Exam Review
- Skin Assessment Highlight the abnormal findings that the nurse should be concerned about. Select all that apply. A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past.(Highlight — findings requiring follow-up are marked)
Skin Assessment
Highlight the abnormal findings that the nurse should be concerned about. Select all that apply.
A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past.
- During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. How do acutely infected lymph nodes typically appear?A)LumpedB)UnilateralC)Soft and nontenderD)Firm but freely movable
- During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects:A)Tactile fremitusB)Crepitus.C)Adventitious sounds.D)Friction rub
- A heart murmur should be assessed for which of the following? Select all that apply.(SATA)A)TimingB)RadiationC)FremitusD)EgophonyE)Location
Exam Review
- A nurse in an emergency department (ED) is admitting a client. Exhibits Select 4 findings in the client's medical record that place them at risk for pneumonia.(SATA)A)Pneumococcal vaccineB)Level of consciousnessC)Influenza vaccineD)Health historyE)Fluid intakeF)AgeG)Smoking history
- During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly. What additional finding would the nurse assess for to confirm this suspicion?A)ExophthalmosB)Coarse facial featuresC)Bowed long bonesD)Acorn-shaped cranium
- A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the gland for the presence of a bruit. What technique should the nurse use to assess for a bruit?A)Palpate the thyroid while the patient holds their breathB)Palpate the thyroid while the patient is swallowingC)Auscultate the thyroid with the bell of the stethoscopeD)Auscultate the thyroid with the diaphragm of the stethoscope
- During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?A)When adventitious sounds are presentB)When the bronchial tree is obstructedC)In conjunction with whispered pectoriloquyD)In conditions of consolidation, such as pneumonia
Exam Review
- A nurse is performing a lymphatic system assessment on a client reporting fatigue and malaise for one week. In which order should the nurse perform the head to toe assessments? Indicate the correct order from first to last. All options must be used.
1 2 3 4 5 Palpate the popliteal nodes ✓ Palpate the preauricular nodes ✓ Palpate the axillary nodes ✓ Palpate the submandibular nodes ✓ Palpate the supraclavicular nodes ✓ - A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?A)XerostomiaB)RhinorrheaC)DysphagiaD)Epistaxis
- The nurse is assessing a lesion on a patient and observes a focal loss of epidermis and dermis, a depression extending into the dermis, irregularly shaped, and bleeding. This type of wound is known as a/anA)UlcerB)ErosionC)NoduleD)Cyst
- A client presents with an infection of the forearm and hand. The nurse should expect what lymph nodes to be swollen on assessment:A)CervicalB)EpitrochlearC)InguinalD)Axillary
Exam Review
- The nurse palpates a swollen inguinal lymph node. Which assessment should the nurse perform next?A)Assess the forearm and hand for infectionB)Assess the lower extremitiesC)Assess the dorsalis pedis pulsesD)None of the above
- The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patient's T4 and T3 hormone levels are elevated. Which of these findings would the nurse most likely find on examination?A)TachycardiaB)DyspneaC)ConstipationD)Atrophied nodular thyroid gland
- A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect to find because of the long- term inadequate tissue perfusion?A)Abdominal retractionB)Clubbing nailsC)RestlessnessD)Dependent edema 4+
- A nurse in a provider's office is preparing to auscultate and percuss a client’s thorax as part of a comprehensive physical examination. Which of the following are considered normal findings? Select all that applyA)ResonanceB)Tactile fremitusC)Bronchovesicular sounds.D)RhonchiE)Crackles
Exam Review
- Mrs. Helms is sitting on the side of the bed, leaning forward, with her arms on the bedside table. What would this indicate to you?A)Improper positioningB)Fatigue or weaknessC)Respiratory distressD)Increased comfort and relaxation
- A nurse is examining a patient and finds a lesion that is a linear arrangement along a unilateral nerve route. The nurse would document this finding asA)CystB)NoduleC)ZosteriformD)Ulcer
- During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:A)Increased tactile fremitus and dull percussion tones.B)Muffled voice sounds and symmetric tactile fremitus.C)Adventitious sounds and limited chest expansion.D)Absent voice sounds and hyper resonant percussion tones.
- A nurse is auscultating heart sounds and hears a murmur. What should be included in the nurse's documentation? Select all that apply.A)Client's blood pressureB)Client's weightC)Client's respiratory rateD)Intensity of the murmurE)Location of the murmurF)Client's temperatureG)Timing of the murmurH)Client's medication history
Exam Review
- The RN is explaining to an elderly client why the skin folds and sags as part of the normal aging process. What is the correct mechanism for this?A)Increasing capillary fragilityB)increased sebaceous and sweat glands.C)Decreased collagen.D)Lose elasticity
- During a cardiac assessment of a client you observed jugular vein distension, and auscultated $3 gallop heart sound. These findings most likely suggest which of the following conditions?A)Peripheral vascular diseaseB)Fluid and electrolyte disturbancesC)Heart failureD)Atrial-septal defect
- The nurse has just completed a lymph node assessment on a healthy 40-year-old female patient. Which of the following is an expected finding?A)Fixed lymph nodesB)Lymph nodes that are large, firm, and fixed to the tissueC)Nonpalpable lymph nodesD)Rubbery, discrete, and mobile lymph nodes
- A nurse is auscultating the aortic area and knows it is in which of the following areas:A)2nd intercostal space right of the sternal borderB)5th intercostal space medial to mid-clavicular lineC)2nd intercostal space left of the sternal border.D)4-5th intercostal space left of the sternal border.