holistic final
A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would: a. Consider this a normal finding. b. Assess the pupillary light reflex for possible blindness. c. Continue with the examination, and assess visual fields. d. Expect that a 2-week-old infant should be able to fixate and follow an object.
a. Consider this a normal finding.
A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding? a. Color variation b. Border regularity c. Symmetry of lesions d. Diameter of less than 6 mm
a. Color variation
Which component of the family assessment includes boundaries?
Internal structure
The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the psychosocial assessment, the nurse expects that this client:
May take a little longer to respond, but his general knowledge and abilities should not have declined
During the taking of the health history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this finding as:
Objective Vertigo
The nurse is obtaining information about a client's past health history. Which of the following statements would be included in this section of the complete health history?
"I underwent an appendectomy 3 years ago"
The nurse has completed the Review of Systems component of the client's health history. Which of the following findings should be documented under the Review of Systems?
"Patient reports that nausea and vomiting began 3 days ago"
A nurse has admitted a client to the medical unit and is describing the purpose for obtaining a comprehensive health history. Which of the following purposes should the nurse describe?
"This helps us have an appropriate focus for the physical examination."
When admitting a client to the medical-surgical unit, which question would be the most appropriate to begin the nutritional assessment?
"What have you eaten in the last 24 hours?"
The nurse is just starting to gather a patient's health history. Which of the following questions should be the first question the nurse should ask?
"What is your primary health concern at this point in time?"
A nurse is collecting subjective data during a client's eye and vision assessment. When asking the question, ìDo you wear sunglasses during exposure to the sun?î the nurse is addressing a known risk factor for what health problem? A) Presbyopia B) Cataracts C) Nystagmus D) Glaucoma
B) Cataracts
A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve? A) III B) VI C) VIII D) XII
D) XII
A client has presented for care with complaints of persistent lower back pain. When using the mnemonic COLDSPA, which question should the nurse use to evaluate the "P"? A) "What makes it worse?" B) "When did it start?" C) "How does it feel?" D) "How would you rate your pain?"
A) "What makes it worse?"
The nurse's assessment reveals that a male client can neither turn his head against resistance nor shrug his shoulders. The nurse should document a potential deficit in the functioning of which cranial nerve? A) Abducens (VI) B) Accessory (XI) C) Hypoglossal (XII) D) Trochlear (IV)
B) Accessory (XI)
A nurse has completed the general survey of a client who has been transferred to the unit. The information gathered during the general survey primarily provides the nurse with which of the following? Select all that apply. A) An indication of the level of physical distress experienced by the client B) Clues about the overall health of the client C) A direct link to the client's medical diagnosis D) Indications about normal variations in the status of body systems E) Data relating to the patient's level of social support
A) An indication of the level of physical distress experienced by the client B) Clues about the overall health of the client D) Indications about normal variations in the status of body systems
A nurse is providing health education about osteoporosis to a community group. What ethnicity is considered to be an independent risk factor for osteoporosis? A) Caucasian B) African American C) South Asian D) Native American
A) Caucasian
Assessment of a client's skin reveals several individual and distinct 2-mm lesions on the client's back. The nurse would document the configuration as which of the following? A) Discrete B) Linear C) Annular D) Confluent
A) Discrete
A pregnant client asks the clinic nurse what she can use to relieve her nasal "stuffiness." The nurse bases the answer on the most likely cause of the congestion, which is attributable to which hormone? A) Estrogen B) Progesterone C) Thyroxine D) Relaxin
A) Estrogen
A nurse is having difficulty getting a 14-year-old child to ìopen upî during the health interview. What strategy is most likely to enhance the nurse's communication with this child? A) Give the child some control over the course and content of the interview. B) Teach the child about the negative consequences of an inadequate interview. C) Arrange for one of the child's parents to speak with him or her privately. D) Promise the child a reward for participating in the interview.
A) Give the child some control over the course and content of the interview.
A client presents with a cluster of upper airway complaints that include rhinorrhea. Which area of assessment would yield the most pertinent information to the etiology of rhinorrhea? A) History of allergies B) Incomplete immunization record C) History of epistaxis (nosebleeds) D) Prolonged tonsillar enlargement.
A) History of allergies
A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data? A) Inspection B) Therapeutic communication C) Interviewing D) Active listening
A) Inspection
A nurse is providing a client with instructions on how to perform self-examination of the skin. The nurse would encourage the client to perform this examination at which frequency? A) Monthly B) Bimonthly C) Quarterly D) Yearly
A) Monthly
Which of the following would the nurse interpret as a positive response to the Phalen test for a client suspected of having carpal tunnel syndrome? A) Numbness B) Atrophy of the thenar prominence C) No tingling D) Hard, painless Bouchard nodes
A) Numbness
When assessing pain in an older adult client who is alert and oriented, which assessment tool would be most appropriate to use? A) Numerical rating scale B) Faces Pain Scale-Revised C) FLACC Scale D) Graphic rating scale
A) Numerical rating scale
A nurse has completed the assessment of a client's direct pupillary response and is now assessing consensual response. This aspect of assessment should include which of the following actions? A) Observing the eye's reaction when a light is shone into the opposite eye B) Shining a light into one eye while covering the other eye with an opaque card C) Moving a finger into the client's peripheral vision field and asking the client tostate when he or she sees the finger D) Comparing the difference between the client's dilated pupil and a constricted pupil
A) Observing the eye's reaction when a light is shone into the opposite eye
The nurse's assessment of an older adult client's ears and hearing suggests the possible presence of conductive hearing loss. Which of the following is the most likely etiology of this abnormal assessment finding? A) Otitis media B) Cranial nerve VIII damage C) Trauma to the temporal lobe D) Age-related hearing changes
A) Otitis media
When reviewing the neural pathways, a group of students is identifying sensations that travel via the spinothalamic tract. Select all the sensations that are carried by this tract. (select all that apply) A) Pain B) Temperature C) Position D) Vibration E) Light touch
A) Pain B) Temperature E) Light touch
An adult client has asked the nurse about actions that she can take to reduce her future risk of stroke. What health promotion activity should the nurse prioritize? A) Smoking cessation B) Annual MRI screening C) Nutritional supplementation D) Improved coping skills
A) Smoking cessation
The nurse is performing the Romberg test as part of a client's focused neurological assessment. What finding would constitute a positive Romberg test? A) The client moves her feet apart to prevent herself from falling. B) The client is unable to consistently touch her finger to her nose while her eyes are close. C) The client experiences pain during neck flexion and extension. D) The client experiences pain when clenching her teeth.
A) The client moves her feet apart to prevent herself from falling.
A community health nurse is assessing an older adult client in the client's home. When the nurse is gathering subjective data, which of the following would the nurse identify? A) The client's feelings of happiness B) The client's posture C) The client's affect D) The client's behavior
A) The client's feelings of happiness
The nurse is preparing to assess the mental status of a 90-year-old client who is being admitted to the hospital from a long-term care facility. Which of the following should the nurse assess first? A) The client's sensory abilities B) The client's general intelligence C) The presence of any phobias D) The client's judgment and insight
A) The client's sensory abilities
A nurse is providing care for a client who has decreased mobility secondary to a recent stroke. Which of the following assessment findings would be indicative of a stage I pressure ulcer? A) There is a nonblanching reddened area on the client's coccyx region. B) There is scant, frank blood present on the skin surfaces surrounding the client's coccyx. C) There is noticeable bruising on and around the client's coccyx region. D) There is a generalized rash on the client's lower back and buttocks.
A) There is a nonblanching reddened area on the client's coccyx region.
The nurse is reviewing a client's health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply. A) ìI feel so tired sometimes.î B) Weight: 145 lbs C) Lungs clear to auscultation D) Client complains of a headache E) My father died of a heart attack. F) Pupils equal, round, and reactive to light
A) ìI feel so tired sometimes.î D) Client complains of a headache E) My father died of a heart attack.
The nurse is assessing CN V (trigeminal nerve) in a newly admitted client. What instruction should the nurse provide to the client during this phase of assessment? A) ìClench your teeth together tightly.î B) ìClose your left eye and look at me with your right.î C) ìLook straight at me while I shine this light in your eye.î D) ìOpen your mouth wide and say 'ah.'î
A) ìClench your teeth together tightly.î
Which of the following is a purpose of the health history? Select the 3 responses that apply. A) Provides information that assists with identification of health risks C) Provides information that assists the examiner with obtaining information to better focus the physical exam E) Provides subjective data for the patient's health record
ALL of the above
The nurse is caring for an adult client and notices that the client consults a parent on all healthcare decisions. What action by the nurse is most culturally competent?
Accept the behavior of the client and family member
Which of the following are components of the family assessment? Select the 3 responses that apply.
Development, structure, and function
A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. Which of the following should the nurse do? A) Use a Snellen chart to test visual acuity. B) Ask a client to identify scents. C) Test extraocular eye movements. D) Perform the Weber test.
B) Ask a client to identify scents.
A client has sought care because he is concerned that a mole on his scalp may be evidence of skin cancer. During assessment using the mnemonic ABCDE, which finding would the nurse identify as being most suggestive of melanoma? A) Solid, dark brown color B) Asymmetric, irregular borders C) Diameter of 3 mm D) Flat with silvery scales
B) Asymmetric, irregular borders
When evaluating a client's risk for cerebrovascular accident, which client should the nurse identify as being at highest risk? A) A 42-year-old Caucasian female who smokes B) A 68-year-old African-American male with hypertension C) A 70-year-old Caucasian male who has one to two beers a day D) A 35-year-old African-American male who has sleep apnea
B) A 68-year-old African-American male with hypertension
What is vertigo? A) Involuntary rapid eye movements B) A feeling of rotation or imbalance C) An infection of the vestibular nerve D) Impaired olfaction
B) A feeling of rotation or imbalance
The nurse is conducting a focused musculoskeletal assessment of an older adult client. When analyzing assessment data, the nurse should be aware of what age-related physiological changes? Select all that apply A) Absence of knee flexion B) Decreased bone density C) Decreased joint flexibility D) Joint capsule calcification E) Reduced muscle strength
B) Decreased bone density C) Decreased joint flexibility D) Joint capsule calcification E) Reduced muscle strength
In response to a client's query, the nurse is explaining the differences between the physician's medical exam and the comprehensive health assessment performed by the nurse. The nurse should describe the fact that the nursing assessment focuses on which aspect of the client's situation? A) Current physiologic status B) Effect of health on functional status C) Past medical history D) Motivation for adherence to treatment
B) Effect of health on functional status
A client's history suggests a need to assess eye muscle strength and cranial nerve function. What assessment should the nurse consequently perform? A) Corneal light reflex test B) Eye positions test C) Cover test D) Visual fields test
B) Eye positions test
While assessing the knee joint of a client, a nurse also explains about the typical motions associated with that joint. Which of the following would the nurse include? A) Circumduction B) Flexion C) Abduction D) Internal rotation
B) Flexion
A nurse is planning care that is grounded in the fact that clients are holistic beings. Which of the following lists of components constitute the view of clients as holistic beings? A) Physical identity, psychosocial identity, religious identity B) Mind, body, spirit C) Id, ego, superego D) Spiritual identity, egocentric nature, naïve identity
B) Mind, body, spirit
A nurse palpates a client's ear and finds that the tragus is exquisitely tender. The nurse should suspect which of the following health problems? A) Otitis media B) Otitis externa C) Ruptured tympanic membrane D) Mastoiditis
B) Otitis externa
A client has presented with ìa terrible head cold,î and the nurse is assessing for signs and symptoms of sinusitis. The nurse should utilize what assessment techniques? Select all that apply. A) Inspection B) Palpation C) Auscultation D) Percussion E) Transillumination
B) Palpation D) Percussion E) Transillumination
A nurse has been asked to assess an older adult resident of a long-term care facility. During assessment of the resident's skin, the nurse notes a break in the skin, erythema, and a small amount of serosanguineous drainage over the resident's sacrum. Inspection reveals that the area appears blister-like. The nurse should interpret this finding as indicating which stage of pressure ulcer? A) Stage I B) Stage II C) Stage III D) Stage IV
B) Stage II
What is one possible conclusion the nurse could draw after assessing a client with the Braden Scale? A) The client is at risk for falls. B) The client is at risk for pressure ulcers. C) The client is at risk for malnutrition. D) The client may be unable to complete activities of daily living.
B) The client is at risk for pressure ulcers.
A nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the client's current health status would be reflected in her score on this scale? A) The client has a full-time caregiver. B) The client is consistently incontinent of urine. C) The client has a surgical diagnosis. D) The client adheres to a vegetarian diet.
B) The client is consistently incontinent of urine.
A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale? A) The client's current medication regimen B) The client's ability to change position C) The pigmentation of the client's skin D) The client's history of integumentary disorders
B) The client's ability to change position
The nurse begins the physical examination of a newly admitted client by assessing the client's mental status. What is the nurse's best rationale for performing the mental status exam early in the assessment? A) The client will be less anxious early, providing the nurse with more accurate and reliable data. B) The exam can provide clues about the validity of the client's responses now and throughout. C) The exam provides data about mental health problems that the client may be afraid to report. D) The client's fears about having a serious illness may be alleviated by the results of the exam.
B) The exam can provide clues about the validity of the client's responses now and throughout.
A nurse is preparing a teaching session for a group of new parents about ear infections and measures to prevent them. The nurse is planning to address the reasons why children are more susceptible to these infections than adults. Which of the following would the nurse describe? A) Young children have a tendency to stick objects into their ear canal. B) The size and shape of children's eustachian tubes makes them vulnerable. C) Children's immune systems lack the maturity to fight infections. D) Children generally have poorer hygiene than adults.
B) The size and shape of children's eustachian tubes makes them vulnerable.
The nurse is conducting a focused neurological assessment of an 81-year-old client. When analyzing the assessment data, the nurse should be aware of what age-related neurological change? A) Impaired judgment B) Tremors accompanying intentional movements C) Loss of remote memory D) Loss of sensation in distal extremities
B) Tremors accompanying intentional movements
A nurse is interviewing a 22-year-old client of the campus medical clinic. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment? A) Standing while the client is seated B) Using a moderate amount of eye contact C) Sitting across the room from the client D) Minimizing facial expressions
B) Using a moderate amount of eye contact
A client has sought care at the clinic, telling the nurse, ìThis ringing in my ears has gone on for weeks, and it's driving me crazy.î The patient denies exposure to excessive noise levels. The nurse recognizes the likely presence of tinnitus and should follow up with which of the following questions? A) ìDid your parents even complain of something similar?î B) ìWhat medications are you currently taking?î C) ìHow would you describe your overall level of health?î D) ìHow do you usually clean your ears?î
B) ìWhat medications are you currently taking?î
A medical nurse has completed the review of systems component of the client's health history. Which assessment finding should the nurse document under the review of systems? A) "High school diploma plus 2 years of college" B) "Caregiver reliable source of information" C) "Menarche at age 13" D) "Lungs clear to auscultation bilaterally"
C) "Menarche at age 13"
Assessment reveals that a client has slight weakness with active range of motion against some resistance. The nurse would document this as which of the following? A) 2/5 B) 3/5 C) 4/5 D) 5/5
C) 4/5
The nurse is collecting data from a client who has recently been diagnosed with type 1 diabetes and who will begin an educational program. The nurse is collecting subjective and objective data. Which of the following would the nurse categorize as objective data? A) Family history B) Occupation C) Appearance D) History of present health concern
C) Appearance
The nurse has identified a need to discuss sexuality with a 15-year-old client. How should the nurse best plan this aspect of the health interview? A) Obtain informed consent for the health interview. B) Begin by explaining appropriate and acceptable sexual behavior. C) Discuss the matter when a parent is not present. D) Ensure that a chaperone is in the room during the interview.
C) Discuss the matter when a parent is not present.
After teaching a group of students about the brain and spinal cord, the instructor determines that the students demonstrate the need for additional teaching when they identify which of the following as being controlled by the brain stem? A) Respiratory function B) Heart rate C) Equilibrium D) Reflex actions
C) Equilibrium
A nurse is preparing a program on osteoporosis for a local women's group. Which of the following should the nurse cite as a risk factor? A) Obesity B) Multiparity (multiple pregnancies) C) History of smoking D) African-American ethnicity
C) History of smoking
A client has suffered a suspected a rotator cuff tear. Which of the following would the nurse expect to find? A) Limitation of all shoulder motion B) Chronic pain C) Limited abduction D) Sharp catches of pain with movement
C) Limited abduction
The nurse is assessing a newborn infant who currently has nasal congestion and rhinorrhea (runny nose). When analyzing these data, the nurse should consider which of the following? A) Nasal congestion in an infant is indicative of infection. B) Nasal mucus in infants should be treated with an inhaled vasoconstrictor. C) Nasal congestion can impair oxygenation because infants are nose breathers. D) Nasal congestion in infants is an expected finding for the first 6 weeks of life
C) Nasal congestion can impair oxygenation because infants are nose breathers.
Which of the following tests would be most appropriate for the nurse to use when assessing motor function of a client's trigeminal nerve? A) Ask client to differentiate sharp and dull sensations on the face. B) Have the client smile, frown, and wrinkle the forehead. C) Palpate temporal and masseter muscles while client clenches the teeth. D) Assess dilatation of the client's pupils with direct light.
C) Palpate temporal and masseter muscles while client clenches the teeth.
A nurse is teaching a recent nursing graduate about the significance of verbal and nonverbal communication during client care. The new graduate demonstrates an understanding of these techniques by citing what example of verbal communication? A) Maintaining an open attitude B) Using silence appropriately C) Providing a laundry list of descriptors when needed D) Maintaining an open and encouraging facial expression
C) Providing a laundry list of descriptors when needed
The nurse is conducting a health interview and is addressing the client's current stressors. What is the primary rationale for including stress as a focus of psychosocial assessment? A) Stress provides the main impetus for psychosocial development and adaptation. B) Psychosocial development cannot progress normally in the presence of stress. C) Psychosocial stress has a major influence on health in many domains. D) The results of the health interview are distorted when the client is experiencing stress.
C) Psychosocial stress has a major influence on health in many domains.
A review of a client's history reveals cranial nerve IV paralysis. Which of the following findings would the nurse expect to assess? A) The eye cannot look to the outside side. B) Ptosis will be evident. C) The eye cannot look down when turned inward. D) The eye will look straight ahead.
C) The eye cannot look down when turned inward.
Otoscopic examination of a 69-year-old client's tympanic membrane reveals that it is red, bulging, and distorted. The nurse also notes a diminished light reflex. To what should the nurse most likely attribute this assessment finding? A) Repeated ear infections B) Trauma C) Age-related changes D) Acute otitis media
D) Acute otitis media
The nurse is assessing a 39-year-old woman who has a 20 pack-year history of cigarette smoking. When reviewing the client's current medication administration record, what drug would the nurse identify as increasing the woman's risk of stroke? A) Acetaminophen B) A beta-adrenergic blocker C) ASA D) An oral contraceptive
D) An oral contraceptive
While examining a client's mouth, the nurse notes the presence of fasciculations (fine tremors) of the client's tongue. How should the nurse best respond to this assessment finding? A) Have the client provide a 24-hour diet recall. B) Review the client's medication regimen. C) Prepare the client for a thyroid screening. D) Assess the client's cranial nerve function.
D) Assess the client's cranial nerve function.
Which of the following best describes tinnitus? A) A ringing sound accompanying perception of high-frequency tones B) Auditory perception from visual stimuli C) Lack of auditory perception of external auditory stimuli D) Auditory perception without external auditory stimuli
D) Auditory perception without external auditory stimuli
A nurse is preparing to assess a client's cerebellar function. Which of the following aspects of neurological function should the nurse address? A) Remote memory B) Sensation C) Judgment D) Balance
D) Balance
During the Romberg test, a client is unable to stand with the feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would interpret this finding as suggestive of which of the following? A) Spastic hemiparesis B) Parkinsonian gait C) Scissors gait D) Cerebellar ataxia
D) Cerebellar ataxia
The nurse is experiencing challenges in eliciting information during the health interview of a 4-year-old boy. How can the nurse best foster communication with the child? A) Set a time limit for completing the interview. B) Ask the child to talk about himself in the third person. C) Explain the purpose of the interview in simple terms. D) Engage the child in play.
D) Engage the child in play.
A nurse is conducting an assessment of a client's eyes and vision and has completed the positions test. Following this test, the nurse will be able to document data that address what aspects of eye health? Select all that apply. A) Distant visual acuity B) Near visual acuity C) Accommodation D) Eye muscle strength E) Cranial nerve function
D) Eye muscle strength E) Cranial nerve function
A nurse is providing care for an 84-year-old client who has diagnoses of middle-stage Alzheimer disease and a femoral head fracture. What assessment tool should the nurse use to assess the client's pain? A) Graphic Rating Scale B) Numeric Rating Scale (NRS) C) Verbal Descriptor Scale D) Faces Pain Scale-Revised (FPS-R)
D) Faces Pain Scale-Revised (FPS-R)
The nurse is assessing the sinuses of a client who exhibits many of the clinical characteristics of sinusitis. When percussing the client's sinuses, what assessment finding would most strongly suggest sinusitis? A) Resonance on percussion B) Dull sounds C) Tympanic sounds D) Pain on percussion
D) Pain on percussion
A 66-year-old client states that he has increasing difficulty hearing high-pitched sounds. The patient's statement most likely suggests that he has what diagnosis? A) Vertigo B) Otalgia C) Tinnitus D) Presbycusis
D) Presbycusis
The nurse is using the Verbal Descriptor Scale to assess a client's pain. The nurse will prioritize which of the following data? A) The client's facial expressions B) The client's report on a 0 to 10 numeric scale C) The client's rating on a 0 to 10 visual analog scale D) The client's explanation of how her pain feels
D) The client's explanation of how her pain feels
The nurse is performing an assessment of a client's musculoskeletal system. The nurse should begin the assessment by examining which of the following? A) The client's leg length B) The client's lateral bending ability C) The client's cervical ROM D) The client's gait
D) The client's gait
A nurse is preparing for an assessment by reviewing a new client's electronic health record, which documents the presence of macules on the client's left flank and mid-back regions. The nurse should recognize what characteristic of these skin lesions? A) The lesions will be raised and have irregular borders. B) The lesions will be acutely painful. C) The lesions will produce eschar. D) The lesions will not be palpable.
D) The lesions will not be palpable.
When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding? A) Stationary soft palate on phonation B) Deviation of uvula when client says ahh C) Asymmetrical soft palate D) Uvula and soft palate rising bilaterally
D) Uvula and soft palate rising bilaterally
A clinic client's primary complaint is earache (otalgia). Consequently, the nurse's assessment is focusing on potential causes of the client's pain. What question should the nurse include in the health interview? A) ìWhat do you do for a living?î B) ìDo you know if your vaccinations are up to date?î C) ìDo you take over-the-counter medications or supplements?î D) ìHave you been swimming lately?î
D) ìHave you been swimming lately?î
The nurse is assessing a client's cultural identity and affiliation during the health interview. How best can the nurse elicit this information? A) ìWhat are your race and culture?î B) ìWould you describe yourself as American?î C) ìHow would you describe your cultural values?î D) ìWith which cultural group do you most closely identify?î
D) ìWith which cultural group do you most closely identify?î
Data that are detectable by an observer or can be measured or tested against an accepted standard are known as A) subjective data or symptoms. B) objective data or symptoms. C) subjective data or signs. D) objective data or signs.
D) objective data or signs.
A client requests a caregiver who is of the same gender as the client due to cultural beliefs. Which response should the nurse make?
Every attempt will be made to honor your request
Which of the following assessment findings suggest that a client is experiencing stress? Select the 3 responses that apply.
Fidgeting, nail biting, and tapping foot
The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find: a. Lesions that run together. b. Annular lesions that have grown together. c. Lesions arranged in a line along a nerve route. d. Lesions that are grouped or clustered together.
a. Lesions that run together.
The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct? Select all that apply. a. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color b. Bulla: Elevated, circumscribed lesion filled with turbid fluid (pus) c. Papule: Hypertrophic scar d. Vesicle: Known as a friction blister e. Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm
a. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color d. Vesicle: Known as a friction blister e. Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm
A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition? a. Acne b. Basal cell carcinoma c. Melanoma d. Squamous cell carcinoma
b. Basal cell carcinoma
A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would: a. Tell the patient to watch the lesion and report back in 2 months. b. Refer the patient because of the suggestion of melanoma on the basis of her symptoms. c. Ask additional questions regarding environmental irritants that may have caused this condition. d. Tell the patient that these signs suggest a compound nevus, which is very common in young to middle-aged adults.
b. Refer the patient because of the suggestion of melanoma on the basis of her symptoms.
A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that: a. At 30 feet the patient can read the entire chart. b. The patient can read at 20 feet what a person with normal vision can read at 30 feet. c. The patient can read the chart from 20 feet in the left eye and 30 feet in the right eye. d. The patient can read from 30 feet what a person with normal vision can read from 20 feet.
b. The patient can read at 20 feet what a person with normal vision can read at 30 feet.
A mother asks when her newborn infant's eyesight will be developed. The nurse should reply: a. "Vision is not totally developed until 2 years of age." b. "Infants develop the ability to focus on an object at approximately 8 months of age." c. "By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object." d. "Most infants have uncoordinated eye movements for the first year of life."
c. "By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object."
Which type of boundaries exist in a highly functional family?
clearly-defined/permeable
Which component of the family assessment would provide information about a family's adherence to the practices of a particular cultural group within the same area?
context
A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The nurse should: a. Examine the retina to determine the number of floaters. b. Presume the patient has glaucoma and refer him for further testing. c. Consider these to be abnormal findings, and refer him to an ophthalmologist. d. Know that floaters are usually insignificant and are caused by condensed vitreous fibers
d. Know that floaters are usually insignificant and are caused by condensed vitreous fibers
The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a: a. Bulla. b. Wheal. c. Nodule. d. Papule.
d. Papule.