Exam#2- Module 4-5

seborrhea

oily skin

pallor

pale or lighter skin color than usual

Diaphoresis

profuse perspiration

Cyanosis

Bluish color of skin

Ecchymosis

Spot or blotch larger than petechiae, bruises

Edema

Swelling, presence of excess interstitial fluid

a nurse is assessing a client who has a lump on their neck. which of the following questions should the nurse ask for the client? select all that apply a. "are you experiencing difficulty breathing?" b. "how long has the lump been on your neck?" c. "is the lump causing you discomfort?" d. "are you have difficulty swallowing?" e. "have you started taking a new medication?"

a. are you experiencing difficulty breathing? b. how long has the lump been on your neck? c. is the lump causing you discomfort? d. are you having difficulty swallowing?

For which of the following findings should you contact the provider? a. clear one-sided nasal drainage in a client who fell down the stairs b. a clearly defined collection of blood in the sclera of a client who has been vomitting c. dark yellow cerumen in the outer ear canal of a client who has been coughing d. palpable lymph nodes in the neck of a client who has a upper respiratory infection

a. clear one-sided nasal drainage in a client who fell down the stairs -a client who has clear or blood-tinged unilateral nasal discharge following head trauma might have a fracture at the base of the skull.

Which of the following are characteristics of the dermis layer of the skin? Select all that apply a. Contains blood vessels, hair follicles, and nerve endings b. contains fat stores for energy c. composed of thick fibrous connective tissue d. prevents excessive water loss e. secretes melanin

a. contains blood vessels, hair follicles, and nerve endings c. composed of thick fibrous connective tissue -structures contained within the dermis layer of the skin along with sweat glands, sebaceous glands, and sensory receptors. it is composed of tough fibrous protein called collagen that provides flexibility to resist tearing with movement

a nurse is assessing the mouth of a client who has candidiasis, an oral fungal infection. Which of the following findings should the nurse expect? a. white patches on the tongue b. beefy red tongue c. petechia on hard palate d. overgrowth of gum tissue

a. white patches on the tongue -should expect white patches on the tongue. indication of candidiasis, which is an oral infection known as thrush

Which of the following tools are used in an assessment of the head and neck? select all that apply a. tape measure b. penlight c. examination gloves d. stethoscope e. doppler f. watch with a second hand

b. penlight c. examination gloves -a penlight is needed to assess pupil response and to improve visualization of the client's mouth and nares, examination gloves are needed when inspecting the mouth and eyes if there is drainage present

a nurse is performing a head and neck assessment on a client. after checking the client's vision, the nurse notes the client has difficulty reading fine print. which of the following sections of the client EHR should the nurse document this finding? a. vital signs b. review of systems c. allergies and home medication d. patient information

b. review of systems - this section contains objective data that the nurse obtains while performing the assessment

You are assessing a client and note a pressure injury on the client's sacrum. The lesion is a deep depression below the level of the skin and subcutaneous fat is visible. What stage of pressure injury would you document for this wound? a. Stage I b. Stage II c. Stage III d. Stage IV

c. Stage III -A stage III pressure injury extends completely through the epidermis and into the subcutaneous tissue. Subcutaneous fat may be visible.

a nurse is assessing the mouth of a client who has a vitamin B12 insufficiency. Which of the following findings should the nurse expect? a. white patches on the tongue b. bleeding in the gums c. beefy red tongue d. petechiae of the hard palate

c. beefy red tongue -client who has a vitamin B12 insufficiency can have a smooth, dark, or swollen tongue

You are collecting subjective data prior to performing a skin assessment on a client. Which of the following responses requires additional investigation? a. "that birthmark on my thigh has always looked the same as it does now" b. "I have stretch marks on my abdomen from being pregnant" c. "I noticed that my freckles get darker in the summertime" d. "one of my moles now has several colors on it"

d. "one of my moles now has several colors on it" -Pigmented nevi, or moles, should be uniform color. Changes in a mole coloration, size and shape can signal the presence of malignancy and require further evaluation.

Which of the following areas should the technique of palpation be used as part of the assessment? a. eye structure b. trachea c. tongue d. sinus cavities

d. sinus cavities -palpate the sinus cavities to assess for pain that can indicate the presence of a sinus infection

Hypopigmentation

decrease in skin color

Xerosis

dry skin

Place the following actions to check capillary refill in the order of performance a. note the amount of time it takes for nail bed to return to baseline color b. document capillary refill as brisk or sluggish c. release pressure on the finger pad d. press on a fingernail pad until it blanches e. explain to client that you are evaluating their circulation

e. explain to the client that you are going to evaluate their circulation d. press on a fingernail pad until it blanches c. release pressure on the finger pad a. note the amount of time it takes it takes for nailbed to return to baseline color b. document capillary refill as brisk or sluggish

Place the steps for assessing a client's skin turgor and mobility in the order of performance a. note how quickly the skin returns to a flat position on the chest b. open the pinch and release the skin c. pinch a large fold of skin between thumb and forefinger d. note the ease with which you were able to move the client's skin e. position your hand with fingers just below the clients collar bone

e. position your hand with fingers just below the client's collar bone c. pinch a large fold of skin between thumb and forefinger d. note the ease with which you were able to move client's skin b. open pinch and release the skin a. note how quickly the skin returns to flat position on chest.

Nevus

mole, birthmark

vitiligo

skin areas without usual brown pigmentation

pigmentation

skin color

petechiae

small reddish or purplish spots caused by bleeding into the skin.

Jaundice

yellowish color of skin

Which of the following questions should you ask the client when assessing for an orientation deficit? select all that apply a. "what is the date?" b. "what is your birthday?" c. "do you know why you're here?" d. "Who is the president?" e. "what time is it?" f. " where are you?"

b. "what is your birthday?" c. "do you know why you're here" d. "who is the president" f. "where are you" -those questions assess client's self/person/place/situation

a nurse is preparing to assess the eyes of a client who has liver disease. which of the following findings should the nurse expect? a. ptosis of an eyelid b. yellow sclera c. edema of the eyelids d. reddened conjunctiva

b. yellow sclera -yellowing of the sclera can indicate that the client has liver disease

a nurse is examining a lesion on a client's back. which of the following characteristics should the nurse identify as a possible indication of a malignant skin lesion? a. smooth, defined bored b. uniform color c. size of a pencil eraser d. symmetrical appearance

c. size of a pencil eraser -lesions that are greater than 6mm, or size of the pencil eraser, in diameter should be recognized as a possible malignant skin lesion should be reported

a nurse is assessing the eye of a client who experienced a subconjunctival hemorrhage as a result of vomiting. which of the following findings should the nurse expect? a. defined reddened area of the sclera b. drooping of the eyelid c. cloudy pupil d. bulging eyes

a. defined reddened area of the sclera -results from leakage of blood outside the blood vessels due to increased pressure within the eye during vomiting

a nurse is performing a head and neck assessment on a client. the client reports a high-pitched ringing in the ears. in which of the following sections of the client's EHR should the nurse document this finding? a. encounter b. vital signs c. patient information d. allergies and home medication

a. encounter -should include the client's report of "high-pitching ringing in the ears" in the encounter section of the client's EHR. subjective data the nurse is obtaining from the client and the purpose of the client's visit

Place the following steps in the correct order to perform an assessment of a client's pupillary reaction to light. a. have the client sit facing you at eye level b. observe the pupillary response in both eyes c. instruct the client to look at a distant object d. observe the pupils for size e. darken the room f. move your penlight in from the side to shine on one pupil

a. have the client sit facing you at eye level d. observe the pupils for size e. darken the room c. instruct the client to look at a distant object f. move your penlight in from the side to shine on one pupil b. observe the pupillary response in both eyes

a nurse is obtaining a client's health history. which of the following questions should the nurse ask the client to obtain a focused history of the ears? select all that apply a. have you had trouble hearing? b. do you ever lose your balance? c. have you ever used hearing aids? d. do you have ringing in the ears? e. do you have problems with nasal drainage?

a. have you had trouble hearing? b. do you ever lose your balance? c. have you ever used hearing aids? d. do you have ringing in the ears?

A nurse is planning care for a client who has a stage I pressure injury on their coccyx. Which of the following interventions should the nurse plan to include? a. limit elevation of the head of the bed to 30 degrees or less b. apply baby powder and massage the area every 2 hr. c. reposition the client every 4 hr d. ensure that the client uses a donut-shaped cushion when sitting in a chair

a. limit elevation of the head of the bed to 30 degrees or less -raising the head of the bed more than 30 degrees increases the risk of skin damage due to shearing forces. shearing occurs when the client slides downward in the bed. the outer skin layer sticks to the bed linens while the deeper skin layers move downward. this results in twisting of blood vessels and can lead to skin damage

a nurse is caring for a client who has a stage I pressure injury. which of the following information should the nurse include when documenting the characteristics of the wound? select all that apply a. location of the pressure injury b. size of the injury in centimeter c. depth of the injury in centimeters d. color and odor of drainage from the wound e. integrity of the skin surrounding the wound

a. location of the pressure injury b. size of the injury in centimeters e. integrity of the skin surrounding the wound -the nurse should document the location of the pressure injury in relation to the adjacent bony prominence, the length and width of the pressure injury in centimeter, the condition of the wound edges and the area of skin surrounding the pressure injury. any changes in temperature, sensation, or firmness in area

a nurse is caring for a client who has suspected stroke. which of the following actions should the nurse take? select all that apply a. make the client NPO b. assess the client's orientation c. check cranial nerves I,II, V d. inspect the client's muscular symmetry e. obtain the client's vital sign

a. make the client NPO b. assess the client's orientation d. obtain the client's vital signs

a nurse is assessing a client's head. which of the following should the nurse identify as an unexpected finding? SATA a. oval white patches in the client's hair b. a lesion on the client's scalp c. protrusion of the client's head d. edema around the client's eyes e. protrusion of the client's mastoid bone

a. oval white patches in the client's hair b. a lesion on the client's scalp c. protrusion on the client's head d. edema around the client's eyes -oval white patches could be head lice (pediculus humanus capitus), the lesions on scalp can be a skin disorder or infection, protrusion of head can indicate trauma, edema on eyes can indicate trauma, infection, or heart disorder

a nurse is inspecting the sinuses of a client who has allergies. which of the following findings should the nurse expect? a. pale mucosa b. bright red mucosa c. green discharge d. yellow discharge

a. pale mucosa -identify a client who has allergies can have pale mucosa, as well as clear discharge

a nurse is preparing to perform a skin assessment on a client. Which of the following tools should the nurse plan to use? a. penlight b. otoscope with a pneumatic bulb attachment c. wide-tipped speculum d. tongue blade

a. penlight -the nurse should plan to perform a skin assessment in an area with strong lighting for general visualization. a penlight is used to illuminate suspicious areas of the skin

Which of the following findings are associated with a possible malignant lesion? Select all that apply a. several colors within a single mole b. an oval shaped mole with smooth borders c. a mole that is larger than a pencil eraser d. a report of a mole being itchy e. occasional bloody discharge from a mole f. a mole that becomes elevated

a. several colors within a single mole c. a mole that is larger than a pencil eraser d. a report of a mole being itchy e. occasional bloody drainage from a mole f. a mole that becomes elevated -Using the ABCDE rule to evaluate malignancy. C stands for a variation in coloration, D stands for diameter in which a lesion is larger than 6mm is concerning. Presence of itching, burning or bleed can be concern for malignancy. E stands for evolving, most sensitive of all criteria.

You are assessing the texture of a client's skin. Which of the following findings require additional investigation? a. smooth, velvety skin b. acne on the back c. moisture in the skin folds d. oily facial skin

a. smooth, velvety skin -Extremely smooth, soft skin is an unexpected finding and may indicate the presence of a thyroid disorder

A nurse is palpating a client's extremities and notes the lower left leg is cooler to the touch than the client's right leg or arms. How should the nurse interpret this finding? a. the client might have a blood clot b. the client might have an infection c. the client is experiencing complications of kidney failure d. the client's blood oxygen levels are lower than expected

a. the client might have a blood clot -unilateral coolness is associated with decreased blood flow to the extremity. this can occur when the client is experiencing a blood clot that is blocking the flow of the blood. additional causes of unilateral coolness of an extremity include chronic disease of the blood vessels or physical obstruction of blood flow, such as a cast that is too tight.

Which of the following instructions should you include while teaching a client about actions to promote the health of their head and neck? select all that apply a. "use ear protection when attending a loud event" b. "brush your teeth once a day" c. "wear eye protection when cutting the grass" d. "Wear a bike helmet if you are going to participate in a bike race" e. "limit music volume when using headphones"

a. use ear protection when attending a loud event c. wear eye protection when cutting the grass d. wear a bike helmet if you are going to participate in a bike race e. limit music volume when using headphones

a nurse is teaching an order adult client about health promotion. the nurse should instruct the client to have which of the following examinations performed on a regular basis? select all that apply a. vision screening every year b. hearing test every 5 years c. dental examination every 6 months d. skin cancer screening every 2 years e. neurological check every 3 months

a. vision screening every year c. dental examination every 6 months

Which of the following statements should you include in a teaching about health promotion screenings for adults? a. you should have your vision checked every 2 years b. you only need your hearing checked if you think you have a problem c. you should have a dental exam every other year d. you can decrease the frequency of screenings after the age of 60

a. you should have your vision checked every 2 years -it is recommended that adults have a routine vision examination every 2 years

which of the following are unexpected findings of the eye? select all that apply a. subconjuctival hemorrhage b. gingivitis c. ptosis d. thrush e. conjuctivitis f. entropion

a.subconjunctival hemorrhage c. ptosis e. conjunctivitis f. entropion -subconjunctival hemorrhage is a localized collection of blood int he sclera caused by increased pressure in the eye. ptosis is drooping of the eye lid over the pupil caused by edema or neuro disorder. conjunctivitis is inflammation of the eye caused by viral/bacterial infections allergies or chemicals. entropion is when the eyelids roll inward and cause the lashes to touch and irritate the conjunctiva and cornea

A nurse is collecting data from a client about their skin and nails. Which of the following statements by the client should the nurse identify as needing further assessment? a. "when I was a child, I developed a rash after taking amoxicillin" b. "I noticed that my fingernails have changed recently" c. "I used to take baths, but I recently switched to showering" d. "In my family, one cousin had basal cell carcinoma"

b. "I noticed that my fingernails have changed recently" -The nurse should follow up with additional questions for the client to obtain specific information about nail changes the client has observed

You are providing health promotion education for a client. Which client statement requires further education? a. "I throw away eye makeup after 4 months of use" b. "I use an indoor tanning bed to improve my skin color" c. "I only bathe twice a week because my skin is dry" d. "I use sunscreen even though I have a dark complexion"

b. "I use an indoor tanning bed to improve my skin color" -Indoor tanning is a source of ultraviolet exposure which increases the risk of developing skin cancer. All clients should be discouraged from using tanning beds

when assessing the ear, which of the following is an emergency and requires immediately contacting the provider? a. conductive hearing loss b. bloody drainage from the ear following head trauma c. edematous outer ear canal d. yellow or green malodorous discharge

b. blood drainage from the ear following head trauma -the presence of this type of drainage from the ear following head trauma could signify the presence of a fracture at the base of the client's skull.

a nurse is preparing to inspect the outer ears of a client who has been in a MVA. the nurse should identify that which of the following findings indicate the client might have a skull fracture? a. edema around the ears b. blood drainage c. yellow drainage d. crusted skin

b. bloody drainage -identify that clear, watery, or bloody drainage can indicate that the client has a skull fracture. the nurse should notify the provider immediately

you are performing an assessment on a client and observe a shallow wound on the client's leg. The wound only penetrates the epidermis ad there is no bleeding present. Which of the following terms correctly describes the wound? a. fissure b. erosion c. wheal d. vesicle

b. erosion -an erosion is a superficial opening contained within the epidermis. There is no bleeding present and this wound heals without leaving a scar. Scratching can produce an erosion

A nurse is preparing to assess the skin turgor of a client who has manifestations of dehydration. In which of the following locations should the nurse perform the assessment? a. lateral to the umbilicus b. inferior to the collar bone c. dorsal side of the hand d. anterior aspect of the neck

b. inferior to the collar bone -assessing skin turgor is performed by pinching a large fold of skin just below the clavicle. Other reliable sites to assess skin turgor include over the sternum and the back of the forearm. In older adults, a natural loss of skin elasticity might slow the recoll time of the skin.

A nurse is assessing a client's skin color. Which of the following findings should the nurse report to the provider? Select all that apply a. patches of increased pigmentation on the client's cheeks b. pinpoint areas of purplish-red coloration across the abdomen c. pale-colored nailbeds d. darkly pigmented area across the client's sacral area e. light-colored jagged lines

b. pinpoint areas of purplish-red coloration across the abdomen c. pale-colored nailbeds -Areas of purplish-red discoloration that are smaller than 3mm in diameter are termed petechia, it is an unexpected finding. indicate bleeding disorder and should be reported. pale nailbeds are an unexpected finding. can indicate low oxygen levels and should be reported.

a nurse is evaluation assessment findings of a client's skin. the nurse should identify that which of the following findings is associated with a possible infection? a. wheals b. vesicles c. papules d. bulla

b. vesicles -vesicles are small serous, raised fluid-filled lesions. the nurse should identify that they are associated with both chickenpox and shingles infections, and should be reported to the provider

a nurse is performing a skin assessment on a client. Which of the following findings should the nurse report to the provider? a. skin tags on the neck b. yellow discoloration of the palms c. brown birthmark on the thigh d. absent tenting of the skin

b. yellow discoloration of the palms -jaundice should be reported to the provider. caused by elevated level of bilirubin, by-produce of the breakdown of red blood cells.

Hematoma

blood clot in organ, space, or tissue

a nurse is providing teaching to a client who reports acne on their face and chest. which of the following client statements indicates an understanding of the teaching? a. "exposing these areas to a tanning bed twice a month will decrease the outbreaks" b."opening the acne lesions will make them drain and go away faster" c. "I should wash the areas frequently with warm water and soap" d. "Keeping the skin moist with oil-based creams will prevent acne outbreaks"

c. "I should was the areas frequently with warm water and soap" -Frequent washing of the affected areas with warm water and soap will remove oil and dirt of the skin. Reduce the risk of secondary infection occurring in the lesions

A nurse is inspecting the fingernails of an older adult client. Which of the following findings should the nurse report to the provider? a. yellowish nail color b. white horizontal lines c. spongy nail base d. capillary refill 2 seconds

c. Spongy nail base -The base of the nail should be firm to palpation. Spongy nail bases are associated with clubbing of the nails, which is a manifestation of chronic hypoxia. The nurse should report this finding to the provider.

A nurse is providing teaching to a client who reports extremely dry skin. Which of the following interventions should the nurse recommend? a. increase the frequency of bathing b. use a dehumidifier to reduce air moisture c. apply an alcohol-free lotion d. cover the dry areas with a thin coating of powder.

c. apply an alcohol-free lotion -The nurse should recommend an alcohol-free lotion that creates a film on the skin to decrease moisture evaporation and dryness. Lanolin, cocoa butter, and petroleum-based lotions are products that retain skin moisture

a nurse is preparing to assess a client's conjunctiva. identify the sequence the nurse should follow when taking the following actions a. instruct the client to look up b. inspect the color and condition of the conjunctiva and sclera, noting any color change, swelling, drainage, or lesions. c. apply examination gloves d. place the thumbs down below each of the client's lower eyelids e. gently pull the client's skin down to the top edge of the bony orbital rim

c. apply examination gloves a. instruct the client to look up d. place the thumbs down below each of the client's lower eyelids e. gently pull the client's skin down to the top edge of the bony orbital rim b. inspect the color and condition of the conjunctiva and sclera, noting any color change, swelling, drainage, or lesions

a nurse is preparing to palpate a client's sinuses. identify the sequence the nurse should follow when taking the following actions. a. firmly press upward on the ridge and make sure not to apply pressure to the eyes b. ask the client if they detect tenderness or pain c. position the thumbs on the supra orbital ridge just below the client's eyebrows to assess the client's frontal sinuses d. position the thumbs below the client's cheekbones with fingers alongside the client's head to assess the clients maxillary sinuses e. apply firm, upward pressure and ask the client if the detect tenderness or pain

c. position the thumbs on the supra orbital ridge just below the client's eyebrows to assess the client's frontal sinuses a. firmly press upward on the ridge and make sure not to apply pressure to the client's eyes b. ask the client if they detect tenderness or pain d. position the thumbs below the client's cheekbones with fingers alongside the client's head to assess the client's maxillary sinuses e. apply firm, upward pressure and ask the client if they detect tenderness or pain

a nurse is performing a head to toe assessment on a client and notes a lump on the anterior portion of their neck. the nurse should identify that this finding can indicate which of the following conditions? a. infection b. cancer c. thyroid disorder d. chest disorder

c. thyroid disorder -anterior lump on the client's neck can indicate that the client has a thyroid disorder

a nurse is performing an eye assessment on a client. which of the following should the nurse identify as the cornea of the eye? a. outer layer of the eyeball b. mucous membrane that lines the eyeball c. transparent layer that covers the iris and pupil d. colored portion in the center of the eye

c. transparent layer that covers the iris and pupil - the nurse should identify that the transparent layer that covers the iris and pupil is the cornea

a nurse is teaching a young adult about risk factors for developing melanoma. which of the following client statements indicates an understanding of the teaching? a. "the fact that I have five moles increases my risk for developing melanoma b. "my cousin had squamous cell carcinoma, which increases my risk for melanoma" c. "having a light complexion decreases my risk for developing melanoma" d. "the blistering sunburns I had as a child increase my risk for melanoma as an adult"

d. "the blistering sunburns I had as a child increase my risk for melanoma as an adult" -excessive sun exposure and severe or blistering sunburn in childhood increase the risk for developing melanoma as an adult

a nurse is performing a focused assessment on a client who reports having difficulty swallowing and continuous headache. the nurse should identify that these findings can indicate which of the following scenarios? a. chest disorder b. thyroid disorder c. musculoskeletal disorder d. central nervous system disorder

d. central nervous system disorder -identifies difficulty swallowing or a headache can indicate that the client has a central nervous system disorder

a nurse is assessing an older adult client's mouth. The nurse should identify that which of the following is an expected variation for this client? a. yellowing of the hard palate b. red spots on the hard palate c. white patches on the tongue d. darkening of the mucosa

d. darkening of the mucosa -darkening, or hyperpigmentation, of the mucosa is expected variation for an older adult client due to the lack of saliva and dryness of the mouth

a nurse is admitting a client who has had a stroke. which of the following actions should the nurse take? a. keep the beside table at the end of the client's bed b. place a towel on the client's bathroom floor c. raise the four side rails on the client's bed d. keep the client's bed in the lowest position

d. keep the client's bed in the lowest position -nurse should keep the client's bed in the lowest position closest to the floor. allows the client to get out of bed easier with assistance

a nurse is assessing a client's skin color. which of the following areas should the nurse check to determine the presence of pallor? a. anterior chest b. palms of the hands c. auricle of the ear d. mucous membrane

d. mucous membranes -Pallor is a pale or lighter skin color than usual that can be caused by anemia or a circulatory problem. It is best observed by inspecting the color of the lips, mucous membranes, and nail beds

a nurse is examining the texture of an older adult client's skin. Which of the following findings should the nurse report to the provider? a. thin skin b. brown macules on the back of the hands c. silver-white depressed scars on the abdomen d. velvety skin

d. velvety skin -Skin that feels smoother and softer than expected, similar to velvet, is associated with thyroid disorders. This is an unexpected finding that should be reported to the provider

urticaria

hives, skin rash with red, raised, and itchy bumps

hyperpigmentation

increase in skin color

Erythema

inflammation of skin area

Pruritus

intense itching causing the desire or reflect to scratch