physical assessment exam 1 study guide

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

An elderly client presents to the health care clinic for a routine physical examination. the client tells the nurse that it has become difficult to cut the toenails because the nails have become hard and brittle. The client also states that the feet are always cold and they must wear socks to bed. Which nursing diagnosis can be confirmed from this data?

risk for impaired skin integrity

in which situation should a nurse perform an emergency assessment of a client?

shortness of breath

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

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

spooning nails

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

tinea corporis

a nurse is interviewing a client regarding her lifestyle and health practices to obtain subjective information to assist in her assessment of her skin. She asks her, do you spend long periods of time sitting or lying in one position? which of the following best rationale for asking this question?

to determine the client's risk for pressure ulcers.

how should the nurse palpate the skin of a client to assess its texture?

touch with the palmar surface of the three middle fingers

a nurse implements which skin assessment to determine the presence of dehydration in a client?

turgor

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

upper abdomen

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

a nurse is preparing a client for a physical examination of his skin, hair, and nails. which of the following interventions should the nurse implement?

wear gloves, use sunlight, client remove toupee, keep door closed.

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

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

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

Asymmetrical shape

a client presents to the health care facility with reports of new onset of chest pain of three days duration. Vital signs are stable and the chest pain has subsided since the client entered the exam room. which type of assessment is most appropriate for a nurse perform for this client?

Comprehensive

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

Cushing's disease

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

Document the findings as normal

During the physical assessment of a client with dark skin, the nurse notices freckle-like pigmentation in the nail beds. What is an appropriate action by the nurse?

Document this as a normal finding

a nurse inspects a client's skin and noticed several flat, brown color change areas on the forearms. What is the proper term for documentation of this finding by the nurse?

Macule

which technique should the nurse use to properly assess a client's skin turgor?

Pinch the skin over the clavicle and observe its return to the original shape

which actions should a nurse perform before beginning the initial shift assessment of a client.

Review the client's record before meeting the client, revise nursing care plans to reflect improvements in the client's condition, check the client's status with the nurse of the previous shift.

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

Wood's light

a nurse is teaching a client how to assess her own knin for possible signs of malignant melanoma. which of the following should the nurse point out as danger signs associated with skin lesions indicating this disease?

asymmetrical, change in size, itching, bleeding of a mole

which assessment finding should the nurse document as objective data?

body functions

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

broken with the presence of a blister

a nurse is instructing a client on how to assess himself for herpes simplex lesions by their configuration. which should the nurse tell the client to look for?

clustered

a nurse conducts an initial comprehensive assessment for a client admitted with a. fever of unknown origin. which area of assessment is primarily the nurse's responsibility?

collect subjective and objective data related to overall function.

which clinical manifestation should the nurse expect to find in a client with edema?

decreased skin mobility

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

dermis

a nurse provides care for a client with an elevated temperature. the client is given the prescribed medication and the nurse checks the client's temp at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment?

evaluation

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

for which client should a nurse perform a focused assessment?

four-day history of sore throat and fever with enlarged lymph nodes

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

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

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

history of cigarette smoking

A client presents to the health care clinic with reports of new onset of generalized hair loss for the past two months. the client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process?

hypothyroidism

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

impetigo

A female client vists the health care clinic with reports of hair falling out in clumps and a butterfly rash on her face. She begins to cry and states: I am so ugly with this rash. Which of the nursing diagnoses can the nurse confirm with this data?

ineffective individual coping, anxiety, disturbed body image.

a nurse is teaching a group of 5th grade children about characteristics of the skin. Which of the following should she mention?

largest organ of the body, helps make vitamin D, aids in maintaining body temp, protects against damage to the body from sunlight

A 5-year-old african american boy asks the nurse what makes his skin so dark. Which of the following substances is the major determinant of skin color?

melanin

which statement by a client about the skin needs validation by the collection of objected data by the nurse?

my feet hurt and are always cold to the touch

a nurse is collecting a thorough and accurate subjective history of a client's nail problems. The client asks why this is necessary. Which of the following should the nurse mention in response?

nail problems can be caused by an underlying systemic illness.

a nurse cares for a client with lung cancer who presents with rust colored sputum and a fever. what type of assessment is the nurse performing?

partial

a client reports feeling short of breath. which area of the body should the nurse inspect for the presence of cyanosis?

perioral

a client admitted to the health care facility has a family history of diabetes mellitus. A nursing health assessment for this client should focus on collection of data in which of these areas?

physiologic, psychological, sociocultural, developmental, and spiritual data