BHA: Exam #2 (PrepU Practice)

During an eye assessment, the nurse is testing a client's visual acuity using a Snellen chart. In order to prepare the client for this component of assessment, what instruction should the nurse provide?

"Cover one of your eyes and then read out the letters on the chart, starting from the top."

A client describes headaches as severe and lasting for days. Which question would be most appropriate to use to determine if these headaches are migraines?

"Do you have any visual changes before the headache?"

Which of the following questions might be asked if a client complains of dysphagia? -Any particular foods? -When did this start? -Is it constant? -What type of toothbrush do you use?

-Any particular foods? -When did this start? -Is it constant?

A nurse notices that a client's nails on the right hand have separated from the nail bed and appear yellow. What could be a cause of this condition? Select all that apply.

-Fungal infections -Trauma -Warts

Which of the following are tests to assess hearing? -Snellen -Whisper -Rinne -Weber

-Whisper -Rinne -Weber

Which of the following are considered red flags for a headache? -altered mental status -like a thunderclap -pregnancy -"worst headache of my life"

-altered mental status -like a thunderclap -pregnancy -"worst headache of my life"

Which of the following signs/symptoms indicates hypothyroidism? -bradycardia -palpitations -constipation -tremor

-constipation -bradycardia

Which of the following is a secondary lesion? -bulla -papule -keloid -crust

-crust -keloid

Which of the following are risk factors for pressure ulcers? -decreased mobility -increased sensation -decreased blood flow -urinary continence

-decreased mobility -decreased blood flow

What do we assess for, when we are assessing the face? -edema -asymmetry -involuntary movements -facial expressions

-edema -asymmetry -involuntary movements -facial expressions

Which of the following is a secondary lesion? -keloid -crust -papule -bulla

-keloid -crust

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?

3

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

67-year-old White female

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

A client's extra ocular movements are asymmetrical and she complains of diplopia.

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

What is the normal result of a Rinne test?

AC>BC

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?

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

A nurse is inspecting the fingernails of an older adult client. Which of the following findings should be reported to the provider? A. yellowed nail color B. White horizontal lines C. spongy nail base D. Capillary refill of 2 seconds

C. spongy nail base

The nurse enters a client's hospital room and the client asks the nurse to raise him up in the bed. What is the nurse's best action?

Call for help and use the draw sheet to move the client

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

A nurse is teaching a young adult about the risk factors for developing melanoma. Which of the following client statements indicates an understanding of the teaching? A. "The fact that I have 5 moles increases my risk for developing melanoma." B. "My cousin had squamous cell carcinoma, which increases my risk for melanoma." C. "Having a light complexion decreases my risk for developing melanoma." D. "The blistering sunburns I had as a child increase my risk for melanoma as an adult."

D. "The blistering sunburns I had as a child increase my risk for melanoma as an adult."

A nurse is assessing a client's skin color. Which of the following areas should the nurse check to determine the presence of pallor? A. anterior chest B. palms of hands C. auricle of ears D. mucous membranes

D. mucous membranes

A client reports having had difficulty breathing through their right nostril for years. The client denies any other symptoms except for unrestful sleep. The nurse suspects that the client may have which of the following conditions?

Deviated Septum

The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions?

Distribution

A nurse observes patchy hair loss of a client who just started chemotherapy a few months earlier. Which of the following actions will the nurse take?

Document findings

TRUE OR FALSE? Migraine headaches are the most common.

FALSE

What is the most common type of hyperthyroidism?

Graves disease

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

Health 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

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

During your physical examination of the client you note an enlarged tender tonsillar lymph node. What would you do?

Look for a source such as infection in the area that it drains

A nurse inspects a client's skin and notices several flat, brown color change areas on the forearms. What is the proper term for documentation of this finding by the nurse?

Macule

The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses, the nurse should proceed to examine the _____________.

Maxillary Sinuses

A nurse is caring for a client admitted with neck pain. The client is febrile. What is the most likely medical diagnosis for this client?

Meningitis

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

A client tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the client's oxygenation level is within normal levels. The nurse knows that the blue color the client described is caused by what?

Peripheral cyanosis

Which technique should the nurse use to properly assess a client's skin turgor?

Pinch the skin over the clavicle and observe its return to the original shape

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

What action should the nurse implement using an otoscope when assessing the ear of an adult client?

Pull the auricle out, up, and back

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

Assessment of a client's mouth reveals a lesion on the client's buccal membrane that is approximately 0.5 cm in diameter. On further questioning, the client states that the lesion has been present for 3 months and that it bleeds intermittently. How should the nurse follow up this assessment finding?

Refer the client to her primary care provider promptly.

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

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

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

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

True or False? For someone who has conductive hearing loss, with a weber test the sound lateralizes to the impaired ear.

True

The nurse is assessing a dark-skinned client whose forearms and hands have distinct regions of depigmentation. The nurse should document the presence of what health problem?

Vitiligo

The nurse is palpating a client's neck as part of a physical assessment. Which of the following blood vessels should the nurse be especially careful to avoid bilaterally compressing during the assessment?

carotid artery

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

Pitting edema is documented based on what?

depression depth

Hair follicles, sebaceous glands, and sweat glands originate from the ___________________.

dermis

Otalgia means what?

ear pain

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

Which of the following is an example of a primary lesion? -papule -scar -crust -scale

papule

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

Photoreceptors of the eye are located in the eye's _____________.

retina

The nurse is preparing to assess the lymph nodes of an adult client. The nurse should instruct the client to

sit in an upright position

A client visits the clinic and tells the nurse that he is depressed because of a recent job loss. He complains of dull, aching, tight, and diffuse headaches that have lasted for several days. The nurse should recognize that these are symptoms of ____________________.

tension headaches

The nurse documents the tonsil size as a +1; the student knows this means which of the following?

visible

During a physical examination of the head and neck, a client reports frequently feeling cold. What additional questions should the nurse ask for more information about the client's symptoms?

"Do you dress more warmly than other people?", "Do you use more blankets than others at home?", "Do you perspire less than others?"

While the nurse is obtaining a client's health history regarding the head and neck, the client tells the nurse about having a lump in the neck. In order to assess for associated manifestations of this problem, which of the following questions should the nurse ask next?

"Do you have difficulty swallowing?"

When assessing the hair, what do we want to note/assess? -quantity -texture -pattern of loss -distribution

-quantity -texture -pattern of loss -distribution

Which of the following do we assess for further if we palpate a lymph node? -size -mobility -shape -tenderness

-size -mobility -shape -tenderness

Which of the following are characteristics of normal skin texture? -smooth -hard -firm -even

-smooth -even -firm

Which of the following is characteristics of normal skin texture? -smooth -hard -firm -even

-smooth -firm -even

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV. -intact, firm skin with redness -necrosis with damage to underlying muscle -full-thickness skin loss -ulceration involving the dermis

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

A nurse is caring for a client who has a stage 1 pressure injury. Which of the following information should the nurse include when documenting characteristics of the wound? Select ll that apply. A. location of a pressure injury B. size of the injury in centimeters C. depth of injury in centimeters D. color and odor of the drainage from the wound E. integrity of the skin surrounding the wound

A. location of a pressure injury B. size of the injury in centimeters E. integrity of the skin surrounding the wound

Where is the temporal artery palpated?

Above the cheek bone near the scalp line

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.

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

A nurse is collecting data from a client about their skin and nails. Which of the following statements by the client should the nurse identify as needing further assessment? A. "When I was a child, I developed a rash after taking amoxicillin." B. "I noticed that my fingernails have changed recently." C. "I use to take baths, but I recently switched to showering." D. "In my family, one cousin has basal cell carcinoma."

B. "I noticed that my fingernails have changed recently."

A nurse is evaluating assessment findings of a client's skin. The nurse should identify that which of the following findings is associated with a possible infection? A. Wheals B. Vesicles C. Papules D. Bulla

B. Vesicles

A nurse is preparing to assess the skin turgor of a client who has manifestations of dehydration. In which of the following locations should the nurse perform the assessment? A. lateral to umbilicus B. inferior to collar bone C. dorsal side of the hand D. anterior aspect of the neck

B. inferior to the collar bone

A nurse is examining a lesion on a client's back. Which of the following characteristics should the nurse identify as a possible indication of a malignant skin lesion? A. smooth, defined border B. uniform color C. Size of a pencil eraser D. Symmetrical appearance

C. Size of a pencil eraser

A nurse is providing teaching to a client who reports extremely dry skin. Which of the following interventions should the nurse recommend? A. increase frequency of bathing B. use dehumidifier to reduce air moisture C. apply alcohol-free lotion D. cover dry areas with thin coating of powder

C. apply alcohol-free lotion

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

Conjunctiva

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?

Dark pink, moist, and free of discharge

When considering eye safety, what instructions should the nurse provide to a client newly prescribed contact lenses?

Do not share lenses. Keep the lenses clean. Wash hands before inserting or removing the lenses. Discard unused portions of contact solutions at the expiration date.

Which action by the nurse indicates the appropriate use of an ophthalmoscope?

Employ the right eye to examine the client's right eye

The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching?

Encourage the use of safety equipment

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

TRUE OR FALSE? A Rosenbaum test tests for near vision and the normal result is 20/20

FALSE

TRUE OR FALSE? A stage 3 pressure ulcer has partial thickness loss with exposed dermis.

FALSE

TRUE OR FALSE? External and middle ear disorders cause sensorineural hearing loss.

FALSE

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

A client presents with purulent, bloody drainage of the ear. Which of the following would the nurse assess first?

Inspect the external ear canal.

A nurse assesses the distant vision acuity of a client using the Snellen chart. Which action should the nurse implement to perform the test with accuracy?

Instruct the client to read without reading glasses

A client comes to the clinic and reports pain when he touches his ear. With what is this finding most consistent?

Otitis externa

Pupils round, reactive to light and accommodation is documented as?

PERRLA

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

Which test is used to test visual acuity and distance?

Snellen

The roof of the oral cavity of the mouth is formed by the anterior hard palate and the

Soft palate

TRUE OR FALSE? Clients with sensorineural hearing loss might complain that people talk muffled and that the environment is noisy.

TRUE

TRUE OR FALSE? Clients with sensorineural hearing loss might complain that people talk muffled and that the environment is noisy.

TRUE

Which of the following would the nurse document as an abnormal finding with lymph node assessment?

Tender

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 ear guards whenever inside the plant

A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve?

XII (12th) -Known as the Hypoglossal nerve

A nurse has been assigned several clients on the hospital unit. Which of the following clients is at highest risk for skin breakdown?

a 30-year-old male who sustained a spinal cord injury who is now paraplegic

A nurse is palpating the head and neck of a newly referred client. Which of the following would the nurse suspect if assessment reveals that the client's skull and facial bones are larger and thicker than normal?

acromegaly

At which location would a nurse palpate a client's submental lymph nodes?

behind the tip of the mandible

A nurse asks the client to describe the pain associated with a headache by rating the pain on a scale from 1 to 10. This subjective data should be documented in which section of the assessment?

characteristic symptoms

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

Excess fluid in the interstitial space is known as?

edema

A nurse receives report from the shift nurse that a client has new onset of peripheral cyanosis. Where should the nurse focus the assessment of the skin to detect the presence of this condition?

fingers and toes

A client reports bleeding gums after brushing their teeth. On further assessment, the nurse observes red, swollen gums but no recession of the gum lines. The nurse determines these signs and symptoms are most likely indicative of which of the following disorders?

gingivitis

The nurse is planning to assess a client's near vision. Which technique should be used?

have the client read newspaper print held 14 inches from the eyes

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

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

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

macular degeneration

A 38-year-old accountant comes to the clinic for evaluation of a headache. The throbbing sensation is located in the right temporal region, and is an 8 on a pain scale of 1 to 10. It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an over-the-counter analgesic, which results in resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache?

migraine

A female client visits the clinic and tells the nurse that she frequently experiences severe recurring headaches that sometimes last for several days and are accompanied by nausea and vomiting. The nurse determines that the type of headache the client is describing is a

migraine headache

A client reports occasionally experiencing hoarseness. In response to this statement, the nurse asks, "What makes the hoarseness go away?" Which characteristic of the client's symptom is the nurse assessing?

relieving factors

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 nurse is preparing to assess the neck of an adult client. To inspect movement of the client's thyroid gland, the nurse should ask the client to

swallow a small sip of water