SFHN questions course point review questions

A client is experiencing pain around the eye that radiates to the face and temporal area. Which image diagrams this client's pain?

(picture indicates pain around the entire eye)

Which of the following scores on the Braden Scale signifies that the client is not at risk for a pressure sore?

19 to 23

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? Select all that apply.

Use sunlight, if possible, to inspect the skin Have the client remove his toupee Wear gloves when palpating lesions Keep the room door closed

The nurse suspects an enlarged thyroid in a client during the physical examination of the head and neck. What should the nurse do first?

ask the client to sip and swallow water

What does the nurse assess the face for? (Select all that apply.)

asymmetry edema involuntary movements

Which vessel is the nurse assessing if the major artery of the neck is being examined?

carotid

When documenting the findings from a physical examination of the head and neck, what will the nurse include when describing the client's head?

hair color

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

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

Which of the following would the nurse consider to be an urgent situation?

new onset chest pain

A nurse has completed an assessment of a client's lymph nodes. Which of the following data would the nurse document as an abnormal finding?

tender

When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?

the underlying bones

A client's skin color depends on melanin and carotene contained in the skin, and the

volume of blood circulating in dermis

While the nurse is obtaining a client's health history regarding the head and neck, the client tells the nurse about having a lump in the neck. In order to assess for associated manifestations of this problem, which of the following questions should the nurse ask next?

"do you have difficulty swallowing?"

A nurse visits an older adult client at home in order to conduct a risk assessment for falls. Which factors would most likely increase the risk for falls for this client? Select all that apply.

a throw rug in the dining room bathtubs in all bathrooms a television cord runs across the floor

The nurse should implement which technique when assessing for jaundice in a dark-skinned client diagnosed with liver disease?

assessing the client's hard palate with a bright light

A nurse is teaching a client how to assess her own skin 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? Select all that apply.

asymmetrical change in size itching bleeding of a mole

At which location would a nurse palpate a client's submental lymph nodes?

behind the tip of the mandible

The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions?

distribution

A nurse is preparing a presentation for a local community group about preventing traumatic brain injury. The nurse would discuss which measure as prevention of the leading cause?

fall prevention

A client presents to the health care clinic with reports of a stiff neck for the past 3 days. What objective information can the nurse obtain during the health history using inspection?

head position

A client complains of a unilateral headache near the scalp line and double vision. The nurse palpates the space above the cheekbone near the scalp line on the affected side, and the client complains of tenderness on palpation. What is the nurse's next action?

notify healthcare provider

A nurse needs to palpate a client's submandibular lymph nodes. Where should the nurse place her hands to do this?

on the medial border of the mandible

The nurse is performing an assessment of a client admitted to the emergency department in status asthmaticus. The nurse should carefully inspect which part of the body in an effort to differentiate central cyanosis from peripheral cyanosis?

oral mucosa

While assessing an older adult client's neck, the nurse observes that the client's trachea is pulled to the left side. The nurse should

refer the client to a physician for further evaluation.

An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse?

the client has chronic hypoxia

The analysis of a client's arterial blood indicates a normal level of arterial oxygen, but the client's skin is cyanotic. What is a likely cause of this condition?

the cyanosis may be a result of a prolonged period of exposure to the cold

What role does oxyhemoglobin play in the physiological process that results in pallor?

the reduction of red pigment in the arteries

The nurse is conducting an assessment of an adult client who describes herself as being in good health. Inspection of the client's nail beds reveals the presence of a bluish tone. The nurse should recognize that this finding is most likely attributable to what phenomenon?

vasocontriction