Health Assessment Ch 11/15
signs and symptoms of hypothyroidism
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
Small pits in the surfaces of the nails
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?
Pityriasis rosea
A 28-year-old client comes to the office for evaluation of a rash. At first there was only one large patch, but then more lesions erupted suddenly on the back and torso; the lesions itch. Physical examination reveals that the pattern of eruption is like a Christmas tree and that various erythematous papules and macules are on the cleavage lines of the back. Based on this description, what is the most likely diagnosis
Pityriasis rosea
A 28-year-old client comes to the office for evaluation of a rash. At first there was only one large patch, but then more lesions erupted suddenly on the back and torso; the lesions itch. Physical examination reveals that the pattern of eruption is like a Christmas tree and that various erythematous papules and macules are on the cleavage lines of the back. Based on this description, what is the most likely diagnosis?
Age
A 35-year-old archaeologist comes to the office for a regular skin examination. She has just returned from her annual dig site in Greece. She has fair skin and reddish-blonde hair. She has a family history of melanoma. She has many freckles scattered across her skin. From this description, what is not a risk factor for melanoma in this client?
Tinea corporis
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?
Perform a random blood sugar test.
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 should the nurse do next?
Inspect the nostrils with an otoscope
A child presents to the health care facility with new onset of a foul smelling, purulent drainage from the right nare. The mother states no other signs of an upper respiratory tract infection are present. What is an appropriate action by the nurse?
Asthma
A client arrives complaining of nasal congestion, drainage of a thick, yellow discharge from the nose, difficulty breathing through the nose, headache, and pressure in the forehead. The nurse suspects sinusitis. What is the associated risk factor?
Asymmetrical shape
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?
ensure a patent airway
A client diagnosed with a peritonsillar abscess exhibits 4+ tonsils and is not able to eat or drink. What is the nurse's priority concern for this client?
Pallor
A client has been brought to the emergency unit of a health care facility following an automobile accident. Which finding about the lips supports the diagnosis of anemia and shock?
Crepitus over the maxillary sinuses
A client has just been diagnosed with a sinus infection accompanied by large amounts of exudate. Which of the following assessment findings should the nurse anticipate along with this condition?
Asymmetric, irregular borders
A client has sought care because he is concerned that a mole on his scalp may be evidence of skin cancer. During assessment using the mnemonic ABCDE, which finding would the nurse identify as being most suggestive of melanoma?
Illuminate the area using a Wood's light.
A client has sought care because of the development of pruritic lesions between her toes, which the nurse suspects are attributable to a fungal etiology. How can the nurse best corroborate this suspicion?
Melasma generally resolves postpartum
A client is 20 weeks pregnant and has melasma. What information can the nurse give the client about melasma, when educating her about the effects of pregnancy?
"Avoid substances that could be irritating to your mouth."
A client is found to have leukoplakia, and the nurse is teaching the client about measures to reduce the client's risk. Which of the following would the nurse include in the teaching?
Native Americans
A client is noted to have a bifid uvula. The nurse understands that this finding is most common in which ethnic group
Diabetes mellitus
A client presents to the health care clinic and reports the appearance of a rough texture and darkening color to the skin around the neck. The nurse knows this client should be assessed for which disease process?
Skin warm and dry to the touch
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?
"Are you experiencing sinus pressure and congestion?'"
A client presents to the health care clinic with reports of inability to concentrate at work and daily frontal headaches for the past two weeks. What additional information should the nurse ask this client?
Hypothyroidism
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
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?
History of allergies
A client presents with a cluster of upper airway complaints that include rhinorrhea. Which area of assessment would yield the most pertinent information to the etiology of rhinorrhea?
History of allergies
A client presents with rhinorhea. Which area of assessment would yield the most pertinent information?`
Vesicle
A client reports that he might have shingles. Which type of lesion would the nurse most likely assess?
association with vitiligo
A client shows the school nurse a rash that has developed on the back of her left hand. The school nurse assesses the rash as a depigmented macular area. The nurse would suspect
Inspect the area
A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?
risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions
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
rinse mouth with antifungal medication as prescribed.
A client who is taking antibiotics for a sinus infection presents with a white coating on the tongue and complains of a burning sensation on the tongue. Which instructions are most appropriate for this client?
pallor
A decrease in oxyhemoglobin will result in
XII
A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve?
Stratum corneum
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?
Fissure
A group of students is reviewing information about common skin variations. The students demonstrate the need for additional review when they identify what as an example?
thick, white plaques on the tongue surface
A medical nurse is preparing to administer a topical antifungal medication to a client who has just been diagnosed with an oral candida infection (thrush). On inspection of the patient's tongue, the nurse should anticipate what appearance?A medical nurse is preparing to administer a topical antifungal medication to a client who has just been diagnosed with an oral candida infection (thrush). On inspection of the patient's tongue, the nurse should anticipate what appearance?
scabies
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
Impetigo
A mother brings her child to the health care clinic and reports that her son has a four-day history of intense itching to his legs. On inspection of the child's legs, the nurse notes a honey-colored exudate coming from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition?
Enlargement of the adenoids
A mother of a client complains of getting no sleep because of excessive snoring from the client every night. The nurse is reviewing with the mother what causes the snoring. Based on this information, what is the best response to the mother of the client about the cause of snoring?
Psoriasis, fungal infections, trauma
A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions?
2+
A nurse examines a client with complaints of a sore throat and finds that the tonsils are enlarged and seen midway between the tonsillar pillars and the uvula. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils?
4+
A nurse examines a client with complaints of a sore throat and finds that the tonsils are enlarged and touching one another. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils?
A large amount of exudate in the sinuses
A nurse finds crepitus when palpating over a client's maxillary sinuses. Which of the following should the nurse most suspect in this client?
a large amount of exudate in the sinuses
A nurse finds crepitus when palpating over a client's maxillary sinuses. Which of the following should the nurse most suspect in this client?
Pustular acne
A nurse in a dermatology clinic cares for an adolescent patient with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this patient?
History of cigarette smoking
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?
"Are you experiencing any tooth pain?"
A nurse inspects the gums and teeth of a middle aged adult and notices the presence of small brown spots on the chewing surfaces of several of the molar teeth. What question should the nurse ask the client to determine the cause of this finding?
The elderly should bathe or shower only every 2 to 3 days
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?
A grey-white line
A nurse is assessing a small child who has lead poisoning. Which characteristic of the gums should the nurse expect this client?
The client is consistently incontinent of urine
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?
B12
A nurse is assessing the mouth of a client and finds that she has a smooth, red, shiny tongue without papillae. The nurse should recognize this as indicative of a loss of which vitamin?
Receding and ischemic gums
A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults?
dark pink, moist, and free of discharge
A nurse is examining a client's nose. Which characteristics of the nasal mucosa should the nurse expect to find if the client is healthy?
red, swollen, with purulent discharge
A nurse is examining the nose of a client diagnosed with an upper respiratory tract infection. Which characteristics of the nasal mucosa should the nurse expect to find during assessment of a client with an upper respiratory tract infection?
To determine the client's risk for pressure ulcers
A nurse is interviewing a client regarding her lifestyle and health practices to obtain subjective information to assist in her assessment of her skin. She asks her, "Do you spend long periods of time sitting or lying in one position?" Which of the following is the best rationale for asking this question?
Monthly
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?
change in size, bleeding of a mole, asymmetrical, itching
A nurse is teaching a client how to assess her own skin for possible signs of malignant melanoma. Which of the following should the nurse point out as danger signs associated with skin lesions indicating this disease?
largest organ of the body, helps make vitamin D in the body, protects against damage to the body from sunlight, aids in maintaining body temperature
A nurse is teaching a group of 5th grade children about characteristics of the skin. What should she mention?
The client's ability to change position
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?
Chewing betel nuts
A nurse is working with a client from Asia who has just been diagnosed with oropharyngeal cancer. Which culture-related risk factor should the nurse most suspect in this client?
Cranial nerve XII (hypoglossal)
A nurse is working with a client who has an impaired ability to move the tongue. He explains that he was in an automobile accident many years ago and suffered nerve damage that resulted in this condition. Which nerve should the nurse suspect was damaged in this client?
cushing's disease
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?
sitting with the head erect and at the eye level of the nurse
A nurse should assist a client to assume what position to best assess the mouth, nose, and sinuses?
is distributed along a dermatome
A patient with a zosteriform rash has a rash that
Mild risk
A patient's risk for pressure sore development according to the Braden Scale is as follows: Sensory perception: 4 Moisture: 4 Activity: 2 Mobility: 2 Nutrition: 1 Friction and Shear: 3
"Sleep apnea is a risk factor for obesity, hypertension, heart attack, and stroke"
A patient's spouse reports to the nurse that the patient sometimes stops breathing during sleep and asks if this is serious. What is the best response by the nurse?
How to reduce periodontal disease
A staff educator from the hospital is providing an event for the hospital staff. The educator is talking about health promotion activities for people with diseases of the nose, mouth, throat, and sinuses. What would the educator include in the presentation?
Psoriasis
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?
Torus palatinus
A young man is concerned about a hard mass in the midline of his palate that he has just noticed. Examination reveals that it is indeed hard and in the midline. No mucosal abnormalities are associated with this lesion. The client has no other symptoms. What is the most likely diagnosis?
maxillary
After describing how to assess the sinuses to a group of students, the students demonstrate understanding of the teaching when they identify which sinuses as being located in the upper jaw?
Alopecia areata
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 behaviour 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?
the client has chronic hypoxia
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?
symptoms of stress
An adult client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for
coining
An elderly Vietnamese client is having his skin assessed. The nurse notes multiple bruises and abrasions on his legs. What practice by Southeast Asian people could this be the result of?
evaluate the client's outcomes, modify nursing interventions
An elderly bedridden client has a pressure ulcer that is not healing on the coccyx. What must the nurse do to improve this client's outcome?
Tenting indicates dehydration
An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse notes considerable skin tenting. Why does this finding require further assessment?
tenting indicates dehydration
An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse notes considerable skin tenting. Why does this finding require further assessment?
Kiesselbach plexus
An emergency department nurse is caring for a young child with intractable nose bleeds. What is the most common site of epistaxis?
sebum production
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?
Bacterial infection
Assessment of a client's nails reveals brownish-black discoloration and crumbling of the nail plate. The nurse should suspect which of the following etiologies?
discrete
Assessment of a client's skin reveals several individual and distinct 2-mm lesions on the client's back. This would be documented as?
Use a square gauze pad to hold the client's tongue to each side
During an examination of the oral cavity, which technique by the nurse is appropriate to examine the sides of the tongue?
either side of the frenulum on the floor of the mouth
During assessment of the oral cavity, the nurse examines the salivary glands. Which area of the mouth should the nurse assess to inspect for the Wharton's ducts?
Oral mucosa
During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack?
Inability to smell
During the history a client reports a blockage in the upper portion of the nasal passage. Which of the following would the nurse expect as a prominent symptom?
Vitamin B12 deficiency
During the nursing assessment, the nurse identifies the client has a smooth, glossy tongue. The nurse understands this is caused by what?
vitamin B12 deficiency
During the nursing assessment, the nurse identifies the client has a smooth, glossy tongue. The nurse understands this is caused by what?
Herpes simplex
During the physical examination of the mouth, the nurse identifies vesicular eruptions along the patient's lips and surrounding skin. The nurse would document this finding as being
dermis
Hair follicles, sebaceous glands, and sweat glands originate from the
impaired sense of smell
In the course of the nurse's health interview, a client reports an occasional blockage in the upper portion of his nasal passage. What is the most pronounced effect that this will have on the client?
Peripheral vascular disease
In which health condition would the nurse most likely expect to assess a capillary refill time that is longer than 2 seconds?
Angular cheilitis
Many older adults are edentulous, which can cause overclosure of the mouth. What can this lead to?
Paralysis of cranial nerve X (vagus)
On assessing a client's mouth, the nurse finds that the uvula is deviated and the palate fails to rise. Which of the following conditions should the nurse most suspect in this client?
small bowel obstruction
On examination of a client, the nurse detects a fecal odor to the breath. The nurse recognizes this finding as characteristic of what disease process?
Respiratory infection
On examining a client, the nurse detects a foul odor to the breath. The nurse recognizes this finding as a characteristic of what disease process?
End-stage liver disease
On examining a client, the nurse detects a sulfur odor to the breath. The nurse recognizes this finding as a characteristic of which disease process?
Chronic allergies
On inspection, the nurse observes a line across the tip of an 8-year-old client's nose. The nurse should consequently focus on which area of assessment?
the frontal sinuses
One of the readily accessible to clinical examination routes
1. intact, firm skin with redness 2. ulceration involving the dermis 3. full-thickness skin loss 4. necrosis with damage to underlying muscle
Pressure ulcers are staged as I through IV. What is the order?
exposure to sun
Primary risk factor associated with lip cancer?
Avoiding sun exposure
Recommended protective measure to avoid skin cancer:
Avoiding sun exposure
Recommended protective measures to avoid skin cancer include which of the following?
Anterior nosebleeds
The Kiesselbach plexus is the most common site for what?
areola of the breast.
The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the
Emotional stress
The apocrine glands are stimulated by what?
Difficulty swallowing
The client has experienced a stroke and has dysphagia. The nurse knows this is what?
gingivitis
The client is experiencing red gums that are bleeding. The nurse identifies this as what?
clopidogrel (Plavix)
The client reports two nosebleeds in the past week. Which medication taken by the client would the nurse suspect is contributing to the nosebleeds?
hoarseness, pharyngitis, nasal congestion
The nurse assess the client for common upper respiratory symptoms which may include what?
stage II.
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
Above the eyes
The nurse assesses the frontal sinus where?
Pinkish, spongy soft palate
The nurse has completed a focused assessment of a client's mouth, nose, and throat. Which finding would a nurse interpret as being normal?
Cilia
The nurse identifies this as trapping debris and propelling it toward the nasopharynx.
Lichenification
The nurse inspects the skin of an older adult client and notes thick, rough skin over the elbows. The nurse would document this finding as which of the following?
The patient may have been abused.
The nurse is admitting a 79-year-old man for outpatient surgery. The patient 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?
How often do you use over-the-counter nasal sprays?"
The nurse is assessing a client who enjoys good health overall but who has brought a complaint of chronic nasal congestion and recurrent nosebleeds. What interview question should the nurse prioritize?
Vitiligo
The nurse is assessing a dark-skinned client whose forearms are hands have distinct regions of depigmentation. The nurse should document the presence of what health problem?
"Do you take steroid medications on a regular basis?"
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 consequently ask?
crepitus
The nurse is assessing an individual with facial injury following a motor vehicle accident. Which finding would suggest a fracture of the nose?
The nurse gently places a tongue blade on the posterior tongue.
The nurse is assessing the client's hypoglossal nerve (CN XII). Which nursing action would the nurse perform?
The nurse asks the client to identify common scents.
The nurse is assessing the older adult for anosomia. Which nursing action would the nurse perform?
cigarette smoke, alcohol abuse, phenytoin
The nurse is conducting an education session for expectant parents. The risk for cleft palate is increased when the mother is exposed to which of the following?
3+
The nurse is inspecting a client's tonsils and notes that they make contact with the client's uvula. The nurse would document this finding as which of the following?
squamous cell carcinomas are most common on body sites with heavy sun exposure
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
15
The nurse is performing a Braden assessment on a 62-year-old retired man. The nurse documents no impairment in sensory perception, skin usually dry, sitting in chair most of the day with ambulation short distances outside the room three times a day, and making frequent changes in position. The nurse would record those portions of the Braden score as
choanal atresia
The nurse is performing the admission assessment of a newborn to the nursery. Which finding noted by the nurse requires further evaluation?
Expose only the body part that is being examined.
The nurse is preparing to examine a client's skin. Which of the following actions would be most important for the nurse to do?
have a nurse who is the same sex as the client examine him
The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs?
Thoroughly chew small amounts of food with each mouthful
The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. What would be most appropriate for the nurse to include?
leukoplakia
The nurse is reviewing a client's electronic health record before assessing her mouth. Which of the following diagnoses would the nurse recognize as an indication for immediate medical follow-up?
tobacco products, alcohol
The nurse is teaching at a community clinic. She explains to the clients that what increases the risk for head and neck cancer?
amoxicillin (Amoxil)
The nurse notes a brown hairy coating on the tongue when assessing the oral cavity of the patient. Which medication would the nurse suspect as the causative agent when reviewing the patient's medications?
excessive collagen formation
The nurse notes a large keloid on the pierced ear of an adolescent. The client asks what caused this finding?
"Are you allergic to foods, medications, or other substances?"
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?
"Have you been on antibiotics recently?"
The nurse notes thrush on the palate of a patient. The most appropriate question the nurse should ask is
malignant melanoma
The nurse prepares to assess the client's skin. The nurse asks the client if there is any family history of skin cancer and should explain to the client that there is a genetic component with skin cancer, especially
55-year-old male who lived in California for 20 years
The nurse recognizes that which client is at greatest risk for the development of skin cancer?
topical decongestants
The nurse teaches the client that overuse of this medication can cause rebound nasal congestion.
pressure ulcer
The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following?
Endocrine
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?
patency of the sinus ostia, normal quality and quantity of the mucus, normal cilia function
The nursing instructor is discussing the normal functioning of the nose and sinuses with the nursing class. What would be the best description of the major factors related to the normal functioning of these structures?
warm and humidify inspired air
The nursing instructor is teaching a pre-nursing pathophysiology class. The class is covering the respiratory system. The instructor explains that the respiratory system is comprised of both the upper and lower respiratory system. The nose is part of the upper respiratory system. The instructor continues to explain that the nasal cavities have a vascular and ciliated mucous lining. What is the purpose of the vascular and ciliated mucous lining of the nasal cavities?
Strep throat
The patient comes to the clinic with complaints of a sore throat, difficulty swallowing, malaise, and anorexia. Upon examination, the nurse notes a red throat with enlargement of the tonsils and jaw and neck lymph nodes. Which condition does the nurse suspect the patient has?
ring worm
The patient presents with pustules with hair loss in patches in an outpatient clinic. The nurse understands this contagious condition might have been caused due to
candidiasis
The patient presents with thick white plaques on the hard palate during your assessment. Patient might be having which condition?
"You have gingival hyperplasia as a result of changes in your hormones with your pregnancy."
The prenatal patient asks the nurse why her gums are swollen. What is the best response by the nurse?
soft palate
The roof of the oral cavity of the mouth is formed by the anterior hard palate and the
allow early identification of neurologic deficits
The student nurse learns that examining the skin cannot
use two fingers to pinch the skin under the clavicle
To assess an adult client's skin turgor, the nurse should
Decreased eccrine and apocrine production
Upon assessment, the nurse notes the client's skin to be dry and thin. The nurse understands that is is related to what?
This is often a normal finding in the Native American population
Upon inspection of a client's oral cavity, a nurse observes a bifid uvula. What should the nurse recognize about this finding?
oral cancer occurs more frequently in males, risk factors for oral cancer includes oral sex, smoking is a risk factor for oral cancer.
What are some facts regarding oral cancer?
Spooning
What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia?
Oropharynx
What is the common channel for the respiratory and digestive systems?
Wood's light
What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?
Area under the tongue
When assessing a client for possible oral cancer, the nurse should most closely inspect which area?
macules
When documenting that a patient has freckles, the appropriate term to use is
diameter great than 6 cm, notched border, asymmetry
When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma?
Vestibule, nasal passages, and nasopharynx
When visualizing the structures of the nose, the nurse recalls that air travels from the anterior nares to the trachea through the:
Ask the client to say "aaah"
Which action by the nurse is appropriate to provide a clear view of the uvula for observation?
Enlarged, reddened
Which characteristic of the gums should a nurse expect to assess in a client who experiences an adverse effect of phenytoin treatment
Red, bleeding
Which characteristic of the gums should a nurse expect to assess in a client who has scurvy?
Pink, moist, firm
Which characteristic of the gums should a nurse expect to assess in a client who is healthy?
Cystic fibrosis
Which genetic disorder would the nurse ask about when conducting a family history regarding upper respiratory illness?
submandibular, parotid, sublingual
Which glands are responsible for mouth drainage?
Keloid formation at the site of an old incision
Which of the following assessment findings most likely constitutes a secondary skin lesion?
Tongue fissures
Which of the following assessment findings of the mouth, nose, and throat of an older adult client would the nurse attribute to the aging process?
Terminal hair growth on chin
Which of the following findings related to hair would the nurse most likely assess in an older adult female client?
19 to 23
Which of the following scores on the Braden Scale signifies that the patient is not at risk for a pressure sore?
Checking for deviated nasal septum
Which of the following would be most important to assess when a client is noted to be a mouth breather?
blue
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
papule
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
hypoxia
While assessing the nails of an adult client the nurse observes late clubbing. The nurse understands that she needs to further evaluate the client for signs and symptoms of
a recent illness
While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had
caused by aging of the skin in older adults
While assessing the skin of an older adult client, the nurse observes that the client has small yellowish brown patches on her hands. The nurse should instruct the client that these spots are
this is a normal finding
While testing the capillary refill in the nail bed of the patient in an outpatient setting the nurse observes that the pink tone returns immediately to blanched nail beds when pressure is released. The nurse understands
the client's perception affects the approach and effectiveness in treating the skin condition
Why is it important for the nurse to ask the client what they think caused a skin condition?
Noisy breathing
You are caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?
Warm the inspired air
You are teaching a physiology class for pre-nursing students. A student asks what the purpose of the upper airway is in regard to the lower airway. What would be your best answer?
oral contraceptives, alcohol, guanethidine
Your patient is complaining of nasal stuffiness. What drugs should you ask if she is taking?
