PRNU 113 Final Exam

A client asks the nurse when a colonoscopy is recommended. Which advise by the nurse provides the most appropriate advice?

"A flexible sigmoidoscopy should be done every five years starting at age 50"

A client presents to the health care clinic with reports of inability to concentrate at work and daily frontal headaches for the past two weeks. What additional information should the nurse ask this client?

"Are you experiencing sinus pressure and congestion?'

A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough?

"Are you taking any medications on a regular basis?"

Which statement by the nurse indicates the best understanding of the purpose of an eye-related health history?

"Broad, open-ended questions provide an opportunity to identify changes in the client's eyes."

The nurse is conducting a health history with a female client who reports upper back and jaw pain. In order to assess the client's risk for a cardiac event, which question should the nurse ask first?

"Do you have any pain or discomfort in your chest?"

The nurse has been asked to perform a stereognosis test on an adult client. Which instructions should the nurse provide to the client before performing the test?

"With your eyes closed, identify the object I place in your hand."

Which reading of the ankle-brachial pressure index (ABPI) should the nurse recognize as indicative of a normal healthy person?

1.00

functions of the skin

1.Protection 2.Prevents penetration 3.Perception 4.Temperature regulation 5.Identification 6.Communication 7.Wound repair 8.Absorption and excretion 9.Production of Vitamin D

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV.

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

A client in the clinic where you work is considered legally blind. The nurse knows that this means the vision in his better eye, corrected by glasses, is what?

20/200 or less

When visual acuity is tested using the Snellen eye chart, which result suggests better distance vision?

30/20

A nurse examines a client with complaints of a sore throat and finds that the tonsils are enlarged and touching one another. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils?

4+

what is active motion against full resistance graded as

5/5

petechiae

A circumscribed deposit of blood Less than 0.5 cm in diameter Does NOT blanch!!

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

A client's extraocular movements are asymmetrical and she complains of diplopia

A 29-year-old woman with a longstanding diagnosis of genital herpes has presented to the clinic because of a recent "flare-up." What should the nurse expect during inspection of this recurrence of herpes?

A local patch of small, painful lesions on the client's vulva

Which of the following wounds is most likely attributable to neuropathy?

A painless wound on the sole of the client's foot, which is surrounded by calloused skin

pustule

Acne & impetigo

A client seeks medical attention for pain when touching the area of the frontal sinuses. Which should the nurse consider as the reason for this client's symptom?

Acute bacterial rhinosinusitis

A hospitalized client experiences respiratory distress. The nurse should include which most appropriate client outcome in the plan of care?

Airway patent, breathing quiet, denies dyspnea

The student nurse learns that examining the skin can do all of the following except?

Allow early identification of neurologic deficits

When doing a shift assessment on a newly admitted client, the nurse notes lack of hair on the right lower extremity; thickened nails on the right lower digits; dry, flaky skin on the right lower extremity; and diminished tibial pulses bilaterally and absent pedal pulses. What nursing diagnosis should be added to the plan of care?

Altered tissue perfusion, arterial related to reduced blood flow

What are the components of S1? (Mark all that apply.)

An earlier mitral sound A later tricuspid sound

The nurse is palpating the apical impulse in a client with heart disease and finds that the amplitude is diffuse and increased. Which of the following conditions could be a potential cause of an increase in the amplitude of the impulse?

Aortic stenosis, with pressure overload of the left ventricle

The nurse would assess for positive Blumberg sign how?

Applying and releasing pressure to the abdomen

Corneal Light Reflex (Hirschberg Test)

Ask patient to straight ahead, Shine light at bridge of nose about 12 to 15 inches away, Light should be symmetrical in both corneas.

A nurse experiences difficulty with palpation of the apical impulse on the precordium. What is an appropriate action by the nurse?

Ask the client to assume the left lateral position

A client visits the health care facility with reports of lumbar back pain that radiates down the back. The nurse performs the straight leg test to determine the origin of the pain. Which techniques should the nurse use to perform this test?

Ask the client to raise the leg to the point of pain and then dorsiflex the foot

How should a nurse assess a client for pulse rate deficit?

Assess for a difference between the apical and radial pulse

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 assessing the mouth of a client and finds that she has a smooth, red, shiny tongue without papillae. The nurse should recognize this as indicative of a loss of which vitamin?

B12

A client has undergone a digital rectal examination. This assessment will allow the clinician to diagnose which of the following?

BPH

A client is explaining to the nurse how vaginal dryness has decreased her enjoyment of sexual intercourse. The nurse is aware that which of the following are the glands that produce mucus that lubricates the vagina during intercourse?

Bartholin's glands

Which of the following are types of connective tissue? Select all that apply.

Bone Ligaments Tendons

A new nurse on the long-term care unit is learning how to assess a client's risk for skin breakdown. What would be the most likely instrument this nurse would use?

Braden scale

Which of the following statements relating to assessment of the lungs and thorax is most accurate?

Bronchitis is characterized by excess mucus production and chronic cough.

A nurse has just finished assessing a client's spine and neck muscles. How would the nurse document normal findings?

C7 and T1 spinous processes prominent. Paravertebral, sternocleidomastoid, and trapezius muscles fully developed, symmetrical, and nontender

AV node

CAUSE VENTRICLES TO CONTRACT, 40-60 BEATS/MIN

A 62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. Examination reveals a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms?

COPD

beau's lines

Caused by temporary cessation of cell division at nail matrix for a variety of reasons. Injury of infection of matrix, beta blockers, hypocalcemia, diabetes, etc. Note: as nails grow 0.1 mm each day, timing of the stress can be guesstimated

angiomas

Cherry Angioma, Spider Angioma (Liver disease, pregnancy, overweight)

vesicle and bulla

Chickenpox & Poison Ivy

A client presents to the health care clinic with reports of swelling, pain, and coolness of the lower extremities. The nurse should recognize that which of these lifestyle practices are risk factors for peripheral vascular disease? Select all that apply.

Cigarette smoking Previous use of hormones High-fat diet

A nurse is unable to palpate the apical impulse on an older client. Which assessment data in the client's history should the nurse recognize as the reason for this finding?

Client has an increased chest diameter

A college student presents to the health care clinic with reports of no bowel movement for 4 days, bloating, and generalized abdominal discomfort. She states that she has not been eating and drinking correctly and is stressed because she has a final exam in 2 days. A nurse assesses the abdomen and finds positive bowel sounds in all four quadrants and tenderness in the left lower quadrant with a few small, round, firm masses. The Rovsing's sign and Psoas sign are negative. What nursing diagnosis can the nurse confirm for this client?

Constipation related to decrease in fluid intake

A nurse examines the external genitalia of a client and observes that the scrotum is underdeveloped and the testis cannot be palpated. How should the nurse document this condition?

Cryptorchidism

fine crackles

Discontinuous, high pitched, short crackling, popping sounds heard during inspiration that are not cleared by coughing. (eg. Pneumonia, heart failure, COPD)

when assessing egophony, an abnormal/normal response is

E is normal, A is abnormal

papule and plaque

Elevate nevi, warts, psoriasis

Which of the following recommendations would a nurse advocate during infancy and childhood to help reduce potential adult complications such as orchitis?

Ensure immunizations against infectious diseases such as mumps.

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

what does the kidney do?

Filtration & Elimination of metabolic waste, Fluid and Electrolyte balance, BP control, Endocrine glands secrete hormones

A nurse receives an order to perform a compression test to assess the competence of the valves in a client's varicose veins. Which action by the nurse demonstrates the correct way to perform this test?

Firmly compress the lower portion of the varicose vein

A nurse assesses the parallel alignment of a client's eyes by testing the corneal light reflex. Where should the nurse shine the penlight to obtain an accurate result?

Focused on the bridge of the nose

macule and patch

Freckles, flat moles, petechiae, vitiligo

The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs?

Have a nurse who is the same sex as the client examine him

During the health history interview with a 40-year-old man, the nurse uses the genogram to specifically assess for major family risk for cardiovascular disease by asking about which of the following?

Heart attacks in his father and siblings

wheal

Hives & insect bites

Symptoms of prostate disorder include which of the following?

Incomplete emptying, nocturia, weak urinary stream

The nurse understands that when the sympathetic nervous system is stimulated what occurs? Select all that apply.

Increased cardiac output Increased blood pressure Increased heart rate

A nurse is having trouble finding the apical pulse on an obese person. What is the most likely reason for this?

Increased distance from the apex of the heart to the pre cordium

A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?

Inspect the area

A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test near visual acuity using a Jaeger reading card?

Instruct the client hold the chart 14 inches from the eyes

An emergency department nurse is caring for a young child with intractable nose bleeds. What is the most common site of epistaxis?

Kiesselbach plexus

What is the level of the spinal cord associated with the knee (patellar) deep tendon reflex?

L2 to L4

The sigmoid colon is located in this area of the abdomen: the

LLQ

what connects bone and bone?

Ligaments

rhonchi

Low-pitched; monophonic single note, musical snoring, moaning sounds. Heard throughout the cycle and may clear somewhat by coughing (eg. Bronchitis)

When performing an assessment of the nervous system, it is most appropriate for a nurse to complete it in which sequence?

Mental status, cranial nerves, motor/cerebellar, sensory, reflexes

Where is the linea alba located?

Middle of the ventral abdominal wall

If palpable, superficial inguinal nodes are expected to be:

Nontender, mobile, and 1 cm in diameter

An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse?

Observe the client's respiratory rate and pattern

When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following?

One deep inspiration and expiration through the open mouth

A nurse is working with a client who demonstrates venous stasis in his legs. The nurse understands that there must be a problem with one of the mechanisms of venous function that help to propel blood back to the heart. Which of the following are included among these mechanisms? Select all that apply.

One-way valves in the veins Skeletal muscle contraction Pressure gradient produced by inspiration

A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed?

Osteomyelitis

SA node

PACEMAKER OF HEART, 60-100 BEATS/MIN, CAUSE ATRIUM TO CONTRACT

On a health history, a client reports no visual disturbances, last eye exam being 2 years ago, and not wearing glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next?

Perform both the distant and near visual acuity tests

Which action by a nurse demonstrates proper technique for assessment of chest expansion?

Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath

pitting

Psoriasis

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

To percuss the liver of an adult client, the nurse should begin the abdominal assessment at the client's

RUQ

pupura

Red or purple discoloration spots visibly notable on the skin; hemorrhage under the skin

A nurse is examining the nose of a client diagnosed with an upper respiratory tract infection. Which characteristics of the nasal mucosa should the nurse expect to find during assessment of a client with an upper respiratory tract infection?

Red, swollen, with purulent discharge

What finding should a nurse expect when performing Phalen's test on a client with suspected carpal tunnel syndrome?

Reports of tingling, numbness, and pain in the involved wrist

secondary skin lesions

Results from changes or trauma to original lesion, exs: Erosion (scratch marks or canker sores), Ulcer (Stasis & pressure ulcers), Scar (Healed wounds), Fissure (Chapped lips & hands)

systole

S1 (LUB) - 1/3 OF CYCLE, AV CLOSE (S1), A/P VALVES OPEN, VENTRICLES CONTRACT & EJECT

When auscultating the heart, the nurse is most likely to hear a diastolic murmur after which heart sound?

S2

diastole

S2 (DUBB) - 2/3 CYCLE, AV VALVES OPEN, VENTRICLES RELAX AND FILL UP, ATRIAL KICK AT THE END

cyst

Sebaceous & epidermoid cysts

Which of the following occurs in respiratory distress?

Skin between the ribs moves inward with inspiration.

Goals, although not specific for peripheral vascular disease, focus on areas of risk. What are these areas of modifiable risk? Select all that apply.

Smoking Overweight Lack of exercise

A 52-year-old man is skeptical about the potentially harmful effect of his smoking on his heart, citing the fact that both his father and grandfather lived long lives despite being lifelong smokers. Which of the following facts would underlie the explanation that the nurse provides the client?

Smoking increases the heart's workload and contributes to atherosclerosis.

What is gynecomastia?

Smooth, firm, moveable disc of glandular tissue, May be seen in male during puberty, often unilateral and temporary, May also be seen in hormonal imbalances, drug abuse, cirrhosis, leukemia, and thyrotoxicosis

The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as

Stage II

During the admission assessment of a new client, the nurse is now preparing to assess the client's thyroid gland. How should the nurse perform this assessment?

Stand behind the client and palpate the sides of the trachea.

Which assessment observation should suggest that the client may be experiencing chronic obstructive pulmonary disease (COPD)?

The chest is measured to be deeper than it is wide.

Which of the following statements provides the most accurate guide to the assessment of the gallbladder?

The gallbladder is deep to the liver and cannot normally be distinguished from the liver clinically.

Where are the heart and great vessels located in the human body?

The mediastinum, between the lungs above the diaphragm

A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes?

There is no reaction in the opposite pupil to light.

nail spooning

Thin, depressed nail with lateral edges turned upwards. May be congenital or an indication of anemia, endocrine or cardiac disease

A female client with HIV has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?

This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) test annually.

A 4-year-old child presents to the health care clinic with circular lesions. Which of the following conditions should the nurse most suspect in this client, based on the configuration of the lesions?

Tinea corporis

leukonychia punctata

Transverse white bands from repeated trauma to matrix

What is the most important focus area for the integumentary system?

UV radiation exposure

Mrs. Anderson presents with an itchy raised rash that appears and disappears in various locations. Each lesion lasts for many minutes. Which most likely accounts for this rash?

Urticaria or hives

Which statement describes the correct technique by a nurse when performing the ankle-brachial pressure index test?

Use a blood pressure cuff that is 20% wider than the diameter of the client's limb.

Which statement demonstrates correct technique by a nurse when using the Doppler device to locate peripheral pulses?

Warming the gel will help to avoid vasoconstriction at the site.

nail clubbing

When the angle of nail base exceeds 180 degrees. Proliferation of connective tissue. Associated with chronic respiratory disease and cardiovascular disease, GI disease, liver disease, other. NOT with COPD

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?

Wood's light

The nurse is speaking to a group of seniors about health promotion and is preparing to discuss the ABCDEs of melanoma. Which of the following descriptions is correct for the ABCDEs?

a = asymmetry; b = irregular borders; c = color changes, esp. blue; d = diameter greater than 6 mm; e = evolution

A young toddler is brought to the emergency room by his parents. The mother states that the child was playing on the floor with toys and suddenly began to wheeze. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is

a foreign body obstruction

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

The peritoneum is a serous membrane that contains which of the following?

a parietal layer

A student states that a client has palpable rushing vibration in the area of the pulmonic valve. What should the instructor explain that the student is feeling?

a thrill

When auscultating the heart sounds of a client, a nurse notes that the S2 is louder than the S1. How should the nurse describe S2?

accentuated

A client presents to the health care clinic with reports of a 3-day history of fever, sore throat, and trouble swallowing. The nurse notes that the client is febrile, with a temperature of 101.5°F, tonsils are 2+ and red, and transillumination of the sinuses is normal. Which nursing diagnosis should the nurse confirm based on this data?

acute pain

what are colorectal cancer risk factors?

african american, HPV

The meibomian glands secrete

an oily substance to lubricate the eyes.

An adult client visits the clinic and tells the nurse that she feels chest pain and pain down her left arm. The nurse should refer the client to a physician for possible

angina

A 68-year-old retired truck driver comes to the office for evaluation of swelling in his legs. He is a smoker and has been taking medications to control his hypertension for the past 25 years. The nurse is concerned about the client's risk for peripheral vascular disease. Which of the following tests is appropriate to order to initially evaluate for this condition?

ankle-brachial index (ABI)

When a client is obese or has a thick chest wall, what is difficult to palpate?

apical impulse

The nurse has completed a Glasgow Coma Scale assessment and assigns the client a score of three. Which is the best way for the nurse to assess pain in this client?

assess for nonverbal signs

half and half nails

associated with chronic renal and liver disease

A 21-year-old college senior presents to the clinic reporting shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory, gastrointestinal, and urinary symptoms and says she has no chest pain. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray; she takes no other medications. She has had no surgeries. Her mother has allergies and eczema; her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and has recently started a job as a bartender in town. On examination she is in no acute distress. Temperature is 98.6, blood pressure is 120/80, pulse is 80, and respirations are 20. Head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this presentation best describe?asthm

asthma

A client arrives complaining of nasal congestion, drainage of a thick, yellow discharge from the nose, difficulty breathing through the nose, headache, and pressure in the forehead. The nurse suspects sinusitis. Which of the following risk factors should the nurse assess for in this client?

asthma

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 "ABCDE" characteristic of malignant melanoma?

asymmetrical

The semilunar valves are located

at the exit of each ventricle at the beginning of the great vessels.

The client asks the nurse what the small P wave on her ECG indicates. What would the nurse answer?

atrial depolarization

During which of the following assessments should the nurse use the bell of the stethoscope during auscultation?

auscultation of a client's heart murmur

An adult woman presents at the clinic with a grayish vaginal discharge with a 'fishy' odor. What should the nurse suspect?

bacterial vaginosis

When assessing a client during the physical examination of the genitalia, the nurse palpates the scrotal contents. Which finding should the nurse recognize as an indication that an infection or cysts are present?

beaded or thickened cord

The bicuspid, or mitral, valve is located

between the left atrium and the left ventricle.

ecchymosis

black, purple, yellow, green

A client is experiencing decreased cardiac output. Which vital sign is priority for the nurse to monitor frequently?

blood pressure

While auscultating a client's abdomen, the nurse hears the client's stomach growling. The nurse knows that this is which type of bowel sound?

borborygmus

The nurse suspects that a male client may have a hernia. The nurse should further assess the client for

bowel sounds at the bulge

A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 8 breaths per minute. The nurse knows the proper term for this rate is what?

bradypnea

A client presents to a primary care office with a complaint of double vision (diplopia). On questioning, the client claims to have not suffered any head injuries. Which of the following underlying conditions should the nurse most suspect in this client?

brain tumor

A nurse cares for a client who suffered a cerebrovascular accident and demonstrates the inability to speak clearly. The nurse recognizes that injury has occurred to what portion of the brain?

brocas area

cullens and turners sign

bruising over pancreas, indicates disease

The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of?

bruits

The nurse is performing the assessment shown. What is the nurse assessing in this client?

buccal mucosa

The nurse observes the client's lower extremities as shown. What should the nurse focus on when teaching this client about upcoming diagnostic tests?

burning when having an MRI

When inspecting the mouth, the nurse focuses on lateral and vertical surfaces of the tongue and its base, because these are regions where:

cancers often occur

The nurse is assessing a client who has been taking antibiotics for an infection for 10 days. The nurse observes whitish curd-like patches in the client's mouth. The nurse should explain to the client that these spots are most likely

candida albicans infection

A student is asked to define the continuous rhythmic movement of blood during contraction and relaxation of the heart. This best describes which of the following?

cardiac cycle

osteoporosis risk factors?

caucasian women, age, poor nutrition

The husband of a 65-year-old female tells the nurse, "My wife is having trouble navigating the steps in our home and needs my help to step down off a curb." What part of the nervous system should the nurse assess for a potential source of the problem?

cerebellum

A 28-year-old married clothing sales clerk comes to the clinic for her annual examination. She requests a refill on her birth control pills. Her only complaint is painless bleeding after intercourse. She denies any other symptoms. Her past medical history consists of two spontaneous vaginal births. Her past six Pap smears have all been normal. She is married with two children. Her mother is in good health, and her father has high blood pressure. Examination shows a young woman appearing healthy and relaxed. Her vital signs are unremarkable, and her head, eyes, ears, throat, neck, cardiac, lung, and abdominal examinations are normal. Visualization of the perineum shows no lesions or masses. Speculum examination shows a red mass at the os. On taking a Pap smear the mass bleeds easily. Bimanual examination shows no cervical motion tenderness. Both ovaries are palpated and nontender. What is the most likely diagnosis related to the abnormality of her cervix?

cervical polyp

A client presents to the health care clinic with reports of onset of neck pain 3 days ago. The nurse recognizes that the most common cause of neck pain is what condition?

cervical strain

The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible

chronic bronchitis

Upon inspection of a client's chest, a nurse observes an increase in the ratio of anteroposterior to transverse diameter. The nurse recognizes this as a finding in which disease process?

chronic obstructive pulmonary disease

The nurse is performing the Romberg test. Which of the following indicate a normal finding?

client stands erect with minimal swaying

Which of the following events occurs at the start of diastole?

closure of the aortic valve

When auscultating a client's lungs, the nurse hears a sound like Velcro being pulled apart over the client's right middle lobe. During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration.How should the nurse document this finding?

coarse crackles

A light is pointed at a client's pupil, which then contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. Which of the following terms describes this latter phenomenon?

consensual reaction

when assessing egophony, an abnormal response indicates

consolidation (pneumonia)

A nurse palpates a client's hands and fingers. Which of the following findings would be consistent with arterial insufficiency?

cool skin

A client has sustained an injury to the cerebellum. Which area would be the primary area for assessment?

coordination

The nurse assess for kidney tenderness at what location?

costovertebral angle

A nurse is working with a client who has an impaired ability to move the tongue. He explains that he was in an automobile accident many years ago and suffered nerve damage that resulted in this condition. Which nerve should the nurse suspect was damaged in this client?

cranial nerve XII (hypoglossal)

A nurse examining a client's external genitalia notices that his scrotum and testes draw up and he shivers. This phenomenon is known as which of the following?

cremasteric reflex

A client complains of abdominal pain with cramping diarrhea, nausea, vomiting, weight loss, and loss of energy. The nurse should suspect which of the following as the underlying cause?

crohn's disease

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

During an interview with the nurse, a client complains of a fatigue that seems to get worse in the evening. Which of the following causes of fatigue would explain this pattern?

decreased cardiac output

A client asks a nurse if any foods promote eye health. What food would the nurse include as a response?

deep water fish

The nurse has assessed the respiratory pattern of an adult client. The nurse determines that the client is exhibiting Kussmaul respirations with hyperventilation. The nurse should contact the client's physician because this type of respiratory pattern usually indicates

diabetic ketoacidosis

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

difficulty swallowing

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

distribution

A nurse is interviewing a client whose chief complaint is temporomandibular joint pain. Which of the following questions should the nurse ask regarding a causative factor?

do you grind your teeth?

An African American client appears to have lumbar lordosis present upon examination of the thoracic and lumbar spine. What should the nurse do in relation to this finding?

document this as a normal variation

Before examining the mouth of an adult client, the nurse should first

don clean gloves for the procedure

A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding?

dyspnea

what causes a pigskin or orange peel like texture of the breast?

edema- often from metastatic breast disease

During palpation of the client's knee, the nurse compresses the suprapatellar pouch against the client's femur with one hand while feeling on each side of the patella with the opposite hand. For which of the following problems is the nurse assessing?

effusion in the knee joint

The nurse is caring for a client with venous ulcers on both legs. The client is complaining of pain. What is the nurse's best action?

elevate the legs on pillows

what is murphy's sign?

elicited in patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the right subcostal area. If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner's hand, it's positive, shows acute cholecystitis

what is the pancreas?

endocrine gland and accessory organ of digestion

what is hepatomegaly?

enlarged liver

The nurse observes an inward turning of the lower lid in a 77-year-old client. The nurse documents

entropion

While reviewing the medical record before examining a male clinic client, the nurse notes that the urinary meatus is located on the top of the glans of the penis. The nurse understands the correct term for this congenital defect is

epispadias

The nurse places the stethoscope on the 3rd intercostal space at the left sternal border. Which area is the nurse auscultating for heart sounds?

erb's point

The outer layer of the vaginal wall is under the direct influence of

estrogen

Which of the following statements is true of prostate cancer?

ethnicity is a risk factor (highest for African American or Caribbean males of African origin; occurs less often in Asian, Hispanic/Latino men than in whites)

what connects muscle to muscle?

fasciae

6 f's

fat, feces, fetus, fibroids, flatulence, and fluid

Upon inspection and palpation of the front of the client's thigh, the nurse discovers a bulge that appears when the client coughs. The nurse should document this finding as which type of hernia?

femoral

three types of joints

fibrous (sutures between skull bones) cartilaginous (between vertebrae) synovial (shoulders, hips, knees)

what does the spleen do?

filter blood of cellular debris, digest microorganisms, and return breakdown products to liver

The tongue is attached to the hyoid bone and styloid process of the temporal bone and is connected to the floor of the mouth by the

frenulum

What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis?

friction rub

The corpora spongiosum extends distally to form the acorn-shaped

glans

A client shares that a first-degree relative has an eye problem, but they not sure what the diagnosis is. What major eye problem will the nurse suggest screening the client for?

glaucoma

In order to effectively assess the oral mucosa, the nurse should have which assessment tools available?

gloves, penlight, tongue depressor

what do liver and gallbladder do?

glucose storage, forms plasma proteins, clotting factors, urea synthesis, cholesterol production, bile formation & storage, destruction of RBCs, storage of iron and vitamins, detoxification

A nurse auscultates a very loud murmur that occurs throughout systole and can be heard with the stethoscope partly off the chest. How should the nurse grade this murmur?

grade 5

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

The thoracic cavity contains which of the following organs? Select all that apply.

heart, lungs, most of the esophagus

The nurse is assessing male genitalia and finds clusters of pimple-like clear vesicles. The nurse recognizes this as what?

herpes

While performing a gynecologic examination, the nurse observes small, painful, ulcer-like lesions with red bases on the client's labia. The nurse should refer the client to a physician for possible

herpes simplex virus infection

A client who is bedfast responds only to painful stimuli, never eats a complete meal, and moves occasionally in bed. Which term should the nurse use to describe this client's risk for skin breakdown?

high

A nurse inspects a client's nails and notes the angle between the nail base and the skin is greater than 180 degrees. What additional data should the nurse collect from this client?

history of cigarette smoking

A 68-year-old man comes to the clinic reporting that he is having difficulty obtaining an erection. When reviewing the client's history what might the nurse note that contributes to impotence?

history of hypertension

A client has a history of emphysema. The nurse percussing the client's chest expects to hear what characteristic sound?

hyperresonance

What term would the nurse use to document a client's report of pain in the lower-middle area of the abdomen?

hypogastric

Which part of the brain controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions and maintains overall autonomic control?

hypothalamus

The nurse notes the client has weak pulses bilaterally. The nurse understands that this could indicate the client is experiencing what?

hypovolemia

The nurse is planning care for a client recovering from orthopedic surgery. Interventions should be included to address which contributing factor to deep vein thrombosis development?

immobility

Upon inspection and palpation of the scrotum, the nurse discovers a mass. The nurse finds that the mass cannot be pushed back into the abdomen. The nurse should document this finding as which type of hernia?

incarcerated

The nurse assesses a hospitalized adult client and observes that the client's jugular veins are fully extended. The nurse contacts the client's physician because the client's signs are indicative of

increased central venous pressure.

What nursing diagnosis would be most appropriate for a client admitted with heart failure?

ineffective tissue perfusion

The client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition?

inflammation of the parietal pleura

A nurse cares for a client who suffered a myocardial infarction 2 days ago. A high-pitched, scratchy, scraping sound is heard that increases with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium?

inflammation of the pericardial sac

Before the nurse begins the physical examination of a client with congestive heart failure, the client reports having to get up at night to void frequently. Which action should the nurse take in response to the client's report?

inspect for dependent edema

A child presents to the health care facility with new onset of a foul-smelling, purulent drainage from the right nare. The mother states that no other signs of an upper respiratory tract infection are present. What is an appropriate action by the nurse?

inspect the nostrils with an otoscope

A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse?

instruct the client to cough forcefully

An elderly client diagnosed with sinusitis undergoes a transillumination test to detect the presence of fluid or pus in the maxillary sinus. Which precaution should the nurse take to avoid an inaccurate result?

instruct the client to remove upper dentures

The nurse is assessing the abdomen of an adult client and observes a purple discoloration at the flanks. The nurse should refer the client to a physician for possible

internal bleeding

cancerous breast tumors

irregular, firm, hard, poorly defined masses, may be fixed or mobile, usually non tender, often after age 50

The nurse auscultates the base of the lungs to assess for what reason?

it is where fluid occurs with pulmonary edema

nodule and tumor

keloid, lipoma, cell carcinoma

The nurse is assessing an elderly client and finds an exaggerated thoracic curve. This would be documented as what?

kyphosis

In order to palpate an apical pulse when performing a cardiac assessment, where should the nurse place the fingers?

left midclavicular line at the fifth intercostal space

fibroadenomas

lobular, ovoid or round, firm, well defined, seldom tender, usually singular and mobile; common between puberty and menopause

A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the client for

lymphedema

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

macular degeneration

While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is deviated to the left. The nurse should refer the client to a physician for possible

masses

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

Mrs. Philips complains of numbness of her right hand. On examination, sensation of the volar aspect of the web of the thumb and index finger and pulp of the middle finger are normal. The pulp of the index finger has decreased sensation. Which of the following is affected?

median nerve

The prostate gland consists of two lobes separated by the

median sulcus

How should a nurse position a client to accurately auscultate the right middle lobe of the lung?

move the right arm away from the body

In auscultating a client's heart sounds, a nurse hears a swooshing sound over the pre cordium. The nurse recognizes this sound as which of the following?

murmur

You are assessing a client for acute cholecystitis. What sign would you assess for?

murphys sign

A nurse observes a few small, yellow nodules on the cervix of a client during the speculum exam. They are not painful or odorous, and a thin, clear discharge is present. The nurse recognizes that these are most indicative of what type of condition?

nabothian cysts

Which of the following would the nurse consider to be an urgent situation

new onset chest pain

Which of the following would the nurse consider to be an urgent situation?

new onset chest pain

Which characteristic of a cough should alert the nurse to assess the client for other findings of sinusitis?

nighttime when lying down

A nurse performs an initial health history on a client admitted for new onset of chest pain. Which data is considered subjective for the cardiovascular system?

no current medications or treatments

Which of the following is a sign or symptom of benign prostatic hypertrophy (BPH)?

nocturia

When assessing the lymph system of an adult client, the nurse notes that the epitrochlear nodes are nonpalpable. What does this indicate?

normal finding

A hospitalized post-operative client exhibits edema, pain, erythema, and warmth in the right calf area. What is the nurse's best action?

notify the healthcare provider

A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation?

observe for the use of accessory muscles

A 58-year-old teacher presents with breathlessness with activity. The client has no chronic conditions and does not take any medications, herbs, or supplements. Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems?

orthopnea

A nurse practitioner documents as follows:"Client reports pain and tenderness over area of right ovary and a history of irregular menses."With which of the following diagnoses are these findings consistent?

ovarian cysts

Identify the location where vesicular, bronchovesicular, bronchial, and tracheal lung sounds are heard (in that order).

over most of both lungs between the scapulae over the manubrium over the trachea in the neck

An 18-year-old college freshman comes to the clinic complaining of severe left-sided lower abdominal pain and a foul yellow discharge. The pain began last night while she was having intercourse with her boyfriend. Afterwards the pain became more severe and the discharge started. By this morning she had a fever of 38.3°C and walking was making the pain worse. Only lying very still makes the pain better. She has tried ibuprofen and acetaminophen without any improvement. She denies any nausea, vomiting, diarrhea, or constipation. Her past medical history is unremarkable. She has had two past sexual partners. She uses the birth control patch instead of condoms. She smokes a half pack of cigarettes a day and drinks four to five beers per weekend night. She denies any illegal drug use. Her parents are both healthy. Examination shows a young woman who appears ill. Her temperature is 38.9°C and her pulse is elevated at 110. She is tender in the left lower quadrant but has no guarding or rebound. Speculum examination reveals yellow purulent drainage from the os. On palpation there is cervical motion tenderness and the left adnexa is swollen and tender. A urine analysis is unremarkable and the urine pregnancy test is pending. What is the best choice of diagnosis for this adnexal swelling?

pelvic inflammatory disease

While performing an admission assessment, the nurse auscultates a high-pitched, scratching, and grating sound at the left lower sternal border. The nurse should use what term to document the sound?

pericardial friction rub

The external covering of the bone that contains osteoblasts and blood vessels is termed the

periosteum

A client complains of pain in the calves, thighs, and buttocks whenever he climbs more than a flight of stairs. This pain, however, is quickly relieved as soon as he sits down and rests. The nurse should suspect which of the following conditions in this client?

peripheral arterial disease

An uncircumcised, 78 year-old male has presented at the clinic complaining that he cannot retract his foreskin over his glans. On examination it is noted that the foreskin is very constricted. What is this condition called?

phimosis

how to test for pyelonephritis

place hand over kidney and strike with fist, pain

A client reports sharp and stabbing chest pain that worsens with deep breathing and coughing. A cardiac cause to this pain is ruled out. The description of the pain is consistent with what respiratory condition?

pleurisy

A 47-year-old receptionist comes to the office with fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Fahrenheit. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms?

pneumonia

hematoma

pocket of blood

The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should

position the client 609.6 cm (20 ft) away from the chart

What information should a nurse give a client who reports a routine of frequent douching?

predisposes the vagina to yeast infections

On inspecting a client's external genitalia, a nurse notes that he is uncircumcised. This means that which of the following covers the glans of the penis?

prepuce

A nurse observes that the mucosa of the rectum and the rectal wall of a female client protrudes out through the anal opening. It appears as a red, doughnut-like mass with radiating folds. How should the nurse document this condition of the rectum?

prolapse

Mr. Jackson, 50 years old, has had discomfort between his scrotum and anus. He also has had some fevers and dysuria. Rectal examination is halted by tenderness anteriorly, but no frank mass is palpable. What is the most likely diagnosis?

prostatitis

Which characteristic of the gums should a nurse expect to assess in a client who has scurvy?

red, bleeding

A client complains of a sudden onset of pain in the back. On questioning the client further, the nurse learns that the cause of the pain is acute pancreatitis. The nurse recognizes that this type of pain is which of the following?

referred pain

While assessing the thoracic area of an adult client, the nurse plans to auscultate for voice sounds. To assess bronchophony, the nurse should ask the client to

repeat the phrase "ninety-nine."

When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields?

resonance

When percussing the posterior lung fields, which of the following findings is expected?

resonance over all lung fields

Photoreceptors of the eye are located in the eye's

retina

A 38-year-old woman presents with multiple small joints that are symmetrically involved with pain, swelling, and stiffness. Which of the following is the most likely explanation?

rheumatoid arthritis

The nurse performs an admission assessment on an adult client admitted through the ED with a myocardial infarction. The nurse auscultates a swooshing sound over right carotid artery. What phrase should the nurse use to correctly document this finding?

right carotid bruit ascultated

The nurse is assessing a client's lymphatic system. For which enlarged node should the nurse suspect that the client has a blockage within the right lymphatic duct?

right cervical node

When visualizing the structures of the abdominal cavity, which of the following would the nurse expect to be in the right upper quadrant?

right kidney, liver, ascending colon

benign breast disease

round, elastic, defined, tender and mobile cysts, common from 30 y/o to menopause

When assessing egophony, the nurse should ask the client to

say "eee"

The school nurse notes that the client carries her left shoulder higher than her right shoulder. You should recognize the likely presence of what health problem?

scoliosis

The spinous process termed the vertebra prominens is in which cervical vertebra?

seventh

A client arrives in the emergency department after a severe motor vehicle accident. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. What pathophysiological process is likely the cause of this breathing pattern?

severe brain damage

A client comes to the emergency department reporting a sudden onset of dyspnea. What finding is a manifestation of dyspnea?

shortness of breath

The nurse notes that a client's heart rate increases with inspiration and slows down with expiration. How should the nurse document this finding?

sinus arrythmia

primary original lesion

skin change due to causative factor, may be characteristic of a disease

The nurse is providing teaching about cardiovascular disease in a community setting. What risk factors would the nurse identify to the group as those they can modify through lifestyle choices? Select all that apply.

smoking, blood pressure, cholesterol

Sensations of temperature, pain, and crude and light touch are carried by way of the

spinothalamic tract

A nurse performs percussion beginning along the left midaxillary line and progressing downward until the sound changes from lung resonance to splenic dullness. The client reports tenderness. The nurse recognizes this as an abnormal finding for which organ?

spleen

When assessing for an inguinal hernia, the nurse asks the client to assume what position?

standing, facing the examiner

A nurse is preparing to perform the nurse's first complete assessment of a client at a hospital. Which of the following should the nurse consult to find out what can legally be assessed and diagnosed?

state's nurse practice act

A client reports the new onset of mucous in the stool. How should the nurse document this in the client's history?

steatorrhea

What is the best guide to make vertical locations on the chest?

sternal angle

A client visits the clinic because she experienced bright hematemesis yesterday. The nurse should refer the client to a physician because this symptom is indicative of

stomach ulcers

An older adult client visits the clinic for a gynecologic examination. The client tells the nurse that she has been told that she has uterine prolapse. The nurse should further assess the client for

stress incontinence

A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what?

stridor

A nurse is working with an older client who has decreased left ventricular compliance. The nurse understands that this condition will cause a decrease in the amount of blood pumped from the heart with each contraction, a measure known as which of the following?

stroke volume

The nurse is assessing a client with a bladder disorder. Where would the nurse expect the pain to be?

suprapubic

Which of the following is an important function of the skin?

synthesis of vitamin d

Skeletal muscles are attached to bones by

tendons

what connects muscle and bone?

tendons

Which observation confirms to the nurse that the client is experiencing a normal inspiration?

the thoracic cavity enlargens

A client's ankle-brachial index is 0.70. What should this finding suggest to the nurse about the client's peripheral vascular integrity?

there is borderline perfusion to the lower extremities

The nurse is auscultating the heart sounds of an adult client. To auscultate Erb point, the nurse should place the stethoscope at the

third to fifth intercostal space at the left sternal border.

An adult male client comes to the clinic for his annual physical examination. During the nursing assessment, the nurse asks, "Do you have any current or chronic illnesses such as diabetes, hypertension, respiratory problems, or cardiovascular disease?" Why does the nurse ask this question?

to assess risk for erectile dysfunction

A client with congestive heart failure presents to the emergency department with soreness from swelling of the ankles. When conducting the physical examination of this client, the nurse would require a stethoscope for which reason?

to auscultate the lungs

A 23 year old male comes to the clinic complaining of sudden and severe pain in his scrotum. The nurse would suspect what?

torsion of the spermatic cord

When the female client reports a frothy yellow-green or brown vaginal discharge, the nurse suspects the client has a vaginal infection caused by which of the following?

trichomonas vaginalis

An adult client visits the clinic and tells the nurse that he has been "spitting up rust-colored sputum." The nurse should refer the client to the physician for possible

tuberculosis

While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is enlarged and everted. The nurse should refer the client to a physician for possible

umbilical hernia

Which area of the body should a nurse inspect for possible loss of skin integrity when performing a skin examination on a female who is obese?

under the breast

When assessing for apocrine gland function, the nurse would assess for moisture where on the client's body?

underarms

Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis?

unequal expansion of the chest

what are breast cancer risks?

use of oral contraceptive, breast consistency, early menarche/late menopause, DES

what is dimpling or retraction of the breast caused by?

usually a malignant tumor

A client tells the nurse he has been having gray-colored stools after recent travel out of the country to an area with known poor sanitation. The nurse needs to investigate the possibility of which condition?

viral hepatitis

A nurse is assessing a client with a history of alcohol abuse. The client reports right upper quadrant pain. Which type of pain is the client experiencing?

visceral

The nurse is caring for an adult client who is in a cast because of a fractured arm. To promote healing of the bone and tissue, the nurse should instruct the client to eat a diet that is high in

vitamin c

The rich blood supply of the nose serves to

warm inspired air

what is emphysema?

•Cause: Destruction of pulmonary connective tissue (elastin, collagen) characterized by permeant enlargement of air sacs with rupture of interalveolar walls. •S/Sx: Barrel chest (increased anteroposterior diameter), Underweight, Diminished LS, prolonged expiration, Wheezing or crackles

A 52-year-old client with myopia calls the ophthalmology clinic very upset. She tells the nurse, "I keep seeing semi-clear spots floating across my vision. What is wrong with me?" What would be the most appropriate response by the nurse?

"It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'."

A 6-year-old boy has come to the clinic with his mother because of recent eye redness and discharge. The nurse's assessment has suggested a diagnosis of conjunctivitis. What should the nurse tell the mother about her son's eye?

"This might have been the result of an allergy, but most likely it was caused by a bacteria or virus."

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 cares for a client of Asian descent and notices that the client sweats very little and produces no body odor. What is an appropriate action by the nurse in regards to this finding?

Document the findings in the client's record as normal

A nurse should assist a client to assume what position to best assess the mouth, nose, and sinuses?

Sitting with the head erect and at the eye level of the nurse

As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test?

The client and the examiner see the examiner's finger at the same time.

The nurse is admitting a 79-year-old man for outpatient surgery. The client has bruises in various stages of healing all over his body. Why is it important for the nurse to promptly document and report these findings?

The client may have been abused.

Why is it important for the nurse to ask the client what they think caused a skin condition?

The client's perception affects the approach and effectiveness in treating the skin condition

The nurse should make it a priority to assess which client for papilledema?

a 45-year-old suspected of experiencing a subarachnoid hemorrhage

The nurse is assessing a dark-skinned client who has been transported to the emergency room by ambulance. When the nurse observes that the client's skin appears pale, with blue-tinged lips and oral mucosa, the nurse should document the presence of

a great degree of cyanosis

While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had

a recent illness

Upon assessing the skin, the nurse finds pustular lesions on the face. The nurse identifies that these could be what?

acne

A client's tongue and oral mucosa are blue-tinged in color. What health problem should the nurse suspect this client is experiencing?

advanced lung disease

A nurse cares for a client with a stage II pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area?

broken with the presence of a blister

What lines the cheeks?

buccal mucosa

The conjunctiva of the eye is divided into the palpebral portion and the

bulbar portion

A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what?

carotene

While assessing the skin of an older adult client, the nurse observes that the client has small yellowish brown patches on her hands. The nurse should instruct the client that these spots are

caused by aging of the skin in older adults.

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

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

conjunctiva

A nurse is working with a 13-year-old boy who complains that he has begun to sweat a lot more than he used to. He asks the nurse where sweat comes from. The nurse knows that sweat glands are located in which layer of skin?

dermis

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

dermis

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

A hospitalized client continues to exhibit residual effects of a stroke. Which symptom is the priority concern?

dysphagia

While assessing the eye of an adult client, the nurse observes an inward turning of the client's left eye. The nurse should document the client's

esotropia

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

What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?

fainting

An adult male client visits the clinic and tells the nurse that he believes he has athlete's foot. The nurse observes that the client has linear cracks in the skin on both feet. The nurse should document the presence of

fissures

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 client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?

lacrimal apparatus

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

A client visits the clinic for a routine physical examination. The nurse prepares to assess the client's skin. The nurse asks the client if there is a family history of skin cancer and should explain to the client that there is a genetic component with skin cancer, especially

malignant melanoma

The optic nerves from each eyeball cross at the

optic chiasma

Squamous cell carcinoma is associated with

overall amount of sun exposure

When assessing a client's terminal hair distribution, the nurse inspects all the following areas except:

palmar surfaces

A young man comes to the clinic with an extremely pruritic rash over his knees and elbows, which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. Examination reveals scabbing and crusting with some silvery scales. The nurse also notices small "pits" in the nails. What would account for these findings?

psoriasis

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

A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults?

receding and ischemic gums

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

A client presents to the health care clinic with reports of changes in the skin. Which data should the nurse document as objective with regards to the skin?

skin warm and dry to touch

The nurse is caring for a 63-year-old client who can neither read nor speak English. What would be the appropriate chart to use to assess this client's vision?

snellen e

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

soft palate

The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that

squamous cell carcinomas are most common on body sites with heavy sun exposure.

A 58-year-old man who is HIV-positive has presented with thick, white plaques on his oral mucosa. What diagnosis would the nurse first suspect?

thrush

A teenager is brought to the clinic for a sports physical examination. The client states plans to play goalie on the community soccer team. What is the most important teaching opportunity presented for this client?

use of safety equipment

An extension of the soft palate of the mouth, which hangs in the posterior midline of the oropharynx, is the

uvula

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's

vesicles

The nurse notes that the client's tongue appears as shown. What should the nurse suspect is occurring with this client?

vitamin deficiency

A client's skin color depends on melanin and carotene contained in the skin, and the

volume of blood circulating in the dermis.