sonyasabrah

A woman brings her 1-month-old infant to the ED. She says the baby is not eating or drinking well. The nurse finds the fontanels are depressed slightly. Why does this require further assessment?

this could be a sign of dehydration

Upon examination of a client, the nurse finds a circumscribed elevated, palpable mass containing serous fluid. How should the nurse properly document this finding?

vesicle

What does examination of the skin involve? Select all that apply.

• Inspection • Palpation

The nurse is gathering equipment to perform a skin assessment on an elderly client. What type of equipment will be needed? Select all that apply.

• Tape measure • Examination gown • Magnifying glass • Adequate light source

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.)

• notched border • diameter great than 6 cm • asymmetry

Which question asked by the nurse is assessing problems with tinnitus?

"Do you experience buzzing in your ears?"

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

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

The patient asks the nurse why the nurse put the tuning fork on the bone behind the ear. Which is the best response by the nurse?

"It identifies a problem with the normal pathways for sound to travel to your inner ear."

. Which of the following are appropriate interventions for the patient who is at risk for ear infection? Select all that apply.

1. Be current on immunizations. 2. Avoid second hand smoke. 3. Clean only external ear.

The nurse recognizes that which client is at greatest risk for the development of skin cancer?

55-year-old male who lived in California for 20 years

Which of the following patients would require the most emergent nursing care?

A 20-year-old man with sudden visual loss after playing football

The nurse notes a tophus of the ear of an older adult. Which assessment data is consistent with a tophus?

A hard nodule composed of uric acid crystals

An increased risk of falls is dangerous for any patient. What patient would be at an increased risk of falls?

A patient with vertigo.

A nurse palpates an enlarged and tender left sided supraclavicular lymph node in a client. Where should the nurse focus the physical assessment to obtain more data about this finding?

Abdomen and thoracic area for changes associated with malignancy

Where is the temporal artery palpated?

Above the cheek bone near the scalp line

Which of the following would the nurse suspect if assessment reveals a skull and facial bones that are larger and thicker than normal?

Acromegaly

What do retinal abnormalities include?

Age-related macular degeneration

Many older adults are edentulous, which can cause overclosure of the mouth. What can this lead to?

Angular cheilitis

When assessing a client's lips, which of the following is an indication of a viral infection?

Aphthous ulcer

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

Behind the tip of the mandible

The nurse is beginning examination of the client. All the following areas are important to observe as part of the general survey except:

Blood pressure

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

Conjunctiva

When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics?

Consistency, delineation, mobility, tenderness

A nurse performs the cover test to assess for proper alignment of the eyes. When uncovering the previously covered eye, the nurse should observe for which response to indicate a normal finding?

Covered eye remains fixed straight ahead

When the nurse is inspecting a client's fingers, a client asks how fingerprints are formed. When deciding on an answer, the nurse recalls that the fingerprints are formed in which skin layer?

Dermal

The nurse is inspecting Wharton's ducts. The nurse would expect to find these at which location?

Either side of frenulum on floor of the mouth

The muscles of the ciliary body control the thickness of the lens, allowing the eye to:

Focus on near or distant objects

A client reports the appearance of rings around lights. A nurse should perform further assessment to confirm the onset of what disorder?

Glaucoma

What is the most common type of hyperthyroidism?

Graves' disease

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

When identifying the midline structures of the neck from the mandible to the sternal notch, the nurse notes the structures in what order?

Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid

A mother brings her child to the health care clinic and reports that her son has a four-day history of intense itching to his legs. On inspection of the child's legs, the nurse notes a honey-colored exudate coming from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition?

Impetigo

The nurse is preparing to palpate the submandibular salivary glands. The nurse would place the hands at which location?

Inferior to the mandible beneath the tongue

The nurse inspects the skin of an older adult client and notes thick, rough skin over the elbows. The nurse would document this finding as which of the following?

Lichenification

When examining a patient's sclera and conjunctiva during an eye examination, the nurse should instruct the patient to:

Look up

During adolescence, what vision change is common?

Nearsightedness

What site for taking body temperature with a glass thermometer is contraindicated in patients who are unconscious?

Oral

nurse assesses the response of the eye to light and documents normal findings as

PERRLA

You are a pediatric nurse caring for a child who has been brought to the clinic with otitis externa. What assessment finding is characteristic of otitis externa?

Pain on manipulation of the auricle

An outcome that is appropriate for a patient with hearing impairment is

Patient explains plan to accommodate hearing impairment.

A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. Which of the following would the nurse do next?

Perform a random blood sugar test.

When testing the pupils for consensual response, how can the nurse increase the accuracy of the test?

Place a barrier between the eyes

Which terms refers to the progressive hearing loss associated with aging?

Presbycusis

Some clients with acoustic neuromas have vertigo. What is a priority nursing action with clients with vertigo?

Protect the client from injury

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

Pull the auricle out, up, and back.

A young adult client has just had X-rays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for next?

Range of motion of the neck

The nurse assesses thick white plaques on the hard palate of a client. Which of the following would the nurse do next?

Refer the client for medication.

A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. Client states 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 at the clinic complaining of a loss of balance. What test should the nurse expect the physician to carry out on a client with a loss of balance?

Romberg test

A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true?

She can see at 20 feet what a normal person could see at 100 feet.

In which position should the nurse place the school-age child when examining the ear?

Sitting position on the examination table

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 the touch

A 15-year-old high school student presents to the emergency department with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On physical examination, the pupils are equal, round, and reactive to light with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. Based on this description, what is the most likely diagnosis?

Subconjunctival hemorrhage

A patient has an open draining wound located on the underside of the chin. Which lymph nodes should the nurse assess in this patient?

Submental

A decrease in oxyhemoglobin will result in documentation of pallor.

TRUE

The nurse tests the six cardinal directions to test extraocular movement of the eye.

TRUE

A client's temperature is 102°F. Which of the following would the nurse also expect to find ?

Tachycardia greater than 100 bpm

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

A nurse is admitting an elderly client for surgery the following morning. The nurse notices that the client has excessively dry skin. The client says showering every day, sometimes twice, but has trouble keeping skin moist. What client education is appropriate?

The elderly should bathe or shower only every 2 to 3 days

Which action by the nurse is consistent with the Rinne test?

The nurse strikes the tuning fork and places it on the patient's mastoid process to measure bone conduction.

Which of the following would a nurse document as a normal finding?

Torus palatinus

The nurse tests the six cardinal directions to test extraocular movement of the eye.

True

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

UV radiation exposure

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 breastExplanation

Which of the following, if obtained during the health history, would alert the nurse to a possible ear-related problem?

Use of cotton swabs inside the ear

A nursing instructor is presenting information to nursing students. The instructor addresses the taking of vital signs on clients from other cultures. What would the nurse address about clients from East African cultures?

Use of henna for body decorations

A child goes to the school nurse and complains of not being able to hear their teacher. What test could the school nurse perform that would indicate hearing loss?

Whisper test

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

XII Hypoglossal

The nurse recognizes that the 60-year-old patient may have difficulty reading fine print because of the loss in the ability of the eye to

accommodate

Peripheral vision is evaluated by the nurse using

confrontation test

. A nursing diagnosis appropriate for a patient with ear problems includes

disturbed sensory perception

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

The nurse notes a large keloid on the pierced ear of an adolescent. The client asks what caused this finding. Which of the following would the nurse incorporate into the response as the most likely cause?

excessive collagen formation

The nurse is using the ophthalmoscope to examine the patient's eyes. The nurse holds the scope

in the right hand for the right eye and in the left hand for the left eye

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

The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an "itching rash." Which question would be most important for the nurse to ask?

"Are you allergic to foods, medications, or other substances?"

When performing a Rinne test, the nurse would perform the steps in what order?

place the base of a vibrating tuning fork on the mastoid bone until the patient says she cannot hear the sound place the tuning fork in front of the ear and ask the patient if she can hear the sound

Cues of hearing loss include which of the following? Choose all that are correct.

1. Using a loud or monotonous voice 2. Asking to repeat questions 3. Concentrating on lip movement 4. Leaning forward to hear

Question: When performing a Rinne test, the nurse would perform the steps in what order?

1. place the base of a vibrating tuning fork on the mastoid bone until the patient says she cannot hear the sound 2. place the tuning fork in front of the ear and ask the patient if she can hear the sound

A group of students are reviewing the structures of the head and neck in preparation for an examination. The students demonstrate understanding of the material when they identify that the face has how many bones?

14

A nurse is examining a client's neck and is preparing to palpate the thyroid gland. The nurse would most likely expect to palpate how many lobes?

2

A nurse examines a client with complaints of a sore throat and finds that the tonsils are enlarged and seen midway between the tonsillar pillars and the uvula. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils?

2+

Which of the following scores for distance vision indicates the patient with the poorest vision?

20/100

Which vision acuity reading indicates blindness?

20/200

in the right hand for the right eye and in the left hand for the left eye

20/200

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

Acute Pain

Assessment of a client's nails reveals Beau's lines. The nurse interprets this finding as indicating which of the following?

Acute illness

Upon examination of the head and neck of a client, a nurse notes that the submandibular nodes are tender and enlarged. The nurse should assess the client for further findings related to what condition?

Acute infection

An 8-year-old girl comes with her mother for evaluation of hair loss. The girls denies pulling or twisting her hair, and her mother has not noted this behaviour at all. She does not put her daughter's hair in braids. Physical examination reveals a clearly demarcated, round patch of hair loss without visible scaling or inflammation. No hair shafts are visible. Based on this description, what is the most likely diagnosis?

Alopecia areata

The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions?

Always use seat belts.

Which of the following teaching points would the nurse emphasize related to eye health

Always wear eye protection for occupational exposures.

Which of the following would the nurse expect to assess when examining the eyes of a client who reports a history of severe allergies?

Areas of dryness

A nurse is preparing to assess the distant visual acuity of a client who wears reading glasses. Which of the following would be most appropriate?

Ask the client to remove the glasses before testing.

While assessing the ears of an 8-year-old client, the nurse observes white spots on the tympanic membrane with no redness present. Which action would be most appropriate?

Ask the mother whether the child has had numerous ear infections.

Which technique by the nurse demonstrates proper use of the ophthalmoscope?

Asks the client to fix the gaze upon an object and look straight ahead

High doses of this medication can produce bilateral tinnitus?

Aspirin

A 66-year-old woman has come to the clinic with complaints of increasing fatigue over the last several months. She claims to frequently feel lethargic and listless and states that, "I can never seem to get warm, no matter what the thermostat is set at." How should the nurse proceed with assessment?

Assess the woman for hypothyroidism.

A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCD" characteristic of malignant melanoma?

Asymmetrical shape

A 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

When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles?

Attempting to roll the structure up and down and side to side

Audiometry is testing that measures hearing acuity precisely. Who does the nurse know can perform audiometric testing?

Audiologist

Which assessment technique should a nurse use to assess for the presence of a bruit in a client with hyperthyroidism?

Auscultation

The nurse is caring for a patient in the emergency department for epistaxis. What information should the nurse include in patient discharge teaching as a way to prevent epistaxis?

Avoid picking the nose.

When inspecting the nose with an otoscope, the nurse:

Avoids contact with the nasal septum

While performing an examination of the head and neck, a nurse notices left sided facial drooping. The nurse recognizes this as what condition?

Bell's palsy

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

Why is it important to collect a thorough and accurate subjective history in regards to a client's nail problems?

Can be caused by an underlying systemic illness

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

Carotid

Inspection of a client's eyelids reveals significant lid swelling, moderate redness, but little pain. Which of the following would the nurse suspect?

Chalazion

Which of the following would be most important to assess when a client is noted to be a mouth breather?

Checking for deviated nasal septum

A woman who is 5 months pregnant is being assessed at a routine visit. She has increased pigmentation around the eyes. This is known as what?

Chloasma

A line across the tip of the nose is seen in an 8-year-old client. The nurse would focus on which area of assessment?

Chronic allergies

An Asian American primipara asks to speak with the nurse about a concern she has over potential genetic defects in her fetus. What congenital problem would the nurse expect questions about based on the patient's ethnicity?

Cleft lip and palate

After having a client perform a Romberg test, which of the following would indicate to the nurse that the test is negative?

Client maintains the position during the exam

A male college student presents to the student health clinic with reports of night-time headaches for the past two weeks. He denies nausea and photosensitivity but states he has noticed his eyes are tearing and his nose runs a lot. He is stressed because of final exams and confesses to drinking more alcohol than normal. The nurse recognizes these findings as indicative of what type of headache?

Cluster

An elderly Vietnamese client is having his skin assessed. The nurse notes multiple bruises and abrasions on his legs. What practice by Southeast Asian people could this be the result of?

Coining

The nurse is preparing to assess a client's visual fields to evaluate her gross peripheral vision. Which test would the nurse perform?

Confrontation test

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

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 55-year-old client is being evaluated for a hearing impairment. Which question would be most appropriate to provide the most useful information?

"Are you having difficulty hearing high-frequency sounds?"

A client is found to have leukoplakia, and the nurse is teaching the client about measures to reduce the client's risk. Which of the following would the nurse include in the teaching?

"Avoid substances that could be irritating to your mouth."

A 61-year-old man has visited the clinic at the prompting of his wife, who states that his hearing is becoming less acute. Which of the following assessment questions is most useful in determining whether the man's hearing loss is sensorineural or conductive?

"Do you find that you have particular difficulty understanding people's speech?"

The nurse notes thrush on the palate of a patient. The most appropriate question the nurse should ask is

"Have you been on antibiotics recently?"

An older adult client with receding gums comes to the clinic. The nurse notes gum ischemia and worn tooth surfaces. Which question would be most important for the nurse to ask?

"Have you lost any teeth recently?"

Which statement by the nurse who is caring for a practicing Muslim patient demonstrates cultural sensitivity?

"I will bring you a basin of water for your prayer time."

A patient asks, "What does SPF 15 mean for a sunscreen?" What should the nurse respond to this patient?

"SPF 15 is the ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B rays."

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 53-year-old client with a sensorineural hearing loss asks the nurse how this occurred. Which of the following responses would be most appropriate?

"Your work in the factory exposed you to loud noises over a long time."

A patient presents with a complaint of drooping of his eyes, cheeks, and mouth on one side. This finding is most likely associated with pathology of which cranial nerve?

Cranial nerve VII

When examining a client's thyroid gland, the nurse ensures that which equipment is readily available?

Cup of water

A nurse observes the presence of hirsuitism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process?

Cushing's disease

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

A nurse examines a client's retina during the ophthalmic examination and notices light-colored spots on the retinal background. The nurse should ask the client about a history of what disease process?

Diabetes

The nurse asks a patient to stand 20 feet from a specific chart that is placed on the wall when beginning the physical examination of the patient's eyes. What is the nurse going to examine in the patient?

Distant vision

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

Distribution

Which question asked by the nurse is assessing problems with vertigo

Do you ever have problems with balance

A woman brings her 1-month-old infant to the ED. The mother states the baby's head bulges when the baby cries. The nurse assesses the baby and notices both fontanels appear normal and the baby seems perfectly healthy. What should the nurse do next?

Document a normal finding

While examining the patient's neck, the nurse finds the trachea midline but has difficulty palpating the thyroid. What action would the nurse take next?

Document this finding as normal.

A nurse is inspecting a client's eyelids and eyelashes. Which of the findings would the nurse document as abnormal?

Drooping of the upper lid

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

Encourage the use of safety equipment

A client is diagnosed with glaucoma. When performing the ophthalmic exam, what changes should the nurse anticipate finding?

Enlarged physiologic cup that occupies more than half of disc's diameter

Which characteristic of the gums should a nurse expect to assess in a client who experiences an adverse effect of phenytoin treatment?

Enlarged, reddened

A mother of a client complains of getting no sleep because of excessive snoring from the client every night. The nurse is reviewing with the mother what causes the snoring. Based on this information, what is the best response to the mother of the client about the cause of snoring?

Enlargement of the adenoids

A nurse is educating a client about the function of the parts of the auditory system. Which is the function of the eustachian tube?

Equalizes the pressure in the middle ear with atmospheric pressure.

(see full question)The nursing student hopefuls are taking a pre-nursing anatomy and physiology class. What will they learn is the anatomical feature that equalizes air pressure in the middle ear?

Eustachian tube

The nurse would suspect a problem at which area when pressure builds up on either side of the tympanic membrane?

Eustachian tube

The nursing student hopefuls are taking a pre-nursing anatomy and physiology class. What will they learn is the anatomical feature that equalizes air pressure in the middle ear?

Eustachian tube

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

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

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

When preparing to examine a client's skin, which of the following would be most important for the nurse to do

Expose only the body part that is being examine

When preparing to examine a client's skin, which of the following would be most important for the nurse to do?

Expose only the body part that is being examined

The nurse in the emergency department is caring for a 4 year-old brought in by his parents with complaints that the child will not stop crying and pulling at his ear. Based upon information collected by the nurse, which of the following statements applies to a diagnosis of external otitis?

External otitis is characterized by pain when the pinna of the ear is pulled.

Which of the following would a nurse expect to assess in a client with esotropia?

Eye turning inward

After teaching a group of students about risk factors for traumatic brain injury, the instructor determines that additional teaching is needed when the students identify which of the following?

Female gender

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

Fingers and toes

Physical examination of a patient reveals an enlarged tonsilar node. Acutely infected nodes would be

Firm but movable and tender

A nurse needs to examine a client's thyroid as part of the head and neck assessment. How should the nurse instruct the client to position the head in order to best facilitate this exam?

Flex the head toward the side being examined

Which of the following symptoms would the nurse expect the patient to report as translucent specks that drift across the visual field?

Floater

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

Risk factors for hearing loss include which of the following? Choose all that are correct

Frequent ear infections Exposure to smoke

. When working with an older adult, what would the nurse emphasize as increased risks for the patient?

Glaucoma and cataracts

On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems would the nurse want to rule out?

Graves' disease

A nurse begins the eye examination on a client who presents to the health care clinic for a routine examination. What is the correct action by the nurse to perform the test for near visual acuity?

Have the client hold the Jaeger card 14 inches from the face & read with one eye at a time

nurse begins the eye examination on a client who presents to the health care clinic for a routine examination. What is the correct action by the nurse to perform the test for near visual acuity?

Have the client hold the Jaeger card 14 inches from the face & read with one eye at a time

In which order will the nurse document findings from the physical examination of the head and neck?

Head, neck, lymph nodes

The nurse is documenting an objective assessment of the client's ears. Which of the following would be the most appropriate documentation?

Hearing intact bilaterally on whisper test

A patient with chronic cellulitis has been receiving intravenous antibiotics for several weeks. Which health promotion activity should the nurse suggest for this patient?

Hearing test

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

During the physical examination of the mouth, the nurse identifies vesicular eruptions along the patient's lips and surrounding skin. The nurse would document this finding as being:

Herpes simplex

Which finding should a nurse recognize as a normal when assessing the ears of an elderly client?

High tone frequency loss

A client presents with rhinorrhea. Which area of assessment would yield the most pertinent information?

History of allergies

The client is having a Weber test. During a Weber test, where should the tuning fork be placed?

In the midline of the client's skull or in the center of the forehead.

A patient is diagnosed with an obstruction of the canal of Schlemm. What will the nurse find when assessing this patient's eyes?

Increased intraocular pressure

The following data are gathered: speaks very softly, denies hearing loss, has never had and cannot afford additional hearing tests, fails whisper test. Which nursing diagnosis would be most appropriate?

Ineffective health maintenance, related to denial of hearing problem and inadequate resources for additional testing

Which of the following denotes the correct procedure for using an otoscope when examining the ears of a 32-year-old client

Inserting the speculum down and forward into the ear canal

Which of the following denotes the correct procedure for using an otoscope when examining the ears of a 32-year-old client?

Inserting the speculum down and forward into the ear canal

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

Inspect the external ear canal.

A child presents to the health care facility with new onset of a foul smelling, purulent drainage from the right nare. The mother states 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 middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test the near visual acuity using a Jaeger reading card?

Instruct the client hold the chart 14 inches from the eyes

During general inspection, the examiner:

Integrates visual, auditory, and olfactory data

A nurse is presenting a class to a local community about vision and eye health. As part of the presentation the nurse explains how visual perception occurs. Which of the following would the nurse include in the explanation?

Involves light rays striking the retina

Which of the following assessment findings most likely constitutes a secondary skin lesion?

Keloid formation at the site of an old incision

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

Kiesselbach plexus

The nurse is examining an unconscious client from another country and notices Beau's lines, a transverse groove across all of her nails, approximately 1 cm from the proximal nail fold. What would the nurse do next?

Look for information from family and records regarding any problems that may have occurred at least 3 months ago.

Which type of vessels filter pathogens from the body and drain the fluid that has moved outside of the circulation back into the vessels?

Lymphatic

When using hand gel to clean the hands, what must the nurse do before touching a client's eyes?

Make sure the hands are completely dry

group of students is reviewing the structures of the ear in preparation for test. The students demonstrate understanding of the material when they identify which structure as part of the middle ear?

Malleus

A client has a 7-mm lesion with irregular borders and color variation that has grown over the last several weeks. The nurse knows that this lesion could possibly be what type of cancer?

Melanoma

A client is 20 weeks pregnant and has melasma. What information can the nurse give the client about melasma, when educating her about the effects of pregnancy?

Melasma generally resolves postpartum

A client presents to the emergency department with reports of neck pain and a sudden onset of a headache. Upon examination, the nurse finds that the client has an increased temperature and nuchal rigidity. The nurse recognizes these findings as most likely to be caused by what condition?

Meningeal inflammation

A client is being assessed for a headache. Symptoms include throbbing and severe pain lasting for the last 8 hours. The client also has a history of vomiting with the headache. What type of headache could these findings indicate?

Migraine

A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms?

Migraine headache

Which of the following best reflects nursing's view of clients as holistic beings?

Mind, body, spirit

Which risk factor for traumatic brain injury should a nurse include in a discussion about prevention for a group of adolescents?

Modes of transportation are the leading cause

A nurse is providing a client with instructions on how to perform self-examination of the skin. The nurse would encourage the client to perform this examination at which frequency?

Monthly

A nurse assesses a client's pupillary reaction and observes pinpoint pupils. The nurse interprets this finding as suggesting which of the following?

Narcotic use

A nurse documents which of the following as a normal finding when examining the thyroid gland of an older adult client?

Nodularity

You are caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?

Noisy breathing

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

Nonreaction of the opposite pupil to light

When performing an assessment of a patient, the nurse observes that the patient begins to cry when asked if she has a religious preference. What part of the care plan would the nurse document this assessment finding?

Objective data

The nurse is preparing to perform the Rinne test on a client. The nurse would place the tuning fork at which location first?

On the mastoid process

Where should a nurse place the hands to palpate the submandibular lymph nodes?

On the medial border of the mandible

When performing an ophthalmoscopic exam, a nurse observes a round shape with distinct margins. The nurse would document this as which of the following?

Optic disc

A nurse palpates a client's ear and finds that the tragus is tender. The nurse suspects which of the following?

Otitis externa

The nursing instructor is discussing the administration of nasal spray with the nursing students. What information is most important to include in this discussion?

Overuse of nasal spray may cause rebound congestion

A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client's symptoms?

Parkinson's disease

Which of the following best describes the instructions the nurse should give a patient when assessing the thyroid from the posterior approach?

Please look straight ahead and tilt your head slightly down and to one side

An adult farm worker presents at the ED after falling out of a hay loft. The client states falling approximately 4 hours ago and did not lose consciousness. The client is experiencing only a mild headache. When asked why the client came to the ED, the patient states that he had a clear discharge from the right ear ever since the accident. What should this finding indicate to the nurse?

Possible basilar skull fracture

The lymph nodes that lie superficial to the mastoid bone are the:

Posterior auricular nodes

A 60-year-old client has difficulty hearing high-pitched sounds. The nurse would document this finding as which of the following?

Presbycusis

The nurse is assessing the hearing of an older adult. Which type of hearing problem might the nurse expect to find in the older adult?

Presbycusis

The nurse observes a middle-aged colleague fully extending her arm to read the label on a vial of medication. Which of the following age-related changes is the nurse likely to have observed?

Presbyopia

A client reports severe pain in the posterior region of the neck and difficulty turning the head to the right. What additional information should the nurse collect?

Previous injuries to the head and neck

What would the nurse identify as a priority educational need for clients with chronic back problems.

Proper posture, bending, and lifting techniques

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

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

When testing the near reaction, an expected finding includes which of the following?

Pupillary constriction on near gaze; dilation on distant gaze

The nurse is performing a physical examination and notes an enlarged left supraclavicular lymph node. The nurse understands that this could be indicative of

Radiation therapy has been linked to the development of thyroid cancer.

While assessing a patient, the nurse finds a palpable lymph node in the left supraclavicular region. Which of the following should be the next action?

Recognize that a palpable node in this region is a dangerous indication of metastatic cancer that requires further evaluation.

Which assessment of the tongue should a nurse recognize as abnormal?

Red with loss of papillae

Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with otitis media?

Red, bulging with an absent light reflex

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 part of the eye receives and transmits visual stimuli to the brain for processing?

Retina

Which of the following tests use a tuning fork between two positions to assess hearing?

Rinne

An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what?

Sebum production

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

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

In which position should the nurse place the toddler when examining the ear?

Sitting on the parent's lap with parent steadying the head

Which of the following descriptions is most consistent with a patient who has hypothyroidism?

Slightly obese female with periorbital edema and a flat facial expression, who complains of constipation, deceased appetite, and fatigue

A 23-year-old woman has presented to the clinician to follow up her recent diagnosis of psoriasis. Which of the following assessments of the client's nails would be consistent with the client's diagnosis?

Small pits in the surfaces of the nails

school nurse is performing annual vision screening for seventh grade students. Which of the following charts would the nurse most likely be using?

Snellen's chart

Which of the following is a symptom related to vertigo?

Spinning sensation

What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia?

Spooning

When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer?

Stage II

The nurse can best palpate the superficial cervical nodes, the deep cervical chain, and the supraclavicular nodes by first locating which muscle?

Sternomastoid

A 12-year-old presents to the clinic with his father for evaluation of a painful lump in the left eye. It started this morning. The client denies any trauma or injury. There is no visual disturbance. Upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. Based on this description, what is the most likely diagnosis?

Stye

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

Tender

A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis?

Tension

A client comes to the trauma unit in respiratory distress following a motor vehicle accident. On examination, the nurse notices that the trachea is deviated from the midline. What does this finding indicate?

Tension pneumothorax

An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse notes considerable skin tenting. Why does this finding require further assessment?

Tenting indicates dehydration

Which of the following findings related to hair would the nurse most likely assess in an older adult female client?

Terminal hair growth on chinExplanation

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 assessing an elderly woman who reports lethargy and weakness. During the examination, the nurse notices that the client's face is drooping slightly on the right side. Why does this finding require emergency intervention?

The client could be experiencing a stroke

A client presents with possible lice infestation of the scalp. The nurse observes nits very close to the scalp. What does this finding tell the nurse?

The client had a recent infestation

An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse?

The client has chronic hypoxia

A client comes to the ICU. The nurse assesses the client using the Braden skin assessment scale and the score is 15. What does this information tell the nurse?

The client is at low risk for pressure ulcer development

The nurse is assessing a new patient's blood pressure using a manual sphygmomanometer. Which of the following sounds constitutes the patient's systolic blood pressure?

The first appearance of faint but distinctive tapping sounds

Which action by the nurse is consistent with Weber's test?

The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears.

When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?

The underlying bones

A nurse is preparing a class for a group of parents about ear infections and measures to prevent them. The nurse is planning to address the reasons why children are more susceptible to this infection than adults. Which of the following would the nurse include?

Their eustachian tube is shorter, straighter, and narrower.

Palpation of a 15-year-old boy's submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse's most reasonable interpretation of this assessment finding?

There is an infection in the area that these nodes drain.

The nurse is assessing a client complaining of swelling in the neck. While palpating the neck, the nurse finds a 2-cm lump that is fixed and hard. Why does this finding require emergency investigation?

This could be a sign of cancer

A woman brings her 1-month-old infant to the ED. She says the baby is not eating or drinking well. The nurse finds the fontanels are depressed slightly. Why does this require further assessment?

This could be a sign of dehydration

Upon inspection of a client's oral cavity, a nurse observes a bifid uvula. What should the nurse recognize about this finding?

This is often a normal finding in the Native American population

The nurse is preparing to teach a class to a group of clients with dysphagia. Which of the following would be most important for the nurse to include?

Thoroughly chew only small amounts of food with each mouthful.

The nurse is performing a physical assessment of a client who complains of a sore throat and stuffy nose. The nurse notes a red inflamed throat and slight fever and suspects strep. Which of the following tests would be ordered to confirm this diagnosis?

Throat culture

A 19-year-old construction worker presents for evaluation of a rash. He says that it started on his back with a multitude of spots and is also on his arms, chest, and neck. It itches a lot. He has been sweating more than before, because being outdoors is part of his job. Physical examination reveals dark tan and reddish patches with sharp borders and fine scales, scattered more prominently around the upper back, chest, neck, and upper arms as well as under the arms. Based on this description, what is the most likely diagnosis?

Tinea versicolor

During a pharmacology class the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?

Tinnitus and sensorineural hearing loss

A young man is concerned about a hard mass in the midline of his palate that he has just noticed. Examination reveals that it is indeed hard and in the midline. No mucosal abnormalities are associated with this lesion. The client has no other symptoms. What is the most likely diagnosis?

Torus palatinus

A parent is very upset because she is told her child has a refractive error. The nurse reassures the parent that refractive errors are the most common visual change in children.

True

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

The nurse is using audiometry to screen the hearing of elementary school students. Which best describes audiometry?

Uses headphones and a box that delivers tones to each ear at variable frequencies and volumes.

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

When planning care for a patient with an inner ear infection, the nurse will include interventions to address which potential problem?

Vertigo

When visualizing the structures of the nose, the nurse recalls that air travels from the anterior nares to the trachea through the:

Vestibule, nasal passages, and nasopharynx

The nursing instructor is teaching a pre-nursing pathophysiology class. The class is covering the respiratory system. The instructor explains that the respiratory system is comprised of both the upper and lower respiratory system. The nose is part of the upper respiratory system. The instructor continues to explain that the nasal cavities have a vascular and ciliated mucous lining. What is the purpose of the vascular and ciliated mucous lining of the nasal cavities?

Warm and humidify inspired air

You are teaching a physiology class for pre-nursing students. A student asks what the purpose of the upper airway is in regard to the lower airway. What would be your best answer?

Warm the inspired air

A nurse is going to inspect and palpate a client's head and neck. After asking the client to remove the wig, what should the nurse do next?

Wash hands

The nurse assessing for unilateral hearing loss by using a tuning fork. What test is the nurse performing?

Weber's test

The three salivary glands also contain drainage ducts. Which drainage ducts are associated with the submandibular gland?

Wharton's ducts

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 > 6 mm; e = evolution

The nurse is assessing a new client in the obstetric clinic. What is the most likely question that the nurse would ask this client when assessing the upper respiratory tract?

are you having nose bleeds

A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCD" characteristic of malignant melanoma?

asymmetrical shape

During the physical examination of the head and neck, the nurse palpates a lymph node after ensuring that it can move in which directions? (Select all that apply.)

c) Up and down d) Side to side

An elderly Vietnamese client is having his skin assessed. The nurse notes multiple bruises and abrasions on his legs. What practice by Southeast Asian people could this be the result of?

coining

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

The nurse asks a patient to stand 20 feet from a specific chart that is placed on the wall when beginning the physical examination of the patient's eyes. What is the nurse going to examine in the patient?

distant vision

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

distribution

During examination of the oral cavity, the nurse examines the salivary glands. Which area of the mouth should the nurse assess to inspect for the Wharton's ducts?

either side of the frenulum on the floor of the mouth

The frontal sinuses are the only ones readily accessible to clinical examination.

false

The meaning of ethnicity is broader than the term culture.

false

When documenting the findings from a physical examination of the head and neck, what will the nurse include when describing the patient's head?

hair color

A patient has conjunctivitis. The nurses understand that conjunctivitis differs from conjunctival hemorrhage in that conjunctivitis

has a watery, mucoid discharge

The nurse does a health history. The patient states he has lost 30 pounds in the last couple months without really trying. The patient also states he feels warm all the time and sometimes feels like he has heart palpitations. The nurse would anticipate orders to evaluate the patient for

hyperthyroidism

While reviewing laboratory values for thyroid function on an adult patient, the nurse sees that the TSH is elevated, and the T3 and T4 are decreased. The nurse recognizes that these findings are indicative of

hypothyroidism

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

intact, firm skin with redness ulceration involving the dermis full-thickness skin loss necrosis with damage to underlying muscle

The nurse is inspecting the ear of a 6-year-old child. Which observation by the nurse is consistent with a scarred tympanic membrane?

looks normal skin tone hole in middle

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

macular degeneration

After describing how to assess the sinuses to a group of students, the students demonstrate understanding of the teaching when they identify which sinuses as being located in the upper jaw?

maxillary

When performing an ophthalmoscopic exam, a nurse observes a round shape with distinct margins. The nurse would document this as which of the following?

optic disc

The patient with psoriasis is admitted to a medical unit for unrelated reasons. When documenting the type of lesion represented by psoriasis, the nurse should document a

papule

The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following?

pressure ulcer

A client reports severe pain in the posterior region of the neck and difficulty turning the head to the right. What additional information should the nurse collect?

previous injury's to head or neck

The inner ear

provides the body with proprioception

The nurse questions a client about any radiation therapy to the neck area based on the understanding about which of the following?

radiation therapy has been linked to the development of thyroid cancer

A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. Client states 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 is assigned a visual acuity of 20/100 in her left eye. Which of the following is true?

she can see at 20 feet what a normal person could see at 100 feet.

When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer?

stage II

A group of students are reviewing the structure and function of the skin in preparation for a test on the material. The students demonstrated understanding when they identify which layer as the outermost layer of the epidermis?

stratum corneum

A patient has an open draining wound located on the underside of the chin. Which lymph nodes should the nurse assess in this patient?

submental

A parent is very upset because she is told her child has a refractive error. The nurse reassures the parent that refractive errors are the most common visual change in children.

true

A patient admitted with dehydration would typically have a decrease in skin turgor.

true

Local redness of the skin warns of impending necrosis.

true

The nurse can best evaluate the strength of the sternocleidomastoid muscle by having the patient

turn his or her head against resistance

Which of the following, if obtained during the health history, would alert the nurse to a possible ear-related problem?

use of cotton swabs

A nurse performs a hearing test on an elderly client. Which result should the nurse recognize as an indication that presbycusis is present? An inability to hear:

whispered sounds

During the health interview of the head and neck, a patient tells the nurse about always feeling cold and preferring warm weather. What additional questions can the nurse ask to learn more information about the patient's symptom? (Select all that apply.)

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

You are teaching an anatomy class to pre-nursing students. Today you are discussing the upper respiratory system. What structures are important links in the chain of lymph nodes guarding the body from invading organisms? (Mark all that apply.) f

• Adenoids • Tonsils

A nurse is caring for an adult client who has just undergone surgery to remove a thyroid tumor. The nurse is assessing for symptoms of hyperthyroidism. What are some of the symptoms of hypermetabolism? Select all that apply.

• Anxiety • Diarrhea • Tachycardia

A family member of a patient recovering from a traumatic brain injury asks the nurse what can be done to prevent future head injuries. What should the nurse instruct this family member? (Select all that apply.)

• Avoid the use of throw rugs. • Never drive under the influence of alcohol. • Wear helmets when playing all contact sports.

An nurse practitioner is assessing a client in the ED following a motor vehicle accident. The client experienced head trauma in the accident. What laboratory studies might the nurse practitioner order for this client? Select all that apply.

• Basic blood panel • Beta-2-transferrin

What should the nurse instruct a patient regarding contact lenses to prevent injury to the eye? (Select all that apply.)

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

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.)

• Examination table • Chair • Gloves • Natural lighting

A nursing student in the otolaryngology clinic is asked by the instructor about what findings during a sinus examination suggest infection. Which of the following findings would the student include in her response? Select all that apply.

• Fullness • Tenderness

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

• Fungal infections • Trauma • Warts

After teaching a group of students about the external and internal structures of the eye, the instructor determines that the teaching was successful when the students identify which of the following as external structures?

• Lacrimal apparatus • Conjunctiva • Caruncle

Equipment used for objective data collection involving the eyes includes which of the following? Select all that apply.

• Penlight • Ophthalmoscope • Occlusive covers • Snellen chart

What interventions might the staff educator at a long-term care facility suggest to improve the status of clients with hearing loss?

• Provide visual aids for detailed discussions • Turn off the television and radio when communicating • Close the door if the hallway noise is loud

Hypothyroidism in the older adult can be difficult to diagnose. What are some of the reasons it is difficult to diagnose? Select all that apply.

• Subtle onset • Symptoms attributed to the aging process • Chronic diseases

A family member of a patient recovering from a traumatic brain injury asks the nurse what can be done to prevent future head injuries. What should the nurse instruct this family member? (Select all that apply.)

• Wear helmets when playing all contact sports. • Never drive under the influence of alcohol. • Avoid the use of throw rugs.

A patient with hypothyroidism is admitted to the medical unit. The nurse would expect to assess which signs/symptoms? Select all that apply.

• lethargy • constipation • cool skin • lower systolic blood pressure