HA Ch 11 -19

Chapter 11

What structures are destroyed in a dermal burn? (Select all that apply.)

Lymphatic vessels; Blood vessels; Sweat glands

What is the purpose of sebum from sebaceous glands?

Assists in keeping the skin intact

What should the nurse teach a client diagnosed with lupus?

The client may experience photosensitivity that worsens the condition.

What would excessive hair growth on the shoulders and upper inner thighs suggest in a teenager?

Ovarian dysfunction

What is the most appropriate teaching for a client with a stable lesion?

Signs and symptoms of melanoma

What is the best response to a newborn with spoon-like nails?

This may be normal in newborns.

How should skin turgor be assessed in an older adult?

Pinch a fold of skin on the client's forearm

What should the nurse note when inspecting the hair? (Select all that apply.)

Color; Condition of hair shaft; Hair shafts that are shiny

What might rough, scaly macules on the back of an older adult indicate?

Possible solar keratosis

What skin condition involves honey-colored crusts and vesicles in children?

Impetigo

What is true about a hemangioma on a newborn's face?

Will usually resolve by the age of 9 years

What does excessive hair loss with the bulb intact indicate?

Abnormal endocrine function

What does a painful, ruddy ulcer on the big toe suggest?

Arterial ulcer

What would a pink lesion with silvery scales on the knee be charted as?

Psoriasis

What does uremic frost along the hairline indicate?

Renal failure

What is the most important outcome for a client with impaired skin integrity?

The client exhibits no signs or symptoms of infection.

What does a red groin sore with satellite pustules suggest?

Candida

What should be documented for a reddened coccyx area? (Select all that apply.)

Location; Size; Texture

What might multiple ecchymoses in various areas indicate in an older adult? (Select all that apply.)

Repeated trauma; Physical abuse; A coagulopathy

What causes acne?

Acne is caused by the impedance of sebum secretion onto the skin's surface.

What depth of burn is moist, red, painful, and has rapid capillary refill?

Superficial

Chapter 12

Where is the thyroid isthmus palpated during a neck assessment?

Just below the cricoid cartilage

What structure is found midline in the tracheal area just beneath the mandible?

Hyoid bone

What screening should be included for pregnant women in head and neck exams?

Thyroid

Which statement suggests the need for neuro assessment related to Parkinson disease?

Dad seems to shuffle instead of walking normally.

What age-related change may cause upper arm tingling in a 67-year-old client?

Arthritic changes in the cervical spine

What is the priority nursing action for a client who can't feel their limbs after a diving injury?

Maintain immobilize of the spine until it is cleared of injury

What should the nurse inspect in the neck during a generalized assessment?

Limitations in movement

What are characteristics of fetal alcohol syndrome? (Select all that apply.)

Microcephaly; Small eyes; Flattened upper lip

What signs suggest Cushing syndrome in a client with diarrhea?

Moon face, buffalo hump, and velvety neck discoloration

Which assessment questions align with hypothyroidism symptoms? (Select all that apply.)

Have there been any changes in your menstrual period?; Have you experienced a decrease in appetite?; Do you find yourself being cold frequently?

What is the best initial intervention for a client reporting chronic cervical pain?

Assess the client regarding characteristics of the pain

What symptom indicates a possible ischemic brain attack?

My vision suddenly became blurred.

How should a painful, matted neck mass be charted?

Nodes feel matted together on palpation.

What sound confirms toxic goiter when auscultating an enlarged thyroid?

Bruit

What infant head sign is consistent with hydrocephalus?

Bulging fontanelles

What culturally varying characteristics should be assessed in the head and neck? (Select all that apply.)

Lips; Nose; Eyes

What is an appropriate nursing diagnosis for an infant with Down syndrome features?

Knowledge deficit related to trisomy 21

Which nodal finding would be of concern to a nurse?

A moveable posterior auricular node

What are the critical interventions for a client with the worst headache ever? (Select all that apply.)

Physical examination for neurological changes; Conduct a focused history interview

What are neck cancer risk factors? (Select all that apply.)

Male gender; Tobacco use; Age older than 50 years

Chapter 13

What is the open space between the eyelids called?

The palpebral fissure

What are parts of the lacrimal apparatus? (Select all that apply.)

Punctum; Lacrimal sac; Lacrimal gland; Nasolacrimal duct

What intervention helps a visually impaired client maintain safety during hygiene tasks?

Encourage him to use a magnifying mirror when shaving

What is the largest chamber of the eye?

Vitreous

What is the effect of mydriatic drops on glaucoma?

Mydriatic drops may precipitate acute angle-closure glaucoma.

Which test assesses boundaries of peripheral vision?

Kinetic confrontation

What eye condition should be screened for in someone with a first-degree relative with an eye problem?

Glaucoma

What statement shows understanding of AMD prevention?

I eat a leafy green salad everyday with either lunch or dinner.

What equipment is needed to assess extraocular movements when one eye moves faster than the other?

Pen

What is true about the cup-disc ratio? (Select all that apply.)

It is genetically determined; It is equal in both eyes.

What might be visualized during an eye exam in a client with long-standing hypertension?

AV nicking

What personal action helps manage cataracts?

Be sure to wear ultraviolet light blocking sunglasses.

What defines legal blindness?

Less than 20/200 bilaterally

What question screens for night blindness?

Does your diet regularly include foods that contain vitamin A?

What test screens for strabismus?

Corneal light reflex

What is the likely diagnosis for eye pain, blurred vision, and headaches from computer use?

Asthenopia

What cranial nerves are involved in eye movement? (Select all that apply.)

CN II; CN III; CN IV; CN VI

What findings are considered normal for older adults during visual testing? (Select all that apply.)

Arcus senilis; Small cataract; Decreased central vision

How is 20/60 vision with glasses documented?

20/60 with glasses

How should thick purulent drainage in both eyes be documented?

Thick, purulent drainage is noted at inner corner of both eyes.

What is the nurse's priority action for sudden visual loss in one eye?

Notify the healthcare provider immediately

Chapter 13

Chapter 14

What is the function of the eustachian tube?

Helps to regulate pressure in the middle ear

What sound components does the cochlea interpret? (Select all that apply.)

Amplitude; Frequency

Where would the malleus be visualized on the tympanic membrane?

Near the center

Where should the cone of light appear on the tympanic membrane?

Anterior-inferior quadrant

What is the next step when drainage persists after 3 antibiotics courses for otitis media?

Refer the client to an otolaryngologist

What does ear drainage after trauma indicate?

Basilar skull fracture

What teaching should be provided regarding noise and hearing loss? (Select all that apply.)

Types of protective equipment used; Instructions for the use of protective ear equipment; Effectiveness of protective equipment

What client education should be included about ear hygiene?

How the client cleans the ears

What is the finding of small, painless nodules on the helix?

Left external ear within normal limits

How should the nurse prepare for objective ear assessment? (Select all that apply.)

Have the client sit on the examination table; Make sure the client is comfortable in a quiet room; Place the client's ears at the nurse's eye level

What do white patches on the tympanic membrane indicate?

Tympanic membrane visualized with areas of sclerosis noted

What is an abnormal ear finding?

Tenderness of the mastoid process

What is a normal structure seen during otoscopy?

The short process of the malleus

What is the correct technique to view the tympanic membrane in an adolescent?

Hold the ear at the helix and lift up and back

What does abnormal Weber test suggest?

The client has unilateral hearing loss.

What movement is expected with bulb insufflation of the tympanic membrane?

Positive pressure pushing down the tympanic membrane

What condition is suggested by pain on palpating the tragus?

Furuncle

What is a primary concern for toddlers with tympanostomy tubes?

Risk of infection

What can be achieved by removing cerumen impaction in older adults? (Select all that apply.)

Improve hearing; Enhance socialization; Prevent injury

What term describes a spinning sensation with nausea?

Vertigo

Chapter 15

What is the best description of the term columella?

The structure that divides the nares

Where would the nurse expect an occult nasopharyngeal malignancy?

Rosenmüller fossa

Where do most nosebleeds originate?

Kiesselbach plexus

What symptom is associated with inflammation of the nose and sinuses?

Anosmia

What health promotion topics are associated with nose, sinuses, mouth, and throat? (Select all that apply.)

Tobacco use; Obstructive sleep apnea; Oral health

What finding might indicate allergy in nose, sinus, mouth, and throat assessment?

Frequent childhood infections

What oral finding may confirm a complication of antibiotic treatment for otitis media?

White patches firmly attached to the buccal mucosa

What does difficulty inserting an NG tube through the nares likely indicate?

Deviated septum

What is the gold standard diagnostic tool for sinus disease?

Computed tomography (CT) scanning

What might dry and cracked lips indicate?

Inadequate hydration

What is the most pertinent nursing diagnosis for a stroke patient with choking and food falling from mouth?

Impaired swallowing

What finding is common in a Hispanic child during oral assessment?

Dental caries