PA Exam 3 Test bank questions

The nurse is performing an ear examination of an 80-year-old patient. Which of these findings would be considered normal? -High-tone frequency loss -Increased elasticity of the pinna -Thin, translucent membrane -Shiny, pink tympanic membrane

A A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging. The pinna loses elasticity, causing earlobes to be pendulous. The eardrum may be whiter in color and more opaque and duller in the older person than in the younger adult.

A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because: -The woman could be at increased risk for infection and lesions because of her chronic disease. -With her diabetes, she has increased circulation to her foot, and it could cause severe bleeding. -She is 75 years old and is unable to see; consequently, she places herself at greater risk for self-injury with the scissors. -With her peripheral vascular disease, her range of motion is limited and she may not be able to reach the corn safely.

ANS: A A personal history of diabetes and peripheral vascular disease increases a person's risk for skin lesions in the feet or ankles. The patient needs to seek a professional for assistance with corn removal.

A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding? -Color variation -Border regularity -Symmetry of lesions -Diameter of less than 6 mm

ANS: A Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.

When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in color and that air bubbles are visible behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that the child: -Most likely has serous otitis media. -Has an acute purulent otitis media. -Has evidence of a resolving cholesteatoma. -Is experiencing the early stages of perforation.

ANS: A An amber-yellow color to the tympanic membrane suggests serum or pus in the middle ear. Air or fluid or bubbles behind the tympanic membrane are often visible. The patient may have feelings of fullness, transient hearing loss, and a popping sound with swallowing. These findings most likely suggest that the child has serous otitis media. The other responses are not correct.

While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a significant amount of aspirin while she was pregnant. What question would the nurse want to include in the history? -"Does your baby seem to startle with loud noises?" -"Has your baby had any surgeries on her ears?" -"Have you noticed any drainage from her ears?" -"How many ear infections has your baby had since birth?"

ANS: A Children at risk for a hearing deficit include those exposed in utero to a variety of conditions, such as maternal rubella or to maternal ototoxic drugs.

The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find: -Lesions that run together. -Annular lesions that have grown together. -Lesions arranged in a line along a nerve route. -Lesions that are grouped or clustered together.

ANS: A Confluent lesions (as with urticaria [hives]) run together. Grouped lesions are clustered together. Annular lesions are circular in nature. Zosteriform lesions are arranged along a nerve route.

The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which one of these reflects the correct procedure? -Pulling the pinna down -Pulling the pinna up and back - Slightly tilting the child's head toward the examiner -Instructing the child to touch his chin to his chest

ANS: A For an otoscopic examination on an infant or on a child under 3 years of age, the pinna is pulled down. The other responses are not part of the correct procedure.

A patient's vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient: -Has poor vision. -Has acute vision. -Has normal vision. -Is presbyopic.

ANS: A Normal visual acuity is 20/20 in each eye; the larger the denominator, the poorer the vision.

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should: -Consider this a normal finding. -Refer the individual for further evaluation. -Document this finding as an asymmetric light reflex. -Perform the confrontation test to validate the findings.

ANS: A Reflection of the light on the corneas should be in exactly the same spot on each eye, or symmetric. If asymmetry is noted, then the nurse should administer the cover test.

The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true? -The outer layer of the eye is very sensitive to touch. -The outer layer of the eye is darkly pigmented to prevent light from reflecting internally. -The trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated when the outer surface of the eye is stimulated. -The visual receptive layer of the eye in which light waves are changed into nerve impulses is located in the outer layer of the eye.

ANS: A The cornea and the sclera make up the outer layer of the eye. The cornea is very sensitive to touch. The middle layer, the choroid, has dark pigmentation to prevent light from reflecting internally. The trigeminal nerve (CN V) and the facial nerve (CN VII) are stimulated when the outer surface of the eye is stimulated. The retina, in the inner layer of the eye, is where light waves are changed into nerve impulses.

The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the: -Auricle. -Concha. -Outer meatus. -Mastoid process.

ANS: A The external ear is called the auricle or pinna and consists of movable cartilage and skin.

The nurse is testing a patient's visual accommodation, which refers to which action? -Pupillary constriction when looking at a near object -Pupillary dilation when looking at a far object -Changes in peripheral vision in response to light -Involuntary blinking in the presence of bright light

ANS: A The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision, which also results in pupil constriction. The other responses are not correct.

The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction? -Air conduction is the normal pathway for hearing. -Vibrations of the bones in the skull cause air conduction. -Amplitude of sound determines the pitch that is heard. -Loss of air conduction is called a conductive hearing loss.

ANS: A The normal pathway of hearing is air conduction, which starts when sound waves produce vibrations on the tympanic membrane. Conductive hearing loss results from a mechanical dysfunction of the external or middle ear. The other statements are not true concerning air conduction.

. The nurse is examining a patient's retina with an ophthalmoscope. Which finding is considered normal? -Optic disc that is a yellow-orange color -Optic disc margins that are blurred around the edges -Presence of pigmented crescents in the macular area -Presence of the macula located on the nasal side of the retina

ANS: A The optic disc is located on the nasal side of the retina. Its color is a creamy yellow-orange to a pink, and the edges are distinct and sharply demarcated, not blurred. A pigmented crescent is black and is due to the accumulation of pigment in the choroid.

When examining the eye, the nurse notices that the patient's eyelid margins approximate completely. The nurse recognizes that this assessment finding: -Is expected. -May indicate a problem with extraocular muscles. -May result in problems with tearing. -Indicates increased intraocular pressure.

ANS: A The palpebral fissure is the elliptical open space between the eyelids, and, when closed, the lid margins approximate completely, which is a normal finding.

A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. His hair seems to be breaking off in patches, and he notices some scaling on his head. The nurse begins the examination suspecting: -Tinea capitis. -Folliculitis. -Toxic alopecia. -Seborrheic dermatitis.

ANS: A Tinea capitis is rounded patchy hair loss on the scalp, leaving broken-off hairs, pustules, and scales on the skin, and is caused by a fungal infection. Lesions are fluorescent under a Wood light and are usually observed in children and farmers; tinea capitis is highly contagious. (See Table 12-12, Abnormal Conditions of Hair, for descriptions of the other terms.)

The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? The infant: -Turns his or her head to localize the sound. -Shows no obvious response to the noise. -Shows a startle and acoustic blink reflex. -Stops any movement, and appears to listen for the sound.

ANS: A With a loud sudden noise, the nurse should notice the infant turning his or her head to localize the sound and to respond to his or her own name. A startle reflex and acoustic blink reflex is expected in newborns; at age 3 to 4 months, the infant stops any movement and appears to listen.

1. The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct? Select all that apply. -Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color -Bulla: Elevated, circumscribed lesion filled with turbid fluid (pus) -Papule: Hypertrophic scar -Vesicle: Known as a friction blister -Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm

ANS: A, D, E A pustule is an elevated, circumscribed lesion filled with turbid fluid (pus). A hypertrophic scar is a keloid. A bulla is larger than 1 cm and contains clear fluid. A papule is solid and elevated but measures less than 1 cm.

18. The nurse is performing the diagnostic positions test. Normal findings would be which of these results? -Convergence of the eyes -Parallel movement of both eyes -Nystagmus in extreme superior gaze -Slight amount of lid lag when moving the eyes from a superior to an inferior position

ANS: B A normal response for the diagnostic positions test is parallel tracking of the object with both eyes. Eye movement that is not parallel indicates a weakness of an extraocular muscle or dysfunction of the CN that innervates it.

While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is not visible. The nurse interprets these findings to indicate a(n): -Fungal infection. -Acute otitis media. -Perforation of the eardrum. -Cholesteatoma.

ANS: B Absent or distorted light reflex and a bright red color of the eardrum are indicative of acute otitis media. (See Table 15-5 for descriptions of the other conditions.)

Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient? -Increased night vision -Dark retinal background -Increased photosensitivity -Narrowed palpebral fissures

ANS: B An ethnically based variability in the color of the iris and in retinal pigmentation exists, with darker irides having darker retinas behind them.

A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition? -Acne -Basal cell carcinoma -Melanoma -Squamous cell carcinoma

ANS: B Basal cell carcinoma usually starts as a skin-colored papule that develops rounded, pearly borders with a central red ulcer. It is the most common form of skin cancer and grows slowly. This description does not fit acne lesions. (See Table 12-11 for descriptions of melanoma and squamous cell carcinoma.)

The nurse is performing a middle ear assessment on a 15-year-old patient who has had a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and landmarks visible. The nurse should: -Refer the patient for the possibility of a fungal infection. -Know that these are scars caused from frequent ear infections. -Consider that these findings may represent the presence of blood in the middle ear. -Be concerned about the ability to hear because of this abnormality on the tympanic membrane.

ANS: B Dense white patches on the tympanic membrane are sequelae of repeated ear infections. They do not necessarily affect hearing.

A 22-year-old woman comes to the clinic because of severe sunburn and states, "I was out in the sun for just a couple of minutes." The nurse begins a medication review with her, paying special attention to which medication class? -Nonsteroidal antiinflammatory drugs for pain -Tetracyclines for acne -Proton pump inhibitors for heartburn -Thyroid replacement hormone for hypothyroidis

ANS: B Drugs that may increase sunlight sensitivity and give a burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.

The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal? -If the drum has ruptured, then purulent drainage will result. -Bloody or clear watery drainage can indicate a basal skull fracture. -The auditory canal many be occluded from increased cerumen. -Foreign bodies from the accident may cause occlusion of the canal.

ANS: B Frank blood or clear watery drainage (cerebrospinal leak) after a trauma suggests a basal skull fracture and warrants immediate referral. Purulent drainage indicates otitis externa or otitis media.

A mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects: -Eczema. -Impetigo. -Herpes zoster. -Diaper dermatitis.

ANS: B Impetigo is moist, thin-roofed vesicles with a thin erythematous base and is a contagious bacterial infection of the skin and most common in infants and children. Eczema is characterized by erythematous papules and vesicles with weeping, oozing, and crusts. Herpes zoster (i.e., chickenpox or varicella) is characterized by small, tight vesicles that are shiny with an erythematous base. Diaper dermatitis is characterized by red, moist maculopapular patches with poorly defined borders.

During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patient's scleras are not yellow. From this finding, the nurse could probably rule out: -Pallor -Jaundice -Cyanosis -Iron deficiency

ANS: B Jaundice is exhibited by a yellow color, which indicates rising levels of bilirubin in the blood. Jaundice is first noticed in the junction of the hard and soft palate in the mouth and in the scleras.

The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS) and notices multiple patchlike lesions on the temple and beard area that are faint pink in color. The nurse recognizes these lesions as: -Measles (rubeola). -Kaposi's sarcoma. -Angiomas. -Herpes zoster.

ANS: B Kaposi's sarcoma is a vascular tumor that, in the early stages, appears as multiple, patchlike, faint pink lesions over the patient's temple and beard areas. Measles is characterized by a red- purple maculopapular blotchy rash that appears on the third or fourth day of illness. The rash is first observed behind the ears, spreads over the face, and then spreads over the neck, trunk, arms, and legs. Cherry (senile) angiomas are small (1 to 5 mm), smooth, slightly raised bright red dots that commonly appear on the trunk in all adults over 30 years old. Herpes zoster causes vesicles up to 1 cm in size that are elevated with a cavity containing clear fluid.

The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal? -Decrease in tear production -Unequal pupillary constriction in response to light -Presence of arcus senilis observed around the cornea -Loss of the outer hair on the eyebrows attributable to a decrease in hair follicles

ANS: B Pupils are small in the older adult, and the pupillary light reflex may be slowed, but pupillary constriction should be symmetric. The assessment findings in the other responses are considered normal in older persons.

38. A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would: pTell the patient to watch the lesion and report back in 2 months. -Refer the patient because of the suggestion of melanoma on the basis of her symptoms. -Ask additional questions regarding environmental irritants that may have caused this c. condition. -Tell the patient that these signs suggest a compound nevus, which is very common in young d. to middle-aged adults.

ANS: B The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, the development of itching, burning, and bleeding, or a new-pigmented lesion. Any one of these signs raises the suggestion of melanoma and warrants immediate referral.

6. A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN ______ and proceeds with the examination by _____________. -XI; palpating the anterior and posterior triangles -XI; asking the patient to shrug her shoulders against resistance -XII; percussing the sternomastoid and submandibular neck muscles -XII; assessing for a positive Romberg sign

ANS: B The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory. The innervated muscles assist with head rotation and head flexion, movement of the shoulders, and extension and turning of the head.

A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that: -At 30 feet the patient can read the entire chart. -The patient can read at 20 feet what a person with normal vision can read at 30 feet. -The patient can read the chart from 20 feet in the left eye and 30 feet in the right eye. -The patient can read from 30 feet what a person with normal vision can read from 20 feet.

ANS: B The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see.

.When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear: -Light pink with a slight bulge. -Pearly gray and slightly concave. -Pulled in at the base of the cone of light. -Whitish with a small fleck of light in the superior portion.

ANS: B The tympanic membrane is a translucent membrane with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The tympanic membrane is oval and slightly concave, pulled in at its center by the malleus, which is one of the middle ear ossicles.

The nurse is assessing a patient who has liver disease for jaundice. Which of these assessment findings is indicative of true jaundice? -Yellow patches in the outer sclera -Yellow color of the sclera that extends up to the iris -Skin that appears yellow when examined under low light -Yellow deposits on the palms and soles of the feet where jaundice first appears

ANS: B The yellow sclera of jaundice extends up to the edge of the iris. Calluses on the palms and soles of the feet often appear yellow but are not classified as jaundice. Scleral jaundice should not be confused with the normal yellow subconjunctival fatty deposits that are common in the outer sclera of dark-skinned persons.

An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination? -Smooth mucous membranes and lips -Dry mucous membranes and cracked lips -Pale mucous membranes -White patches on the mucous membranes

ANS: B With dehydration, mucous membranes appear dry and the lips look parched and cracked. The other responses are not found in dehydration.

In performing a voice test to assess hearing, which of these actions would the nurse perform? -Shield the lips so that the sound is muffled. -Whisper a set of random numbers and letters, and then ask the patient to repeat them. -Ask the patient to place his finger in his ear to occlude outside noise. -Stand approximately 4 feet away to ensure that the patient can really hear at this distance.

ANS: B With the head 30 to 60 cm (1 to 2 feet) from the patient's ear, the examiner exhales and slowly whispers a set of random numbers and letters, such as "5, B, 6." Normally, the patient is asked to repeat each number and letter correctly after hearing the examiner say them.

The nurse is testing the hearing of a 78-year-old man and is reminded of the changes in hearing that occur with aging that include which of the following? Select all that apply. -Hearing loss related to aging begins in the mid 40s. -Progression of hearing loss is slow. -The aging person has low-frequency tone loss. -The aging person may find it harder to hear consonants than vowels. -Sounds may be garbled and difficult to localize. -Hearing loss reflects nerve degeneration of the middle ear.

ANS: B, D, E Presbycusis is a type of hearing loss that occurs with aging and is found in 60% of those older than 65 years. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve, and it slowly progresses after the age of 50 years. The person first notices a high- frequency tone loss; it is harder to hear consonants (high-pitched components of speech) than vowels, which makes words sound garbled. The ability to localize sound is also impaired.

A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer. Which of these findings are characteristic of a stage II pressure ulcer? Select all that apply. -Intact skin appears red but is not broken. -Partial thickness skin erosion is observed with a loss of epidermis or dermis. -Ulcer extends into the subcutaneous tissue. -Localized redness in light skin will blanch with fingertip pressure. -Open blister areas have a red-pink wound bed. -Patches of eschar cover parts of the wound.

ANS: B, E Stage I pressure ulcers have intact skin that appears red but is not broken, and localized redness in intact skin will blanche with fingertip pressure. Stage II pressure ulcers have partial thickness skin erosion with a loss of epidermis or also the dermis; open blisters have a red-pink wound bed. Stage III pressure ulcers are full thickness, extending into the subcutaneous tissue; subcutaneous fat may be seen but not muscle, bone, or tendon. Stage IV pressure ulcers involve ll skin layers and extend into supporting tissue, exposing muscle, bone, and tendon. Slough (stringy matter attached to the wound bed) or eschar (black or brown necrotic tissue) may be present.

The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is very concerned. She tells the nurse that she noticed the lump approximately 8 hours after her baby's birth and that it seems to be getting bigger. One possible explanation for this is: a. Hydrocephalus. -Craniosynostosis. -Cephalhematoma. -Caput succedaneum.

ANS: C A cephalhematoma is a subperiosteal hemorrhage that is the result of birth trauma. It is soft, fluctuant, and well defined over one cranial bone. It appears several hours after birth and gradually increases in size.

A patient comes in for a physical examination and complains of "freezing to death" while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to: -Venous pooling. -Peripheral vasodilation. -Peripheral vasoconstriction. -Decreased arterial perfusion.

ANS: C A chilly or air-conditioned environment causes vasoconstriction, which results in false pallor and coolness (see Table 12-1).

A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to: -Speak loudly so the patient can hear the questions. -Assess for middle ear infection as a possible cause. -Ask the patient what medications he is currently taking. -Look for the source of the obstruction in the external ear.

ANS: C A simple increase in amplitude may not enable the person to understand spoken words. Sensorineural hearing loss may be caused by presbycusis, which is a gradual nerve degeneration that occurs with aging and by ototoxic drugs, which affect the hair cells in the cochlea.

A patient with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the patient that the middle ear functions to: -Maintain balance. -Interpret sounds as they enter the ear. -Conduct vibrations of sounds to the inner ear. -Increase amplitude of sound for the inner ear to function.

ANS: C Among its other functions, the middle ear conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear. The other responses are not functions of the middle ear.

The nurse is performing an assessment on a 65-year-old man. He reports a crusty nodule behind the pinna. It intermittently bleeds and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this: -Is most likely a benign sebaceous cyst. -Is most likely a keloid. -Could be a potential carcinoma, and the patient should be referred for a biopsy. -Is a tophus, which is common in the older adult and is a sign of gout.

ANS: C An ulcerated crusted nodule with an indurated base that fails to heal is characteristic of a carcinoma. These lesions fail to heal and intermittently bleed. Individuals with such symptoms should be referred for a biopsy (see Table 15-2). The other responses are not correct.

During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? This finding: -Is probably the result of lesions from eczema in his ear. -Represents poor hygiene. -Is a normal finding, and no further follow-up is necessary. -Could be indicative of change in cilia; the nurse should assess for hearing loss.

ANS: C Asians and Native Americans are more likely to have dry cerumen, whereas Blacks and Whites usually have wet cerumen.

The nurse is assessing for inflammation in a dark-skinned person. Which technique is the best? -Assessing the skin for cyanosis and swelling -Assessing the oral mucosa for generalized erythema -Palpating the skin for edema and increased warmth -Palpating for tenderness and local areas of ecchymosis

ANS: C Because inflammation cannot be seen in dark-skinned persons, palpating the skin for increased warmth, for taut or tightly pulled surfaces that may be indicative of edema, and for a hardening of deep tissues or blood vessels is often necessary.

The nurse is preparing to perform an otoscopic examination of a newborn infant. Which statement is true regarding this examination? -Immobility of the drum is a normal finding. -An injected membrane would indicate an infection. -The normal membrane may appear thick and opaque. -The appearance of the membrane is identical to that of an adult.

ANS: C During the first few days after the birth, the tympanic membrane of a newborn often appears thickened and opaque. It may look injected and have a mild redness from increased vascularity. The other statements are not correct.

The nurse notices that a patient's palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)? -III -V -VII -VIII

ANS: C Facial muscles are mediated by CN VII; asymmetry of palpebral fissures may be attributable to damage to CN VII (Bell palsy).

A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find: -Pallor -Coolness -Distended veins -Prolonged capillary filling time

ANS: C Keeping the feet in a dependent position causes venous pooling, resulting in redness, warmth, and distended veins. Prolonged elevation would cause pallor and coolness. Immobilization or prolonged inactivity would cause prolonged capillary filling time (see Table 12-1).

A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this? -Perform the confrontation test. -Assess the individual's near vision. -Observe the distance between the palpebral fissures. -Perform the corneal light test, and look for symmetry of the light reflex.

ANS: C Ptosis is a drooping of the upper eyelid that would be apparent by observing the distance between the upper and lower eyelids. The confrontation test measures peripheral vision. Measuring near vision or the corneal light test does not check for ptosis.

30. A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say, "The physician is referring to the: -"Blue dilation of blood vessels in a star-shaped linear pattern on the legs." -"Fiery red, star-shaped marking on the cheek that has a solid circular center." -"Confluent and extensive patch of petechiae and ecchymoses on the feet." - "Tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color."

ANS: C Purpura is a confluent and extensive patch of petechiae and ecchymoses and a flat macular hemorrhage observed in generalized disorders such as thrombocytopenia and scurvy. The blue dilation of blood vessels in a star-shaped linear pattern on the legs describes a venous lake. The fiery red, star-shaped marking on the cheek that has a solid circular center describes a spider or star angioma. The tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color describes petechiae.

A patient has been admitted for severe psoriasis. The nurse expects to see what finding in the patient's fingernails? -Splinter hemorrhages -Paronychia -Pitting -Beau lines

ANS: C Sharply defined pitting and crumbling of the nails, each with distal detachment characterize pitting nails and are associated with psoriasis. (See Table 12-13 for descriptions of the other terms.)

1. A physician tells the nurse that a patient's vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is: -Just above the diaphragm. -Just lateral to the knee cap. -At the level of the C7 vertebra. -At the level of the T11 vertebra.

ANS: C The C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable when the head is flexed

The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct? -Sticky honey-colored cerumen is a sign of infection. -The presence of cerumen is indicative of poor hygiene. -The purpose of cerumen is to protect and lubricate the ear. -Cerumen is necessary for transmitting sound through the auditory canal.

ANS: C The ear is lined with glands that secrete cerumen, which is a yellow waxy material that lubricates and protects the ear.

A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors? -Subcutaneous fat deposits are high in the newborn. -Sebaceous glands are overproductive in the newborn. -The newborn's skin is more permeable than that of the adult. -The amount of vernix caseosa dramatically rises in the newborn.

ANS: C The newborn's skin is thin, smooth, and elastic and is relatively more permeable than that of the adult; consequently, the infant is at greater risk for fluid loss. The subcutaneous layer in the infant is inefficient, not thick, and the sebaceous glands are present but decrease in size and production. Vernix caseosa is not produced after birth.

The nurse is performing an otoscopic examination on an adult. Which of these actions iscorrect? -Tilting the person's head forward during the examination -Once the speculum is in the ear, releasing the traction -Pulling the pinna up and back before inserting the speculum -Using the smallest speculum to decrease the amount of discomfort

ANS: C The pinna is pulled up and back on an adult or older child, which helps straighten the S-shape of the canal. Traction should not be released on the ear until the examination is completed and the otoscope is removed.

When assessing the pupillary light reflex, the nurse should use which technique? -Shine a penlight from directly in front of the patient, and inspect for pupillary constriction. -Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction. -Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction. -Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately 7 cm from the nose.

ANS: C To test the pupillary light reflex, the nurse should advance a light in from the side and note the direct and consensual pupillary constriction.

When examining the face of a patient, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the ___________ and ___________ glands. -Occipital; submental -Parotid; jugulodigastric -Parotid; submandibular -Submandibular; occipital

ANS: C Two pairs of salivary glands accessible to examination on the face are the parotid glands, which are in the cheeks over the mandible, anterior to and below the ear; and the submandibular glands, which are beneath the mandible at the angle of the jaw. The parotid glands are normally nonpalpable.

A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is: -Caused by an excess of melanin pigment -Caused by an excess of apocrine glands in her feet -Caused by the complete absence of melanin pigment -Related to impetigo and can be treated with an ointment

ANS: C Vitiligo is the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orifices—otherwise, the depigmented skin is normal.

A black patient is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patient's skin? -Ruddy blue. -Generalized pallor. -Ashen, gray, or dull. -Patchy areas of pallor.

ANS: C WWW.TESTBANKTANK.COM Pallor attributable to shock, with decreased perfusion and vasoconstriction, in black-skinned people will cause the skin to appear ashen, gray, or dull (see Table 12-2).

The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition? Severe obesity Childhood growth spurts Severe dehydration Connective tissue disorders such as scleroderma

ANS: C Decreased skin turgor is associated with severe dehydration or extreme weight loss.

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a: -Bulla. -Wheal. -Nodule. -Papule.

ANS: D A papule is something one can feel, is solid, elevated, circumscribed, less than 1 cm in diameter, and is due to superficial thickening in the epidermis. A bulla is larger than 1 cm, superficial, and thin walled. A wheal is superficial, raised, transient, erythematous, and irregular in shape attributable to edema. A nodule is solid, elevated, hard or soft, and larger than 1 cm.

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult? -Increased vascularity of the skin -Increased numbers of sweat and sebaceous glands -An increase in elastin and a decrease in subcutaneous fat -An increased loss of elastin and a decrease in subcutaneous fat

ANS: D An accumulation of factors place the aging person at risk for skin disease and breakdown: the thinning of the skin, a decrease in vascularity and nutrients, the loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, the social changes of aging, a increasingly sedentary lifestyle, and the chance of immobility.

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding? -Anasarca -Scleroderma -Pedal erythema -Clubbing of the nails

ANS: D Clubbing of the nails occurs with congenital cyanotic heart disease and neoplastic and pulmonary diseases. The other responses are assessment findings not associated with pulmonary diseases.

An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. The nurse would need to know additional information that includes which of these? -Any change in the ability to hear -Any recent drainage from the ear -Recent history of trauma to the ear -Any prolonged exposure to extreme cold

ANS: D Frostbite causes reddish-blue discoloration and swelling of the auricle after exposure to extreme cold. Vesicles or bullae may develop, and the person feels pain and tenderness.

During an interview, the patient states he has the sensation that "everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is the: -Cochlea. -CN VIII. -Organ of Corti. -Labyrinth.

ANS: D If the labyrinth ever becomes inflamed, then it feeds the wrong information to the brain, creating a staggering gait and a strong, spinning, whirling sensation called vertigo.

A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next? -Refer the patient to an ophthalmologist or optometrist for further evaluation. -Assess whether the patient can count the nurse's fingers when they are placed in front of his or her eyes. -Ask the patient to put on his or her reading glasses and attempt to read the Snellen chart again. -Shorten the distance between the patient and the chart until the letters are seen, and record that distance.

ANS: D If the person is unable to see even the largest letters when standing 20 feet from the chart, then the nurse should shorten the distance to the chart until the letters are seen, and record that distance (e.g., "10/200"). If visual acuity is even lower, then the nurse should assess whether the person can count fingers when they are spread in front of the eyes or can distinguish light perception from a penlight. If vision is poorer than 20/30, then a referral to an ophthalmologist or optometrist is necessary, but the nurse must first assess the visual acuity.

In performing an examination of a 3-year-old child with a suspected ear infection, the nurse would: -Omit the otoscopic examination if the child has a fever. -Pull the ear up and back before inserting the speculum. -Ask the mother to leave the room while examining the child. -Perform the otoscopic examination at the end of the assessment.

ANS: D In addition to its place in the complete examination, eardrum assessment is mandatory for any infant or child requiring care for an illness or fever. For the infant or young child, the timing of the otoscopic examination is best toward the end of the complete examination.

29. A patient has had a "terrible itch" for several months that he has been continuously scratching. On examination, the nurse might expect to find: -keloid. -A fissure. -Keratosis. -Lichenification.

ANS: D Lichenification results from prolonged, intense scratching that eventually thickens the skin and produces tightly packed sets of papules. A keloid is a hypertrophic scar. A fissure is a linear crack with abrupt edges, which extends into the dermis; it can be dry or moist. Keratoses are lesions that are raised, thickened areas of pigmentation that appear crusted, scaly, and warty.

The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse? -"It is unusual for a small child to have frequent ar infections unless something else is wrong." -"We need to check the immune system of your son to determine why he is having so man year infections." -"Ear infections are not uncommon in infants and toddlers because they tend to have more c. cerumen in the external ear." -"Your son's eustachian tube is shorter and wider than yours because of his age, which d. allows for infections to develop more easily."

ANS: D The infant's eustachian tube is relatively shorter and wider than the adult's eustachian tube, and its position is more horizontal; consequently, pathogens from the nasopharynx can more easily migrate through to the middle ear. The other responses are not appropriate.

The nurse is assessing for clubbing of the fingernails and expects to find: -Nail bases that are firm and slightly tender. -Curved nails with a convex profile and ridges across the nails. -Nail bases that feel spongy with an angle of the nail base of 150 degrees. -Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy.

ANS: D The normal nail is firm at its base and has an angle of 160 degrees. In clubbing, the angle straightens to 180 degrees or greater and the nail base feels spongy.

A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that: -The eyes converge to focus on the light. -Light is reflected at the same spot in both eyes. -The eye focuses the image in the center of the pupil. -Constriction of both pupils occurs in response to bright light.

ANS: D The pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina. The other responses are not correct.

The nurse notices that a school-aged child has bluish-white, red-based spots in her mouth that are elevated approximately 1 to 3 mm. What other signs would the nurse expect to find in this patient? -Pink, papular rash on the face and neck -Pruritic vesicles over her trunk and neck -Hyperpigmentation on the chest, abdomen, and back of the arms -Red-purple, maculopapular, blotchy rash behind the ears and on the face

ANS: D With measles (rubeola), the examiner assesses a red-purple, blotchy rash on the third or fourth day of illness that appears first behind the ears, spreads over the face, and then over the neck, trunk, arms, and legs. The rash appears coppery and does not blanch. The bluish-white, red- based spots in the mouth are known as Koplik spots.

A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: -Bell palsy. -Damage to the trigeminal nerve. -Frostbite with resultant paresthesia to the cheeks. -Scleroderma.

B Facial sensations of pain or touch are mediated by CN V, which is the trigeminal nerve. Bell palsy is associated with CN VII damage. Frostbite and scleroderma are not associated with this problem.

When examining a patient's eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system: -Causes pupillary constriction. -Adjusts the eye for near vision. -Elevates the eyelid and dilates the pupil. -Causes contraction of the ciliary body

C Stimulation of the sympathetic branch of the autonomic nervous system dilates the pupil and elevates the eyelid. Parasympathetic nervous system stimulation causes the pupil to constrict. The muscle fibers of the iris contract the pupil in bright light to accommodate for near vision. The ciliary body controls the thickness of the lens.

he nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed? -Perform the confrontation test. -Ask the patient to read the print on a handheld Jaeger card. -Use the Snellen chart positioned 20 feet away from the patient. -Determine the patient's ability to read newsprint at a distance of 12 to 14 inches.

C The Snellen alphabet chart is the most commonly used and most accurate measure of visual acuity. The confrontation test is a gross measure of peripheral vision. The Jaeger card or newspaper tests are used to test near vision.

During an otoscopic examination, the nurse notices an area of black and white dots on the tympanic membrane and the ear canal wall. What does this finding suggest? -Malignancy -Viral infection -Blood in the middle ear -Yeast or fungal infection

D A colony of black or white dots on the drum or canal wall suggests a yeast or fungal infection (otomycosis).

The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for conducting nerve impulses to the brain from the organ of Corti? -I -III -VIII -XI

NS: C The nerve impulses are conducted by the auditory portion of CN VIII to the brain.

When a light is directed across the iris of a patient's eye from the temporal side, the nurse is assessing for: -Drainage from dacryocystitis. -Presence of conjunctivitis over the iris. -Presence of shadows, which may indicate glaucoma. -Scattered light reflex, which may be indicative of cataracts.

NS: C The presence of shadows in the anterior chamber may be a sign of acute angle-closure glaucoma. The normal iris is flat and creates no shadows. This method is not correct for the assessment of dacryocystitis, conjunctivitis, or cataracts.