Physical Assessment Final

a. nasolabial folds

what area should the nurse inspect for facial symmetry when performing a head and neck assessment? a. nasolabial folds b. pre auricular nodes c. temporomadibular joint d. earlobe placement

b. wood's light

what light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus? a. sunlight b. wood's light c. flashlight d. artificial light

a. at the center of the client's forehead

where would you place a tuning fork on a client when conducting a weber test, to examine for hearing loss? a. at the center of the client's forehead b. in front of the external auditory canal c. behind the external auditory canal d. on the client's mastoid process

c. red, bugling, with an absent light reflex

which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media? a. pearly, translucent, with no bulging b. yellowish, bulging, with fluid bubbles c. red, bulging, with an absent light reflex d. gray, translucent, with no retraction

a. Physiologic, psychological, sociocultural, developmental, and spiritual data

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? a. Physiologic, psychological, sociocultural, developmental, and spiritual data b. Involves the client's musculoskeletal system and ADL's c. Focuses primarily on the client's physiologic development status d. Focus only on the client's psychological, sociocultural, and spiritual well-being

c. perioral (nail bed and conjunctival areas)

A client reports feeling short of breath. Which area of the body should the nurse inspect for the presence of cyanosis? a. facial b. chest c. perioral d. palms

c. broken with the presence of a blister (superficial skin loss of the epidermis alone or the dermis also)

A nurse cares for a client with a stage II pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area? a. unbroken but red in color b. exposure of subcutaneous tissue and muscle c. broken with the presence of a blister d. ulceration resembling a crater

a. vesicle

Upon examination of a client, the nurse finds a circumscribed elevated, palpable mass containing serous fluid. How should the nurse properly document this finding? a. vesicle b. cyst c. papule d. wheal

c. decreased skin mobility

Which clinical manifestation should the nurse expect to find in a client with edema? a. mottled skin tones b. decreased skin turgor c. decreased skin mobility d. prominent blood vessels

c. migraine headache

a client reports right-sided temporal headache accompanied by nausea and vomiting. a nurse recognizes that which condition is likely to produce these symptoms? a. temporal arteritis b. bell's palsy c. migraine headache d. tension headache

b. on the medial border of the mandible

a nurse needs to palpate a client's submandibular lymph nodes. where should the nurse place her hands to do this? a. a few centimeters behind the tip of the mandible b. on the medial border of the mandible c. at the posterior base of the skull bone d. at the angle of the mandible on the anterior edge of the sternocleidomastoid

c. fixed to underlying tissue (could be metastatic disease)

a nurse performs palpation of a client's lymph nodes. which finding should be reported to the health care provider? a. mobile from side to side b. round and 8 mm in size c. fixed to underlying tissue d. soft in consistency

b. atelectasis

during the physical examination of a client, a nurse notes that a client's trachea has been pushed to the right side. the nurse recognizes that the pathophysiologic cause for this finding is related to what disease process? a. endocarditis b. atelectasis c. bronchitis d. tuberculosis