Chapter 11 My Nursing Test Banks

DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 11

Question 1

Type: HOTSPOT

The nurse has performed a focused interview with the client and is preparing to perform a skin assessment while the student nurse observes. The student nurse asks, Where exactly is the stratum basale located? Identify the stratum basale in the following figure by placing an arrow pointing toward this area. [Please insert figure 11-1 from DAmico 2nd edition: Skin structure, 3-dimensional view of skin.Remove all labels]

Screen Shot 2015-09-24 at 11.55.01 AM

Rationale : The epidermis is a layer of epithelial tissue that comprises the outermost portion of the skin. Where exposure to friction is greatest, such as on the fingertips, palms, and soles of the feet, the epidermis consists of five layers (or strata). These five layers are, from deep to superficial, the stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum.

Global Rationale:

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11.1: Identify the anatomy and physiology of the skin, hair, and nails.

Question 2

Type: HOTSPOT

The nurse is assessing the clients nail. Identify the lunula by drawing an arrow pointing toward this area on the following figure.

Screen Shot 2015-09-24 at 11.56.00 AM

Rationale : The lunula is a moon-shaped crescent that appears on the nail body over the thickened nail matrix.

Global Rationale:

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11.1: Identify the anatomy and physiology of the skin, hair, and nails.

Question 3

Type: MCSA

The nurse is conducting a focused interview on the clients integumentary system and prepares to obtain data related to risk factors for the development of integumentary disorders. Which of the following questions by the nurse would be unexpected based on the specific data the nurse is attempting to gain during the interview?

1. How much time do you spend outdoors?

2. How do you care for your skin?

3. Do you have any tattoos or body piercings?

4. Have you noticed any drainage from your skin?

Correct Answer: 4

Rationale 1: The nurse can ask the client about the amount of time that the client spends outside. Spending time outside in the sunshine is a risk factor for the development of skin disorders, such as squamous cell carcinoma.

Rationale 2: The nurse can ask the client about the way that the client cares for the skin. There may be something that the client is doing while caring for the skin that is a risk factor for the development of an integumentary disorder.

Rationale 3: Tattoos and body piercings can increase the clients risk for developing an integumentary disorder.

Rationale 4: When the nurse asks the client about the presence of drainage from the skin, this question is directed at determining the presence of a clinical manifestation of an integumentary disorder. This question is not necessarily directed at gaining information about risk factors.

Global Rationale: When the nurse asks the client about the presence of drainage from the skin, this question is directed at determining the presence of a clinical manifestation of an integumentary disorder. This question is not necessarily directed at gaining information about risk factors. The nurse can ask the client about the amount of time that the client spends outside. Spending time outside in the sunshine is a risk factor for the development of skin disorders, such as squamous cell carcinoma. The nurse can ask the client about the way that the client cares for the skin. There may be something that the client is doing while caring for the skin that is a risk factor for the development of an integumentary disorder. Tattoos and body piercings can increase the clients risk for developing an integumentary disorder.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11.2: Develop questions to be used when completing the focused interview.

Question 4

Type: MCSA

The nurse is completing a focused interview to assess the skin, hair, and nails of a pregnant client. Which of the following questions would be most important for the nurse to include in the interview?

1. Do you use any skin creams?

2. Do you try to avoid exposure to the sun?

3. Have you lost any hair during your pregnancy?

4. Have you had any nail changes?

Correct Answer: 1

Rationale 1: Topical medications may be absorbed through the skin and harm the fetus. Those that can cause birth defects include Retin A, antifungal agents, and minoxidil for hair growth. Other topical medications that can harm the baby include antibiotics, steroids, and medication for muscle pain.

Rationale 2: Client should avoid sun exposure to prevent skin damage.

Rationale 3: Losing hair during pregnancy is not necessarily as important to assess as the clients use of skin creams. Topical medications may be absorbed through the skin and harm the fetus.

Rationale 4: Nail changes can be assessed, but it is most important to assess the clients use of skin creams. Topical medications may be absorbed through the skin and harm the fetus.

Global Rationale: Topical medications may be absorbed through the skin and harm the fetus. Those that can cause birth defects include Retin A, antifungal agents, and minoxidil for hair growth. Other topical medications that can harm the baby include antibiotics, steroids, and medication for muscle pain.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11.2: Develop questions to be used when completing the focused interview.

Question 5

Type: MCSA

The nurse is preparing to assess the clients skin, hair, and nails. Which of the following techniques will the nurse use initially during this assessment?

1. Percussion

2. Palpation

3. Auscultation

4. Inspection

Correct Answer: 4

Rationale 1: There is no need to use percussion to assess the clients skin, hair, and nails.

Rationale 2: The nurse inspects then palpates during the assessment of the clients skin, hair, and nails.

Rationale 3: There is no need to use auscultation to assess the clients skin, hair, and nails.

Rationale 4: Inspection is the nurses first step when assessing the clients skin, hair, and nails.

Global Rationale: Physical assessment of the skin, hair, and nails is conducted by inspection and then with palpation. There is no need to use percussion to assess the clients skin, hair, and nails. There is no need to use auscultation to assess the clients skin, hair, and nails.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11.3: Explain client preparation for assessment of the skin, hair, and nails.

Question 6

Type: MCMA

The client is visiting the healthcare providers office for a head-to-toe assessment. During the nurses assessment of the clients skin, the nurse notes that the client is pale. Which of the following findings may be related to the clients color?

Standard Text: Select all that apply.

1. Clients blood pressure is 96/62.

2. The client states, I just smoked a cigarette before I came in the office.

3. The clients oxygen saturation level is 86% on room air.

4. The client states, I have been diagnosed with osteoporosis.

5. The client states, It is snowing again outside with a wind chill factor of 11 degrees Fahrenheit.

Correct Answer: 1,2,3,5

Rationale 1: Clients blood pressure is 96/62. Pallor may be seen in the client with hypotension.

Rationale 2: The client states, I just smoked a cigarette before I came in the office. It can be produced by the sympathetic nervous stimulation that results in vasoconstriction due to smoking cigarettes.

Rationale 3: The clients oxygen saturation level is 86% on room air. The client with a decreased oxygen saturation level may exhibit pallor.

Rationale 4: The client states, I have been diagnosed with osteoporosis. Pallor is not normally associated with osteoporosis.

Rationale 5: The client states, It is snowing again outside with a wind chill factor of 11 degrees Fahrenheit. A cold environment can produce vasoconstriction and pallor.

Global Rationale: Pallor may be seen in the client with hypotension. It can be produced by the sympathetic nervous stimulation that results in vasoconstriction due to smoking cigarettes. The client with a decreased oxygen saturation level may exhibit pallor. A cold environment can produce vasoconstriction and pallor. It is not normally associated with osteoporosis.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.

Question 7

Type: MCSA

The nurse is assessing a client with liver disease and notes that the skin, mucous membranes, and sclerae are yellowish in color. The nurse would correctly document this finding as which of the following?

1. Uremia

2. Cyanosis

3. Jaundice

4. Carotenemia

Correct Answer: 3

Rationale 1: Uremic skin is pale and yellow, but is associated with renal, and not liver, disease. The yellow tinge seen in the patient with uremic skin is very pale and does not affect conjunctivae or mucous membranes.

Rationale 2: Cyanotic skin is bluish in color.

Rationale 3: The nurses findings indicate jaundice, which is due to increased levels of bilirubin in the blood. Jaundice is visible in the sclerae, oral mucosa, junction of hard and soft palate, palms of the hands, and soles of the feet.

Rationale 4: Carotenemic skin has a yellow-orange tinge. The yellow-orange tinge seen in the client with carotenemia is most visible in palms of the hands and soles of the feet. This client would not exhibit yellowing of sclerae or mucous membranes.

Global Rationale: The nurses findings indicate jaundice, which is due to increased levels of bilirubin in the blood. Jaundice is visible in the sclerae, oral mucosa, junction of hard and soft palate, palms of the hands, and soles of the feet. Uremic skin is pale and yellow, but is associated with renal, and not liver, disease. The yellow tinge seen in the patient with uremic skin is very pale and does not affect conjunctivae or mucous membranes. Cyanotic skin is bluish in color. Carotenemic skin has a yellow-orange tinge. The yellow-orange tinge seen in the client with carotenemia is most visible in palms of the hands and soles of the feet. This client would not exhibit yellowing of sclerae or mucous membranes.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.

Question 8

Type: MCSA

The nurse is performing a skin assessment on a client and notes a round, elevated, fluid-filled mass approximately 0.4 cm in size. The nurse would correctly document this finding as which of the following?

1. Vesicle

2. Macule

3. Papule

4. Tumor

Correct Answer: 1

Rationale 1: The area described is a vesicle and may be caused by herpetic lesions, poison ivy, and small burn blisters.

Rationale 2: A macule is a flat, nonpalpable change in skin color.

Rationale 3: A papule is an elevated, solid, palpable mass.

Rationale 4: Tumors are elevated, but solid, hard, or soft palpable and extend deeper into the dermis.

Global Rationale: The area described is a vesicle and may be caused by herpetic lesions, poison ivy, and small burn blisters. A macule is a flat, nonpalpable change in skin color. A papule is an elevated, solid, palpable mass. Tumors are elevated, but solid, hard, or soft palpable and extend deeper into the dermis.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.

Question 9

Type: MCSA

The nurse is caring for a client who has smoked for many years and documents that clubbing is present. Which of the following techniques is the best way for the nurse to determine the presence of clubbing?

1. Place two thumbs touching side-by-side.

2. Place two of the same fingers from each hand together.

3. Place two index fingers together tip-to-tip.

4. Place the hands out straight with the palm sides down.

Correct Answer: 2

Rationale 1: Placing the thumbs together side-by-side is not an appropriate way to determine the presence of clubbing.

Rationale 2: To assess for clubbing, the nurse can use the Schamroth technique in which the nurse asks the client to bring the dorsal aspect of corresponding fingers together and if there is clubbing, a diamond is not formed and the distance increases at the fingertip.

Rationale 3: Placing the index finger tip-to-tip is not an appropriate way to determine the presence of clubbing.

Rationale 4: Placing the hands straight out with the palms facing downward is not an appropriate way to determine the presence of clubbing.

Global Rationale: To assess for clubbing, the nurse can use the Schamroth technique in which the nurse asks the client to bring the dorsal aspect of corresponding fingers together and if there is clubbing, a diamond is not formed and the distance increases at the fingertip. Placing the thumbs together side-by-side is not an appropriate way to determine the presence of clubbing. Placing the index finger tip-to-tip is not an appropriate way to determine the presence of clubbing. Placing the hands straight out with the palms facing downward is not an appropriate way to determine the presence of clubbing.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.

Question 10

Type: MCSA

The nurse is assessing a female client and notes facial hirsutism. The client asks the nurse, Why did this happen to me? Which of the following statements is the nurses best response?

1. Your diet is not nutritionally balanced.

2. You may have some hormone imbalances.

3. Usually, there is not a known cause for this condition.

4. You need to take vitamins.

Correct Answer: 2

Rationale 1: Hirsutism is not typically linked to nutrition.

Rationale 2: Hirsutism is the occurrence of excess body hair in females on the face, chest, abdomen, arms, and legs, following the male pattern. It is typically due to endocrine or metabolic dysfunction, but may be idiopathic in nature.

Rationale 3: Hirsutism is typically due to endocrine or metabolic dysfunction.

Rationale 4: Clients with hirsutism do not need more vitamins, since hirsutism is often the result of endocrine or metabolic dysfunction.

Global Rationale: Hirsutism is the occurrence of excess body hair in females on the face, chest, abdomen, arms, and legs, following the male pattern. It is typically due to endocrine or metabolic dysfunction, but may be idiopathic in nature. Hirsutism is not typically linked to nutrition. Hirsutism is typically due to endocrine or metabolic dysfunction. Clients with hirsutism do not need more vitamins, since hirsutism is often the result of endocrine or metabolic dysfunction.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.

Question 11

Type: MCSA

The nurse is inspecting the fingernails of a client with a diagnosis of polycythemia. Which of the following findings would be expected with this diagnosis?

1. Dark red nails

2. Horizontal white bands

3. Pale nail beds

4. Spoon-shaped nails

Correct Answer: 1

Rationale 1: The client with polycythemia has nails that appear dark red due to a pathological increase in red blood cells.

Rationale 2: Horizontal white bands in the nails are seen with the client who has been diagnosed with chronic hepatitis.

Rationale 3: Pale nail beds are associated with anemia or peripheral circulatory disorders.

Rationale 4: Spoon-shaped nails may be related to iron deficiency.

Global Rationale: The client with polycythemia has nails that appear dark red due to a pathological increase in red blood cells. Horizontal white bands in the nails are seen with the client who has been diagnosed with chronic hepatitis. Pale nail beds are associated with anemia or peripheral circulatory disorders. Spoon-shaped nails may be related to iron deficiency.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.

Question 12

Type: MCSA

The nurse is assessing the skin of a teenage male client and notes the presence of a musky odor. The client states that this is embarrassing for him and that he showers daily. Which of the following actions should the nurse take in this situation?

1. Reassure the teen that this is normal.

2. Notify the clients healthcare provider.

3. Obtain a dietary referral.

4. Educate the client regarding the importance of increased water intake.

Correct Answer: 1

Rationale 1: The apocrine glands are dormant until the onset of puberty when they become active and produce secretion of water, salts, fatty acids, and proteins. This secretion is released into hair follicles primarily in auxiliary and anogenital areas and when mixed with bacteria on skin surface produces a musky odor. This is a normal part of normal growth and development.

Rationale 2: The teenage clients healthcare provider does not need to be notified because this odor is associated with normal growth and development.

Rationale 3: The nurse does not need to obtain a dietary referral because this odor is associated with normal growth and development.

Rationale 4: Increasing fluid intake will not help prevent the occurrence of this odor. It is a normal part of normal growth and development.

Global Rationale: The apocrine glands are dormant until the onset of puberty when they become active and produce secretion of water, salts, fatty acids, and proteins. This secretion is released into hair follicles primarily in auxiliary and anogenital areas and when mixed with bacteria on skin surface produces a musky odor. This is a normal part of normal growth and development. The teenage clients healthcare provider does not need to be notified because this odor is associated with normal growth and development. The nurse does not need to obtain a dietary referral because this odor is associated with normal growth and development. Increasing fluid intake will not help prevent the occurrence of this odor. It is a normal part of normal growth and development.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.

Question 13

Type: MCSA

The nurse is caring for a client complaining of a painful, hot area located on the clients leg. Erythema and edema are present in the localized area. Which of the following actions should the nurse perform next?

1. Palpate the area.

2. Place a heating pad on the area.

3. Notify the healthcare provider.

4. Place client on bed rest.

Correct Answer: 3

Rationale 1: The nurse would not palpate the area. Reddened, swollen, localized, painful areas should not be palpated because these signs and symptoms indicate the presence of inflammation and possible infection. Disturbance may spread the infection into skin layers.

Rationale 2: The nurse would not apply a heating pad to this site. Disturbance may spread the infection into skin layers.

Rationale 3: Reddened, swollen, localized, painful areas should not be palpated because these signs and symptoms indicate the presence of inflammation and possible infection. Disturbance may spread the infection into skin layers. The healthcare provider should be notified.

Rationale 4: The nurse would not necessarily place the client on bed rest. The healthcare provider should be notified.

Global Rationale: Reddened, swollen, localized, painful areas should not be palpated because these signs and symptoms indicate the presence of inflammation and possible infection. Disturbance may spread the infection into skin layers. The healthcare provider should be notified. The nurse would not palpate the area. The nurse would not apply a heating pad to this site. The nurse would not necessarily place the client on bed rest.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.

Question 14

Type: MCSA

The nurse is performing a skin assessment on a client and notes an oval-shaped, elevated, fluid-filled mass that is approximately 1.5 centimeter in size. The nurse would correctly document this finding as which of the following?

1. Vesicle

2. Bulla

3. Papule

4. Tumor

Correct Answer: 2

Rationale 1: Vesicles are smaller than 0.5 centimeters but are also described as elevated, fluid-filled, round or oval-shaped, palpable mass with thin, translucent walls and circumscribed borders.

Rationale 2: The area described is a bulla and may be caused by contact dermatitis, friction blisters, and large burn blisters.

Rationale 3: A papule is an elevated, solid palpable mass with a circumscribed border. Papules are smaller than 0.5 centimeters.

Rationale 4: Tumors are elevated, solid, hard, or soft palpable and extend deeper into the dermis.

Global Rationale: The area described is a bulla and may be caused by contact dermatitis, friction blisters, and large burn blisters. Vesicles are smaller than 0.5 centimeters but are also described as elevated, fluid-filled, round or oval-shaped, palpable mass with thin, translucent walls and circumscribed borders. A papule is an elevated, solid palpable mass with a circumscribed border. Papules are smaller than 0.5 centimeters. Tumors are elevated, but solid, hard, or soft palpable and extend deeper into the dermis.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.

Question 15

Type: MCSA

The adult client is visiting the outpatient clinic. The client states, I have sores in my mouth and on my lips. The nurse notes the presence of crusted lesions on the lips and inside the clients mouth along the cheek. The client states that the lesions do not itch. These findings are most consistent with the development of which of the following conditions?

1. Chickenpox

2. Contact dermatitis

3. Herpes simplex

4. Psoriasis

Correct Answer: 3

Rationale 1: Chickenpox is a mild infectious disease caused by the herpes zoster virus. It begins as groups of small, red, fluid-filled vesicles usually on the trunk, and progresses to the face, arms, and legs. Vesicles erupt over several days, forming pustules, then crusts. The condition may cause intense itching. It occurs mostly in children.

Rationale 2: Contact dermatitis is inflammation of the skin due to an allergy to a substance that comes into contact with the skin, such as clothing, jewelry, plants, chemicals, or cosmetics. The location of the lesions may help identify the allergen. It may progress from redness to hives, vesicles, or scales, and is usually accompanied by intense itching.

Rationale 3: The lesions described are typical for herpes simplex, which is a viral infection that produces such lesions.

Rationale 4: Psoriasis is thickening of the skin in dry, silvery, scaly patches. It occurs with overproduction of skin cells resulting in buildup of cells faster than they can be shed. It may be triggered by emotional stress or generally poor health. It may be located on scalp, elbows and knees, lower back, and perianal area.

Global Rationale: The lesions described are typical for herpes simplex, which is a viral infection that produces such lesions. Chickenpox is an infectious disease caused by the herpes zoster virus. It begins as groups of small, red, fluid-filled vesicles usually on the trunk, and progresses to the face, arms, and legs. Vesicles erupt over several days, forming pustules, then crusts. The condition may cause intense itching. It occurs mostly in children. Contact dermatitis is inflammation of the skin due to an allergy to a substance that comes into contact with the skin, such as clothing, jewelry, plants, chemicals, or cosmetics. The location of the lesions may help identify the allergen. It may progress from redness to hives, vesicles, or scales, and is usually accompanied by intense itching. Psoriasis is thickening of the skin in dry, silvery, scaly patches. It occurs with overproduction of skin cells resulting in buildup of cells faster than they can be shed. It may be triggered by emotional stress or generally poor health. It may be located on scalp, elbows and knees, lower back, and perianal area.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.

Question 16

Type: MCSA

The nurse is assessing a clients skin and notes that the color of the skin, nails, and the clients mucous membranes are very light. Which of the following descriptions would the nurse use when documenting this finding?

1. Cyanosis

2. Pallor

3. Erythema

4. Jaundice

Correct Answer: 2

Rationale 1: Cyanotic skin is bluish in color.

Rationale 2: Pallor is pale skin. It may occur with hypoxia, cold environment, stress, shock, hypotension, and anemia.

Rationale 3: Erythema indicates that the skin is reddened.

Rationale 4: Jaundice is used to describe yellowish skin.

Global Rationale: Pallor, or paleness of the skin, may occur with hypoxia, cold environment, stress, shock, hypotension, and anemia. Cyanotic skin is blue in color; erythema is redness of the skin; and jaundiced skin has yellow undertones.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.

Question 17

Type: MCSA

The client visits the outpatient clinic. During the assessment of the clients skin, the nurse notes the presence of several abdominal lesions that appear in distinct clusters. The nurse would document these lesions in which of the following ways?

1. Grouped

2. Annular

3. Discrete

4. Confluent

Correct Answer: 1

Rationale 1: The lesions described are grouped lesions because they appear in clusters.

Rationale 2: Annular lesions are lesions with a circular shape.

Rationale 3: Discrete lesions are lesions that are separate and discrete.

Rationale 4: Confluent lesions run together.

Global Rationale: The lesions described are grouped lesions because they appear in clusters. Annular lesions are lesions with a circular shape. Discrete lesions are separate. Confluent lesions run together.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.

Question 18

Type: MCMA

The nurse has assessed the clients skin. The nurse is preparing to document the appearance of herpetic lesions found over a clients nose and mouth region. The healthcare provider diagnosed the client with herpes simplex. Which of the following are common words that are used to describe these types of lesions?

Standard Text: Select all that apply.

1. Vesicular

2. Pustular

3. Pruritic

4. Ulcerated

5. Crusty

Correct Answer: 1,2,5

Rationale 1: Vesicular. Herpes simplex lesions may be described as vesicular.

Rationale 2: Pustular. Herpes simplex lesions may be described as pustular.

Rationale 3: Pruritic. Herpes simplex lesions are not associated with pruritis.

Rationale 4: Ulcerated. Herpes simplex lesions are not typically ulcerated.

Rationale 5: Crusty. Herpes simplex lesions may be described as crusty.

Global Rationale: Herpes simplex lesions progress from vesicles to pustules, and then crusts. They are not typically itchy (pruritic). They are not often described as being ulcerated.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.

Question 19

Type: MCSA

The student nurse assessed the clients skin. The student nurse documented +1 edema right lower leg. The experienced nurse expects to find which of the following based on the student nurses documentation?

1. The presence of slight pitting, no obvious distortion

2. Deep pitting, obvious distortion

3. Pitting is obvious, extremities are swollen

4. Moderate amount of edema

Correct Answer: 1

Rationale 1: Edema, or accumulation of fluid in the bodys tissues, is recorded as +1, +2, +3, or +4. The designation +1 means the client has slight pitting in the right lower leg with no obvious distortion.

Rationale 2: Deep pitting with obvious distortion may be documented as +4 edema.

Rationale 3: Obvious pitting with swollen extremities may be described as +3 edema.

Rationale 4: A moderate amount of edema may be described as +2 to +3 edema.

Global Rationale: Edema, or accumulation of fluid in the bodys tissues, is recorded as +1, +2, +3, or +4. The designation +1 means the client has slight pitting in the right lower leg with no obvious distortion.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.

Question 20

Type: MCSA

During the assessment of a clients integumentary status the nurse notes vitiligo present bilateral hands. This documentation indicates which of the following information?

1. Nodules with ulcerations

2. Dark, asymmetrical colored patches

3. Grouped vesicles

4. Abnormal loss of melanin in patches

Correct Answer: 4

Rationale 1: The term vitiligo does not indicate the presence of nodules with ulcerations.

Rationale 2: The term vitiligo does not indicate the presence of dark, asymmetrical colored patches.

Rationale 3: The term vitiligo does not indicate the presence of grouped vesicles.

Rationale 4: Vitiligo is an abnormal loss of melanin in patches, typically occurring over the face, hands, or groin.

Global Rationale: Vitiligo is an abnormal loss of melanin in patches, typically occurring over the face, hands, or groin. The term vitiligo does not indicate the presence of nodules with ulcerations. The term vitiligo does not indicate the presence of dark, asymmetrical colored patches. The term vitiligo does not indicate the presence of grouped vesicles.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 11.4: Differentiate normal from abnormal findings in physical assessment.

Question 21

Type: MCSA

The nurse is admitting a newly admitted client and notes skin vitiligo, which is highly visible even from a distance. The client asks the nurse to place a No Visitors sign on the door the patients room. The client states, I hate the way my skin looks. Some people just stare at me. Which of the following nursing diagnoses should be incorporated into the clients plan of care?

1. Defensive coping

2. Risk for loneliness

3. Deficient knowledge

4. Disturbed body image

Correct Answer: 4

Rationale 1: Defensive coping is not the best nursing diagnosis to apply to this client. This client has a disturbed body image.

Rationale 2: The client does have a risk for loneliness but it is most likely due to the underlying disturbed body image.

Rationale 3: There is nothing to indicate that the client has a deficient knowledge. This client is suffering from a disturbed body image due to the skins appearance.

Rationale 4: This client has a visible skin disorder and is exhibiting signs that the client has a disturbed body image.

Global Rationale: A visible skin disorder may trigger psychosocial problems and a disturbed body image. This client has vitiligo, which is a skin condition. The client will exhibit patchy depigmented areas over some or all of the following body areas: face, neck, hands, feet, and body folds. A client with vitiligo may suffer a severe disturbance in body image.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 11.5: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 22

Type: MCSA

The nurse received a phone call from a mother who was discharged with her newborn several days ago. The mother completed the infant care teaching prior to discharge. The nurse would determine that the teaching had been effective if the mother reported which of the following?

1. Tiny, white facial bumps

2. Yellow skin and mucous membrane color

3. Irregular red patches on the back of the neck

4. Dark spots on the sacral area

Correct Answer: 2

Rationale 1: Milia are tiny, white facial papules due to sebum and will resolve within a few weeks of birth.

Rationale 2: Yellowing of skin and mucous membranes in an infant who is 34 days old is temporary jaundice form of jaundice called physiological jaundice, but may require treatment with fluids and phototherapy.

Rationale 3: Vascular markings are also called stork bites and may be located on the back of the neck.

Rationale 4: Harmless skin markings requiring no intervention include gray, blue, or purple spots (Mongolian spots) on the buttocks or sacral area.

Global Rationale: Yellowing of skin and mucous membranes in an infant who is 34 days old is temporary form of jaundice called physiological jaundice, but may require treatment with fluids and phototherapy. Milia are tiny, white facial papules due to sebum and will resolve within a few weeks of birth. Vascular markings are also called stork bites and may be located on the back of the neck. Harmless skin markings requiring no intervention include gray, blue, or purple spots (Mongolian spots) on the buttocks or sacral area.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 11.5: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 23

Type: MCSA

The nurse is caring for a client with dark skin and needs to assess the skin for jaundice. Which of the following actions would be appropriate for the nurse in this situation?

1. Use a bright lamp and a magnifying glass.

2. Document unable to assess for skin changes.

3. Assess the skin the same way you would inspect a client with lighter skin.

4. Inspect the lips, oral mucosa, sclera, conjunctivae, and palms.

Correct Answer: 4

Rationale 1: A bright light may assist the nurse, but the nurse should inspect the clients lips, oral mucosa, sclera, conjunctivae, and palms when assessing for jaundice.

Rationale 2: It is not appropriate to document that the nurse is unable to assess the client for jaundice.

Rationale 3: The nurse will not find it as useful to assess the client with darker skin in the same way that the nurse would assess the client with lighter skin. The nurse should inspect areas of the body with less pigmentation such as the lips, oral mucosa, sclera, palms of the hand, and conjunctivae.

Rationale 4: Changes in skin color may be difficult to discover when assessing clients with dark skin. The nurse should inspect areas of the body with less pigmentation such as the lips, oral mucosa, sclera, palms of the hand, and conjunctivae.

Global Rationale: Changes in skin color may be difficult to discover when assessing clients with dark skin. The nurse should inspect areas of the body with less pigmentation such as the lips, oral mucosa, sclera, palms of the hand, and conjunctivae. A bright light may assist the nurse, but the nurse should inspect the clients lips, oral mucosa, sclera, conjunctivae, and palms when assessing for jaundice. It is not appropriate to document that the nurse is unable to assess the client for jaundice. The nurse will not find it as useful to assess the client with darker skin in the same way that the nurse would assess the client with lighter skin. The nurse should inspect areas of the body with less pigmentation such as the lips, oral mucosa, sclera, palms of the hand, and conjunctivae.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11.5: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 24

Type: MCSA

The nurse is assessing the skin of a newborn infant and notes a bright red, raised lesion on the lateral aspect of the thigh. The lesion is 4.5 centimeters in diameter. When light pressure is applied to the lesion, the site does not blanch. The mother expresses concern about the appearance of this site, and asks the nurse if it should be removed. Which of the following would be the best response for the nurse in this situation?

1. Your pediatrician can make a surgical referral for you.

2. It really is not that noticeable.

3. You should be happy that your baby is healthy overall.

4. These types of lesions usually disappear by the time a child turns 10 years old.

Correct Answer: 4

Rationale 1: There is no reason for the nurse to speak with the pediatrician regarding a surgical referral. These types of lesions usually disappear by the time a child turns 10 years old.

Rationale 2: The nurse should not indicate that the lesion is not that noticeable. The nurse should educate the mother about the lesion.

Rationale 3: The nurse should not state that the mother should be happy with the overall health of the newborn. The mother is concerned about the appearance of the lesion and should be educated about the lesion and its normal course.

Rationale 4: The lesion described is a hemangioma, which is a cluster of immature capillaries that can be found on any part of the body. These lesions usually disappear by age 10, and no intervention is needed.

Global Rationale: The lesion described is a hemangioma, which is a cluster of immature capillaries that can be found on any part of the body. These lesions usually disappear by age 10, and no intervention is needed. The nurse should educate the mother about the lesion. The mother does not require comments suggesting she should ignore the lesion or be happy that the infant does not have more serious problems. The nurse should not state that the mother should be happy with the overall health of the newborn. The mother is concerned about the appearance of the lesion and should be educated about the lesion and its normal course.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11.5: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 25

Type: MCSA

The nurse is performing a skin assessment on an African American client and notes an elevated, irregular band of jagged tissue on the clients left arm. The client states, I had a burn here a long time ago, but it seemed to keep on getting bigger. The nurse would correctly document this finding in which of the following ways?

1. Ulcer

2. Keloid

3. Fissure

4. Scar

Correct Answer: 2

Rationale 1: An ulcer is a deep, irregularly shaped area of skin loss extending into the dermis or subcutaneous tissue. This tissue is best described as a keloid.

Rationale 2: This is most likely a keloid, which is an elevated, irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. It extends beyond the site of the original injury. There is higher incidence in people of African descent.

Rationale 3: A fissure is a crack in the skin extending to the dermis. This tissue is best described as a keloid.

Rationale 4: A scar is connective tissue left after healing, but is flat and usually linear. This is most likely a keloid, which is an elevated, irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. It extends beyond the site of the original injury. There is higher incidence in people of African descent.

Global Rationale: This is most likely a keloid, which is an elevated, irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. It extends beyond the site of the original injury. There is higher incidence in people of African descent. An ulcer is a deep, irregularly shaped area of skin loss extending into the dermis or subcutaneous tissue. A fissure is a crack in the skin extending to the dermis. A scar is connective tissue left after healing, but is flat and usually linear. This tissue is best described as a keloid.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11.5: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 26

Type: MCSA

The nurse is caring for a client who had abdominal surgery several months ago. The client has verbalized concern that the scar from the surgery is purplish in color. Which of the following statements is the nurses best response?

1. Having a scar is unavoidable.

2. The color is normal and will fade with time.

3. You can have plastic surgery to remove the scar later.

4. You should be glad your surgery was a success.

Correct Answer: 2

Rationale 1: The nurse should indicate that the scar will fade over time. The client is expressing concern regarding the appearance of the scar.

Rationale 2: New scars may be red or purple in color and will fade to silvery or white with time.

Rationale 3: The nurse should not suggest that the plastic surgery is an alternative to dealing with the scar. The nurse should indicate that the scar will fade over time. The client is expressing concern regarding the appearance of the scar.

Rationale 4: The nurse should not express disapproval regarding the clients concerns. The nurse should indicate that the scar will fade over time. The client is expressing concern regarding the appearance of the scar.

Global Rationale: New scars may be red or purple in color and will fade to silvery or white with time. The nurse should not suggest plastic surgery, nor use statements that infer disapproval that the client is asking about the scar.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11.5: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 27

Type: MCSA

During the assessment of an elderly clients skin, the nurse notes small areas of hyperpigmentation on the dorsal aspect of the clients hands. The client states, Ive been getting more of these big freckles as I get older. The nurse realizes this finding is due to:

1. Senile lentigines

2. Cherry angiomas

3. Cutaneous tags

4. Cutaneous horns

Correct Answer: 1

Rationale 1: The nurse is describing liver spots or areas of hyperpigmentation over the backs of the clients hands.

Rationale 2: Cherry angiomas are small, bright red spots common in older adults.

Rationale 3: Cutaneous tags may appear on the neck and upper chest.

Rationale 4: Cutaneous horns may occur on any part of the face.

Global Rationale: The nurse is describing liver spots or areas of hyperpigmentation over the backs of the clients hands. Cherry angiomas are small, bright red spots common in older adults. Cutaneous tags may appear on the neck and upper chest. Cutaneous horns may occur on any part of the face.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 11.5: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 28

Type: MCSA

The nurse is planning to assess an African Americans integumentary status. Which of the following statements by the client is most consistent with the presence of cyanosis?

1. The whites of my eyes dont look as white anymore; they have a little bit of a yellow cast to them.

2. My nails look a little bit bluish.

3. My nails are bright red.

4. My palms and the inside of my mouth look really pale.

Correct Answer: 2

Rationale 1: The client who states that the sclerae appear yellowish may have become jaundiced.

Rationale 2: Cyanosis is more readily assessed in the nail beds, oral mucous membranes, and conjunctivae in clients with darker skin color.

Rationale 3: The client with bright red nails may be experiencing a sign of polycythemia.

Rationale 4: The client with pale palms and mucous membranes may have developed pallor.

Global Rationale: Cyanosis is more readily assessed in the nail beds, oral mucous membranes, and conjunctivae in clients with darker skin color. The client who states that the sclerae appear yellowish may have become jaundiced. The client with bright red nails may be experiencing a sign of polycythemia. The client with pale palms and mucous membranes may have developed pallor.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 11.5: Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

Question 29

Type: MCMA

The nurse is preparing an educational program regarding the objectives listed in Healthy People 2020. Which of the following are specifically related to these objectives?

Standard Text: Select all that apply.

1. African American females often require information regarding gentle hair and scalp care.

2. Infants have difficulty regulating their own body temperatures.

3. Older clients have increased sweat gland activity.

4. Clients with diabetes mellitus have an increased risk for skin breakdown.

5. Clients should monitor their moles for any changes, regardless of their age.

Correct Answer: 1,2,4,5

Rationale 1: African American females often require information regarding gentle hair and scalp care. Nurses should provide African American women with information about the risks associated with chemical treatments, excessive combing, and pulling to braid fragile hair.

Rationale 2: Infants have difficulty regulating their own body temperatures. Infants skin lacks the ability to contract. Therefore, they cannot shiver and do not perspire, limiting thermal regulation. Infants require clothing that is appropriate for the external temperature and environment.

Rationale 3: Older clients have increased sweat gland activity Older clients are prone to reduced sweat gland activity, which can result in dry skin.

Rationale 4: Clients with diabetes mellitus have an increased risk for skin breakdown. Clients with diabetes are at increased risk for problems with the skin and with healing of existing skin problems.

Rationale 5: Clients should monitor their moles for any changes, regardless of their age. All clients should monitor moles for any changes in color, size, or texture.

Global Rationale: Nurses should provide African American women with information about the risks associated with chemical treatments, excessive combing, and pulling to braid fragile hair. Infants skin lacks the ability to contract. Therefore, they cannot shiver and do not perspire, limiting thermal regulation. Infants require clothing that is appropriate for the external temperature and environment. Clients with diabetes are at increased risk for problems with the skin and with healing of existing skin problems. All clients should monitor moles for any changes in color, size, or texture. Older clients are prone to reduced sweat gland activity, which leads to drier skin.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11.6: Discuss the objectives related to overall health of the skin as presented in Healthy People 2020 documents.

Question 30

Type: MCSA

The nurse is performing an assessment of the clients skin when the nurse notes that the client has become pale and diaphoretic. The clients vital signs have remained stable since the beginning of the examination: blood pressure 138/76, heart rate is 88 beats per minute, and respiratory rate is 18 breaths per minute. Which of the following actions should the nurse take first?

1. The nurse immediately raises the clients head of bed.

2. The nurse asks the client, Are you feeling anxious during this assessment?

3. The nurse immediately notifies the clients healthcare provider.

4. The nurse provides the client with cup of orange juice.

Correct Answer: 2

Rationale 1: The client who was suffering from the clinical manifestations associated with impending shock would experience a drop in blood pressure and an increase in heart rate and respiratory rate. This clients vital signs have remained stable. The nurse does not need to alter the position of the clients head of bed.

Rationale 2: Anxiety is commonly associated with the development of pallor and diaphoretic skin. This can often be resolved by determining the clients level of anxiety and acknowledging the clients anxiety. The client who was suffering from the clinical manifestations associated with impending shock would experience a drop in blood pressure and an increase in heart rate and respiratory rate. This clients vital signs have remained stable.

Rationale 3: The nurse does not need to notify the clients healthcare provider. The client who was suffering from the clinical manifestations associated with impending shock would experience a drop in blood pressure and an increase in heart rate and respiratory rate. This clients vital signs have remained stable.

Rationale 4: The nurse does not need to provide the client with orange juice. Prior to providing the client with orange juice, the nurse would want to determine if the client was feeling anxious. The clients serum glucose level should be assessed if hypoglycemia was suspected.

Global Rationale: Anxiety is commonly associated with the development of pallor and diaphoretic skin. This can often be resolved by determining the clients level of anxiety and acknowledging the clients anxiety. The client who was suffering from the clinical manifestations associated with impending shock would experience a drop in blood pressure and an increase in heart rate and respiratory rate. This clients vital signs have remained stable. The nurse does not need to alter the position of the clients head of bed. The nurse does not need to notify the clients healthcare provider. The nurse does not need to provide the client with orange juice. Prior to providing the client with orange juice, the nurse would want to determine if the client was feeling anxious. The clients serum glucose level should be assessed if hypoglycemia was suspected.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11.7: Apply critical thinking in selected simulations related to physical assessment of the skin, hair, and nails.

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