Chapter 13 Physical Assessment

During the assessment of an older adult client's skin, the nurse notes small areas of hyperpigmentation on the dorsal aspect of the client's hands. The client states, "I've been getting more of these big freckles as I get older." Which term will the nurse use when documenting this finding in the medical record? 1. Senile lentigines. 2. Cherry angiomas. 3. Cutaneous tags. 4. Cutaneous horns.

1

The nurse is assessing a client in an outpatient clinical and notes the notes the presence of several abdominal lesions that appear in distinct clusters. When documenting this finding, which term will the nurse use? 1. Grouped. 2. Annular. 3. Discrete. 4. Confluent.

1

The nurse is assessing the skin of an adolescent client and notes the presence of a musky odor. The client states that this is embarrassing for him and that he showers daily. Which action should the nurse take in this situation? 1. Reassure the teen that this is normal. 2. Notify the client's healthcare provider. 3. Obtain a dietary referral. 4. Educate the client regarding the importance of increased water intake.

1

The nurse is completing a focused interview to assess the skin, hair, and nails of a pregnant client. Which question would be most important for the nurse to include in the interview? 1. "Do you use any skin creams?" 2. "Do you try to avoid exposure to the sun?" 3. "Have you lost any hair during your pregnancy?" 4. "Have you had any nail changes?"

1

The nurse is inspecting the fingernails of a client who is diagnosed with polycythemia. Which assessment data would be expected for this client? 1. Dark red nails. 2. Horizontal white bands. 3. Pale nail beds. 4. Spoon-shaped nails.

1

The nurse is performing a skin assessment on a client and notes a round, elevated, fluid-filled mass approximately 0.4 cm in size. Which term is the most appropriate for the nurse to use when documenting this finding in the medical record? 1. Vesicle. 2. Macule. 3. Papule. 4. Tumor.

1

The nurse is reviewing documentation for a client from the previous shift. The documentation states, "+1 edema right lower leg." Based on this data, what does the nurse expect when assessing this client? 1. The presence of slight pitting, no obvious distortion. 2. Deep pitting, obvious distortion. 3. Pitting is obvious, extremities are swollen. 4. Moderate amount of edema.

1

The client is visiting the healthcare provider's office for a head-to-toe assessment. During the nurse's assessment of the client's skin, the nurse notes that the client is pale. Which assessment data may be related to the client's color? Standard Text: Select all that apply. 1. Client's blood pressure is 96/62. 2. The client states, "I just smoked a cigarette before I came in the office." 3. The client's oxygen saturation level is 86% on room air. 4. The client states, "I have been diagnosed with osteoporosis." 5. The client states, "It is snowing again outside with a wind chill factor of -11 degrees Fahrenheit."

1, 2, 3, 5

During the assessment of a client's integumentary status the nurse notes "vitiligo present bilateral hands." Which analysis of this information is the most appropriate by the nurse? 1. Nodules with ulcerations. 2. Dark, asymmetrical colored patches. 3. Grouped vesicles. 4. Abnormal loss of melanin in patches.

4

The nurse is assessing the skin of a newborn and notes a bright red, raised lesion on the lateral aspect of the thigh. The lesion is 4.5 centimeters in diameter. When light pressure is applied to the lesion, the site does not blanch. The mother expresses concern about the appearance of this site, and asks the nurse if it should be removed. Which response by the nurse is the most appropriate? 1. "Your pediatrician can make a surgical referral for you." 2. "It really is not that noticeable." 3. "You should be happy that your baby is healthy overall." 4. "These types of lesions usually disappear by the time a child turns 10 years old."

4

The nurse is caring for a client with dark skin and needs to assess the skin for jaundice. Which action would be appropriate for the nurse in this situation? 1. Use a bright lamp and a magnifying glass. 2. Document "unable to assess" for skin changes. 3. Assess the skin the same way you would inspect a client with lighter skin. 4. Inspect the lips, oral mucosa, sclera, conjunctivae, and palms.

4

The nurse is preparing to assess the client's skin, hair, and nails. Which technique will the nurse use initially during this assessment? 1. Percussion. 2. Palpation. 3. Auscultation. 4. Inspection.

4

The nurse is conducting a focused interview on the client's integumentary system and prepares to obtain data related to risk factors for the development of integumentary disorders. Which question by the nurse would be unexpected based on the specific data the nurse is attempting to gain during the interview? Standard Text: Select all that apply. 1. "How much time do you spend outdoors?" 2. "How do you care for your skin?" 3. "Do you have any tattoos or body piercings?" 4. "Have you noticed any drainage from your skin?" 5. "Do you take any medications on a regular basis?"

1, 2, 3, 5

The nurse is preparing an educational program regarding the objectives listed in Healthy People 2020. Which statements in the presentation support these objectives? Standard Text: Select all that apply. 1. African American females often require information regarding gentle hair and scalp care. 2. Infants have difficulty regulating their own body temperatures. 3. Older clients have increased sweat gland activity. 4. Clients with diabetes mellitus have an increased risk for skin breakdown. 5. Clients should monitor their moles for any changes, regardless of their age.

1, 2, 4, 5

The nurse completes a skin assessment for a client and is preparing to document the appearance of herpetic lesions found over a client's nose and mouth region. Which terms can the nurse use when documenting the skin assessment for this client in the medical record? Standard Text: Select all that apply. 1. Vesicular. 2. Pustular. 3. Pruritic. 4. Ulcerated. 5. Crusty.

1, 2, 5

The nurse is preparing a client for a detailed assessment of the integumentary system. Which statements by the nurse are useful to prepare the client for this examination? Standard Text: Select all that apply. 1. "Please remove all jewelry so that I can conduct a full assessment." 2. "I will turn the temperature down in the exam room before we begin." 3. "Use this blanket to cover up until we are ready to begin." 4. "I will be touching your skin as part of the process." 5. "I will need you to take off your head dress for the entire examination."

1, 3, 4

The nurse is assessing a client's skin and notes a very light color on the skin, nails, and the client's mucous membranes. Which descriptions would the nurse use when documenting this finding? 1. Cyanosis. 2. Pallor. 3. Erythema. 4. Jaundice.

2

The nurse is assessing a female client and notes facial hirsutism. The client asks the nurse, "Why did this happen to me?" Which statement is the nurse's best response? 1. "Your diet is not nutritionally balanced." 2. "You may have some hormone imbalances." 3. "Usually, there is not a known cause for this condition." 4. "You need to take vitamins."

2

The nurse is caring for a client who had abdominal surgery several months ago. The client has verbalized concern that the scar from the surgery is purplish in color. Which response by the nurse is the most appropriate? 1. "Having a scar is unavoidable." 2. "The color is normal and will fade with time." 3. "You can have plastic surgery to remove the scar later." 4. "You should be glad your surgery was a success."

2

The nurse is caring for a client who has smoked for many years and documents that "clubbing is present." Which technique is the best way for the nurse to determine the presence of clubbing? 1. Place two thumbs touching side-by-side. 2. Place two of the same fingers from each hand together. 3. Place two index fingers together tip-to-tip. 4. Place the hands out straight with the palm sides down.

2

The nurse is performing a skin assessment on a client and notes an oval-shaped, elevated, fluid-filled mass that is approximately 1.5 centimeters in size. Which term will the nurse use when documenting this assessment data? 1. Vesicle. 2. Bulla. 3. Papule. 4. Tumor.

2

The nurse is performing a skin assessment on an African American client and notes an elevated, irregular band of jagged tissue on the client's left arm. The client states, "I had a burn here a long time ago, but it seemed to keep on getting bigger." Which term will the nurse use when documenting this finding in the client's medical record? 1. Ulcer. 2. Keloid. 3. Fissure. 4. Scar.

2

The pediatric nurse conducts a follow-up phone call for a mother who was discharged with her newborn several days ago. The mother tells the nurse that she thinks her newborn is jaundice. Which question by the nurse will help to support this mother's statement? 1. "Does your baby have tiny, white facial bumps?" 2. "Does your baby's skin and mucous membranes have a yellowish color?" 3. "Does your baby have irregular red patches on the back of the neck?" 4. "Does your baby have dark spots on the area above the buttock?"

2

While performing a skin assessment for a client, the nurse notes that the client becomes pales and diaphoretic. The client's vital signs have remained stable since the beginning of the examination: blood pressure 138/76 mmHg, heart rate is 88 beats per minute, and respiratory rate is 18 breaths per minute. Which is the priority response by the nurse? 1. The nurse immediately raises the client's head of bed. 2. The nurse asks the client, "Are you feeling anxious during this assessment?" 3. The nurse immediately notifies the client's healthcare provider. 4. The nurse provides the client with ½ cup of orange juice.

2

The adult client is being assessed at an outpatient clinic and states, "I have sores in my mouth and on my lips." The nurse notes the presence of crusted lesions on the lips and inside the client's mouth along the cheek. The client states that the lesions do not itch. Based on this assessment data, which condition is this client likely experiencing? 1. Chickenpox. 2. Contact dermatitis. 3. Herpes simplex. 4. Psoriasis.

3

The nurse is assessing a client with liver disease and notes that the skin, mucous membranes, and sclerae are yellowish in color. Which term is most appropriate for the nurse to use to describe this condition when documenting in the medical record? 1. Uremia. 2. Cyanosis. 3. Jaundice. 4. Carotenemia.

3

The nurse is caring for a client complaining of a painful, hot area located on the client's leg. Erythema and edema are present in the localized area. Which action should the nurse perform next? 1. Palpate the area. 2. Place a heating pad on the area. 3. Notify the healthcare provider. 4. Place client on bed rest.

3

The nurse is conducting an admission assessment for a client and notes skin vitiligo, which is highly visible even from a distance. The client asks the nurse to place a "No Visitors" sign on the door. The client states, "I hate the way my skin looks. Some people just stare at me." Which nursing diagnosis should be incorporated into the client's plan of care? 1. Defensive coping. 2. Risk for loneliness. 3. Deficient knowledge. 4. Disturbed body image.

4

The nurse is planning to assess the integumentary status for an African American client. Which client statement supports the nurse's documentation that the client is experiencing pallor? 1. "The whites of my eyes don't look as white anymore; they have a little bit of a yellow cast to them." 2. "My nails look a little bit bluish." 3. "My nails are bright red." 4. "My palms and the inside of my mouth look really pale."

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