Practice exam 2- Health Assessment

The nurse is conducting a focused interview on the client's integumentary system and prepares to obtain data related to risk factors for the development of integumentary disorders. Which question by the nurse would be unexpected based on the specific data the nurse is attempting to gain during the interview? Select all that apply.

"Do you take any medications on a regular basis?" "How much time do you spend outdoors?" "How do you care for your skin?" "Do you have any tattoos or body piercings?"

An older adult client says to the nurse, "I'm gaining weight around my middle and my legs look like chicken legs." Which response by the nurse is the most appropriate?

"Older people often put on weight around the middle, but lose muscle in the legs, making the legs appear thinner. This is normal."

An older client's physical examination reveals the presence of a number of bright red-colored lesions scattered on the trunk and tights. The nurse interprets that this indicates which of the following lesions due to alterations in blood vessels of the skin?

Cherry angioma

A female client exhibits s purplish bruise to the skin after a fall. The nurse would document this finding most accurately using which of the following terms?

Ecchymosis

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

Which of the following clients is at greatest risk for impaired wound healing after abdominal surgery?

Female, age 35, poorly controlled diabetes

The nurse is preparing an educational program regarding the objectives listed in Healthy People 2020. Which statements in the presentation support these objectives? Select all that apply.

Infants have difficulty regulating their own body temperatures. Clients should monitor their moles for any changes, regardless of their age Clients with diabetes mellitus have an increased risk for skin breakdown African American females often require information regarding gentle hair and scalp care.

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.)

Penetration by microorganisms Loss of water and electrolytes Injury caused by mechanical or chemical sources

The nurse documents in a patient's medical record: "5-mm oval lesion located on left forearm, color purple with areas of green and yellow." The nurse is describing which type of lesion?

Purpuric

During the assessment of an older adult client's skin, the nurse notes small areas of hyperpigmentation on the dorsal aspect of the client's hands. The client states, "I've been getting more of these big freckles as I get older." Which term will the nurse use when documenting this finding in the medical record?

Senile lentigines

The nurse is assessing the skin of a newborn and notes a bright red, raised lesion on the lateral aspect of the thigh. The lesion is 4.5 centimeters in diameter. When light pressure is applied to the lesion, the site does not blanch. The mother expresses concern about the appearance of this site, and asks the nurse if it should be removed. Which response by the nurse is the most appropriate?

These types of lesions usually disappear by the time a child turns 10 years old."

The nurse is concerned that a patient is at risk for the development of skin cancer when what was assessed? (Select all that apply.)

age 55 years Actinic keratosis on face light-colored hair

A patient presents to the clinic with "sores around the mouth." The nurse notes vesicular lesions on the upper lip and right corner of the lips. The patient describes these as painful. The nurse suspects what condition?

angioedema

Why is it important to ask the client regarding discharge or drainage from the eyes?

associated with infection or inflammation

The nurse is performing a skin assessment on a client and notes an oval-shaped, elevated, fluid-filled mass that is approximately 1.5 centimeters in size. Which term will the nurse use when documenting this assessment data?

bulla

A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse best assess this patient for cyanosis?

check lips and mucous membranes

The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what?

conjuctiva

A client visits the health care clinic with reports of itchy and watery eyes for three days. The nurse observes a generalized redness to the conjunctiva. The nurse recognizes this as what condition?

conjuctivitis

While the nurse examines a patient's pupillary response to light in the right eye, the pupil in the left eye is constricted. What does this finding suggest to the nurse?

consensual reaction

The nurse completes a skin assessment for a client and is preparing to document the appearance of herpetic lesions found over a client's nose and mouth region. Which terms can the nurse use when documenting the skin assessment for this client in the medical record? Select all that apply.

crusty vesicular pustular

A patient 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. The nurse realizes that this patient's burn extended into which skin layer?

dermis

The client has experienced a stroke and has dysphagia. The nurse knows this is what?

difficulty swallowing

What eye function is the nurse preparing to assess when the patient is asked to stand 20 feet from a specific chart that is mounted on the examination room wall?

distant vision

The nurse is completing a focused interview to assess the skin, hair, and nails of a pregnant client. Which question would be most important for the nurse to include in the interview?

do you use any skin creams?

After completing an integument physical examination, the nurse is documenting information about the patient's lesions. What will the nurse include in this documentation? (Select all that apply.)

elevation location and distribution color

The nurse is assessing a client who has suffered a cerebral vascular accident (CVA or stroke) and has difficulty with verbal expression, but no other deficits. What approach should the nurse use to assess this client's level of pain?

faces scale

The adult client is being assessed at an outpatient clinic and states, "I have sores in my mouth and on my lips." The nurse notes the presence of crusted lesions on the lips and inside the client's mouth along the cheek. The client states that the lesions do not itch. Based on this assessment data, which condition is this client likely experiencing?

herpes simplex

You are the nurse caring for a client with an enlarged thyroid. What nutritional deficiency is linked to an enlarged thyroid?

iodine

A patient, with a family history of melanoma, wants to have specific body moles assessed. When performing this assessment, the nurse will use what equipment? (Select all that apply.)

natural lighting gloves exam table chair

The nurse is caring for a client complaining of a painful, hot area located on the client's leg. Erythema and edema are present in the localized area. Which action should the nurse perform next?

notify healthcare provider

As part of assessing the client's level of consciousness, the nurse asks questions related to person, place, and time. Which of these statements is true?

orientation to time is lost first; person last

A male client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

scale

During assessment of the patient's skin, the nurse observes a similar pattern of small, raised lesions on the left and right upper back areas. Which term should the nurse use to document these lesions?

symmetric

The nurse is assessing the skin of an adolescent client and notes the presence of a musky odor. The client states that this is embarrassing for him and that he showers daily. Which action should the nurse take in this situation?

tell them it is normal

The prognosis of malignant melanoma depends primarily on:

the thickness of the lesion

The clinic nurse is assessing an older adult client who fell. The nurse asks if the client ever feels dizzy or has problems with balance. For what is the nurse assessing?

vertigo

A client who works in a manufacturing plant is attending a teaching session on plant safety. Which of the following would be an important risk prevention measure to teach regarding hearing?

wearing earguards inside the plant