Practice Exam 2

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?"

The pediatric nurse conducts a follow-up phone call for a mother who was discharged with her newborn several days ago. The mother tells the nurse that she thinks her newborn is jaundice. Which question by the nurse will help to support this mother's statement?

"Does your baby's skin and mucous membranes have a yellowish color?"

The nurse is caring for a client who had abdominal surgery several months ago. The client has verbalized concern that the scar from the surgery is purplish in color. Which response by the nurse is the most appropriate?

"The color is normal and will fade with time."

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."

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?

"This is very unusual. I will let the healthcare provider know.

The nurse is obtaining the height and weight of an older adult client. The client asks why the height is 1 inch less than last year. Which response by the nurse is the most appropriate?

"Your height decreases with age due to musculoskeletal changes."

Which vision acuity reading indicates blindness?

20/200

Where is the temporal artery palpated?

Above the cheek bone near the scalp line

nurse assesses an older adult client who lives alone and is unable to drive a vehicle. Which of the following assessment areas of the nutritional history will most likely impact the client's nutritional status?

Accessibility

The nurse is preparing to assess a client's mental status within the general survey. Which data should the nurse use to assess this status?

Asking the client to describe elements of his health history.

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

Which vessel is the nurse assessing if the major artery of the neck is being examined?

Carotid

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 the lips and oral mucous membranes.

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

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

Conjunctiva

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?

Conjunctivitis

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 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 conducting an admission assessment for a client and notes skin vitiligo, which is highly visible even from a distance. The client asks the nurse to place a "No Visitors" sign on the door. The client states, "I hate the way my skin looks. Some people just stare at me." Which nursing diagnosis should be incorporated into the client's plan of care?

Disturbed body image.

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 do you care for your skin Do you have any tattoos or body piercings how much time do you spend out doors

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

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 color location and distribution

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

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?

Herpes simplex

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.

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

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

Iodine

The nurse is conducting a general survey on an infant for a health maintenance visit. During the survey, the infant has a liquid stool. The mother becomes very angry and asks the nurse to change the diaper because she just can't "deal with the odor." Why is this mother's statement important to the nurse?

It may be a reflection of the mother-child relationship.

Before completing the physical examination, the nurse determines that the patient is awake, alert, and oriented. This information would be important for which part of the general survey?

Level of consciousness

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

Light-colored hair age over 55 Actinic keratosis on face

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.)

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

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 the healthcare provider.

A client presents to the primary care clinic and is disheveled in appearance, with stained, dirty clothing, body odor, and uncombed hair. Based on this observation, which topics should the nurse assess during the history and physical exam? Select all that apply.

Occupation self concept depression

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 usually lost first and orientation to person is usually lost last.

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?

Reassure the teen that this is normal.

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.

A young adult client notes height as "5 feet 11 inches" and weight as "200 lbs." Upon assessment, the client is found to be 5 feet 9 inches tall with a weight of 225 lbs. Which is the most likely cause of this discrepancy?

The client may have an image of self that is inconsistent with actual findings.

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?

The nurse uses the Wong-Baker "FACES" pain rating scale.

During a general survey, the nurse asks if the patient is feeling cold. What did the nurse most likely observe in the patient?

The patient is wearing clothing that is inconsistent with warm weather.

Parents bring a school age child to the emergency department after a bicycle accident. The father tells the nurse that the child was not wearing a helmet when thrown over the handlebars, striking the child's head on the sidewalk. What would be the most important information for the nurse to include in education for this child and family?

Use of safety equipment

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 ear guards whenever inside the plant

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

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 pustular vesicular

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

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

discharge is associated with inflammation or infection

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 chair gloves examination table

Excessively increased dietary intake of carrots, squash, and sweet potatoes can change the skin

orange

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

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 prognosis of malignant melanoma depends primarily on:

the thickness of the lesion