N336 Final Skin, Hair, Nail, HEENT PREP U

History of allergies

A client presents with rhinorrhea. Which area of assessment would yield the most pertinent information?

Weber

A client tells the nurse that it is difficult to hear normal conversation when in a room with a lot of noise. Which test should the nurse perform to assess the hearing ability of the client?

Document this as an expected assessment finding

A nurse has performed a head and neck assessment of an adult patient and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?

Turgor

A nurse implements which skin assessment to determine the presence of dehydration in a client?

When palpating lesions on the client's skin

A nurse is implementing appropriate infection control precautions while performing a client's skin assessment. The nurse would wear gloves during which part of the assessment?

is distributed along a dermatome

A patient with a zosteriform rash has a rash that

Touch with the palmar surface of the three middle fingers

How should the nurse palpate the skin of a client to assess its texture?

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?

Percussion

A nursing educator is evaluating a colleague's examination of a client's thyroid gland. The educator would determine that the nurse needs additional instruction when the nurse demonstrates which technique?

Normal findings for client's age

During a health history, a 42-year-old male client reveals that he is seeing spots before his eyes. The nurse interprets this finding as the result of which of the following?

Auscultate the client's thyroid

The nurse is assessing the head and neck of a 51-year-old male client. Following inspection and palpation of the client's thyroid gland, the nurse determines that the gland is enlarged. What is the next action that the nurse should perform?

position the client 609.6 cm (20 ft) away from the chart

The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should

On each side between the top of the ear and the eye

The nurse is preparing to palpate a client's temporal artery. The nurse would place the hands at which location?

"You have a conductive hearing loss."

The results of a client's Rinne test are as follows: bone condcution > air conduction. How should the nurse explain these findings to the client?

wood's light

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?

conductive hearing loss in right ear

When conducting the Weber test a client reports hearing the sound better in the right ear. What should this finding indicate to the nurse?

macules

When documenting that a patient has freckles, the appropriate term to use is

Attempting to roll the structure up and down and side to side

When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles?

30/20

When visual acuity is tested using the Snellen eye chart, which result suggests better distance vision?

Employ the right eye to examine the client's right eye

Which action by the nurse indicates the appropriate use of ophthalmoscope?

Ask the client to say "aaah"

Which action by the nurse is appropriate to provide a clear view of the uvula for observation?

At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet

A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding?

client has a recent infestation

A client presents with possible lice infestation of the scalp. The nurse observes nits very close to the scalp. What does this finding tell the nurse?

acute bacterial sinusitis

A client reports experiencing chronic headache after a recent upper respiratory tract infection. On physical examination, the nurse notes tenderness when palpating over the sinuses. Which condition is likely?

Perioral

A client reports feeling short of breath. Which area of the body should the nurse inspect for the presence of cyanosis?

Fluid-filled lesions less than 1 cm in diameter

A community health nurse is planning an educational event for the parent-teacher association of the local elementary school. In discussing chickenpox, how would the nurse describe the rash?

fluid intake

A female client visits the clinic and complains to the nurse that her skin feels "dry." The nurse should instruct the client that skin elasticity is related to adequate

Braden scale

A new nurse on the long-term care unit is learning how to assess a patient's risk for skin breakdown. What would be the most likely instrument this nurse would use?

Compressing the arteries bilaterally

A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated?

Ask the client to remove the glasses before testing.

A nurse is preparing to assess the distant visual acuity of a client who wears reading glasses. Which of the following would be most appropriate?

Fingers and toes

A nurse receives report from the shift nurse that a client has new onset of peripheral cyanosis. Where should the nurse focus the assessment of the skin to detect the presence of this condition?

Consensual response

A nurse shines a light into one of the client's eyes during an ocular exam and the pupil of the other eye constricts. The nurse interprets this as which of the following?

Tenting indicates dehydration

An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse notes considerable skin tenting. Why does this finding require further assessment?

The client and the examiner see the examiner's finger at the same time

As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test?

Whisper test

The nurse is assessing auditory acuity in a college student. Which test would the nurse perform to assess for loss of high-frequency sounds?

Normal finding

The nurse notes that a client has longitudinal ridges in the nails of both thumbs. What should the nurse consider as being the reason for this finding?

Cranial nerve VII

The nurse notes unilateral facial drooping and reports the finding immediately to the healthcare provider. The client is diagnosed with Bell palsy. The nurse should include assessment of which affected cranial nerve in the client's head and neck assessment?

Accessory (XI)

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?

The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears.

Which action by the nurse is consistent with Weber's test?

Keloid formation at the site of an old incision

Which of the following assessment findings most likely constitutes a secondary skin lesion?

19-23 higher the score = not at risk

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

Annular

Which of the following terms is used to describe the arrangement of skin lesions?

Rinne

Which of the following tests use a tuning fork between two positions to assess hearing?

Petechiae

While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse should recognize the presence of which of the following?

Can be caused by an underlying systemic illness

Why is it important to collect a thorough and accurate subjective history in regards to a client's nail problems?