Health Assessment Prep U Exam 3

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 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? a) 2 b) 4 c) 3 d) 1

3 Explanation: 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Assessing Skin, Hair, and Nails, p. 264.

A nurse examines a client with a paralytic ileus. Which alteration in the bowel sounds should the nurse expect to find with auscultation of the client's abdomen? a) Absent b) Erratic c) Hypoactive d) Hyperactive

Correct response: Absent Explanation: The nurse should find that bowel sounds are absent in a client with paralytic ileus. Paralytic ileus is a condition characterized by absence of bowel sounds, not normal bowel sounds. Hyperactive bowel sounds may be caused by diarrhea, gastroenteritis, and early bowel obstruction. Hypoactive bowel sounds may be due to surgery or late bowel obstruction. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 23: Assessing Abdomen, p. 487.

A student nurse is auscultating for bowel sounds on a client who returned from surgery 48 hours ago. The student tells the charge nurse that she cannot hear bowel sounds in the lower quadrants. What is the appropriate response by the charge nurse to this information? a) "The nasogastric tube is preventing you from hearing the bowel sounds correctly." b) "You need to call the health care provider immediately for orders." c) "Did you listen for 5 minutes in all four quadrants of the abdomen?" d) "It takes about 3 to 5 days after surgery for the bowel sounds to return completely."

"It takes about 3 to 5 days after surgery for the bowel sounds to return completely." Explanation: Bowel sounds will return gradually after surgery, the timing depending on the location of the surgery. The small intestine functions normally in the first few hours postoperatively; stomach emptying takes 24 to 48 hours; and the colon can take 3 to 5 days to recover. There is no need to call the health care provider because there is no need for intervention. Listening longer is not necessary because the client is 48 hours postoperative and the colon is not functioning yet. A nasogastric tube does not stop the bowel from working, but is used in the event the client experiences nausea. (less) Reference: Weber, J.R., & Kelley, J.H. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 23: Assessing Abdomen, p. 487.

A college student presents to the health care clinic with reports no bowel movement for four (4) days, bloating, and generalized abdominal discomfort. She states she has not been eating and drinking correctly and is stressed because she has a final exam in two (2) days. A nurse assesses the abdomen and finds positive bowel sounds in all four quadrants, tenderness in the left lower quadrant with a few small round, firm masses. Rovsing's sign and the Psoas sign are negative. What nursing diagnosis can the nurse confirm for this client? a) Ineffective Nutrition: Less Than Body Requirements b) Constipation related to decrease in fluid intake c) Risk for Fluid Volume Deficit d) Ineffective Health Maintenance

Correct response: Constipation related to decrease in fluid intake Explanation: The nurse can confirm constipation because the major defining characteristics of decreased frequency and abdominal discomfort are present. A few days of altered nutrition does not meet the necessary criteria to confirm Ineffective Nutrition or risk for Fluid Volume Deficit. Ineffective Health Maintenance cannot be confirmed because there is no evidence that the client lacks the knowledge to eat properly. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 23: Assessing Abdomen, p. 503.

A nurse is working with an older client who has had diarrhea for the past week and is dehydrated. The nurse understands that older clients are especially at risk for potential complications with diarrhea due to which of the following factors? a) Tendency to have an inadequate fluid intake b) Decreased sensitivity to pain c) Large numbers of medications taken d) Higher fat-to-lean muscle ratio

Correct response: Higher fat-to-lean muscle ratio Explanation: Older adult clients are especially at risk for potential complications with diarrhea, such as fluid volume deficit, dehydration, electrolyte, and acid-base imbalances, because they have a higher fat-to-lean muscle ratio. It is not established that older adults have a tendency to have an inadequate fluid intake. An increased number of medications taken would not explain increased risk for potential complications with diarrhea, and neither would decrease sensitivity to pain. (less) Reference: Weber, J.R., & Kelley, J.H. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 23: Assessing Abdomen, p. 479.

Which of the following assessment findings most likely constitutes a secondary skin lesion? a) Keloid formation at the site of an old incision b) Facial acne c) Facial lesions associated with herpes simplex d) Psoriasis

Correct response: Keloid formation at the site of an old incision Explanation: A secondary lesion emerges from an existing primary lesion, such as the keloids that can emerge from the site of a healed wound. Acne and the lesions associated with psoriasis and herpes do not meet this criterion. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Assessing Skin, Hair, and Nails, p. 266.

A nurse receives a report from the shift nurse that a client has new onset of peripheral cyanosis. The nurse recognizes that which of the following is the most likely underlying cause? a) Skin cancer b) Diabetes mellitus c) Local vasoconstriction d) Cardiopulmonary problem

Correct response: Local vasoconstriction Explanation: Peripheral cyanosis is usually a local problem with manifestations of cyanosis, a blue-tinged color to the skin, caused by problems resulting in vasoconstriction. Central cyanosis results from a cardiopulmonary problem. Diabetes mellitus and skin cancer are not associated with peripheral cyanosis. (less) Reference: Weber, J. R., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Assessing Skin, Hair, and Nails, p. 249.

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

Correct response: • Asymmetrical • Change in size • Itching • Bleeding of a mole Explanation: Malignant melanoma is usually evaluated according to the mnemonic ABCDE: A for asymmetrical; B for borders that are irregular (uneven or notched); C for color variations; D for diameter exceeding 1/8 to 1/4 of an inch; and E for elevated, not flat. Danger signs of malignant melanoma include any of these factors. However, smaller areas may indicate early-stage melanomas. Other warning signs include itching, tenderness, or pain, and a change in size or bleeding of a mole. New pigmentations are also warning signs. (less) Reference: Weber, J. R., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Assessing Skin, Hair, and Nails, p. 268.

Choice Multiple question - Select all answer choices that apply. A patient has sustained burns over 50% of the body. When planning care for this patient, the nurse will include interventions to address an alteration in the skin's barrier function, specifically: (Select all that apply.) a) Penetration by microorganisms b) Injury caused by mechanical or chemical sources c) Synthesis of vitamin D d) Loss of water and electrolytes e) Regulation of body temperature

Correct response: • Injury caused by mechanical or chemical sources • Penetration by microorganisms • Loss of water and electrolytes Explanation: The skin provides a barrier protecting the body from injury caused by mechanical or chemical sources, penetration by microorganisms, and the loss of water and electrolytes. Regulation of body temperature is another function of the skin that allows heat to dissipate through sweat glands or permit heat storage through subcutaneous tissue. Synthesis of vitamin D is another function of the skin that occurs from cholesterol by the action of ultraviolet light. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Assessing Skin, Hair, and Nails, p. 239.

A nurse cares for a client of Asian descent and notices that the client sweats very little and produces no body odor. What is an appropriate action by the nurse in regards to this finding? a) Suggest that the client use antiperspirant products b) Monitor the client for additional findings of cystic fibrosis c) Assess the client for changes in sensation due to vascular problems d) Document the findings in the client's record as normal

Document the findings in the client's record as normal Explanation: Asians and Native Americans have fewer sweat glands than Caucasians and therefore produce less sweat and less body odor. Changes in sensation are not caused by alterations in sweat glands but are a circulation issue. Cystic fibrosis is an alteration in the exocrine glands that causes the production of thick mucus, especially in the lungs. Use of antiperspirants would be needed for excessive sweating, not a lack of sweating. (less) Reference: Weber, J. R., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Assessing Skin, Hair, and Nails, p. 241.

A client is admitted to a health care facility with new onset of abdominal pain, fatigue, and low back pain. The client relates a 10-year history of high blood pressure. When auscultating the client's abdomen for bowel sounds, what other assessment should the nurse perform at this time? a) Listen with the bell of the stethoscope for vascular sounds b) Observe for evidence of increased abdominal girth c) Obtain a complete set of vital signs and pain assessment d) Inspect the abdomen for color, shape, and symmetry

Listen with the bell of the stethoscope for vascular sounds Explanation: A client with a history of hypertension is at risk for bruits over any of the vascular areas on the abdomen such as renal artery, iliac artery, or femoral artery. The bell of the stethoscope is used for this assessment because bruits are low-pitched, murmur-like sounds. Inspection of the abdomen should be performed before auscultation. Vital signs are part of the general survey and are usually the first hands-on assessment of a client. Measuring abdominal girth is done if the nurse observes a distended abdomen or there are other signs of fluid retention within the abdomen. (less) Reference: Weber, J.R., & Kelley, J.H. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 23: Assessing Abdomen, p. 488.

A client reports the onset of discomfort and pain in the right upper quadrant of the abdomen after eating. The nurse should assess this finding using which test? a) Obturator b) Rovsing's c) Murphy's d) Psoas

Murphy's Explanation: The gallbladder is located in the right upper quadrant of the abdomen. When it is inflamed (cholecystitis), performing the Murphy's sign will cause the client to hold the breath (inspiratory arrest). The Obturator & Psoas tests are to determine if the appendix is inflamed. Rovsing's sign test for rebound tenderness which may indicate peritoneal irritation. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 23: Assessing Abdomen, p. 499.

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? a) Eczema b) Tinea infection c) Pityriasis rosea 3 Explanation: 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Assessing Skin, Hair, and Nails, p. 264. d) Psoriasis

Psoriasis Explanation: 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Assessing Skin, Hair, and Nails, p. 256.

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? a) Skin warm and dry to the touch b) Denies any skin color changes c) Dry and flaky skin in the winter months d) Small lesion left forearm for one month

Skin warm and dry to the touch Explanation: 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Assessing Skin, Hair, and Nails, p. 248.

A nurse examines a client with a paralytic ileus. Which alteration in the bowel sounds should the nurse expect to find with auscultation of the client's abdomen? a) Hyperactive b) Hypoactive c) Absent d) Erratic

Stress incontinence Explanation: Stress incontinence occurs with an increase in intra-abdominal pressure such as when coughing or laughing. This is what the nurse should focus additional questions during the health history. Urge incontinence is the inability to hold the urine. Overflow incontinence is the inability to empty the bladder unless the bladder pressure exceeds urethral pressure. Obstructive is not a type of incontinence. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 23: Assessing Abdomen, p. 502.

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? a) Purpura b) Psoriasis c) Urticaria or hives d) Insect bites

Urticaria or hives Explanation: 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Assessing Skin, Hair, and Nails, p. 265.

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

a = asymmetry; b = irregular borders; c = color changes, esp. blue; d = diameter > 6 mm; e = evolution Explanation: This is the correct description for the mnemonic. Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Assessing Skin, Hair, and Nails, p. 268.

When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant? a) left upper b) right lower c) left lower d) right upper

right upper Explanation: The liver is usually not palpable, although it may be felt in some thin clients. If the lower edge is felt, it should be firm, smooth, and even. Mild tenderness may be normal. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 23: Assessing Abdomen, p. 494.

Choice Multiple question - Select all answer choices that apply. An elderly bedridden patient has a pressure ulcer that is not healing on her coccyx. What must the nurse do to improve this patient's outcome? a) Modify nursing interventions b) Notify the physician c) Keep to the established care plan d) Evaluate the patient's outcomes e) Document the findings

• Evaluate the patient's outcomes • Modify nursing interventions Explanation: The nurse evaluates care according to the developed patient outcomes, thereby reassessing the patient and continuing or modifying the interventions as appropriate. The care plan is a guide, something that changes with the patient's status. There is no need to notify the physician. Documenting findings needs to be done, but it does not improve the patient's outcome. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Assessing Skin, Hair, and Nails, p. 262.

Choice Multiple question - Select all answer choices that apply. 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. a) Involved in digestion of food b) Circulates blood throughout the body c) Helps make vitamin D in the body d) Protects against damage to the body from sunlight e) Aids in maintaining body temperature f) Largest organ of the body

• 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 Explanation: 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. (less) Reference: Weber, J. R., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Assessing Skin, Hair, and Nails, p. 239.