3306 Assessment final review
What does HOH stand for?
hard of hearing
A client tells a nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?
inspect the area
A client has a 7-mm lesion with irregular borders and color variation that has grown over the last several weeks. The nurse knows that this lesion could possibly be what type of cancer?
melanoma
What does PERRLA stand for?
pupils are equal, round, reactive to light and accommodation
A client comes to the clinic with reports of a reddened, tender lump on the left breast. What would the nurse document about the lump?
size
An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse noted considerable skin tenting. Why does this finding require further assessment?
tenting indicates dehydration
A client in the ED tells a nurse that she feels short of breath. The nurse would document this finding as dyspnea. true or false
true
The nurse should recognize that the presence of a wheeze can result from air passing through constricted passageways.
true
When using an otoscope to assess the inner ear the nurse should hold the patient's ear at the helix, lifting up and back for best visualization. true or false
true
What techniques can be performed when palpating the breasts? Select all that apply.
wedge pattern circular pattern vertical pattern
A nurse is inspecting a client's nipples. Which of the following findings should the nurse regard as a cause for concern?
A recently retracted nipple that was previously everted
Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect the client is compensating for what pathophysiological disorder?
Chronic obstructive pulmonary disease
Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields?
Listen to the lungs starting in the apices.
The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?
The right lung has three lobes, while the left lung has two lobes.
The nurse is preparing to palpate the breasts of a female client. Which technique would be most appropriate?
Use the flat pads of three fingers.
The nurse recognizes that the 60-year-old patient may have difficulty reading fine print because of
asthenopia
A new nurse on the long-term care unit is learning how to assess a client's risk for skin breakdown. What would be the most likely instrument this nurse would use?
braden scale
Peripheral vision is evaluated by the nurse using the
confrontation test
What characteristic nail color should the nurse recognize as an indication of hypoxia?
cyanotic
Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?
dermis
