diagram provided, select the area where fat cells, blood vessels, and nerves are located.

- Beneath the dermis lies the subcutaneous tissue, a loose connective tissue containing fat cells, blood vessels, nerves, and the remaining portions of sweat glands and hair follicles.

Why is it important to collect a thorough and accurate subjective history in regards to a client's nail problems?

- Can be caused by an underlying systemic illness Diseases or disorders of the nails can be a local problem or they may be a sign of an underlying systemic disease that needs to be assessed. A nurse should be sensitive when interviewing a client with nail problem because they can be damaging to a person's self image. A nurse should ask questions in a nonjudgmental manner if the client has abnormalities of the nails that are due to poor hygiene.

A nurse is instructing a client on how to assess himself for herpes simplex lesions by their configuration. Which configuration should the nurse tell the client to look for?

- Clustered In a clustered configuration, lesions are grouped together; an example is herpes simplex. In a linear configuration, the lesion is a straight line, such as in a scratch or streak due to dermatographism. In an annular configuration, the lesion is circular; an example is tinea corporis. In a discrete configuration, the lesions are individual and distinct; an example is multiple nevi.

A nurse observes a bluish discoloration in a client's toes. What is the first action of the nurse?

- Complete a comprehensive assessment. Changes in skin color may indicate an underlying illness, so the nurse should first perform a comprehensive assessment on the client. The nurse needs to determine if there is adequate perfusion to the toes. Even though the nurse would document the findings, the nurse still needs to assess this finding further first. The nurse would not contact the health care provider until all assessment data have been obtained. The nurse may provide the client with warm socks at a later time, but an assessment still needs to be conducted first.

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. Iron deficiency anemia is associated with spoon-shaped nails but not with excessive hair. Carcinoma of the skin causes lesions but not facial hair. Lupus erythematosus causes patchy hair loss but does not cause excessive facial hair.

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

- Dermis The dermis is a well-vascularized, connective tissue layer containing collagen and elastic fibers, nerve endings, and lymph vessels. It is also the origin of sebaceous glands, sweat glands, and hair follicles. The epidermis, the outer layer of skin, is composed of four distinct layers: the stratum corneum, stratum lucidum, stratum granulosum, and stratum germinativum. The outermost layer consists of dead, keratinized cells that render the skin waterproof.

A client recovering from a burn injury is told by the health care provider that hair will no longer grow on the body part that was burned. When the client questions why this is true, the nurse will base the response on what physiological event that occurred as a result of the burn?

- Destruction of hair follicles located in the dermis layer Damage to hair follicles located in the dermis layer of the skin would result in the body's inability to regrow hair on burn damaged areas. The remaining options suggest correct information but none are associated with the regrowth of hair after a burn.

During the physical assessment of a client with dark skin, the nurse notices freckle-like pigmentation in the nail beds. What is an appropriate action by the nurse?

- Document this as a normal finding The nurse should consider the freckle-like pigmentation in the nail beds of the client as a normal finding in dark-skinned people. The variations are due to different amounts of melanin in certain areas. Asking the client about injury to the nail and reporting the finding to the health care provider are not appropriate because there is no pathology involved. Pressing the pigmented area to assess for blood flow is not necessary because there is no evidence of inadequate circulation to the nail beds.

The nurse's assessment of an adult female client reveals the presence of excessive hair on her face and chest. The nurse should plan further evaluation of which body system?

- Endocrine Excess body hair on the face and chest (masculine pattern of hair distribution) is suggestive of possible hormonal dysfunction. The nurse would need to assess the client's endocrine system and function and likely refer her to endocrinology.

During the integument health history, the nurse asks the client about both current and previous prescription medications, immunizations, and diagnosed illnesses. What is the primary benefit derived from the data provided by this questioning?

- Existence of systemic diseases that have skin manifestations One purpose of the integumentary health history is to identify systemic diseases that have skin manifestations. Questions to determine systemic diseases that the patient may have include asking about prescribed medications, immunizations, and diagnosed illnesses. Such a history would provide little information regarding health promotion care, or risks for skin cancer or skin ulcer formation.

When preparing to examine a client's skin, which of the following would be most important for the nurse to do?

- Expose only the body part that is being examined. When preparing to examine a client's skin, the nurse would expose only the body part to be examined to ensure privacy. The room should be at a comfortable temperature, one that is not too warm or too cool. Gloves are needed when palpating any lesions. The client needs to remove all clothing and jewelry and put on an examination gown.

The nurse is caring for a female client with hormone disorder producing excessive testosterone. Which of the following is an expected finding when assessing this client?

- Hirsutism Excessive androgenic hormones in a female client can increase testosterone levels and cause masculinization changes, including hair in male distribution patterns. This hair growth is called hirsutism. Muscle cramps and cold sensitivity are associated with decreased thyroid hormone levels, and a rapid heart rate is associated with increased thyroid hormone levels.

A nurse inspects a client's nails and notes the angle between the nail base and the skin is greater than 180 degrees. What additional data should the nurse collect from this client?

- History of cigarette smoking An increase in the angle between the nail base and the skin is seen in clients with clubbing which occurs from hypoxia to the tissue secondary to cigarette smoking. Iron deficiency will produce nails that are spoon shaped in appearance. Exposure to chemicals can cause the nails to be excessively dry or to have splinter hemorrhages due to trauma to the nail bed. Fungal infections can cause a yellow discoloration to the nails.

The student nurse learns that examining the skin can do all of the following except?

- allow early identification of neurologic deficits. Examination of the skin can reveal signs of systemic diseases, medication side effects, dehydration or overhydration, and physical abuse; allow early identification of potentially cancerous lesions and risk factors for pressure ulcer formation; and identify the need for hygiene and health promotion education.

A client presents to the health care clinic with reports of new onset of generalized hair loss for the past 2 months. The client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process?

- Hypothyroidism Generalized hair loss can be a finding in hypothyroidism. None of the other conditions listed is associated with generalized hair loss. Diabetes is a problem with glucose regulation. Crohns disease is an inflammatory process in the large intestines. Liver disease results in many problems with fluid regulation, metabolism of drugs, and storage of glucose.

During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack?

- Oral mucosa Central cyanosis results from a cardiopulmonary problem. The oral mucosa is normally pink. When a bluish discoloration exists it may indicate systemic hypoxemia. Peripheral cyanosis that results from vasoconstriction would most likely be noted in the nailbeds and conjunctival areas.

An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should assess for central cyanosis by observing the client's..

- Oral mucosa Central cyanosis results from a cardiopulmonary problem, whereas peripheral cyanosis may be a local problem resulting from vasoconstriction. To differentiate between central and peripheral cyanosis, look for central cyanosis in the oral mucosa.

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. What would the nurse do next?

- Perform a random blood sugar test. Linear hyperpigmented areas (Acanthosis nigricans) present in the skin of the neck, axillae, and perianal folds in dark-skinned people suggest diabetes mellitus. A random blood sugar test would provide an objective assessment to identify hyperglycemia. The findings are not indicative of skin cancer, nor are they benign. The client may be referred for medical follow up after additional assessment is completed.

For which client condition would the nurse most likely expect a capillary refill time longer than 2 seconds?

- Peripheral vascular disease. Peripheral vascular disease decreases the circulation of the periphery of the body, causing hypoxia and a capillary refill greater than 2 seconds. Inflammatory bowel disease, multiple sclerosis, and malignant melanoma are not associated with changes in capillary refill.

The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following?

- Pressure ulcer. An older adult client most likely would have thin, fragile skin, which can result in easy breakdown and slower wound healing. Evidence of a pressure ulcer would require additional assessment. A cherry angioma usually is not clinically significant. A cutaneous horn or seborrheic keratosis is considered a common skin variation.

A young man comes to the clinic with an extremely pruritic rash over his knees and elbows, which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. Examination reveals scabbing and crusting with some silvery scales. The nurse also notices small "pits" in the nails. What would account for these findings?

- Psoriasis This is a classic presentation of plaque psoriasis. Eczema is usually over the flexor surfaces and does not scale, whereas psoriasis affects the extensor surfaces. Pityriasis usually is limited to the trunk and proximal extremities. Tinea has a much finer scale associated with it, almost like powder, and is found in dark and most areas.

A nurse in a dermatology clinic cares for an adolescent client with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this client?

- Pustular acne Acne presents as an inflammatory and non-inflammatory skin disorder characterized by one or a combination of the following lesions: comedo, papule, pustule, or cyst. Distribution of acne is frequently on the face, neck, torso, upper arms, and legs, although lesions may occur in other areas.

An older adult female 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 Sebum production decreases with age, therefore increasing the incidence of dry skin in the older adult. The dry skin is not related to a decrease in squamous cells, sweat glands, or subcutaneous tissue. - sebum (is produced by sebaceous glands when they disintegrate. The gland cells last about a week, from formation to discharge. The sebaceous glands produce lipids, triglycerides, which are broken down by bacterial enzymes (lipases) in the sebaceous duct to form smaller compounds, free fatty acids.) - sebaceous glands (A sebaceous gland is a microscopic exocrine gland in the skin that opens into a hair follicle to secrete an oily or waxy matter, called sebum, which lubricates the hair and skin of mammals.)

A client presents to the health care clinic with reports of changes in the skin. Which data should the nurse document as objective with regards to the skin?

- Skin warm and dry to the touch Objective data is data obtained by the nurse during the physical assessment using the techniques of inspection, palpation, percussion, and auscultation. The nurse would have observed that the client's skin is warm and dry to the touch. The client supplies the subjective data of a lesion that has been present for one month, no color changes to the skin, and skin is dry and flaky in the winter.

A 23-year-old woman has presented to the clinician to follow up her recent diagnosis of psoriasis. Which of the following assessments of the client's nails would be consistent with the client's diagnosis?

- Small pits in the surfaces of the nails - Small pits in the nails are an early sign of, though not specific for, psoriasis. Small pits in the nails are an early sign of, though not specific for, psoriasis. Beau's lines and white lines and spots are not associated with psoriasis.

An older adult client reports that he is experiencing severe trunk pain and is concerned that he might have shingles. Which type of lesion would the nurse most likely assess?

- Vesicle Herpes zoster (shingles) is characterized by grouped vesicular skin eruptions along a cutaneous sensory nerve line. The vesicles typically are less than 0.5 cm. Elevated nevi or warts would be noted as papules. Bulla would be vesicles greater than 0.5 cm. Crust is a dried residue of serum, blood, or pus on the skin, such as what is left after a vesicle ruptures.

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?

- Stage II A stage II ulcer is manifested by a partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough; an intact or open/ruptured serum-filled blister; a shiny or dry shallow ulcer without slough or bruising (bruising indicates suspected deep tissue injury). A stage I ulcer is manifested by intact skin with nonblanchable redness of a localized area, usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III ulcer is manifested by full-thickness tissue loss; possible visible subcutaneous fat with no exposure of bone, tendon, or muscle; possible slough that does not obscure the depth of tissue loss; possible undermining and tunneling. A stage IV ulcer is manifested by full-thickness tissue loss with exposed bone, tendon, or muscle; possible slough or eschar on some parts of the wound bed; often with undermining and tunneling.

A group of students are reviewing the structure and function of the skin in preparation for a test on the material. The students demonstrated understanding when they identify which layer as the outermost layer of the epidermis?

- Stratum corneum The epidermis consists of four distinct layers: the stratum corneum, stratum lucidum, stratum granulosum, and stratum germinativum, in that order.

A client presents with possible lice infestation of the scalp. The nurse observes nits very close to the scalp. What does this finding tell the nurse?

- The client had a recent infestation The closer to the scalp the nit is located, the more recent the infestation. The client is not presenting with lice which have been present for a long time or that the infestation is over. The client is not presenting with scabies.

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 Clubbing of the nails indicates chronic hypoxia. Clubbing is identified when the angle of the nail to the finger is more than 160 degrees. Melanoma does not present with the symptom of clubbing. The scenario described does not give enough information to indicate that the client has COPD or asthma.

A nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client's current health status would be reflected in her score on this scale?

- The client is consistently incontinent of urine. The Braden Scale assesses skin moisture, which is strongly influenced by urinary incontinence. This scale does not specifically address the role of a caregiver, recent surgery, or a vegetarian diet.

The nurse is admitting a 79-year-old man for outpatient surgery. The client has bruises in various stages of healing all over his body. Why is it important for the nurse to promptly document and report these findings?

- The client may have been abused. Multiple ecchymoses may be from repeated trauma (falls), clotting disorder, or physical abuse.

A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?

- The client's ability to change position The Braden Scale appraises the client's level of mobility but does not directly include data related to medications, history of skin disorders, or pigmentation.

A nurse is admitting an elderly client for surgery the following morning. The nurse notices that the client has excessively dry skin. The client says showering every day, sometimes twice, but has trouble keeping skin moist. What client education is appropriate?

- The elderly should bathe or shower only every 2 to 3 days. Showering or bathing more than once daily in the normal adult causes excessive loss of skin oils. Showering daily and using lots of moisturizer is not the best answer. Elderly clients need to bathe less often, usually every 2 to 3 days. Bathing less often than every 2 or 3 days would not be often enough.

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? - The most unusual aspect of this condition is that the lesions move from place to place.

- This is a typical case of urticaria (hives) This is a typical case of urticaria. The most unusual aspect of this condition is that the lesions move from place to place. This would be distinctly unusual for the other causes listed.

A 4-year-old child presents to the health care clinic with circular lesions. Which of the following conditions should the nurse most suspect in this client, based on the configuration of the lesions?

- Tinea corporis In an annular configuration, the lesion is circular; an example is tinea corporis. In a discrete configuration, the lesions are individual and distinct; an example is multiple nevi. In a confluent configuration, smaller lesions run together to form a larger lesion; an example is tinea versicolor. In a clustered configuration, lesions are grouped together; an example is herpes simplex.

What is the most important focus area for the integumentary system?

- UV radiation exposure Excessive UV radiation is the most important focus area for the integumentary system, because exposure to it has been shown to cause skin cancers, particularly melanoma. Chemical exposure, moles with defined borders smaller than 6 mm, and hygiene of the face and hands are not the most important focus areas for the integumentary system.

Which area of the body should a nurse inspect for possible loss of skin integrity when performing a skin examination on a female who is obese?

- Under the breast The nurse should inspect the area under the breast for skin integrity in obese clients. The area between the skin folds is more prone to loss of skin integrity; therefore, the presence of skin breakdown should be inspected on the skin on the limbs, under the breasts, and in the groin area. Perspiration and friction often cause skin problems in these areas in obese clients. The areas over the chest and abdomen and on the neck are not prone to skin breakdown.

While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had...

- a recent illness. Beau's lines occur after acute illness and eventually grow out.

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

- areola of the breast. The apocrine glands are associated with hair follicles in the axillae, perineum, and areola of the breast. Apocrine glands are small and non-functional until puberty at which time they are activated and secrete a milky sweat. (Areola: The area of dark-colored skin on the breast that surrounds the nipple.)

A nurse performs a focused assessment on a new client. The nurse observes pustules and erythema around the client's hair follicles. The nurse recognizes these are signs and symptoms of which of the following disorders?

- folliculitis Folliculitis is an infection of the follicle causing pustules and erythema. Alopecia is thinning of the hair. Scalp ringworm is a fungal infection that is scaly, red, and itchy and may cause bald patches in children; it is also known as tinea capitis.

A nurse is performing a comprehensive assessment on a client. The nurse observes pale, cyanotic nails with a 180-degree angle with spongy sensation and clubbing of the distal ends of the fingers. The nurse identifies these signs and symptoms as indications of which of the following conditions?

- hypoxia Pale or cyanotic nails may indicate hypoxia or anemia. Early clubbing (180-degree angle with spongy sensation) and late clubbing (greater than 180-degree angle) can occur from hypoxia. Spoon nails (concave) may be present with iron deficiency anemia. Yellow discoloration may be seen in fungal infections or psoriasis. Nail pitting is also common in psoriasis.

While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 0.75 cm. The nurse documents this as a

- papule Papules are elevated, palpable, solid masses smaller than 1 cm. Plaques are greater than 1 cm and may be coalesced papules with a flat top.

A nurse is performing an assessment on a client with a long history of hypothyroidism. What findings would the nurse expect with this client?

- patchy, thin hair The thyroid gland controls metabolism. In hypothyroidism, the slowed metabolism decreases the rate of hair growth, resulting in thin patchy hair. This is more pronounced than typical age-related changes in hair. Hypothyroidism does not cause premature graying of hair. Increased facial hair is seen in Cushing's disease as a result of increased sex hormones from the adrenal gland (hirsutism).

The nurse is assessing a client exhibiting round, red and purple macules that are approximately 1 to 2 mm in size. The nurse should document which type of vascular skin lesion?

- petechiae. The nurse should document the presence of petechiae for a client exhibiting round, red and purple macules that are approximately 1 to 2 mm in size. Ecchymoses are round or irregular macular lesions that are larger than petechial lesions. Hematoma refers to a localized collection of blood creating an elevated ecchymosis. Cherry angiomas are papular and round, red or purple lesions found on the trunk or extremities that may blanch with pressure.

The nurse notes that a client's nails are greater than a 160-degree angle. What should the nurse assess as a priority for this client?

- pulse oximetry A nail angle greater than 160 degrees indicates clubbing which is caused by chronic hypoxia. Measuring the client's pulse oximetry would be a priority. Heart sounds, bowel sounds, and body temperature will not provide information to determine the cause for the clubbed nails.

The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as

- stage II. Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured, serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising; bruising indicates suspected deep tissue injury. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.

Connecting the skin to underlying structures is/are the

- subcutaneous tissue. Subcutaneous tissue, which contains varying amounts of fat, connects the skin to underlying structures.

Connecting the skin to underlying structures is/are the...

- subcutaneous tissue. Subcutaneous tissue, which contains varying amounts of fat, connects the skin to underlying structures.

A client seeks medical attention for the skin lesion shown. What should the nurse document as this type of lesion?

- wheal. A wheal is an elevated mass with transient borders that is often irregular. A papule is an elevated, palpable, solid mass, with a circumscribed border and less than 0.5 cm in size. A pustule is a pus-filled vesicle or bulla. An erosion is a loss of superficial epidermis that does not extend to the dermis.

Hirsutism (hypertrichosis)

Extreme hairiness or excessive growth of hair