Test bank Bates’ Nursing Guide to Physical Examination and History Taking 2nd Edition
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1. A patient recovering from a burn injury is told by the health care provider that hair will no longer grow on the body part that was burned. The nurse realizes that this patient's burn extended into which skin layer?
A) Epidermis
B) Dermis
C) Subcutaneous tissue
D) Distal phalanx
2. A patient has sustained burns over 50% of the body. When planning care for this patient, the nurse will include interventions to address which alteration in the skin's barrier function?(Select all that apply.)
A) Synthesis of vitamin D
B) Regulation of body temperature
C) Mechanical or chemical injuries
D) Penetration by microorganisms
E) Loss of water and electrolytes
3. A patient's risk for pressure sore development according to the Braden Scale is as follows: Sensory perception: 4
Moisture: 4
Activity: 2
Mobility: 2
Nutrition: 1
Friction and Shear: 3
From this assessment, the nurse determines that the patient's risk for pressure sore development is:
A) No risk
B) Mild risk
C) Moderate risk
D) High risk
4. What data collected during an integumentary assessment should cause the nurse to be concerned that a patient is at risk for the development of skin cancer? (Select all that apply.)
A) Age 55 years
B) Light-colored hair
C) Actinic keratosis on face
D) Poor skin turgor
E) Yellow palms of the hands
5. During the integument health history, the nurse asks the patient about both current and previous prescription medications, immunizations, and diagnosed illnesses. What is the primary benefit derived from the data provided by this questioning?
A) History of previous medical health promotion care
B) Identifying the patient's risk for developing skin cancer
C) Minimizing the patient's potential risk for pressure ulcer formation
D) Existence of systemic diseases that have skin manifestations
6. The nurse preparing to conduct an integumentary assessment will include which interventions when preparing the patient for this examination? (Select all that apply.)
A) Assisting the patient to put on a gown.
B) Providing adequate drapes.
C) Using the mnemonic OLDCART as a guide.
D) Wearing gloves when palpating lesions.
E) Using cotton balls to assess for sensation.
7. A patient, with a family history of melanoma, wants to have specific body moles assessed. When performing this assessment, the nurse will use what equipment? (Select all that apply.)
A) Warm water
B) Examination table
C) Chair
D) Gloves
E) Natural lighting
8. After completing an integument physical examination, the nurse is documenting information about the patient's lesions. What will the nurse include in this documentation? (Select all that apply.)
A) Condition of surrounding skin
B) Location and distribution
C) Amount of drainage
D) Elevation
E) Color
9. While assessing a patient's arms, the nurse notes a 3-mm oval lesion located on left forearm. The lesion is primarily purple with areas of green and yellow. Which descriptive term should the nurse use to document this lesion in the client's medical record?
A) Vascular
B) Purpuric
C) Primary
D) Secondary
10. What medical outcomes are directly associated with a nursing observation made during an integumentary systems assessment? Select all that apply.
A) the loss of skin turgor as a result of aging
B) a cancerous skin lesion located on the back
C) presence of a systemic disease like measles
D) a rash triggered by taking the medication ibuprofen
E) a reddened area on the heel that indicates a potential risk for pressure ulcer formation
11. The nurse is preparing an educational program on effective hygiene methods for a group of high school teens. When discussing the need for antiperspirants and effective bathing, the nurse will focus on which layer of the skin?
A) dermis
B) adipose
C) epidermis
D) subcutaneous
12. What role does oxyhemoglobin play in the physiological process that results in pallor?
A) the circulation of oxygen in the blood
B) the reduction of red pigment in the arteries
C) the increase of blue pigment in the venous system
D) the loss of this component from the circulatory system
13. The analysis of a client's arterial blood indicates a normal level of arterial oxygen, but the client's skin is cyanotic. What is the cause of this observation?
A) The client is demonstrating central cyanosis.
B) The cyanosis may be a result of a prolonged period of exposure to the cold.
C) The client's arterial blood will appear bluish when observed in the test tube.
D) The cyanosis is a result of body tissue extracting less than usual amounts of oxygen from the blood.
14. The nurse expects what change in a client's hair as a result of aging?
A) The is an increase in the loss of fine, relatively unpigmented hair referred to as villus hair.
B) The existing terminal hair will become coarser and less pigmented.
C) Sebaceous glands will secrete less causing hair to be drier.
D) Eyebrows will thin and gradually disappear.
15. When assessing for apocrine gland function, the nurse would assess for moisture where on the client's body?
A) palms of the hands
B) face
C) soles of the feet
D) underarms
16. When assessing a Pakistani American for possible pallor, the nurse should focus on what location on the body?
A) lips
B) nails of the hands
C) soles of the feet
D) mucous membranes
17. What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?
A) fainting
B) vomiting
C) diarrhea
D) diaphoresis
18. The nurse should implement which technique when assessing for jaundice in a dark-skinned patient diagnosed with liver disease?
A) asking the client to blink rapidly before assessing the palpebral conjunctiva of the eye
B) assessing the skin covering the client's elbow while applying moderate pressure
C) asking the client to stick out the tongue and assess the presenting surface
D) assessing the client's hard palate with a bright light
19. Which situations should the nurse identify as being risk factors of the development of pressure sores? Select all that apply.
A) pressure that impairs capillary blood flow to the skin
B) friction created by dragging the skin against bedlinen
C) shearing that occurs when sliding down in bed
D) moisture being allowed to accumulate on the skin
E) restlessly changing position frequently