Download BSN 246 HESI HEALTH ASSESSMENT UPDATED EXAM and more Exams Nursing in PDF only on Docsity!
BSN 246 HESI HEALTH ASSESSMENT UPDATED EXAM
QUESTIONS AND VERIFIED ANSWERS |100% CORRECT| GRADE A+
“The nursing process offers a framework to identify needs, create a plan of care, and determine the effectiveness of interventions. Which of the following stages of the nursing process involves the assessment of which interventions were successful and which ones were not? a.Assessment b.Diagnosis c.Planning
d.Evaluation - CORRECT ANSWER D. Evaluation"
"Which nurse is performing the technique of light palpation appropriately? a) Nurse A applies the bimanual technique to determine size and location of the patient's heart. b) Nurse B uses the fingertips to feel for temperature differences on the patient's legs. c) Nurse C places the ulnar surface of the hands on the patient's thorax to detect vibrations.
d)Nurse D depresses the patient's abdomen approximately 4 cm to assess pulsations. -
CORRECT ANSWER c) Nurse C places the ulnar surface of the hands on the patient's thorax
to detect vibrations." "A patient has been complaining of abdominal cramping and gas; the nurse notes that his abdomen is slightly distended. Which sound does the nurse expect to hear during percussion of this patient's abdomen? a) Flatness b) Dullness c) Resonance
d) Tympany - CORRECT ANSWER d) Tympany"
"A nurse is using the finger pads to palpate a patient's dorsalis pedis pulses and is unable to feel any pulses. Which action is appropriate for the nurse to perform next? a) Document that the dorsalis pedis pulses are not palpable. b) Have the patient stand and try again to palpate the pulses. c) Use a Doppler to detect the presence of the pulses.
d) Palpate the dorsalis pedis pulses using the ulnar surface of the hand. - CORRECT ANSWER
c) Use a Doppler to detect the presence of the pulses." "A 24-year-old male patient tells the nurse he has had no energy for 2 weeks. He has no trouble falling asleep; in fact, he sleeps deeply about 12 hours every night. He states that he has gained 10 lb in the past 2 months and has no friends. The nurse associates these manifestations with which mental health disorder? a) Depression
b) Schizophrenia c) Bipolar disorder
d) Anxiety disorder - CORRECT ANSWER Depression"
"While assessing a man during a physical examination for work, the nurse suspects alcohol use. Which assessment tool is appropriate in this situation? a) AUDIT screening tool b) Rapid eye test c) Mental status examination
d) Holmes Social Readjustment Rating Scale - CORRECT ANSWER a) AUDIT screening tool"
"*A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds? A. Use the bell of the stethoscope to listen to the lung fields over lower lobes. B. Have the client lay flat while listening to the anterior surface of the chest. C. Press the stethoscope's diaphragm firmly on the skin over each lung field. D. Shave all chest
hair that may distort sounds heard through the diaphragm. - CORRECT ANSWER C. Press the
stethoscope's diaphragm firmly on the skin over each lung field." "A patient complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what of the following findings will suggest that the cause of this patient's dyspnea is due to heart disease rather than respiratory disease? a) Increased anteroposterior diameter b) Clubbing of the fingers c) Bilateral peripheral edema
d) Increased tactile fremitus - CORRECT ANSWER c) Bilateral peripheral edema"
"A nurse is auscultating the lungs of a healthy male patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding? a) Make sure the bell of the stethoscope is used, rather than the diaphragm. b) Hold stethoscope firmly to prevent movement when placed over chest hair. c) Ask the patient not to talk while the nurse is listening to the lungs.
Change the patient's position to ensure accurate sounds. - CORRECT ANSWER b) Hold
stethoscope firmly to prevent movement when placed over chest hair."
d) Temporal lobe - CORRECT ANSWER a) Frontal lobe"
"A patient reports having difficulty swallowing. Based on this information, how does the nurse assess the appropriate cranial nerve? a) Ask the patient to stick out the tongue and move it in all directions. b) Ask the patient to move the head to the right and left. c) Observe the symmetry of the face when the patient talks.
d) Assess for taste on the anterior part of the tongue. - CORRECT ANSWER a) Ask the patient
to stick out the tongue and move it in all directions." "the nurse is caring for a client just admitted to the mental health unit the client is displaying immobile and mute behaviors and is withdrawn. the client is lying on the bed in a fetal position. which is the most appropriate nursing interventions? a. ask direct questions to encourage talking b. leave the client alone so as to minimize external stimuli c. sit beside the client in silence with occasional open ended questions
d. take the client into the dayroom with other clients so that they can help watch the client -
CORRECT ANSWER c. sit beside the client in silence with occasional open ended questions"
"the nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. which assessment findings would the nurse expect to note? SATA a. dental decay b. moist, oily skin c. loss of tooth enamel d. electrolyte imbalances
e. body weight well below ideal range - CORRECT ANSWER a. dental decay
c. loss of tooth enamel d. electrolyte imbalances" "the nurse is monitoring a hopsitalized client who abuses alcohol. which findings would alert the nurse to the potential for alcohol withdrawal delirium? a. hypotension, ataxia, hunger b. stupor, lethargy, muscle rigidity c. hypotension, coarse hand tremors, lethargy
d. hypertension, changes in level of consciousness, hallucinations - CORRECT ANSWER d.
hypertension, changes in level of consciousness, hallucinations"
"a moderately depressed client who was hopsitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. the client says to the nurse "I'm finally cured." how would the nurse interpret this behavior as a cue to modify the treatment plan? a. suggesting a reduction in medication b. allowed increased "in room" activities c. increasing the level of suicide precautions
d. allowing the client off-unit privileges as needed - CORRECT ANSWER c. increasing the
level of suicide precautions" "the nurse is performing an assessment on a client with dementia. which piece of data gathered during the assessment indicates a manifestation associated with dementia? a. use of confabulation b. improvement in sleeping c. absence in sundown syndrome
d. presence of personal hygenic care - CORRECT ANSWER a. use of confabulation"
"which client is at greatest risk for committing suicide? a. a client with metastatic cancer b. a client with a newly diagnosed cardiac disorder c. a client who just had an argument with the fiance
d. a newly divorced client who states has custody of the children - CORRECT ANSWER a. a
client with metastatic cancer" "the nurse is performing an admission assessment on a client at high risk for suicide. which assessment question will best elicit data related to this risk? a. "what are you feeling right now?" b. "do you have a plan to commit suicide?" c. "how many times have you attemped suicide int he past?"
d. "why were your attemps at suicide unsuccessful in the past?" - CORRECT ANSWER b. "do
you have a plan to commit suicide?"" "the nurse notes documentation that a newly admitted client experiences flashbacks. what diagnosis would this notation support? a. anxiety b. agoraphobia c. PTSD
d. schizophrenia - CORRECT ANSWER c. PTSD"
"the nurse notes that a clients cardiac rhythm shows absent P waves, no PR interval, and an irregular rhythm. how would the nure interpret this rhythm? a. bradycardia b. tachycardia c. atrial fibrillation
d. normal sinus rhythm (NSR) - CORRECT ANSWER c. atrial fibrillation"
"A client with an acute respiratory infection is admitted to the hospital with a diagnosis of sinus tachycardia. Which nursing action should be included in the client's plan of care? 1.Limiting oral and intravenous fluids 2.Measuring the client's pulse each shift 3.Providing the client with short, frequent walks
4.Eliminating sources of caffeine from meal trays - CORRECT ANSWER 4.Eliminating
sources of caffeine from meal trays" "the nurse is conducting a health history of a client with a primary diagnosis of heart failure. which conditions reported by the client could play a role in exacerbating the heart failure? SATA a. emotional stress b. AFIB c. nutrtional anemia d. peptic ulcer disease
e. recent upper resp. infection - CORRECT ANSWER a. emotional stress
b. AFIB c. nutrtional anemia e. recent upper resp. infection" "the nurse is preparing to care for a burn client schedueld for an escahrotomy procedure being perofmed for a third degree dcircumferential arm burn. the nurse understand that which finding is the anticipated therapeutic outcome of the escharotomy? a. return of distal pulses b. brisk bleeding from the site c. decreasing edema formation
d. formation of granulation tissue - CORRECT ANSWER a. return of distal pulses"
"The nurse is assessing a healthy adult male during an annual physical examination. The nurse auscultates the client's abdomen and hears gurgling sound every ten seconds. What action should the nurse take in response to this finding?
A. Document this normal bowel sound activity in the record. B. Encourage increased consumption of fiber in the diet. C. Observe the next bowel movement for signs of bleeding.
D. Report the hyperactivity to the healthcare provider. - CORRECT ANSWER Correct answer
is A. Normal Bowel sound consist of clicks and gurgles and 5-30 per minute. An occasional borborygmus (Loud prolonged gurgle) may be hear." "In observing a client's face, which assessment finding requires the most immediate intervention by the nurse? A. Eyelids are matted and crusted. B. Cornea are jaundiced. C. Oral mucosa is cyanotic.
D. Face is flushed and diaphoretic. - CORRECT ANSWER Answer is C. Blue lips occur when
the skin on the lips takes on a bluish tint or color. This generally is due to either a lock of oxygen in the blood or to extremely cold temperatures. When the skin becomes a bluish color, the symptom is called cyanosis. Most commonly, blue lips are caused by a lack of oxygen in the blood. Most causes of cyanosis are serious and symptom of your body not getting enough oxygen. Over time, this condition will become life-threatening. It can lead to respiratory failure, heart failure, and even death, if left untreated." "While obtaining a health history, a male client tells the nurse that he sometimes experiences shortness of breath. The nurse determines that the client's respirators are regular and deep, and his respiratory rate is 14 breaths/minutes. What is the best nursing action? A. Ask the client to perform light exercise and observe the respiratory effect. B. Document "dyspnea on exertion" in the client's medical record. C. Ask the client to describe the episodes of dyspnea in more detail.
D. Explain to the client the possible causes of dyspnea or "shortness of breath." - CORRECT
ANSWER Correct answer is C. Both respiratory rate and breath sounds are normal. Further
assessment is needed by asking the client to describe his SOB" "When assessing a male client's respiratory status, which technique should the nurse use to assess his anterior- posterior (AP) chest diameter? A. Auscultation. B. Percussion. C. Palpation. D.
Observation. - CORRECT ANSWER Correct answer is D. Observation is the way to detect
barrel chest which is associated with COPD" "Which assessment finding supports the client statement, "My feet swell all the time?" A. 2+ pitting edema of ankles bilaterally. B. Capillary refill both feet > 3 seconds. C. Pedal pulses weak
and thread. D. Positive Homan's sign bilaterally. - CORRECT ANSWER Correct answer is A. 2+
pitting edema indicate swelling in the lower extremities. Homans's sign is often used in the diagnosis of deep venous thrombosis of the leg. A positive Homans's sign (calf pain at dorsiflexion of the foot) is thought to be associated with the presence of thrombosis."
color. - CORRECT ANSWER Correct answer is D. Symmetry is a great value of normal body
imagine while performing inspection." "Which skill should the nurse have an older client demonstrate to evaluate performance of daily living activities? A. Opening a bar soap package. B. Sorting a collection of socks. C. Reading a short
paragraph. D. Telephoning a family member. - CORRECT ANSWER Correct answer is B. ADL
is used as an indicator of a person's functional status. The inability to perform ADLs results in the dependence of other individuals and/or mechanical devices. The inability to accomplish essential activities of daily living may lead to unsafe conditions and poor quality of life." "A client sustained a subconjunctival hemorrhage. The presence of which set of symptoms indicate that the client needs to be seen for further evaluation by an ophthalmologist? A. Acute pain, change in visual acuity, and foreign body sensation. B. Frequent burning, irritation and tearing of the eyes. C. Bilateral itchy, red eyes with watery discharge
D. Diminished ability to focus on close work and excessive illumination required. - CORRECT
ANSWER Correct answer is D. Diminished ability to focus on close work could be a sign of
cranial nerve damage and could lead to reduced visual acuity, due to a reduced ability of the lens in the eye to focus light on the retina, results in images that appear blurry." "To assess a female client for hirsutism, which action should the nurse take? A. Lightly palpate over the client's entire scalp. B. Apply and release light pressure to the skin. C. Assess the appearance of the client's face.
D. Observe the hair shafts on the client's scalp - CORRECT ANSWER Correct answer is C.
Hirsutism is a condition in women that results in excessive growth of dark or coarse hair in a male-like pattern like face, chest and back." "An older adult client is admitted to the medical unit because of loss of appetite and generalized malaise. To analyze the client medical condition, which laboratory value is most important for the nurse to review? A. Hematocrit. B. Serum Calcium. C. Hemoglobin.
D. Serum pre-albumin - CORRECT ANSWER Correct answer is C. Hemoglobin is the main lab
value to check for anemia. Anemia is a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues. Having anemia can make you feel tired and weak. There are many forms of anemia, each with its own cause. Anemia can be temporary or long term, and it can range from mild to severe." "A male client returns to the clinic for a follow-up visit after being treated for a bladder infection. While examining the client, which finding indicated an expected response to the treatment?
A. Orange sized prostate gland. B. Post-voided residual volume of 50 mL. C. Pain score of 1 out of 10 with urination. D. Decreasing
sperm cell count. - CORRECT ANSWER C"
"The nurse completes palpitation of the abdomen on an older adult client. Which finding is considered normal for the client? A. Non-tender. B. Gallop. C. Thrill.
D. Peristaltic waves. - CORRECT ANSWER Correct answer is D. The small intestine undergoes
segmental contractions and peristaltic waves Segmental contractions occur for short distances only along the small intestine Peristaltic waves occur for variable distances to cause the chyme to move along the small intestine." "The nurse has just completed palpitation maneuvers for lymph nodes on a 75-year-old female client. Which findings are considered normal for this elderly client? A. Nodes are non-palpable. B. Axillary nodes feel soft and fatty. C. Nodes feel ropey and rubbery.
D. Inguinal nodes are enlarged and warm to the touch. - CORRECT ANSWER Correct answer
is A. Normal lymph nodes are non-palpable." "A women comes to the clinic for her first prenatal visit. The nurse is conducting a health history and the women begins to cry when asked about previous pregnancies. Which response is best for the nurse to provide? A. "Why don't I come back in a few minutes after you are more composed." B. Offer a tissue and sit quietly until the crying subsides. C. Allow the client to compose herself then change the subject.
D. "I'm so sorry that I made you cry. I didn't mean to upset you." - CORRECT ANSWER
Correct answer C. Try always to listen to the patient when she is in a bad mood or wants to express her feeling." "While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take? A. Apply warm blankets to both feet. B. Palpate pulse points with legs dependent. C. Notify the healthcare provider.
D. Use a doppler ultrasonic stethoscope. - CORRECT ANSWER Correct answer is D. Doppler
ultrasonic stethoscope is used when the nurse couldn't palpate a pedal pulse of a client." "A homeless male client with a history of alcohol abuse had a cerebrovascular accident (CVA) 10 years ago that resulted in left hemiparesis. Today he is complaining of pain in his left leg, is
"A client comes to the clinic due to shoulder discomfort and intermittent pain while swimming today. To assist normal range of motion (ROM) of the client's shoulder, which assessment techniques should the nurse ask the client to perform? A. Alternate both index fingers to tough the tip of nose accurately. B. Extend arms up to 180 degrees besides the ears. C. Extend arms straight out and hold without drifting.
D. Hold arms up at 90 degree while arms are pushed downward - CORRECT ANSWER Correct
answer is D." "A client reports to the healthcare provider's office for a routine post-surgical evaluation six weeks after a hysterectomy. Which history-taking approach should the nurse use to gather the needed information? A. Conduct a comprehensive review of systems. B. Perform a head-to-toe physical assessment. C. Prepare to collect a vaginal specimen for Papanicolaou smear.
D. Collect information about the client's activities since surgery. - CORRECT ANSWER
Correct answer is D." "In assessing a male client's level of consciousness, the nurse determines that the client does not open his eyes spontaneously. What should the nurse do next? A. Notify the healthcare provider. B. Observe for eye opening to a painful stimulus.
C. Check the pupillary response to light. D. Ask the client to open his eyes - CORRECT
ANSWER Correct answer is C."
"In assessing a client's sensory nerve function, the nurse prepares to assess the client's response to temperature. What action should the nurse include during this assessment? A. Darken the client's room environment. B. Cover the client with a warmed blanket. C. Measure the client's body temperature.
D. Instruct the client to close both eyes. - CORRECT ANSWER Correct answer is B"
"The nurse is obtaining a health history for a client during an annual physical examination. When evaluating the client for menopausal symptoms, which finding indicates the client is perimenopausal? A. Drenching night sweats. B. Excessive vaginal moisture. C. Increase in sexual desire.
D. Cessation of menstruation. - CORRECT ANSWER correct answer is A"
"A client states that he is legally blind. Which assessment techniques should the nurse use to obtain data to support the client's statement? A. Observe the client's optic disc through an ophthalmoscope.
B. Assess the client's ability to read a Snellen chart from a distance of 20 feet. C. Observe the client's pupillary response to a penlight.
D. Observe the client's eye movements through the cardinal fields of vision. - CORRECT
ANSWER correct answer B."
"Which question by the nurse is likely to elicit the most information regarding a client's use of medications to treat a chronic cough? A. What medications are you currently taking? B. Have you tried any generic brands of cough syrup? C. Have you been prescribed any medications for your cough?
D. What medications have you used for your cough? - CORRECT ANSWER Correct answer is
A. The nurse should always ask general questions about medication which include OTC and herbal products. Also, there might be other medications that cause cough like ACE inhibitors so the nurse should assist the who image." "After a young adult woman describes feeling palpitations when she lies on her left side it is most important for the nurse to auscultate heart sounds at which anatomical location? A. Second intercostal space, left of the sternal border. B. Left third intercostal space, left lateral sternal border. C. Base of the heart at second intercostal space, right of the sternal border.
D. Apex of the heart at the left fifth intercostal space at the midclavicular line - CORRECT
ANSWER Correct answer is D. The apex beat or apical impulse is the palpable cardiac impulse
farthest away from the sternum and farthest down on the chest wall, usually caused by the LV and located near the midclavicular line (MCL) in the fifth intercostal space" "While assessing the legs of a female client, the nurse observes leathery-looking skin. The client reports aching tired legs that swell if she stands for long periods of time. To screen for venous insufficiency, the nurse should ask the client if she has experienced which subject finding? A. Decreased pain when legs are elevated. B. Deep, continuous pain in the calf muscles. C. Cool, pale skin below the knees.
D. Painful symptoms alleviated by warmth. - CORRECT ANSWER Correct answer is A.
Elevation of the legs decreases welling and helps with blood flow." "During an abdominal assessment, a client with a temperature of 103 F (39.4 C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement? A. Electrocardiogram. B. Complete bed rest. C. Monitor urinary output.
D. Nothing by mouth. - CORRECT ANSWER Correct answer is D."
"When auscultating a client's lung sounds, the nurse hears rhonchi in the upper lung fields anteriorly. Which action should the nurse take first? A. Measure capillary refill. B. Ask the client to cough. C. Monitor oxygen saturation.
D. Document the finding. - CORRECT ANSWER Correct answer is B. Many abnormal breath
sounds are best heard asking the patient to cough." "During a health assessment, the client reports being treated for osteoarthritis. The nurse examines a client's hands and finds Heberden's nodes. Which finding should the nurse document in the client's medical record? A. Proximal intertarsal join swelling of big toe. B. Non-painful enlarged interphalangeal joints. C. Distal interphalangeal joint nodules that deviate.
D. Frozen, non-movable phalangeal joints. - CORRECT ANSWER correct answer is C.
Heberden nodes (hard or bony swelilngs in the distal interphalangeal joints) along with a deviated distal finger are a classic finding in osteoarthritis." "The nurse asks a 50-year-old female client what her natural hair color is. The client replies, "I've been dying my hair for so long, I'm not even sure,,,, I just know that this month it's ravishing red." Based on this information, the nurse expects to obtain which finding when palpating this client's scalp hair? A. Excess vellus hair. B. Receding front hairline. C. Fine, thin, limp texture.
D. Coarse, dry, brittle texture. - CORRECT ANSWER Correct answer is D. Excessive dying of
the hair will lead the hair to be coarse and dry." "The school nurse is interviewing a 13-year-old girl who wants to go home from school because of "back pain". Which question should the nurse ask the adolescent first? A. "Have you taken any medications to relieve the pain?" B. "What were you doing when you first noticed the problem?" C. "Do you remember ever having this type of pain in the past?"
D. "Does changing your position make the pain worse?" - CORRECT ANSWER Correct answer
is C. Scoliosis (a severe curvature of the spine) is a possible cause of back pain, especially in adolescent girls. Your pediatrician evaluates your child's posture during regular well-child visits to make sure her back is straight and she's growing normally." "During a health assessment for a young adult female client's gynecological annual screening, the client reports amenorrhea. The nurse calculates the client body mass index (BMI) as 16. Which finding should the nurse document in the electronic medical record that indicates an expected rationale for this condition?
A. Increased calcium intake with 3 glasses if non-fat milk daily. B. Reports a history of chronic urinary tract infections. C. Trains for competition and runs 12 miles every day.
D. Received an implanted intrauterine device (IUD) last month. - CORRECT ANSWER Correct
answer is D. When using IUD, the hormones act locally on the uterus—versus hanging out in your bloodstream, like with the pill—they also thin the uterine lining. In some women, the uterine lining is so thinned by the IUD that nothing comes out, aka no period." "A male client reports the onset of a burning sensation in his hands and legs. How should the nurse document this finding in the electronic medical record? A. Circulation impaired. B. Inflammation present. C. Reports feeling "on fire."
D. Paresthesia reported. - CORRECT ANSWER Correct answer D."
"The nurse prepares to begin a systematic assessment of a client's heart sounds. Upon positioning the stethoscope as seen in the picture what should the nurse do first? A. Identify S1 and S2 heart sounds. B. Change to the bell of the stethoscope. C. Move the stethoscope to the apical site.
D. Listen for abnormal sounds - CORRECT ANSWER Correct answer is A. 1st assessment of
hearts sounds is to identify S1 and S2 heart sounds. S1 is normally a single sound because mitral and tricupsid valve closure occurs almost simultaneously. Clinically S1 corresponds to the pulse. The second sound S2 represents closure of the smilunar (aortic and pulmonary) valves." "During assessment of a client's neck, the nurse prepares to assess for jugular vein distention (JVD) as seen in the picture. What should the nurse do next? A. Listen to swishing sound during systole. B. Use the bell of the stethoscope to auscultate. C. Remove the stethoscope to observe the site.
D. Palpate the site of erythema and tenderness. - CORRECT ANSWER Correct answer is C."
"A client reports to the healthcare provider's office for a routine post-surgical evaluation six weeks after a hysterectomy. Which history-taking approach should the nurse use to gather the needed information? A. Conduct a comprehensive review of systems. B. Perform a head-to-toe physical assessment. C. Prepare to collect a vaginal specimen for Papanicolaou smear.
D. Collect information about the client's activities since surgery. - CORRECT ANSWER D.
Collect information about the client's activities since surgery." "*A client presents with "cough." Which question by the nurse is likely to elicit the most information regarding a client's use of medications?
"Which is an example of data a nurse collects during a physical examination? A. The patient's lack of hair and shiny skin over both shins B. The patient's stated concern about lack of money for prescriptions C. The patient's complaints of tingling sensations in the feet
D. The patient's mother's statements that the patient is very nervous lately - CORRECT
ANSWER A. The patient's lack of hair and shiny skin over both shins"
"What is the most important nursing action to reduce transmission of microorganisms during a physical assessment? a) Clean the bell and diaphragm of the stethoscope between patients. b) Perform hand hygiene. c) Wear gloves when anticipating exposure to body fluids.
d) Wear eye protection when anticipating spatter of body fluids. - CORRECT ANSWER b)
Perform hand hygiene." "Based on the picture, what is an appropriate nursing diagnosis for this client? a.Infection b.Fluid Volume Deficit c.Decreased Cardiac Output
d.Acute Pain - CORRECT ANSWER b.Fluid Volume Deficit"
"A nurse assessing a patient with liver disease expects to find which manifestation during the examination? a) Yellowish color in the axilla and groin b) Yellow pigmentation in the sclera c) Very pale skin on the palms
d) Ashen-gray color in the oral mucous membranes - CORRECT ANSWER b) Yellow
pigmentation in the sclera" "When performing a skin assessment of an adult patient, the nurse expects what finding? a) Reddened area does not blanch when gentle pressure is applied b) Indentation of the finger remains in the skin after palpation c) Flaking or scaling of the skin
d)Return of skin to its original position when pinched - CORRECT ANSWER d)Return of skin
to its original position when pinched" "A 45-year-old woman tells the nurse she is distressed by the presence of dark, coarse hair on her face that has recently developed. What is the nurse's most appropriate response to this patient?
a) "This is simple vellus hair and it will decrease in amount over time." b) "Some women in your cultural group normally have dark hair on their faces." c) "This is unusual; female hair distribution should be limited to arms, legs, and pubis."
d) "Coarse dark hair could result from hormonal changes such as from menopause." -
CORRECT ANSWER d) "Coarse dark hair could result from hormonal changes such as from
menopause.""
"What type of scale is used to measure pressure ulcers? - CORRECT ANSWER *The Braden
Scale uses a scores from less than or equal to 9 to as high as 23. The lower the number, the higher the risk for developing an acquired ulcer/injury. *19-23 = no risk *15-18 = mild risk *13-14 = moderate risk *less than 9 = severe risk"
"What is used to assess eyes? - CORRECT ANSWER Snellen Chart"
"* A client with streptococcus pharyngitis reports high fever, difficulty swallowing and a muffled voice. Which complication should the nurse suspect? A. Foreign body obstruction. B. Laryngeal polyps. C. Peritonsillar abscess.
D. Nasal polyps - CORRECT ANSWER C. Peritonsillar abscess."
"Which findings does the nurse expect when assessing the mouth of a healthy adult? Select all that apply. a.Lips appear pink, smooth, moist, and symmetric b.Teeth are white, yellow, or gray, with smooth edges c.Slight roughness on the dorsum of the tongue d.Hard palate appears smooth, pale, and immovable
e.Mucous membranes are dry and intact - CORRECT ANSWER a.Lips appear pink, smooth,
moist, and symmetric b.Teeth are white, yellow, or gray, with smooth edges c.Slight roughness on the dorsum of the tongue d.Hard palate appears smooth, pale, and immovable" "During the history, a 65-year-old male patient reports smoking two packs of cigarettes a day for more than 40 years. With this knowledge, what should the nurse look for during the examination of this patient's mouth? a) Cracks and erythema in the corners of the mouth
