Quiz 3 - Final Exam

During a skin assessment, an adult client asks the nurse, "Why do you need to know about sunburns I had as a kid?" Which of the following is the best response by the nurse? A. "Having bad sunburns as a child puts you at risk for skin cancer later in life." B. "When you burn your skin as a child, it makes your skin more sensitive and slower to heal when you're older." C. "This is one of the assessments we use to determine how well you took care of your skin when you were young." D. "Repeated sunburns in childhood may explain the presence of some of your moles."

A. "Having bad sunburns as a child puts you at risk for skin cancer later in life."

While examining the muscle tone of a client, the nurse finds only a slight flicker of contraction. The nurse would document this finding on the strength table as which of the following? A. 1 B. 5 C. 3 D. 0

A. 1

A male construction worker asks the nurse if the mole on his arm is skin cancer. Using the mnemonic device ABCDE, which finding by the nurse would suggest skin cancer? A. Asymmetric, irregular borders B. Flat with waxy, crusty scales C. Solid, dark brown color D. Diameter of 2 mm

A. Asymmetric, irregular borders

Assessment of a client's skin reveals several individual and distinct 2-mm lesions on the client's back. The nurse would document the configuration as which of the following? A. Discrete B. Linear C. Annular D. Confluent

A. Discrete

The nurse asks a client to bring his hands together behind his lower back with his elbows flexed. Which range of motion movement is the nurse assessing? A. Internal rotation B. Adduction C. Abduction D. External rotation

A. Internal rotation

The nurse is checking an elderly client for signs of dehydration. Which of the following would be a correct action by the nurse when assessing the client's skin turgor? A. The nurse pinches the skin over the client's clavicle. B. The nurse pinches the skin on the client's forearm. C. The nurse pinches the skin on the back of the client's upper warm. D. The nurse pinches the skin on the back of the client's hand.

A. The nurse pinches the skin over the client's clavicle.

An older client is concerned about new seborrheic keratoses appearing on the skin. How should the nurse respond to this client's concern? A. "I will report these to the health care provider so that medication can be prescribed." B. "These are considered a normal age-related change in the skin." C. "It means you have skin cancer and need to have them removed." D. "These areas need to be cleansed daily and treated with a topical antibiotic ointment."

B. "These are considered a normal age-related change in the skin."

The nurse is caring for an African American client admitted to the unit for cirrhosis of the liver. Which of the following areas would the nurse inspect to determine if the client has jaundice? A. Legs B. Eyes C. Face D. Ears

B. Eyes

Which of the following findings related to hair would the nurse most likely assess in an older adult female client? A. Patchy hair loss on the scalp B. Terminal hair growth on chin C. Thick elastic scalp hair D. Increased hair in the axilla and on the legs

B. Terminal hair growth on chin

The nurse is performing the ballottement test during the assessment of a client's knee. The nurse understands that performing this test would give further information on which of the following? A. Whether the client experiences pain during range of motion B. Whether the client is experiencing increased fluid in the knee joint C. Whether the client's knee joint is capable of flexion and extension D. Whether the swelling in the knee joint is a normal age-related change or an infection

B. Whether the client is experiencing increased fluid in the knee joint

During the assessment of a client's deep tendon reflexes, the nurse notes a few short taps while dorsiflexing the foot. The nurse would document this finding as which of the following? A. 3+ B. 2+ C. 4+ D. 5+

C. 4+

The nurse is assessing the client's temporomandibular joint (TMJ). Which of the following findings by the nurse would be documented as normal? A. Swelling around the joint space B. Tenderness on palpation C. Clicking when the mouth opens D. Popping and grating sounds

C. Clicking when the mouth opens

The nurse is caring for a client with eczema and extremely dry skin. The nurse notes deep linear cracks to the client's heels. The nurse would document the assessment findings as which of the following? A. Erosion B. Scar C. Fissure D. Ulcer

C. Fissure

A client tells the nurse that she is having a hard time bringing her hand to her mouth during meals. To assess the client's range of motion in the elbow, the nurse would have the client demonstrate which of the following? A. Internal rotation B. Circumduction C. Flexion D. Abduction

C. Flexion

The nurse notes that a client's capillary refill is 5 seconds. What should this finding indicate to the nurse? A. A normal finding B. Vitamin deficiency C. Hypoxia D. Infection of the nailbed

C. Hypoxia

During the musculoskeletal assessment of a pregnant client, the nurse notes an increased concave curvature of the lumbar spine. The nurse would document this finding as which of the following? A. Scoliosis B. Osteoporosis C. Lordosis D. Kyphosis

C. Lordosis

While inspecting the skin of a client, the nurse notes multiple pinpoint, flat, reddish-purple macules. The nurse should recognize the presence of which of the following? A. Purpura B. Cherry angioma C. Petechiae D. Ecchymosis

C. Petechiae

The nurse is assessing a client's gait. Which of the following would indicate to the nurse that further evaluation is warranted? A. Arms swinging in opposition to legs B. Stands on heels and toes C. Shuffling of feet D. Weight evenly distributed

C. Shuffling of feet

During the history, a young adult woman tells the nurse, "My mother has osteoporosis. What can I do to help reduce my risk?" Which response by the nurse would be most appropriate? A. "Increase the amount of non-weight-bearing physical activity that you do." B. "Avoid being out in the sun for long periods of time." C. "Decrease your calcium intake to around 800 milligrams each day." D. "Try to avoid drinking too much coffee or other caffeinated fluids."

D. "Try to avoid drinking too much coffee or other caffeinated fluids."

Assessment of a client's nails reveals the presence of Beau's lines. The nurse interprets this finding as suggestive of which of the following? A. Psoriasis B. Vitamin B deficiency C. Prolonged oxygen deficiency D. Acute illness

D. Acute illness

When assessing muscle strength, the nurse notes that the client is unable to move her right arm against both resistance and then gravity. Which of the following actions would the nurse perform next? A. Document strength of 0 B. Inspect the arm for palpable contraction of the muscle C. Palpate the client's shoulder joint D. Move arm passively through its range of motion

D. Move arm passively through its range of motion

A client shows the nurse a "bump" on his neck. The nurse observes a palpable, raised, solid, 0.3 cm by 0.2 cm lesion. The nurse would document the presence of which of the following? A. Macule B. Pustule C. Nodule D. Papule

D. Papule

The nurse asks the client to perform dorsiflexion of the foot. Which of the following actions should the client perform? A. Point toes toward the floor B. Turn toes inward toward midline of body C. Turn toes outward away from midline of body D. Point their toes to the ceiling

D. Point their toes to the ceiling

The nurse suspects a client has carpal tunnel syndrome and asks her to perform Tinel's test. To perform this test, the client would demonstrate which of the following? A. Hold hands palm to palm while extending the wrists 90 degrees for 60 seconds B. Hold hands back to back while flexing the wrists 90 degrees for 60 seconds C. Hyperextend the wrists and hold for 90 seconds D. Tap the inner aspect of the wrist over the median nerve

D. Tap the inner aspect of the wrist over the median nerve

When performing a musculoskeletal assessment on an elderly client, which of the following considerations should the nurse keep in mind? A. The elderly client may have an increase in the curvature of the lumbar spine. B. The elderly client may point their toes outward during ambulation. C. The elderly client may have an increased elasticity of tendons, increasing the risk of injury. D. The elderly client may have decreased flexibility and need frequent breaks.

D. The elderly client may have decreased flexibility and need frequent breaks.