Health assessment for nursing practice 5th edition wilson test bank

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Chapter 9: Skin, Hair, and Nails Test Bank MULTIPLE CHOICE 1. A patient asks the nurse if it is possible to grow new skin. What is the nurse’s most

appropriate response? a. “Even if new skin growth is required, the melanocytes do not regenerate.” b. “The avascular epidermis sheds slowly and is replaced completely every 4 weeks.” c. “The outer layer of skin remains the same over the lifetime except for repairing injuries.” d. “Epidermal regeneration is impossible because it is avascular.”

ANS: B Feedback A

B

C D

Melanocytes are not involved in regeneration. They secrete melanin, which provides pigment for the skin and hair and serves as a shield against ultraviolet radiation.

Within this deepest layer of epidermis, active cell generation takes place. As cells are produced, they push up the older cells toward the skin surface. The entire process takes about 30 days.

The dead cells are continuously sloughed off and replaced by new cells moving up from the underlying epidermal layers.

Within this deepest layer of epidermis, active cell generation takes place.

DIF: Cognitive Level: Understand REF: 98 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 2. 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 ANS: B Feedback A B C D

Instead of the axilla and groin, assess the sclera of the eyes, fingernails, palms of hands, and oral mucosa.

Jaundice is manifested by a yellowish color in the sclera of the eyes and palms of the hands in both light- and dark-skinned patients.

Pale skin may indicate anemia, but not jaundice. Yellow color of the palms indicates jaundice.

Ashen-gray color may be seen in dark-skinned patients who are cyanotic.

DIF: Cognitive Level: Apply

REF: 98| 101

TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 3. How does the nurse recognize jaundice in a dark-skinned patient? a. Inspect the conjunctiva for ashen-gray color. b. Inspect the nail beds for a deeper brown or purple skin tone. c. Inspect the palms and soles for yellowish-green color. d. Inspect the oral mucous membrane for yellow color.

ANS: C Feedback A B C D

Ashen-gray color may be seen in dark-skinned patients who are cyanotic.

Brown or purple tone is seen in dark-skinned patients with erythema.

In dark-skinned patients, jaundice manifests as a yellowish-green color that can be seen most obviously in the sclera, palms of hands, and soles of feet.

Mucous membranes do not change color from jaundice.

DIF: Cognitive Level: Understand REF: 103, Table 9-1 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 4. What signs of cyanosis does a nurse inspect for in a dark-skinned patient? a. Ashen-gray color of the oral mucous membranes b. Blue color in the nail beds c. Ashen-blue color in the palms and soles d. Blue-gray color in the ear lobes and lips ANS: A Feedback A B C D

Cyanosis is manifested by ashen-gray color of the oral mucous membranes and nail beds in a dark-skinned patient.

An ashen-gray color of the nail beds is expected in a dark-skinned patient, rather than blue.

An ashen-gray color of the oral mucous membranes and nail beds are expected in a dark-skinned patient.

An ashen-gray color of the oral mucous membranes and nail beds are expected in a dark-skinned patient.

DIF: Cognitive Level: Apply REF: 103, Table 9-1 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 5. When the patient’s chart includes a notation that petechiae are present, what finding does a

nurse expect during inspection? a. Purplish-red pinpoint lesions b. Deep purplish or red patches of skin

c. Small raised fluid-filled pinkish nodules d. Generalized reddish discoloration of an area of skin ANS: A Feedback A B C D

Purplish-red pinpoint lesions describes the appearance of petechiae.

Petechiae are pinpoints, not as large as a patch.

Petechiae are pinpoints, not raised as a nodule.

Petechiae are pinpoints, not generalized.

DIF: Cognitive Level: Understand REF: 103, Table 9-1| 117 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 6. 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 up slightly ANS: D Feedback A B C D

This is an indication of a stage I pressure ulcer.

This is a description of edema.

This may be an indication of dry skin, systemic disease, or nutritional deficiency.

This is an assessment of skin turgor; skin should return to its original position.

DIF: Cognitive Level: Apply REF: 106 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Reduction of Risk Potential: System Specific Assessments 7. A nurse notices a patient’s nails are thin and depressed with the edges turned up. What

additional abnormal data should the nurse expect to find on this patient? a. Pale conjunctiva b. Jaundice c. Ecchymosis d. Rashes ANS: A Feedback A B C

The abnormal nail finding was koilonychia, which occurs in patients with anemia who frequently have pale conjunctiva.

Jaundice is due to increased serum bilirubin, indicating liver or gallbladder disease, and does not create changes in nail structure.

Ecchymosis occurs after trauma to the blood vessel resulting in bleeding under the tissue and does not cause changes in nail structure.

D

Rashes indicate an inflammation or allergic reaction that does cause changes in the nails.

DIF: Cognitive Level: Analyze REF: 108 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 8. 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.”

ANS: D Feedback A

B

C D

This response is not true. This example describes hirsutism, a condition associated with an increase in the growth of facial, body, or pubic hair in women. It does not decrease over time and the hair is not vellus.

Although it is true that women of some cultural groups normally have dark hair on the face, women in these cultural groups have darker facial hair most of their adult lives; the patient in this item has a new onset of hirsutism.

It is not true that female hair distribution should normally be limited to arms, legs, and pubis. Women do have hair on their faces and other areas.

Coarse, dark hair on the face describes hirsutism, an increase in the growth of facial, body, or pubic hair in women that can be associated with menopause or an endocrine disorder.

DIF: Cognitive Level: Apply REF: 107 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 9. What findings does a nurse expect when inspecting and palpating a patient’s nails? a. A nail base angle of not more than 90 degrees b. Whitish to clear nails in darker-skinned patients c. Nail surface is smooth and rounded d. Transverse depression running across the nails ANS: C Feedback A B C D

The expected angle of the nail base is 160 degrees.

Patients with darker-pigmented skin typically have nails that are yellow or brown, and vertical banded lines may appear.

Nail surface that is smooth and rounded is an expected finding.

This is a description of Beau lines.

DIF: Cognitive Level: Apply REF: 107 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 10. A nurse notices that the angle of the patient’s proximal nail fold and the nail plate are almost a

flat line; about 160 degrees. How does the nurse interpret this finding? a. This patient has chronic pulmonary disease. b. This is an expected finding. c. This is due to stress to the nails. d. This is associated with anemia.

ANS: B Feedback A B C

D

This patient has chronic pulmonary disease, which causes clubbing (when the angle of the nail base exceeds 180 degrees).

The expected angle of the nail base is 160 degrees.

This answer describes Beau lines, which appear as a groove or transverse depression running across the nail. It results from a stressor that temporarily impairs nail formation.

This is associated with anemia, which causes koilonychia, a thin, depressed nail with the lateral edges turned upward.

DIF: Cognitive Level: Understand REF: 108-109 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 11. As a nurse is inspecting the nails of a patient with chronic hypoxemia and notices

enlargements of the ends of the fingers and angles of the nail base greater than a straight line (exceeding 180 degrees). How does the nurse document these findings? a. An expected finding b. Koilonychia (spoon nail) c. Clubbing d. Leukonychia ANS: C Feedback A B C

D

This is clubbing, which is not an expected finding.

Koilonychia is a thin, depressed nail with the lateral edges turned upward and is associated with anemia.

Clubbing is present when the angle of the nail base exceeds 180 degrees. It is caused by proliferation of the connective tissue resulting in an enlargement of the distal fingers and is most commonly associated with chronic respiratory or cardiovascular disease.

Leukonychia appears as white spots on the nail plate, usually caused by minor trauma or manipulation of the cuticle.

DIF: Cognitive Level: Apply REF: 108-109 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 12. While giving a history, a patient reports itching arms, legs, and chest after using a new soap.

What manifestations does the nurse expect to find on the arms, legs, and chest when inspecting this patient’s skin? a. Elevated irregularly shaped areas of edema of variable diameter b. Elevated, firm, and rough lesions with flat surface greater than 1 cm in diameter c. Elevated circumscribed superficial lesions less than 1 cm in diameter filled with serous fluid d. Elevated, firm circumscribed areas less than 1 cm in diameter ANS: A Feedback A B C D

This is a description of wheals, which occur as a result of allergic reactions.

This is a description of plaque.

This is a description of a vesicle.

This is a description of a papule.

DIF: Cognitive Level: Analyze REF: 112| 123-124 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 13. While inspecting the skin, a nurse notices a lesion on the patient’s upper right arm. What is

the best way to document the size of this lesion? a. Compare its size to the size of a coin. b. Estimate its size to the nearest inch. c. Use a centimeter ruler to measure the lesion. d. Trace the lesion onto a piece of paper.

ANS: C Feedback A B C

D

Comparing its size to the size of a coin can be done if no measurement tool is available, but the best way is to measure the lesion.

Estimating size to the nearest inch is not recommended due to inaccuracy.

A centimeter ruler to measure the size of lesions may be helpful. The lesion is documented based on its characteristics, including location, distribution, color, pattern, edges, flat or raised, and size.

Tracing the lesion onto a piece of paper can be done if no measurement tool is available, but the best way is to measure the lesion.

DIF: Cognitive Level: Apply REF: 110-111, Box 9-2 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems

14. During shift report, a nurse learns that a patient has a macular rash. As the nurse inspects the

patient’s skin, what finding will confirm the rash? a. Elevated, firm, well-defined lesions less than 1 cm in diameter b. Depressed, firm, or scaly, rough lesions greater than 1 cm in diameter c. Elevated, fluid-filled lesions less than 1 cm in diameter d. Flat, well-defined, small lesions less than 1 cm in diameter ANS: D Feedback A B C D

Elevated, firm, well-defined lesions less than 1 cm in diameter is a description of a papule.

Depressed, firm, or scaly, rough lesions greater than 1 cm in circumference is an incorrect description.

Elevated, fluid-filled lesions less than 1 cm in diameter is a description of a vesicle.

Flat, well-defined, small lesions less than 1 cm in diameter is a description of a macule.

DIF: Cognitive Level: Apply REF: 111 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 15. During inspection of a patient’s upper back, the nurse notices three small, elevated superficial

lesions filled with purulent fluid. How does the nurse document this finding? a. As three cysts on the upper back b. As several bullae on the back c. As three pustules on the upper back d. As three wheals on the upper back ANS: C Feedback A B C

D

Cysts are elevated, circumscribed, encapsulated lesions.

Bullae are vesicles greater than 1 cm in diameter. This documentation is not specific to the number or exact location.

Pustules are elevated, superficial lesions similar to vesicles but filled with purulent fluid. This is a specific documentation of what the nurse saw (three pustules) and their location (upper back).

Wheals are elevated irregular-shaped areas of cutaneous edema that are solid, transient, and of variable diameter.

DIF: Cognitive Level: Understand REF: 113 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 16. A nurse notices multiple lesions on a patient’s left hand that are 0.5 cm in width, elevated,

circumscribed, and filled with serous fluid. What kind of primary lesions are these? a. Macules

b. Patches c. Vesicles d. Bullae ANS: C Feedback A B C

D

Macules are flat, circumscribed areas that are a change in the color of the skin and are less than 1 cm in diameter.

Patches are flat, nonpalpable, irregular-shaped macules greater than 1 cm in diameter.

Vesicles are elevated, circumscribed, superficial (do not extend into dermis), filled with serous fluid, and less than 1 cm in diameter. This documentation tells the number and location of the lesions.

Bullae are large vesicles greater than 1 cm in diameter.

DIF: Cognitive Level: Understand REF: 113 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 17. A nurse notices multiple lesions on the back of a patient’s left hand that are 0.5 cm in width,

elevated, circumscribed, and filled with serous fluid. How does the nurse document these lesions? a. As multiple macules on the dorsum of the left hand b. As multiple vesicles on the dorsum of the left hand c. As several patches on the left hand d. As several bullae on the dorsum of the left hand ANS: B Feedback A B

C D

Macules are flat, circumscribed areas that are a change in the color of the skin and are less than 1 cm in diameter.

Vesicles are elevated, circumscribed, superficial (do not extend into dermis), filled with serous fluid, and less than 1 cm in diameter. This documentation tells the number and location of the lesions.

Patches are flat, nonpalpable, irregular-shaped macules greater than 1 cm in diameter. This documentation does not include location of lesions.

Bullae are large vesicles greater than 1 cm in diameter.

DIF: Cognitive Level: Understand REF: 113 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 18. A patient has come to the clinic complaining of a “bump” behind his right ear. Upon

inspection, the nurse notes a lesion that is elevated, solid, and 4 cm in diameter. What does the nurse call this lesion when she reports her findings to the health care provider? a. Tumor b. Nodule

c. Keloid d. Papule ANS: A Feedback A B C D

A tumor is an elevated and solid lesion, may or may not be clearly demarcated, extends deeper in the dermis, and greater than 2 cm in diameter.

A nodule is an elevated, firm, circumscribed lesion that extends deeper into the dermis than a papule and is 1 to 2 cm in diameter.

A keloid is an irregularly-shaped, elevated, progressively-enlarging scar that grows beyond the boundaries of the wound.

A papule is an elevated, firm, circumscribed area less than 1 cm in diameter.

DIF: Cognitive Level: Understand REF: 112 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 19. A nurse is inspecting the skin of a patient who has had skin problems after multiple piercings.

How will the nurse recognize the characteristics of keloids? a. Roughened and thickened scales involving flexor surfaces b. Hypertrophic scarring extending beyond the original wound edges c. Thin, fibrous tissue replacing normal skin following injury d. Loss of the epidermal layer, creating a hollowed-out or crusted area ANS: B Feedback A B C D

Roughened and thickened scales involving flexor surfaces is a description of lichenification.

Hypertrophic scarring extending beyond the original wound edges is a description of a keloid.

Thin, fibrous tissue replacing normal skin following injury is a description of a scar.

Loss of the epidermal layer, creating a hollowed-out or crusted area is a description of excoriation.

DIF: Cognitive Level: Understand REF: 114 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 20. A patient reports the mole on the scalp has started itching and it bleeds when scratching it.

What other finding is a danger sign for pigmented skin lesions? a. Symmetry of the lesion b. Rounded border c. Color variation d. Size less than 6 mm wide ANS: C

Feedback A B C D

Symmetry is an expected finding for moles. Asymmetric lesions are an early sign of malignant melanoma.

A rounded border is an expected finding. A border that is poorly defined or irregular is an early sign of malignant melanoma.

Uneven, variegated color is an early sign of malignant melanoma.

A size of less than 6 mm wide is an expected finding. A lesion greater than 6 mm is an early sign of malignant melanoma.

DIF: Cognitive Level: Analyze REF: 111| 130 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 21. A toddler patient has a small, slightly raised bright red area on the trunk. The child’s mother

reports that the lesion has been present since birth and has become a little larger. What type of lesion does the nurse suspect? a. Vascular nevi b. Purpura c. Ecchymosis d. Cherry hemangioma is a benign tumor consisting of a mass of small blood vessels and can vary in size. These are typically small, slightly raised lesions that are bright red in color appearing on the face, neck and trunk of the body. These lesions increase in size with age.

ANS: D Feedback A

B C D

Vascular nevi is a type of angioma that involves the capillaries within the skin producing an irregular macular patch that can vary from light red to dark red to purple in color.

Purpura is a flat, reddish purple, nonblanchable discoloration in the skin greater than 0.5 cm in diameter.

Ecchymosis is a reddish purple, nonblanchable spot of variable size.

Cherry hemangioma is a benign tumor consisting of a mass of small blood vessels and can vary in size. These are typically small, slightly raised lesions that are bright red in color appearing on the face, neck and trunk of the body. These lesions increase in size with age.

DIF: Cognitive Level: Understand REF: 117-118 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 22. A nurse notices several reddish purple, nonblanchable spots of different sizes on the arms and

legs of a patient with a low platelet count. How does the nurse distinguish ecchymosis from purpura? a. Ecchymosis is variable in size and a purpura is greater than 0.5 cm in diameter. b. Ecchymosis does not blanch and purpura does blanch. c. Ecchymosis has raised lesions and purpura has flat lesions. d. Ecchymosis is irregularly shaped and purpura is round.

ANS: A Feedback A B C D

Ecchymosis is variable in size and a purpura is greater than 0.5 cm in diameter.

This is an accurate statement.

Ecchymosis does not blanch and purpura does blanch. Both of these lesions are nonblanchable.

Ecchymosis has raised lesions and purpura has flat lesions. Both of these lesions are flat.

Ecchymosis is irregularly shaped and purpura is round. There is no specified shape for either type of lesion.

DIF: Cognitive Level: Apply REF: 118, Table 9-4 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 23. A patient is visiting an urgent care center after being hit in the back with a baseball. Upon

examination, the nurse notes a flat, nonblanchable spot 2.25 cm wide that is reddish-purple in color. How does the nurse document this lesion? a. As an angioma b. As purpura c. As petechiae d. As ecchymosis ANS: D Feedback A

B C

D

An angioma is characterized by a small central red area with radiating spider-like legs that blanches with pressure. The lesion of this patient does not blanch.

Purpura is flat, reddish purple, non-blanchable, and greater than 0.5 cm in size. It is caused by infection or a bleeding disorder, not trauma.

Petechiae are tiny, flat, reddish-purple, non-blanchable spots in the skin less than 0.5 cm in diameter and appear as tiny red spots that are pinpoint to pinhead in size.

Ecchymosis is reddish purple in color, nonblanchable and is caused by trauma (being hit with a baseball) to the blood vessel which results in bleeding underneath the skin. The size of the ecchymotic area varies depending on the level of trauma.

DIF: Cognitive Level: Understand REF: 118 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 24. A nurse is performing an admission physical examination on a patient who has been

bedridden for a month. The nurse notices a pressure ulcer on the patient’s left trochanter area that involves partial-thickness skin loss with damage to the subcutaneous tissue. The nurse reports this ulcer at what stage?

a. b. c. d.

Stage I Stage II Stage III Stage IV

ANS: B Feedback A B C D

Stage I ulcers have persistent redness, but the epidermis is intact.

Stage II ulcers have partial-thickness skin loss of dermis. It appears as a shiny or dry shallow open ulcer with pink wound bed without slough or bruising.

Stage III ulcers have full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend to, but not through, underlying fascia.

Stage IV ulcers have full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be within the wound bed.

DIF: Cognitive Level: Understand REF: 121-122 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 25. A patient complains of itching on her feet. On inspection the nurse observes weeping vesicles

and skin that is softened and broken down between the toes? What explanation does the nurse give the patient about the cause of this skin disorder? a. “Your itching is caused by a bacterial infection.” b. “Your itching is caused by an allergic reaction.” c. “Your itching is caused by a viral infection.” d. “Your itching is caused by a fungal infection.”

ANS: D Feedback A B C D

Bacterial infections such as cellulitis cause redness, warmth, and tenderness, rather than itching.

Allergic reactions such as contact dermatitis cause itching, but they appear as localized erythema, and may also form edema, wheals, scales, or vesicles.

Viral infection such as herpes form grouped vesicles that are painful, rather than itching.

This is a description of tinea pedia, which is caused by a number of dermophyte fungal infections.

DIF: Cognitive Level: Analyze REF: 127 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 26. A patient expresses concern that a new lesion may be melanoma. Which finding suggests a

malignant melanoma? a. Nonblanching lesion b. Irregular border c. Diameter less than 5 mm

d. Black color of the lesion ANS: B Feedback A B C D

Blanching is not assessed in malignant skin lesions.

Irregular border or poorly defined border is an indication of a malignancy.

Diameter of a malignant skin lesion is usually greater than 6 mm.

Melanoma is a variety of colors.

DIF: Cognitive Level: Apply REF: 102| 129-130 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems 27. During a health fair, which recommendation is appropriate as a primary prevention measure to

reduce the risk for skin cancer? a. Use a tanning booth instead of sunning outside if a tan is desired. b. Wear protective clothing while in the sun. c. Perform self-examination of skin monthly. d. Use sunscreen with a sun protection except on overcast days.

ANS: B Feedback A B C D

Avoiding tanning and sunning are part of primary prevention.

Wearing protective clothing while in the sun provides primary prevention for skin cancer.

Performing self-examination of skin monthly is secondary prevention.

Sunscreen also needs to be used on overcast days.

DIF: Cognitive Level: Understand REF: 102 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Self-Care 28. A nurse notes that a 2-year-old child has multiple bruises over his body at different stages of

healing. What is the most appropriate action for the nurse at this time? a. Obtain further data now to rule out abuse. b. Remind parents that toddlers are clumsy and may fall, causing bruising. c. Determine if this toddler has a coagulation disorder. d. Recommend further observation at future visits.

ANS: A Feedback A

B C

Further investigation is needed to rule out abuse. The important clue is bruises in different stages in healing. Injuries to the skin are generally recognized in three forms: bruises, bites, and burns.

Remind parents that toddlers are clumsy and may fall, causing bruising. The important clue is bruises in different stages of healing.

A coagulation disorder can be ruled out by a laboratory test for platelets.

D

Recommend further observation at future visits. Action must be taken during this visit if abuse is suspected.

DIF: Cognitive Level: Apply REF: 101| 118| 130-131 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems MULTIPLE RESPONSE 1. What findings does the nurse expect when assessing skin, hair, and nails of a healthy male

adult? Select all that apply. a. Transverse depression noticed across nails b. Scalp is bald c. Elevated, firm, circumscribed area less than 1 cm wide found on the fingers d. Purpura and ecchymosis are noticed on arms and legs e. Freckles are noted on face, back, arms, and legs f. Skin turgor is elastic ANS: B, E, F

Correct:Scalp is bald; freckles are noted on face, back, arms and legs; and skin turgor is elastic . These are expected findings for a healthy adult male.

Incorrect: Transverse depression across the nails describes Beau lines. It results from a stressor that temporarily impairs nail formation. An elevated, firm, circumscribed area, less than 1 cm wide on the fingers describes a papule, such as a wart. Purpura and ecchymosis on arms and legs are indications of bleeding.

DIF: Cognitive Level: Analyze REF: 106-107| 119 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 2. Which questions are appropriate to ask a patient when performing a symptom analysis for a

rash? Select all that apply. a. “When did the rash first start?” b. “Do you have a family history of rashes?” c. “What makes the rash worse?” d. “What do you do to make your rash better?” e. “Describe the sensation from the rash, does it burn or itch?” f. “Describe what the rash looked like initially.”

ANS: A, C, D, E, F

Correct: These are questions asked in a symptom analysis that includes the following variables: onset of symptoms, location and duration of symptoms, characteristics, severity of symptoms, related symptoms, alleviating factors, aggravating factors, and attempts at self-treatment.

Incorrect: This question relates to the patient’s history.

DIF: Cognitive Level: Analyze TOP: Nursing Process: Assessment

REF: 100

MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alterations in Body Systems