NUR EXAM 2

The nurse is performing an assessment in a client with a suspected diagnosis of cataract. The chief clinical manifestation that the nurse would expect to note in the early stages of cataract formation is

A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception.

Which of the following instruments is used to record intraocular pressure?

A tonometer is a device used in glaucoma screening to record intraocular pressure. A goniometer measures joint movement and angles. An ophthalmoscope examines the interior of the eye, especially the retina. A slit lamp evaluates structures in the anterior chamber in the eye.

Excoriation

An excoriation is a self-inflicted abrasion that is superficial.

The nurse is assigned to care for a female client with herpes zoster (Shingles). Which of the following characteristics would the nurse expect to note when assessing the lesions of this infection?

clustered skin vesicles

Fissure

A fissure is a narrow opening of tissue or skin.

Excessive bruising can occur in response to?

A traumatic event or a coagulation abnormality. It is associated with erythema.

A client who is complaining of tinnitus is describing a symptom that is:

A subjective symptom such as ringing in the ears can be felt only by the client.

Risk factors that may lead to skin disease and breakdown include:

Accumulating factors that place an aging person at risk for skin disease and breakdown include thinning of the skin, decrease in vascularity and nutrients, loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, social changes of aging, an increasingly sedentary lifestyle, and the chance of immobility. Aging results in the loss of protective cushioning of the subcutaneous layer of the skin. Aging results in decreased vascularity of the skin. Aging results in thinning of the skin.

A 36 yr old female who sun-bathes frequently develops red-tan scaly plaques on her face and arms. Which of the following, "common variations of hyperpimentation," was described?

Actinic (senile or solar) keratosis

An ecchymosis is a?

An ecchymosis is a hemorrhage that is greater than 3 mm

Ulcer

An ulcer is a deeper depression extending into the dermis.

When taking the health history, the patient complains of pruritus. What is a common cause of this symptom?

Drug reactions can lead to pruritus or itching

Pitting Edema that is grades as 3+ describes which of the following?

Deep pitting; indentation remains for a short time

Functions of the skin include:

Functions of the skin include protection, prevention of penetration, perception (of touch, pain, temperature, and pressure), temperature regulation, identification, communication, wound repair, absorption and excretion, and production of vitamin D.

When developing a teaching session on glaucoma for the community, which of the following statements would the nurse stress?

Glaucoma can be painless and vision may be lost before the person is aware of a problem Open-angle glaucoma causes a painless increase in intraocular pressure (IOP) with loss of peripheral vision. A variety of miotics and agents to decrease IOP and occasional surgery are used to treat glaucoma. Blacks have a threefold greater chance of developing with an increased chance of blindness than other groups. Individuals older than 40 should be screened.

While inspecting nails, the nurse observes them as thin, and depressed with the lateral edges tilting up. Which of the following terms best describes this "spooned" appearance?

Koilonychia

The client arrives in the emergency room with a penetrating eye injury from wood chips while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye, what is the initial nursing action?

Perform visual acuity tests

Which of the following purpuric lesions, is a tiny punctuate hemorrhage, that is typically 1 to 3 mm, round/discreet, and caused by bleeding from superficial arteries?

Petechiae

Petechiae

Petechiae are tiny punctate hemorrhages that are 1 to 3 mm; round and discrete; and dark red, purple, or brown caused by bleeding from superficial capillaries.

Which of the following conditions cause the appearance of a ruddy blue color in face, oral mucosa, conjunctivae, hands/feet?

Polycythemia

A flat macular hemorrhage is called a

Purpura is a flat, macular, red-to-purple hemorrhage that is a confluent and extensive patch of petechiae and ecchymoses greater than 3 mm

purpura

Purpura results from hemorrhage into the skin.

Sebum is produced by?

Sebum is produced by the sebaceous glands to lubricate the skin and hair.

An example of a primary lesion is a(n):

Urticaria is a primary lesion; a primary lesion is one that develops on previously unaltered skin.

What term refers to a linear skin lesion that runs along a nerve route?

Zosteriform describes a lesion that has a linear arrangement along a nerve root.

Which of the following diseaes is characterized by a bronze appearance, an "eternal tan"

addison's disease

A patient with a bright red cherry coloring of the face, upper torso, nail beds, lips, and oral mucosa, may be at risk of which of the following

carbon monoxide poisoning

While assessing a 40 yr old female's trunk area, the nurse notices small smooth, slighly raised bright red dots. Whech of the following is described, if the nurse documents the spots as "normal"

cherry (senile)angioma

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 Cherry angioma occurs with increasing age and has no clinical significance. It appears as a small, round, bright red-colored lesion on the trunk or extremities.

To determine if a dark-skinned patient is pale, the nurse should assess the color of the:

conjunctivae To detect pallor in a dark-skinned patient, the nurse should assess an area with the least pigmentation, such as the conjunctivae or mucous membranes.

Upon assessment of a black male, the nurse observes that his skin is dark/dull, and conjuctivae, nail bes and oral, mucosa are slightly blue in color. Her observations lead her to believe that the patient may be suffering from which of the following?

cyanosis

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

Which of the following symptoms would occur in a client with a detached retina?

flashing lights and floaters Signs and symptoms of retinal detachment include abrupt flashing lights, floaters, loss of peripheral vision, or a sudden shadow or curtain in the vision. Occasionally visual loss is gradual.

While inspecting a lesion with a Wood's light, lesions with blue-green fluorescence indicate which of the following?

fungal infections

An assessment of skin texture that is noted as smoother, softer, and feels like velvet...may be associated with which of the following?

hyperthyroidism

The nurse is assessing for the presence of cyanosis in a male dark-skinned client. The nurse understands that which body area would provide the best assessment?

lips In a dark-skinned client, the nurse examines the lips, tongue, nail beds, conjunctivae, and palms of the hands and soles of the feet at regular intervals for subtle color changes. In a client with cyanosis, the lips and tongue are gray; the palms, soles, conjunctivae, and nail beds have a bluish tinge.

Anemia in light skinned people may be detected in color as which of the following?

pallor

impetigo and acne are common examples of a.

pustule

When assessing a fair skinned patient with jaundice, possible areas with yellow color include.

sclera, skin, mucous membranes, hard palate

Hair assessment of a 45 yr old female undergoing chemothrapy treatment shows patchy asymmetric balding. The term describing this sort of hair loss, is which of the following..

toxic alopecia

While in a skilled nursing facility, a male client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter's home, where six other persons are living. During her visit to the clinic, she asks a staff nurse, "What should my family do?" The most accurate response from the nurse is:

All family members will need to be treated

The client with glaucoma asks the nurse is complete vision will return. The most appropriate response is:

Although some vision as been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan."

The part of the ear that contains the receptors for hearing is the:

The dendrites of the cochlear nerve terminate on the hair cells of the organ of Corti in the cochlea.

The nurse is performing a voice test to assess hearing. Which of the following describes the accurate procedure for performing this test?

The examiner stands 1-2 feet away from the client and asks the client to block one external ear canal. The nurse whispers a statement and asks the client to repeat it. Each ear is tested separately.

The components of a nail examination include:

The nails should be assessed for shape and contour, consistency, and color.

Nurse Kevin reviews the client's chart and notes that the physician has documented a diagnosis of paronychia. Based on this diagnosis, which of the following would the nurse expect to note during the assessment?

red shiny skin around nail bed

A 54 year old male alcoholic, shows up at the doctors complaining of a fiery red, star-shaped marking with a solid circular center appearing on his face. The nurse finds these descriptions to be consistent with which of the following vascular skin lesions

spider or star angioma

What is melasma

Melasma (also known as chloasma or the mask of pregnancy) is a facial skin discoloration related to hormones of pregnancy.

Which of the following are skin lesions associated with AIDS?

Epidemic Kaposi's sarcoma

venous star

A venous star results from increased pressure in veins, usually in the lower legs, and has an irregularly shaped bluish center with radiating branches.

Nerve deafness would most likely result from an injury or infection that damaged the:

Because the organ of hearing is the organ of Corti, located in the cochlea, nerve deafness would most likely accompany damage to the cochlear nerve.

Cellulitis

Cellulitis is a skin infection into deeper dermal and subcutaneous tissues that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. Warm compresses may be used to decrease the discomfort, erythema, and edema.

The nurse is caring for a client with a diagnosis of detached retina. Which assessment sign would indicate that bleeding has occurred as a result of the retinal detachment?

Complaints of a sudden burst of black spots or floaters indicate that bleeding has occurred as a result of the detachment.

An example of secondary lesion

Erosions are secondary lesions; a secondary lesion is one that changes over time or changes because of a factor such as scratching or infection. Ulcers are secondary lesions; a secondary lesion is one that changes over time or changes because of a factor such as scratching or infection

Hemangiomas

Hemangiomas are vascular lesions caused by a benign proliferation of blood vessels in the dermis

Shingles (Herpes Zoster)

Shingles (herpes zoster) are small grouped vesicles that emerge along the route of a cutaneous sensory nerve, followed by pustules, and then crusts; shingles is caused by the herpes zoster virus.

Apocrine glands

The apocrine glands produce a thick, milky secretion and open into the hair follicles; they are located mainly in the axillae, anogenital area, nipples, and navel.

what do the basal cell layer of the epidermis form?

The basal cell layer of the epidermis forms new skin cells. Melanocytes produce melanin, which gives brown tones to the skin and hair.

The ear bones that transmit vibrations to the oval window of the cochlea are found in the:

The bones in the middle ear transmit and amplify air pressure waves from the tympanic membrane to the oval window of the cochlea, which is the inner ear. The tympanic membrane separates the other from the middle ear

The client's vision is tested with a Snellen's chart. The results of the tests are documented as 20/60. The nurse interprets this as:

The client can read only at a distance of 20 feet what a client with normal vision can read at 60 feet.

A client is diagnosed with a disorder involving the inner ear. Which of the following is the most common client complaint associated with a disorder in this part of the ear?

Tinnitus is the most common complaint of clients with otological disorders, especially disorders involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client's thinking process and attention span.

Which of the following describes lesions that run together (e.g., urticaria

confluent

A scooped-out, shallow depression in the skin is called a(n):

An erosion is a scooped-out, shallow depression in the skin.

A 20 yr old male patient, comes to the doctor, complaining of a flat macular patch that ranges from red, bluish, and purple color. Upon further assessment you discover that the patch intensifies with crying, exertion, and exposure to heat or cold. Which of the following lesions is consistent with your findings?

Port-Wine Stain (Nevus Flammeus)

The clinic nurse assesses the skin of a white characteristic is associated with this skin disorder?

Silvery-white scaly patches on the scalp, elbow, knees, and sacral regions

Spider angiomas

Spider angiomas have a bright red center with legs that radiate outward. These lesions commonly are seen in liver disease and vitamin B deficiency, although they occasionally can occur without underlying pathology.

A white fair skinned females skin assessment shows orange-green color overlying pallor of anemia. Ecchymoses and purpura are present. The nurse suspects which of the following?

uremia

The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which of the following is associated with this eye disorder?

A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options B and D are not characteristics of this disorder. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal.

A student nurse has been assigned to teach fourth graders about hygiene. While preparing, the student nurse adds information about the sweat glands. Which of the following should be included while discussing this topic?

Newborn infants do not sweat and use compensatory mechanisms to control body temperature. Newborn infants' eccrine glands do not secrete sweat in response to heat until the first few months of life; newborn temperature regulation is ineffective.

The nurse has notes that the physician has a diagnosis of presbycusis on the client's chart. The nurse plans care knowing the condition is:

Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve.

The nurse is caring for a client that is hearing impaired. Which of the following approaches will facilitate communication?

Speaking in a normal tone to the client with impaired hearing and not shouting are important. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse should avoid talking directly into the impaired ear.

While assessing a hemangioma on a 3 yr old girl, the nurse documents it as a raised bright red area, with well defined borders and notes that it does not blanch with pressure. These descriptions are consistent with what vascular lesion?

Strawberry Mark (Immature Hemangioma)

The following is a vascular lesion caused by vascular dilation. It is characterized by permanently enlarged and dilated blood vessels that are visible on the skin surface

Telangegiectases

When using a Snellen alphabet chart, the nurse records the client's vision as 20/40. Which of the following statements best describes 20/40 vision?

The client can see at 20 feet what the person with normal vision can see at 40 feet.

When teaching the client about Meniere's disease, which of the following instructions would a nurse give about vertigo?

Turning the entire body, not the head, will prevent vertigo. Dizziness is expected but can be prevented. The client shouldn't drive as he may reflexively turn the wheel to correct vertigo. Turning the client in bed slowly and smoothly will be helpful; logrolling isn't needed.

Which of the following are types of Telangiectases?

Venous Lake Spider or Star Angiomas

The clinic nurse is preparing to test the visual acuity of a client using a Snellen chart. Which of the following identifies the accurate procedure for this visual acuity test?

Visual acuity is assessed in one eye at a time, and then in both eyes together with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes then are tested together. Visual acuity is measured with or without corrective lenses and the client stands at a distance of 20ft. from the chart.

A 15 yr old girl comes to the doctor with an irregular shpaed patch of hair missing. In the patch are hairs growing with varying lengths. Upon assessmetn the nurse learns that the girl twists and rubs her hair often. Which term best describes this self-induced hair loss condition?

trichotillomania

Which of the following describes, Lesions found on the legs near varicose veins, and also on the face, lips, and ears, that tend to be blue-purple in color and color disappears when pressure is applied.

venous lake

Which of the following is patchy depigmentation from destruction of melanocytes that can be describes as patchy milky white spots, often symmetrically bilateral.

vitiligo