Chapter 58 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 58

Question 1

Type: MCSA

The nurse is conducting an integumentary assessment on an older adult. Which patient statement would the nurse prioritize as it does not reflect a normal age-related change?

1. My skin is so thin and gets injured so easily.

2. My skin is so greasy even though I wash frequently.

3. My nails are growing more slowly.

4. Ive had mostly gray hair since I was in my thirties.

Correct Answer: 2

Rationale 1: Both the epidermis and the dermis thin with aging, making skin more susceptible to breakdown.

Rationale 2: Sebaceous gland activity decreases in older adults, resulting in drier and scalier skin. Greasy skin is not part of normal aging.

Rationale 3: Both hair and nail growth slows with aging.

Rationale 4: Hair graying is related to genetics. Some patients gray very early, and others do not gray until late in life.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-1

Question 2

Type: MCSA

During a conversation with the nurse, a patient says, I avoid going outside when the sun is shining because I dont want to get skin cancer. The nurse should inform the patient that sun avoidance may predispose the patient to which condition?

1. Vitamin D deficiency

2. Hypokalemia

3. Hypernatremia

4. Hypercholesterolemia

Correct Answer: 1

Rationale 1: The skin functions as a synthesizer of vitamin D (sunlight reacts with cholesterol).

Rationale 2: Exposure to sunlight is not a primary cause of hypokalemia.

Rationale 3: Exposure to sun would not cause an increase in sodium.

Rationale 4: Hypercholesterolemia results from factors such as dietary intake and cholesterol that is produced by the body, not from exposure to the sun.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-1

Question 3

Type: MCSA

While recording the health history, the nurse learns that a patient has worked at a landfill for the last 35 years. Why is this information important?

1. It reflects the patients level of education.

2. The patient has had possible exposure to environmental toxins.

3. Patients who work out of doors are more likely to develop skin cancer.

4. The patient probably also uses tobacco.

Correct Answer: 2

Rationale 1: Working in a landfill is not pertinent to the patients education level.

Rationale 2: Occupation can reveal the potential for exposure to toxins such as arsenic, coal tar, creosote, and petroleum products. Even if the patient does not work directly with these chemicals, they may be present in the atmosphere and environment.

Rationale 3: Working in a landfill does not necessarily mean working in the sun. The patient could work in an office or in an area not in sunlight.

Rationale 4: It would be stereotyping for the nurse to assume that a patient who works in a landfill uses tobacco. The nurse should ask about personal habits, not make assumptions.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-2

Question 4

Type: MCSA

Which information would the nurse identify as a patients chief complaint about a skin disorder?

1. My rash first started a week ago.

2. I have a rash on my arm.

3. I put some ointment on this rash, but it did not help.

4. My son had a similar rash last month.

Correct Answer: 2

Rationale 1: This statement provides information about the onset of the rash.

Rationale 2: The chief complaint is the patients current issue or reason for seeking health care. In this situation the patient has presented with a rash.

Rationale 3: This statement indicates the patients attempt at self-care.

Rationale 4: This statement gives information about the possible etiology of the rash.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-3

Question 5

Type: MCSA

After assisting a patient to turn in bed, the nurse notes that the patients leg has indentations that clearly show where the leg was supported by the nurses hand. How would the nurse document this finding?

1. Pitting edema

2. Loss of skin elasticity

3. Increased skin turgor

4. Reduced sensation

Correct Answer: 1

Rationale 1: If pressure leaves an indentation in the skin, pitting edema is present. Edema is caused by the accumulation of fluid in the intercellular spaces. Pitting edema is generally evaluated on a 4-point scale.

Rationale 2: Loss of skin elasticity causes the skin to lack firmness, but the skin does not indent when compressed.

Rationale 3: Skin turgor is assessed by pinching the skin to determine how quickly it returns to its normal shape.

Rationale 4: The nurse would have to conduct additional assessments to determine if sensation is reduced.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-4

Question 6

Type: MCSA

How should the nurse conduct the physical examination of a patients skin?

1. Inspect the skin while the patient is standing up.

2. Be aware of ethnic differences.

3. Examine the least-exposed areas first.

4. Examine only the areas of specific concern.

Correct Answer: 2

Rationale 1: The nurse should inspect the skin while the patient is in a sitting or lying position.

Rationale 2: Ethnic differences are important because of the difference in skin color. For example, in dark-skinned people the best areas to assess pallor, cyanosis, and jaundice are the oral mucous membranes and conjunctiva.

Rationale 3: The nurse should begin by examining the most frequently exposed areas first.

Rationale 4: To examine the skin properly the nurse must take a brief but careful look at the patients entire body and then examine specific areas of concern in detail.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-4

Question 7

Type: MCSA

During a physical exam of the patients nails, the nurse depresses the nail edge to blanch it, and then releases it. What is the nurse assessing with this technique?

1. Whether clubbing of the nail is present

2. How brittle the nails are

3. Whether the nail is well attached to the nail bed

4. Capillary refill

Correct Answer: 4

Rationale 1: Clubbing is assessed by looking at the angle of the nail bed.

Rationale 2: Brittle nails are diagnosed by looking at the distal plates of the nail to inspect for splitting and peeling.

Rationale 3: This technique does not assess how well the nail is attached to the nail bed.

Rationale 4: The nail plate is translucent. To determine capillary refill, the nail edge is depressed to blanch and then released. Capillary refill is usually documented as a brisk return of color, which is the normal response.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-4

Question 8

Type: MCSA

Which technique would the nurse use to assess a patients skin turgor?

1. Palpate the skin.

2. Grasp a fold of the patients skin between the forefinger and thumb.

3. Determine the patients fluid intake for past 2 hours.

4. Blanch the nail bed.

Correct Answer: 2

Rationale 1: Elasticity and mobility or turgor of the skin cannot be determined by palpating.

Rationale 2: Turgor refers to the elasticity and mobility of the skin. To assess turgor, the nurse would grasp a fold of the patients skin between the forefinger and thumb and note how rapidly the skin returns to its normal shape.

Rationale 3: Turgor is an indication of hydration but cannot be assessed by measuring fluid intake.

Rationale 4: Blanching the nail bed assesses capillary refill, which indicates circulation in the extremity.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-4

Question 9

Type: MCSA

The emergency department nurse palpates a patients skin to assess its texture. The nurse manager would evaluate that this nurse is following protocol if which technique is used?

1. The nurse palpates the skin with the dorsal surface of the hand.

2. The nurse palpates the skin with the palmar surface of the fingers and finger pads.

3. The nurse places the palm of the hand on the patients skin.

4. The nurse touches the skin with the anterior surface of the wrist.

Correct Answer: 2

Rationale 1: The dorsal surface of the hand will reveal information about moisture, but not texture.

Rationale 2: The palmar surface of the fingers and finger pads should be used to assess the skins texture.

Rationale 3: The palm of the hand does not have as many nerve endings and is not as sensitive to changes in texture as another part of the hand.

Rationale 4: The anterior surface of the wrist does not have discriminatory nerve endings that would provide information about texture.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-4

Question 10

Type: MCMA

While performing the assessment for bilateral symmetrical skin temperature, the nurse finds that the skin temperature of the patients left hand is much cooler than the skin temperature of the right hand. The nurse should conduct additional assessment for which possible conditions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Peripheral arterial insufficiency

2. Hypothyroidism

3. Overuse

4. Infection

5. Differences in ambient room temperature

Correct Answer: 1,4

Rationale 1: Peripheral arterial insufficiency reduces blood flow to an area, which results in a lower local skin temperature.

Rationale 2: Hypothyroidism would cause a generalized decrease in skin temperature, not different temperatures on each side.

Rationale 3: Overuse is not likely to cause a difference in temperature.

Rationale 4: An infection could cause an increase in local skin temperature.

Rationale 5: Differences in ambient room temperature are not likely to be significant enough to result in noticeable differences in skin temperature from side to side.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-5

Question 11

Type: FIB

A patient is admitted with edematous lower extremities. The nurse palpates the patients skin and finds that when pressure is applied, a deep indentation occurs and lasts for a short time. The nurse would document this finding as ____ + pitting edema.

Standard Text:

Correct Answer: 3

Rationale : Edema is rated on a 4-point scale. Pitting that lasts for a short time is documented as 3+ pitting edema. If the pitting lasts longer, it is documented as 4+.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-4

Question 12

Type: MCSA

A patient is very concerned about a vesicle on the lip that extends onto the skin. The patients history reveals this vesicle has been present for 3 days. Which assessment question would the nurse ask?

1. Do you have any pets that live inside your house?

2. Has anyone in your family ever had skin cancer?

3. Have you recently experienced dehydration?

4. Have you ever had a cold sore or herpes infection on your lip?

Correct Answer: 4

Rationale 1: There is no indication that this lesion is related to pets living in the house.

Rationale 2: Skin cancer most commonly occurs on the lower lip or underside of the tongue and is suspected when there is an open area that does not heal.

Rationale 3: Systemic dehydration may be manifested in dry, scaling, cracked lips.

Rationale 4: Herpes is a viral infection that presents with a vesicle on the lip that extends onto the skin. These infections are often called cold sores.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-6

Question 13

Type: MCSA

The nurse discovers a vascular lesion on a patients chest. What should the nurse check to help determine if the lesion is petechiae or telangiectasia?

1. Is the lesion scaly?

2. Is the lesion raised?

3. Does the lesion blanch?

4. Is the lesion painful?

Correct Answer: 3

Rationale 1: Neither petechiae nor telangiectasia is scaly.

Rationale 2: Neither petechiae nor telangiectasia is raised.

Rationale 3: Determining whether a lesion blanches will help identify the type of lesion. Petechiae do not blanch, whereas telangiectasia does.

Rationale 4: Neither petechiae nor telangiectasia is painful.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-5

Question 14

Type: MCSA

A patient with a history of chronic allergic dermatitis is concerned because of an area where the skin has become thickened and rough. How would the nurse document this lesion?

1. Excoriation

2. Ulceration

3. Lichenification

4. Ecchymosis

Correct Answer: 3

Rationale 1: Excoriation is an abrasion of the epidermis.

Rationale 2: Ulceration is a localized area of tissue necrosis.

Rationale 3: Conditions such as chronic dermatitis can cause the epidermis to become rough and thickened. Superficial skin markings also become more visible. This is called lichenification.

Rationale 4: Ecchymosis is a red-purple discoloration of the skin.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-6

Question 15

Type: MCSA

A 50-year-old patient is concerned because several firm, deep-red papules have appeared on both legs and the number is increasing. The nurse should recognize these as which type of lesion?

1. Cherry angiomas

2. Venous stars

3. Purpura

4. Spider angiomas

Correct Answer: 1

Rationale 1: A cherry angioma is a firm, deep-red papule and is a benign vascular lesion. It is generally found on most people after age 30, and the incidence increases with age.

Rationale 2: A venous star is a bluish, irregular spider shape with linear lines and is caused by increased pressure in superficial veins.

Rationale 3: A purpura is a red-purple lesion more than 0.5 centimeter in diameter that is caused by intravascular defects or infection.

Rationale 4: A spider angioma has a red central body with radiating spiderlike legs. It can be caused by liver disease or vitamin B deficiency.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-6

Question 16

Type: MCSA

The nurse notes a yellowish discoloration of the patients skin, but it does not involve the sclera or mucous membranes. The nurse should question the patient about which history?

1. Dietary intake

2. History of hepatitis

3. Food allergies

4. History of hyperlipidemia

Correct Answer: 1

Rationale 1: The yellowish discoloration of the patients skin could be carotenemia. It is often associated with a high intake of foods with carotene (sweet potatoes, squash, and carrots).

Rationale 2: Jaundice associated with liver involvement, such as occurs with hepatitis, usually involves the sclera of the eyes.

Rationale 3: Food allergies do not cause discoloration of the skin, but usually cause a reaction such as a rash or urticaria.

Rationale 4: Hyperlipidemia is not associated with yellowing of the skin.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-5

Question 17

Type: MCSA

While palpating the nail bed of an African American patient, the nurse notes that the nails have linear bands along the nail edge. How would the nurse evaluate this finding?

1. It likely indicates a nutritional deficiency.

2. This is a common finding in dark-skinned individuals.

3. Additional areas should be assessed for cyanosis.

4. The patient has a fungal infection of the nail bed.

Correct Answer: 2

Rationale 1: A vitamin deficiency may cause nails to have pits, transverse grooves, or lines, but the nurse would consider a different etiology for this finding in this patient.

Rationale 2: Dark-skinned individuals may have brownish pigmented areas or linear bands along the nail edge.

Rationale 3: The nail beds of a patient who is cyanotic have a bluish hue.

Rationale 4: A fungal infection of the nail usually causes deformed, cracked nails that turn yellow or brown.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-7

Question 18

Type: MCSA

A patient from Southeast Asia who has been ill with influenza is admitted with self-inflicted open sores and bruising on both forearms. When questioned about the wounds, the patient states that they were inflicted to aid the healing process. What should the nurse consider when assessing these wounds?

1. The cause of the wounds is unimportant.

2. This may be a cultural practice.

3. The patient belongs to a cult.

4. The patient is delusional.

Correct Answer: 2

Rationale 1: It is important to determine the cause of the wounds. This is an opportunity for the nurse to educate the patient regarding safe health practices while remaining nonjudgmental.

Rationale 2: The patients actions may reflect a cultural practice. It is important for the nurse to inquire about any cultural habits or practices that may affect the patients skin.

Rationale 3: Another explanation is more likely.

Rationale 4: The patient is not necessarily delusional; another explanation is more likely.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-7

Question 19

Type: MCMA

A patient has been admitted with damage to the skin over both lower legs. The nurse immediately institutes measures to help prevent infection. The nurses rationale for this action relates to damage of which cells?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Merkels cells

2. Langerhans cells

3. Dermal dendrocytes

4. Keratinocytes

5. Melanocytes

Correct Answer: 2,3,4

Rationale 1: Merkels cells provide sensory information.

Rationale 2: Langerhans cells are macrophages of the immune system that arise from the bone marrow and migrate to the epidermis.

Rationale 3: Dermal dendrocytes have phagocytic properties and participate in the immune function of the skin.

Rationale 4: Keratinocytes produce keratin, which provides the skin with its outermost protective barrier.

Rationale 5: Melanocytes are the pigment-producing cells of the skin. They do not influence immunity.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 58-1

Question 20

Type: MCMA

During completion of a health history, the patient reports being allergic to strawberries. What additional questions should the nurse ask?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. How long has it been since you ate strawberries?

2. What happens when you eat strawberries?

3. What treatments do you use to treat this allergic reaction?

4. When was your last allergic reaction?

5. Are you allergic to any other foods?

Correct Answer: 2,3,4,5

Rationale 1: This question is not pertinent to the patients assessment.

Rationale 2: The nurse should ask about the patients response to the allergen. Skin responses are common.

Rationale 3: The nurse should ask about treatments the patient uses for allergies.

Rationale 4: The nurse should inquire about the last time this allergic reaction occurred.

Rationale 5: The nurse should determine if the allergy is only to strawberries or to other foods as well.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-2

Question 21

Type: MCMA

A patient presents to the urgent care clinic for treatment of an upper respiratory virus. During assessment, the nurse notes lesions the patient says are caused by skin popping. How should the nurse respond to this discovery?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. You really shouldnt do this to yourself.

2. Skin popping increases your risk for staph infection.

3. When did you have your last tetanus immunization?

4. Dont you know this is not legal?

5. Skin popping is probably the way you got the flu.

Correct Answer: 2,3

Rationale 1: The nurse should provide care for the patient without being judgmental.

Rationale 2: This is a statement of fact and is good information for the nurse to provide.

Rationale 3: Skin popping can increase the patients risk for tetanus. Immunization status should be verified and immunization provided if necessary.

Rationale 4: The patient probably does know that injecting illegal drugs is not legal. This statement is judgmental and may adversely impact the relationship between the patient and the nurse.

Rationale 5: Upper respiratory viruses are contracted through the respiratory tract, not through breaks in the skin.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 58-5

Question 22

Type: MCMA

The nurse would interpret which patient findings as increasing the risk for development of skin cancer?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient is 58 years old.

2. The patient has blonde hair.

3. The patient has an olive complexion.

4. The patient is female.

5. The patient has blue eyes.

Correct Answer: 1,2,5

Rationale 1: Patients over age 50 have an increased risk for skin cancer.

Rationale 2: Patients with light-colored hair have a higher risk for skin cancer.

Rationale 3: Patients with a fair complexion have an increased risk of skin cancer.

Rationale 4: Males have an increased risk for skin cancer.

Rationale 5: Patients with light-colored eyes have an increased risk for skin cancer.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-2

Question 23

Type: MCMA

A patient with dark skin has been admitted for treatment of anemia. The nurse would plan which physical assessments for pallor in this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Assess for areas of vitiligo.

2. Look for an ashen appearance.

3. Inspect the palpebral conjunctiva.

4. Assess the color of the earlobes.

5. Inspect the sclera.

Correct Answer: 2,3

Rationale 1: Vitiligo is the absence of pigmentation. The nurse would not assess for pallor in area with vitiligo.

Rationale 2: Dark skin takes on an ashen or dull appearance when pallor is present.

Rationale 3: The palpebral conjunctiva, or inside the lower eyelid, are pale when pallor is present.

Rationale 4: The nurse would not assess for pallor in the earlobes of a dark-skinned patient.

Rationale 5: The sclera is a good place to assess for jaundice, but not pallor, in a patient with dark skin.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 58-3

Question 24

Type: MCMA

Review of a patients medical record reveals the presence of a rash consisting of discrete arciform lesions. The nurse would anticipate that the patients rash has which characteristics?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The rash is localized.

2. The rash consists of individual lesions.

3. The rash forms a line across the body.

4. The individual lesions are arc-shaped.

5. The lesions arch across the body.

Correct Answer: 2,5

Rationale 1: There is not enough information to determine if this rash is localized or generalized.

Rationale 2: Discrete lesions are individual, as opposed to congruent lesions, which run together.

Rationale 3: The term that describes a rash that forms a line across the body is linear.

Rationale 4: Arciform does not refer to the shape of individual lesions.

Rationale 5: Arciform refers to the grouping of the lesions in an arc-shaped configuration.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-6

Question 25

Type: MCMA

A patients skin lesion has been described as a nodule. The nurse expects which findings to be present?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The margins of the lesion are clearly identifiable.

2. The lesion is pus-filled.

3. The lesion is flat and nonpalpable.

4. The lesion is firm.

5. The lesion is within the dermis.

Correct Answer: 1,4,5

Rationale 1: A nodule is well circumscribed.

Rationale 2: Pustules, abscesses, and furuncles are pus-filled lesions.

Rationale 3: Flat, nonpalpable lesions are macules. An example is a freckle.

Rationale 4: Nodules are firm and palpable.

Rationale 5: Nodules are located within the dermis, deeper than a papule.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-6

Question 26

Type: FIB

The nurse is assessing for changes in the nails of a patient with chronic obstructive pulmonary disease. The nurse would document clubbing of the fingers if the angle of the nail bed exceeds _________ degrees.

Standard Text:

Correct Answer: 160

Rationale : A nail bed with an angle greater than 160 degrees suggests a clubbed nail.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-5

Question 27

Type: MCSA

A patient has a surgical scar that extends beyond the original incision site. The area is raised and smooth, and the patient reports that it occasionally itches but is not tender. How would the nurse document this lesion?

1. Cicatrix

2. Hypertrophic scar

3. Fissure

4. Keloid

Correct Answer: 4

Rationale 1: A cicatrix is a scar. It does not manifest the additional findings described.

Rationale 2: A hypertrophic scar does not extend beyond the initial wound.

Rationale 3: A fissure is a linear crack or break from the epidermis to the dermis.

Rationale 4: A keloid results from the overproduction of scar tissue. It extends laterally beyond the initial wound and is usually raised and smooth. Keloids may or may not be tender and may itch.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-6

Question 28

Type: MCSA

The nurse assesses the presence of linea nigra on the abdomen of a pregnant patient. Which information should the nurse provide about this finding?

1. You should use a good emollient lotion to help prevent more of these lines.

2. These lines are caused by the stretching of the skin.

3. This line will probably go away after your baby is delivered.

4. We will monitor this lesion for possible removal after you deliver your baby.

Correct Answer: 3

Rationale 1: Linea nigra is a color variation and is not affected by the application of lotion.

Rationale 2: Linea nigra is not caused by the stretching of the skin.

Rationale 3: Linea nigra appears during pregnancy and typically disappears after delivery.

Rationale 4: Linea nigra is not a lesion but rather a color change. It does not need to be removed.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 58-5

Question 29

Type: MCSA

A patient has been diagnosed with a fungal infection in the intertriginous areas of the toes. The nurse would assess which area for this infection?

1. The area between the toes

2. The distal end of the toes

3. The base of the toenails

4. The underside of the toes

Correct Answer: 1

Rationale 1: An intertriginous rash occurs where two surfaces are close together.

Rationale 2: The intertriginous area is not at the distal end of the toes.

Rationale 3: The base of the toenails is not the intertriginous area.

Rationale 4: Intertriginous does not refer to the underside of the toes.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 58-6

Question 30

Type: MCSA

The nurse assesses several spider angiomas across the chest and lower abdomen of a 60-year-old patient. The patient reports that these lesions have developed within the last several months. Which nursing statement is indicated?

1. We should check your blood glucose.

2. Do you take any vitamin supplements?

3. These commonly occur with aging.

4. We should check you for a bladder infection.

Correct Answer: 2

Rationale 1: There is no indication that diabetes would increase the appearance of spider angiomas.

Rationale 2: Vitamin B deficiency may result in the appearance of spider angiomas.

Rationale 3: Spider angiomas in this quantity are not a result of aging.

Rationale 4: Spider angiomas are not associated with bladder infection.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 58-6

 

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