Physical assessment exam 2
A nurse notes that a 2-year-old child has multiple bruises over his body at different stages of healing. What is the most appropriate action for the nurse at this time? a. Obtain further data now to rule out abuse. b. Remind parents that toddlers are clumsy and may fall, causing bruising. c. Determine if this toddler has a coagulation disorder. d. Recommend further observation at future visits.
A
A patient reports having migraine headaches on one side of the head that often start with an aura and last 1 to 3 days. As a part of the symptom analysis, the patient reports which associated symptoms of migraine headaches? a. Nausea, vomiting, or visual disturbances b. Nasal stuffiness or discharge c. Ringing in the ears or dizziness d. Red, watery eyes or drooping eyelids
A
What signs of cyanosis does a nurse inspect for in a dark-skinned patient? a. Ashen-gray color of the oral mucous membranes b. Blue color in the nail beds c. Ashen-blue color in the palms and soles d. Blue-gray color in the ear lobes and lips
A
. When the patient's chart includes a notation that petechiae are present, what finding does a nurse expect during inspection? a. Purplish-red pinpoint lesions b. Deep purplish or red patches of skin c. Small raised fluid-filled pinkish nodules d. Generalized reddish discoloration of an area of skin
A A Purplish-red pinpoint lesions describes the appearance of petechiae. B Petechiae are pinpoints, not as large as a patch. C Petechiae are pinpoints, not raised as a nodule. D Petechiae are pinpoints, not generalized.
. Which cranial nerve is assessed by using the Snellen visual acuity chart? a. Optic cranial nerve (CN II) b. Oculomotor cranial nerve (CN III) c. Abducens cranial nerve (CN IV) d. Trochlear cranial nerve (CN VI)
A The optic cranial nerve (CN II) provides vision tested by the Snellen visual acuity chart. B CN III controls pupillary constriction, eyelid movement, and eyeball movement. C CN IV controls eyeball movement. D CN VI controls eyeball movement.
. While giving a history, a patient reports itching arms, legs, and chest after using a new soap. What manifestations does the nurse expect to find on the arms, legs, and chest when inspecting this patient's skin? a. Elevated irregularly shaped areas of edema of variable diameter b. Elevated, firm, and rough lesions with flat surface greater than 1 cm in diameter c. Elevated circumscribed superficial lesions less than 1 cm in diameter filled with serous fluid d. Elevated, firm circumscribed areas less than 1 cm in diameter
A This is a description of wheals, which occur as a result of allergic reactions. B This is a description of plaque. C This is a description of a vesicle. D This is a description of a papule.
A woman's waist circumference is 32 inches and her hip circumference is 29 inches. Her waist-to-hip ratio is _____.
ANS: 1.10 Calculate waist-to-hip by dividing waist measurement by the hip measurement, 32 inches/29 = 1.10.
. A woman who is 4 feet 11 inches tall is told by her provider to lose weight so that she is closer to her desired body weight. She asks the nurse, "How can I find out what my desired body weight should be?" The nurse responds, "Let me show you how to calculate it. Your desired body weight (DBW) should be _____ lb."
ANS: 103.25 4 feet 11 inches = 59 inches. DBW = 105 lb for the 60 inches + 5 lb for every other inch. However this woman is under 5 feet in height. Thus 105 lb/60 inches = 1.75 lb/inch. 1.75 ´ 59 inches = 103.25 lb.
A patient has come to the clinic complaining of a "bump" behind his right ear. Upon inspection, the nurse notes a lesion that is elevated, solid, and 4 cm in diameter. What does the nurse call this lesion when she reports her findings to the health care provider? a. Tumor b. Nodule c. Keloid d. Papule
ANS: A Feedback A A tumor is an elevated and solid lesion, may or may not be clearly demarcated, extends deeper in the dermis, and greater than 2 cm in diameter. B A nodule is an elevated, firm, circumscribed lesion that extends deeper into the dermis than a papule and is 1 to 2 cm in diameter. C A keloid is an irregularly-shaped, elevated, progressively-enlarging scar that grows beyond the boundaries of the wound. D A papule is an elevated, firm, circumscribed area less than 1 cm in diameter.
During the history, a patient reports watery nasal drainage from allergies. Based on this information, what does the nurse expect to find on inspection of the nares? a. Enlarged and pale turbinates b. Polyps within the nares c. High vascularity of the turbinates d. Dry and dull turbinates
ANS: A Feedback A Enlarged and pale turbinates are expected findings for allergic rhinitis. B Polyps within the nares is not an expected finding. C High vascularity of the turbinates is not an expected finding. D Dry and dull turbinates is not an expected finding.
. During a physical examination, the nurse notes that the patient's skin is dry and flaking, with patches of eczema, and suspects a nutritional deficiency. What additional data should the nurse expect to find to confirm the suspicion? a. Hair loss and hair that is easily removed from the scalp b. Inflammation of the tongue and fissured tongue c. Inflammation of peripheral nerves, and numbness and tingling in extremities d. Fissures and inflammation of the mouth .
ANS: A Feedback A Hair loss (alopecia) and hair that is easily removed from the scalp (easy pluck ability), such as dry, flaking skin, is caused by essential fatty acid deficiency. B Inflammation of the tongue (glossitis) and fissured tongue are manifestations of a niacin deficiency. C Inflammation of peripheral nerves (neuropathy) and numbness and tingling in extremities (paresthesia) are manifestations of a thiamine deficiency. D Fissures of the mouth (cheilosis) and inflammation of the mouth (stomatitis) are manifestations of a pyridoxine deficiency.
A patient who has anorexia nervosa reports a healthy diet and no protein calorie malnutrition. Which lab value best confirms this patient's report? a. Prealbumin b. Serum albumin c. Blood glucose d. Serum cholesterol
ANS: A Feedback A Prealbumin is a reflection of protein and calorie intake for the previous 2 to 3 days
A nurse notices a patient's nails are thin and depressed with the edges turned up. What additional abnormal data should the nurse expect to find on this patient? a. Pale conjunctiva b. Jaundice c. Ecchymosis d. Rashes
ANS: A Feedback A The abnormal nail finding was koilonychia, which occurs in patients with anemia who frequently have pale conjunctiva. B Jaundice is due to increased serum bilirubin, indicating liver or gallbladder disease, and does not create changes in nail structure. C Ecchymosis occurs after trauma to the blood vessel resulting in bleeding under the tissue and does not cause changes in nail structure. D Rashes indicate an inflammation or allergic reaction that does cause changes in the nails
A patient complains of itching, swelling, and drainage from the eyes with a postnasal drip and sneezing. What type of nasal drainage does the nurse anticipate seeing during inspection of this patient's nares? a. Clear b. Malodorous c. Yellow d. Green
ANS: A Feedback A The patient has allergic rhinitis, which produces clear drainage. B Malodorous drainage is associated with bacterial infection, which is not consistent with the history given by this patient. C Yellow drainage is associated with bacterial infection, which is not consistent with the history given by this patient. D Green drainage is associated with bacterial infection, which is not consistent with the history given by this patient.
A nurse shines a light toward the bridge of the patient's nose and notices that the light reflection in the right cornea is at the 9 o'clock position and in the left cornea at the 9 o'clock position. What is the interpretation of this finding? a. The extraocular muscles of both eyes are intact. b. The cornea of each eye is transparent. c. The sclera of each eye is clear. d. The consensual reaction of both eyes is intact.
ANS: A Feedback A The reflection of the light in both eyes in the same location indicates muscles holding the eyes are symmetric. B The reflection of the light in both eyes in the same location indicates muscles holding the eyes are symmetric. C The reflection of the light in both eyes in the same location indicates muscles holding the eyes are symmetric. D Consensual reaction involves constriction of pupils
During symptom analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates dizziness? a. "I felt faint, like I was going to pass out." b. "It felt like I was on a merry-go-round." c. "The room seemed to be spinning around." d. "My body felt like it was revolving and could not stop."
ANS: A Feedback A This is a description of lightheadedness, a form of dizziness. B This is consistent with objective vertigo because it includes a sensation of motion. C This is consistent with objective vertigo because it includes a sensation of motion. D This is consistent with subjective vertigo because it includes a sensation of one's body rotating in space.
While giving a history, a patient reports itching arms, legs, and chest after using a new soap. What manifestations does the nurse expect to find on the arms, legs, and chest when inspecting this patient's skin? a. Elevated irregularly shaped areas of edema of variable diameter b. Elevated, firm, and rough lesions with flat surface greater than 1 cm in diameter c. Elevated circumscribed superficial lesions less than 1 cm in diameter filled with serous fluid d. Elevated, firm circumscribed areas less than 1 cm in diameter .
ANS: A Feedback A This is a description of wheals, which occur as a result of allergic reactions. B This is a description of plaque. C This is a description of a vesicle. D This is a description of a papule
Which findings does the nurse expect when assessing the mouth of a healthy adult? Select all that apply. a. Lips appear pink, smooth, moist, and symmetric b. Teeth are white, yellow, or gray, with smooth edges c. Exposed tooth neck and brown spots between teeth d. Slight roughness on the dorsum of the tongue e. Hard palate appears smooth, pale, and immovable f. Mucous membranes are dry and intact
ANS: A, B, D, E
Which questions are appropriate to ask a patient when performing a symptom analysis for a rash? Select all that apply. a. "When did the rash first start?" b. "Do you have a family history of rashes?" c. "What makes the rash worse?" d. "What do you do to make your rash better?" e. "Describe the sensation from the rash, does it burn or itch?" f. "Describe what the rash looked like initially."
ANS: A, C, D, E, F
A nurse is assessing an 80-year-old patient who is cared for at home by his 79-year-old wife. Which data indicate this patient has malnutrition? Select all that apply. a. Body mass index (BMI) of 17 b. Waist-to-hip ratio of 1.0 c. Weight loss of 6% since last month's visit d. Prealbumin level of 16 mg/dl e. Hematocrit level of 50% f. Hemoglobin level of 20 g/dl
ANS: A, C, F
What findings does the nurse expect when assessing the ears of a healthy adult? Select all that apply. a. Cerumen noted in the outer ear canal b. Pinna located below the external corner of the eye c. Cone of light located in the 5 o'clock position in the left ear d. Ratio of air conduction to bone conduction 2:1 e. Tympanic membrane pearly gray f. Whispered words repeated accurately
ANS: A, D, E, F
A patient who keeps his fat consumption at 10% of his total caloric intake is at risk for deficiency of which nutrient(s)? a. Iron b. Vitamins A, D, and K c. Zinc d. B and C vitamins
ANS: B Feedback A Iron absorption is not affected by low fat intake. B Vitamins A, D, and K are fat soluble vitamins. If the patient does not have enough fat intake, adequate amounts of these vitamins cannot be absorbed. Fat soluble vitamins should be linked to a lack of body fat.
A nurse notices multiple lesions on the back of a patient's left hand that are 0.5 cm in width, elevated, circumscribed, and filled with serous fluid. How does the nurse document these lesions? a. As multiple macules on the dorsum of the left hand b. As multiple vesicles on the dorsum of the left hand c. As several patches on the left hand d. As several bullae on the dorsum of the left hand
ANS: B Feedback A Macules are flat, circumscribed areas that are a change in the color of the skin and are less than 1 cm in diameter. B Vesicles are elevated, circumscribed, superficial (do not extend into dermis), filled with serous fluid, and less than 1 cm in diameter. This documentation tells the number and location of the lesions. C Patches are flat, nonpalpable, irregular-shaped macules greater than 1 cm in diameter. This documentation does not include location of lesions. D Bullae are large vesicles greater than 1 cm in diameter.
. A nurse is performing an admission physical examination on a patient who has been bedridden for a month. The nurse notices a pressure ulcer on the patient's left trochanter area that involves partial-thickness skin loss with damage to the subcutaneous tissue. The nurse reports this ulcer at what stage? a. Stage I b. Stage II c. Stage III d. Stage IV
ANS: B Feedback A Stage I ulcers have persistent redness, but the epidermis is intact. B Stage II ulcers have partial-thickness skin loss of dermis. It appears as a shiny or dry shallow open ulcer with pink wound bed without slough or bruising. C Stage III ulcers have full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend to, but not through, underlying fascia. D Stage IV ulcers have full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be within the wound bed.
A nurse shines a light toward the bridge of the patient's nose and notices that the light reflection in the right cornea is at the 2 o'clock position and in the left cornea at the 10 o'clock position. Based on these data, the nurse should take what action? a. Document these findings as normal. b. Perform the cover-uncover test. c. Perform the confrontation test. d. Document these findings as abnormal.
ANS: B Feedback A The findings are abnormal. The light should appear in the same location in each cornea. B The nurse is performing the corneal light reflex test and the findings are abnormal. Thus, when the corneal light reflex is asymmetric, the cover-uncover test is performed to determine which eye has the weak extraocular muscle(s). C The confrontation test is used to assess peripheral visual fields and is not appropriate to perform when the corneal light reflex is asymmetric. D The asymmetric corneal light reflex is abnormal, but the cover-uncover test should follow the abnormal finding to determine which eye has the weak extraocular muscle(s).
. During an eye examination of an Asian patient, a nurse notices an involuntary rhythmical, horizontal movement of the patient's eyes. How does a nurse document this finding? a. An expected racial variation b. Nystagmus c. Exophthalmus d. Myopia
ANS: B Feedback A This is not a racial variation. B An involuntary rhythmical, horizontal movement of the patient's eyes is a description of nystagmus. C Exophthalmus is the bulging of the eyeball forward, seen in patients with hyperthyroidism. D Myopia is an elongated eyeball found in patients who are nearsighted.
A nurse calculates a patient's body mass index (BMI) as 33. This measurement indicates which class of weight? a. Overweight b. Obesity class I c. Obesity class II d. Obesity class III
ANS: B A Overweight is a BMI of 25 to 29.9. B Obesity class I is a BMI of 30 to 34.9. C Obesity class II is a BMI of 35 to 39.9. D Obesity class III is a BMI greater than 40.
A nurse is inspecting the skin of a patient who has had skin problems after multiple piercings. How will the nurse recognize the characteristics of keloids? a. Roughened and thickened scales involving flexor surfaces b. Hypertrophic scarring extending beyond the original wound edges c. Thin, fibrous tissue replacing normal skin following injury d. Loss of the epidermal layer, creating a hollowed-out or crusted area
ANS: B A Roughened and thickened scales involving flexor surfaces is a description of lichenification. B Hypertrophic scarring extending beyond the original wound edges is a description of a keloid. C Thin, fibrous tissue replacing normal skin following injury is a description of a scar. D Loss of the epidermal layer, creating a hollowed-out or crusted area is a description of excoriation.
Which patient may require additional nutritional assessment? a. A male patient with a blood glucose level of 100 mg/dl b. A pregnant patient with a hemoglobin level of 10.5 g/dl c. A female patient with a prealbumin level of 25 mg/dl d. A male patient with a serum triglyceride level of 100 mg/dl
ANS: B This patient's glucose level is within normal limits. B The expected hemoglobin level for a pregnant patient is 12 to 16 g/dl. C This patient's prealbumin level is within normal limits. D This patient's triglyceride level is within normal limits.
. During an eye assessment, the nurse asks the patient to keep the head stationary and by moving the eyes only follow the nurse's finger as it moves side to side, up and down, and obliquely. This assessment technique collects what data about which cranial nerves? Select all that apply. a. Cranial nerve II (optic) b. Cranial nerve III (oculomotor) c. Cranial nerve IV (trochlear) d. Cranial nerve VI (abducens) e. Cranial nerve V (trigeminal)
ANS: B, C, D
What findings does the nurse expect when assessing skin, hair, and nails of a healthy male adult? Select all that apply. a. Transverse depression noticed across nails b. Scalp is bald c. Elevated, firm, circumscribed area less than 1 cm wide found on the fingers d. Purpura and ecchymosis are noticed on arms and legs e. Freckles are noted on face, back, arms, and legs f. Skin turgor is elastic
ANS: B, E, F
A patient tells the nurse that she tries to keep her fat intake at less than 15% of her total caloric intake per day. What is the nurse's most appropriate response to this patient's comment? a. "That is admirable; how do you accomplish fat intake that low on a daily basis?" b. "Eating fat is essential for good health, and you should consume about 40% of your fats as monounsaturated fat." c. "Limiting fat prevents some diseases, but your fat intake is much lower than the 25% recommended." d. "If you want to bring your fat intake down further, you might want to eliminate eating fast foods."
ANS: C
As a nurse is inspecting the nails of a patient with chronic hypoxemia and notices enlargements of the ends of the fingers and angles of the nail base greater than a straight line (exceeding 180 degrees). How does the nurse document these findings? a. An expected finding b. Koilonychia (spoon nail) c. Clubbing d. Leukonychia
ANS: C
. A patient's current body weight (304 lb) and his desirable body weight of 190 lb. How does the nurse classify this patient's weight? a. Within expected range b. Mildly obesity c. Moderate obesity d. Morbid obesity
ANS: C Feedback A A range of 90% to 110% of DBW is considered normal. This patient's weight of 304 is 60% above his DBW. 190 divided by 304 = .62 = 60%
A patient reports a history of snorting cocaine and is concerned about his bloody nasal drainage. What does the nurse expect to see on inspection of his nose? a. Deviated septum b. Pale turbinates c. Perforated nasal septum d. Localized erythema and edema
ANS: C Feedback A Deviated septum may be from birth or trauma to the nose, but not from cocaine use. B Pale turbinates are an indication of allergies. C Perforated nasal septum develops from cocaine use. D Localized erythema and edema are nonspecific and indicate inflammation somewhere in the nose
. A nurse notices multiple lesions on a patient's left hand that are 0.5 cm in width, elevated, circumscribed, and filled with serous fluid. What kind of primary lesions are these? a. Macules b. Patches c. Vesicles d. Bullae
ANS: C Feedback A Macules are flat, circumscribed areas that are a change in the color of the skin and are less than 1 cm in diameter. B Patches are flat, nonpalpable, irregular-shaped macules greater than 1 cm in diameter. C Vesicles are elevated, circumscribed, superficial (do not extend into dermis), filled with serous fluid, and less than 1 cm in diameter. This documentation tells the number and location of the lesions. D Bullae are large vesicles greater than 1 cm in diameter.
What is the desired body weight for a male who is 7 feet tall? a. 178 lb b. 225 lb c. 250 lb d. 275 lb .
ANS: C Feedback A This incorrect result is obtained when 106 lb is used for the first 6 feet rather than 5 feet (84 inches - 72 inches = 12); thus, 106 + (12 ´ 6) = 178 lb. B This incorrect result is obtained when the scale for women is used rather than the scale for men (84 inches - 60 inches = 24); thus, 105 + (24 ´ 5) = 225. C The patient is 84 inches tall. Use 106 lb for the first 5 feet (60 inches) and 6 lb/ inch for the remaining 24 inches (84 inches - 60 inches = 24); thus, 106 + (24 ´ 6) = 250 lb. Students must perform a calculation to find the answer. D A result of 275 lb uses an incorrect calculation
During symptom analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates vertigo? a. "I felt faint, like I was going to pass out." b. "I just could not keep my balance when I sat up." c. "It seemed that the room was spinning around." d. "I was afraid that I was going to lose consciousness."
ANS: C Feedback A This is a description of lightheadedness, a form of dizziness. B This is a description of disequilibrium, a form of dizziness. C This is consistent with vertigo because it includes a sensation of motion. D This is a description of syncope, a form of dizziness.
The nurse is taking a health history on a patient who reports frequent headaches with pain in the front of the head, but sometimes felt in the back of the head. Which statement by the patient is most indicative of tension headaches? a. "I usually have nausea and vomiting with my headaches." b. "My whole head is constantly throbbing." c. "It feels like my head is in a vice." d. "The pain is on the left side over my eye, forehead, and cheek."
ANS: C Feedback A This is descriptive of migraines rather than tension headaches. B This is descriptive of migraines rather than tension headaches. C This is descriptive of tension headaches, which is consistent with the rest of the data reported by the patient. D This is consistent with cluster headaches rather than tension headaches.
. During a physical examination, the nurse notes that the patient's skin is dry and flaking, with patches of eczema. Which nutritional deficiency might be present? a. Vitamin C b. Vitamin B c. Essential fatty acid d. Protein
ANS: C Feedback A Vitamin C deficiency causes bleeding gums, arthralgia, and petechiae. B Vitamin B deficiency is too large a category to consider. Specific categories of vitamin B deficiency have been identified, such as pyridoxine and thiamine. C Dry and scaly skin is a manifestation of essential fatty acid deficiency. D Protein deficiency causes decreased pigmentation and lackluster hair.
A male patient weighs 205 lb and his desired body weight (DBW) is 190 lb. How should the nurse counsel this patient about his weight? a. He has mild obesity and needs to increase exercise and assess his diet for nutrients and calories. b. He has moderate obesity and needs to consult a health care provider about weight loss therapy. c. He is within normal limits and need not be concerned at this time. d. Further data are needed before an interpretation can be determined.
ANS: C C Ideally, the patient will fall between 90% and 110% of DBW, which for this patient is between 171 lb and 209 lb. A calculation is required to answer the question
A male patient weighs 205 lb and his desired body weight (DBW) is 190 lb. How should the nurse counsel this patient about his weight? a. He has mild obesity and needs to increase exercise and assess his diet for nutrients and calories. b. He has moderate obesity and needs to consult a health care provider about weight loss therapy. c. He is within normal limits and need not be concerned at this time. d. Further data are needed before an interpretation can be determined.
ANS: C C Ideally, the patient will fall between 90% and 110% of DBW, which for this patient is between 171 lb and 209 lb. A calculation is required to answer the question divide 190 by 205 to find his weight percentage 190/ 205= .92= 90%
A nurse is asking questions about the present health status of a young woman who has lost weight recently. Which question is most appropriate when inquiring about present health status? a. "What concerns have you had in the past regarding your weight?" b. "Do you have anorexia?" c. "Describe the recent changes in your weight." d. "Do you have a family history of eating disorders?"
ANS: C because A implies that the patient should be concerned about their weight
Which tool is the best choice for a nurse to use as a quick screening tool to assess a patient's dietary intake? a. Food diary b. Calorie count c. Comprehensive diet history d. 24-hour recall
ANS: D
. Nurses use which measurement as the most highly correlated with risk of morbidity and mortality? a. Waist-to-hip ratio b. Triceps skinfold measure c. Desirable body weight d. Body mass index (BMI)
ANS: D Feedback A The waist-to-hip ratio is an indication of the risk of unhealthy fat distribution. A ratio that exceeds the desired ratio is indicative of upper body obesity. This increases the risk of developing health problems related to obesity (e.g., diabetes, hypertension, coronary artery disease, gallbladder disease, osteoarthritis, and sleep apnea). B Triceps skinfold measurement provides an estimate of total body fat, which is only one measure of risk for obesity, and not, by itself, the most reliable and valid measurement to determine risk. C Calculating desirable body weight and comparing it to actual body weight does not consider height in the assessment of obesity. D The BMI considers both weight and height in the calculation. The U.S. Preventive Services Task Force advocates the BMI assessment as reliable and valid for identifying adults at risk of morbidity and mortality because of being overweight or obese. For this reason, calculating BMI is recommended for all individuals on a periodic basis.
Nurses use which measurement as the most highly correlated with risk of morbidity and mortality? a. Waist-to-hip ratio b. Triceps skinfold measure c. Desirable body weight d. Body mass index (BMI)
ANS: D Feedback A The waist-to-hip ratio is an indication of the risk of unhealthy fat distribution. A ratio that exceeds the desired ratio is indicative of upper body obesity. This increases the risk of developing health problems related to obesity (e.g., diabetes, hypertension, coronary artery disease, gallbladder disease, osteoarthritis, and sleep apnea). B Triceps skinfold measurement provides an estimate of total body fat, which is only one measure of risk for obesity, and not, by itself, the most reliable and valid measurement to determine risk. C Calculating desirable body weight and comparing it to actual body weight does not consider height in the assessment of obesity. D The BMI considers both weight and height in the calculation. The U.S. Preventive Services Task Force advocates the BMI assessment as reliable and valid for identifying adults at risk of morbidity and mortality because of being overweight or obese. For this reason, calculating BMI is recommended for all individuals on a periodic basis.
When performing a skin assessment of an adult patient, the nurse expects what finding? a. Reddened area does not blanch when gentle pressure is applied b. Indentation of the finger remains in the skin after palpation c. Flaking or scaling of the skin d. Return of skin to its original position when pinched up slightly
ANS: D Feedback A This is an indication of a stage I pressure ulcer. B This is a description of edema. C This may be an indication of dry skin, systemic disease, or nutritional deficiency. D This is an assessment of skin turgor; skin should return to its original position.
. Which patient needs to be taught about how diet and exercise can lower lipids to reduce the risk for coronary artery disease? a. A woman with a high-density lipoprotein (HDL) level of 53 mg/dl b. A man with an HDL level of 43 mg/dl c. A woman with a low-density lipoprotein (LDL) level of 125 mg/dl d. A man with an LDL level of 200 mg/dl
ANS: D Feedback A This patient's HDL level is in the expected range. B This patient's HDL level is in the expected range. C This patient's LDL level is in the expected range. D The healthy range of LDL for men and women is <130 mg/dl.
Which patient has the least risk for unhealthy fat distribution? a. The man whose triceps skinfold is at the 25th percentile b. The woman whose triceps skinfold is at the 72nd percentile c. The man whose waist circumference is 46 inches and hip circumference is 40 inches d. The woman whose waist circumference is 30 inches and hip circumference is 38 inches
ANS: D Feedback A Triceps skinfold is an estimate for total body fat, rather than risk. The expected value is near the 50th percentile. B Triceps skinfold is an estimate for total body fat, rather than risk. The expected value is near the 50th percentile. C This man's waist-to-hip ratio is 1.15, which is higher than the 1.0 or less expected value for a man. D This woman's waist-to-hip ratio is 0.789, which is below 0.8, the expected value for women
Which patient has the least risk for unhealthy fat distribution? a. The man whose triceps skinfold is at the 25th percentile b. The woman whose triceps skinfold is at the 72nd percentile c. The man whose waist circumference is 46 inches and hip circumference is 40 inches d. The woman whose waist circumference is 30 inches and hip circumference is 38 inches
ANS: D Feedback A Triceps skinfold is an estimate for total body fat, rather than risk. The expected value is near the 50th percentile. B Triceps skinfold is an estimate for total body fat, rather than risk. The expected value is near the 50th percentile. C This man's waist-to-hip ratio is 1.15, which is higher than the 1.0 or less expected value for a man. D This woman's waist-to-hip ratio is 0.789, which is below 0.8, the expected value for women.
. A nurse assessing a patient with liver disease expects to find which manifestation during the examination? a. Yellowish color in the axilla and groin b. Yellow pigmentation in the sclera c. Very pale skin on the palms d. Ashen-gray color in the oral mucous membranes
B
. Which patient in the eye clinic should the nurse assess first? a. The patient who reports a gradual clouding of vision b. The patient who complains of sudden loss of vision c. The patient who complains of double vision d. The patient who complains of poor night vision
B
A patient asks the nurse if it is possible to grow new skin. What is the nurse's most appropriate response? a. "Even if new skin growth is required, the melanocytes do not regenerate." b. "The avascular epidermis sheds slowly and is replaced completely every 4 weeks." c. "The outer layer of skin remains the same over the lifetime except for repairing injuries." d. "Epidermal regeneration is impossible because it is avascular."
B
A patient complains of nasal drainage and sinus headache. The nurse suspects a nasal infection and anticipates observing which finding during examination? a. Foul-smelling drainage b. Purulent green-yellow drainage c. Bloody drainage d. Watery drainage
B
A patient expresses concern that a new lesion may be melanoma. Which finding suggests a malignant melanoma? a. Nonblanching lesion b. Irregular border c. Diameter less than 5 mm d. Black color of the lesion
B
During a health fair, which recommendation is appropriate as a primary prevention measure to reduce the risk for skin cancer? a. Use a tanning booth instead of sunning outside if a tan is desired. b. Wear protective clothing while in the sun. c. Perform self-examination of skin monthly. d. Use sunscreen with a sun protection except on overcast days
B
Which finding on assessment of a patient's eyes should the nurse document as abnormal? a. An Asian American patient with an upward slant to the palpebral fissure b. A Caucasian American patient whose sclerae are visible between the upper and lower lids and the iris c. An African American patient who has off-white sclerae with tiny black dots of pigmentation near the limbus d. An American Indian patient whose pupillary diameters are 5 mm bilaterally
B A Caucasian American patient whose sclerae are visible between the upper and lower lids and the iris has eyeball protrusion beyond the supraorbital ridge, which indicates exophthalmos caused by hyperthyroidism
A patient is admitted with edema of the occipital lobe following a head injury. The nurse correlates which finding with damage to this area? a. Ipsilateral ptosis b. Impaired vision c. Pupillary constriction d. Increased intraocular pressure
B A Ipsilateral ptosis (drooping of the eye lid) is controlled by the oculomotor cranial nerve (CN III) that is located in the midbrain. The nurse must correlate anatomy with function and assessment. B The occipital lobe contains the visual context. C Pupillary constriction is controlled by the oculomotor cranial nerve (CN III) that is located in the midbrain. D This abnormality is associated with glaucoma rather than injury to the occipital lobe.
During symptom analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates vertigo? a. "I felt faint, like I was going to pass out." b. "I just could not keep my balance when I sat up." c. "It seemed that the room was spinning around." d. "I was afraid that I was going to lose consciousness."
C
How does the nurse recognize jaundice in a dark-skinned patient? a. Inspect the conjunctiva for ashen-gray color. b. Inspect the nail beds for a deeper brown or purple skin tone. c. Inspect the palms and soles for yellowish-green color. d. Inspect the oral mucous membrane for yellow color.
C
What instructions does the nurse give the patient before using the Snellen visual acuity chart? a. "Remove your eyeglasses before attempting to read the lowest line." b. "Stand 10 feet from the chart and read the first line aloud." c. "Hold a white card over one eye and read the smallest possible line." d. "Squint if necessary to improve the ability to read the largest letters."
C
While inspecting the skin, a nurse notices a lesion on the patient's upper right arm. What is the best way to document the size of this lesion? a. Compare its size to the size of a coin. b. Estimate its size to the nearest inch. c. Use a centimeter ruler to measure the lesion. d. Trace the lesion onto a piece of paper.
C
A patient complains of right ear pain. What findings does the nurse anticipate on inspecting the patient's ears? a. Redness and edema of the pinna of the right ear b. Report of pain when the nurse manipulates the right ear c. Bulging and red tympanic membrane in the right ear d. Increased cerumen in the right ear canal
C A Redness and edema of the pinna of the right ear is consistent with external ear pain that may be associated with otitis externa or swimmer's ear. B Report of pain when the nurse manipulates the right ear is consistent with external ear pain that may be associated with otitis externa or swimmer's ear. C Bulging and red tympanic membrane in the right ear is consistent with internal ear pain that may be associated with otitis media. D Increased cerumen in the right ear canal is not consistent with internal ear pain.
A patient reports the mole on the scalp has started itching and it bleeds when scratching it. What other finding is a danger sign for pigmented skin lesions? a. Symmetry of the lesion b. Rounded border c. Color variation d. Size less than 6 mm wide
C A Symmetry is an expected finding for moles. Asymmetric lesions are an early sign of malignant melanoma. B A rounded border is an expected finding. A border that is poorly defined or irregular is an early sign of malignant melanoma. C Uneven, variegated color is an early sign of malignant melanoma. D A size of less than 6 mm wide is an expected finding. A lesion greater than 6 mm is an early sign of malignant melanoma.
A nurse shines a light in the right pupil to test constriction and notices that the left pupil constricts as well. Based on these data, the nurse should take what action? a. Document this finding as an abnormal finding. b. Assess the patient for accommodation. c. Document this finding as a consensual reaction. d. Assess the patient's corneal light reflex.
C A This is a description of an expected finding—consensual reaction. B Accommodation is not assessed in response to consensual reaction; it tests the function of the oculomotor cranial nerve (CN III). C This is a description of expected consensual reaction. D This item describes a consensual reaction rather than a corneal light reflex.
How does a nurse assess movements of the eyes? a. By assessing peripheral vision b. By noting the symmetry of the corneal light reflex c. By assessing the cardinal fields of gaze d. By performing the cover-uncover test
C A This tests the function of cranial nerve I (optic). B This indicates symmetry of eye muscles. C This tests the movement of the eye in all directions, which assesses the functions of the cranial nerves III (oculomotor), IV (abducens), and VI (trochlear). D This is performed after the corneal light reflex is abnormal, indicating asymmetric eye muscles
. During shift report, a nurse learns that a patient has a macular rash. As the nurse inspects the patient's skin, what finding will confirm the rash? a. Elevated, firm, well-defined lesions less than 1 cm in diameter b. Depressed, firm, or scaly, rough lesions greater than 1 cm in diameter c. Elevated, fluid-filled lesions less than 1 cm in diameter d. Flat, well-defined, small lesions less than 1 cm in diameter
D
A patient is visiting an urgent care center after being hit in the back with a baseball. Upon examination, the nurse notes a flat, nonblanchable spot 2.25 cm wide that is reddish-purple in color. How does the nurse document this lesion? a. As an angioma b. As purpura c. As petechiae d. As ecchymosis
D
How does a nurse recognize a patient's mydriasis? a. The lens of each of the patient's eyes is opaque. b. There is involuntary rhythmical, horizontal movement of the patient's eyes. c. There is a white opaque ring encircling the patient's limbus. d. The patient's pupils are 7 mm and do not constrict.
D
On inspection of the external eye structures of an African American patient, the nurse notices the sclerae are not white, but appear a darker shade with tiny black dots of pigmentation near the limbus. How does the nurse document this finding? a. As an indication of a type of anemia b. As a hordeolum or sty c. As jaundice d. As an expected racial variation
D
A patient complains of itching on her feet. On inspection the nurse observes weeping vesicles and skin that is softened and broken down between the toes? What explanation does the nurse give the patient about the cause of this skin disorder? a. "Your itching is caused by a bacterial infection." b. "Your itching is caused by an allergic reaction." c. "Your itching is caused by a viral infection." d. "Your itching is caused by a fungal infection."
D A Bacterial infections such as cellulitis cause redness, warmth, and tenderness, rather than itching. B Allergic reactions such as contact dermatitis cause itching, but they appear as localized erythema, and may also form edema, wheals, scales, or vesicles. C Viral infection such as herpes form grouped vesicles that are painful, rather than itching. D This is a description of tinea pedia, which is caused by a number of dermophyte fungal infections.
The nurse is taking a health history on a patient who reports frequent stabbing headaches occurring once a day lasting about an hour. Which statement by the patient is most indicative of cluster headaches? a. "I usually have nausea and vomiting with my headaches." b. "My whole head is constantly throbbing." c. "It feels like my head is in a vice." d. "The pain is on the left side over my eye, forehead, and cheek."
D A This is descriptive of migraines rather than cluster headaches. B This is descriptive of migraines rather than cluster headaches. C This is descriptive of tension rather than cluster headaches. D This description is consistent with cluster headaches.
. A toddler patient has a small, slightly raised bright red area on the trunk. The child's mother reports that the lesion has been present since birth and has become a little larger. What type of lesion does the nurse suspect? a. Vascular nevi b. Purpura c. Ecchymosis d. Cherry hemangioma
D Cherry hemangioma is a benign tumor consisting of a mass of small blood vessels and can vary in size. These are typically small, slightly raised lesions that are bright red in color appearing on the face, neck and trunk of the body. These lesions increase in size with age
. The nurse palpates the patient's jaw movement, placing two fingers in front of each ear and asking the patient to slowly open and close the mouth. What additional request does the nurse ask the patient to do to assess the jaw? a. Clinch the jaws together as tightly as possible. b. Move the lower jaw from side to side. c. Open the mouth as wide as possible, like a yawn. d. Move the lower jaw forward and backward several times.
b
. During an eye assessment, a nurse asks the patient to cover one eye with a card as the nurse covers his or her eye directly opposite the patient's covered eye. The nurse moves an object into the field of vision and asks the patient to tell when the object can be seen. This assessment technique collects what data about the patient's eyes? a. Symmetry of extraocular muscles b. Visual acuity in the uncovered eye c. Peripheral vision of the uncovered eye d. Consensual reaction of the uncovered eye
c
A patient is in a sitting position as the nurse palpates the temporal arteries and feels smooth, bilateral pulsations. What is the appropriate action for the nurse at this time? a. Auscultate the temporal arteries for bruits. b. Palpate the arteries with the patient in supine position. c. Document this as an expected finding. d. Measure the patient's blood pressure.
c
A nurse uses which technique to assess a patient's peripheral vision? a. The nurse asks the patient to keep the head still and by moving the eyes only, follow the nurse's finger as it moves side to side, up and down, and obliquely. b. The nurse covers one of the patient's eyes with a card and observes the uncovered eye for movement, then removes the card and observes the just uncovered eye for movement. c. With the patient and nurse facing each other and a card covering their corresponding eyes, the nurse moves an object into the visual field and the patient reports when the object is seen. d. The nurse shines a light on both corneas at the same time and notes the location of the reflection in each eye.
c. With the patient and nurse facing each other and a card covering their corresponding eyes, the nurse moves an object into the visual field and the patient reports when the object is seen. A This technique tests extraocular muscle symmetry. B This cover-uncover technique is performed when the corneal light reflex is asymmetric. C This is the confrontation test that tests peripheral vision. D This describes the corneal light reflex that tests the symmetry of the eye muscles
A 45-year-old woman tells the nurse she is distressed by the presence of dark, coarse hair on her face that has recently developed. What is the nurse's most appropriate response to this patient? a. "This is simple vellus hair and it will decrease in amount over time." b. "Some women in your cultural group normally have dark hair on their faces." c. "This is unusual; female hair distribution should be limited to arms, legs, and pubis." d. "Coarse dark hair could result from hormonal changes such as from menopause."
d
