• The nurse is preparing to examine a patient's skin. Which of the following actions would be most important for the nurse to do? • Ensure that the room is hot to prevent chilling. • Wear gloves when preparing to inspect the skin and nails. • Expose only the body part that is being examined. • Have the patient remove clothing from the upper body. • A nurse is providing a patient with instructions on how to perform self-examination of the skin. The nurse would encourage the patient to perform this examination at which frequency? • Monthly • Bimonthly • Quarterly • Yearly • Assessment of a patient's skin reveals several individual and distinct 2-mm lesions on the patient's back. The nurse would document the configuration as which of the following? • Discrete • Linear • Annular • Confluent • Assessment of a patient's nails reveals the presence of Beau's lines. The nurse interprets this finding as suggestive of which of the following? • Oxygen deficiency • Acute illness • Psoriasis • Trauma • A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult patient. What assessment parameter will the nurse evaluate when using this scale? • The patient's current medication regimen • The patient's ability to change position • The pigmentation of the patient's skin • • A nurse is assessing a 49-year-old patient who questions the nurse's need to know about sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment? • ìRepeated sunburns in childhood may explain the presence of some of your moles.î • ìThis is one of the assessments we use to determine whether your parents took good care of your skin when you were young.î • ìWhen you burn your skin as a child, it makes your skin more sensitive and slower to heal when you're older.î • ìHaving bad sunburns when you're a child puts you at risk for skin cancer later in life.î • A nurse is implementing appropriate infection control precautions while performing a patient's skin assessment. During which of the following components of the assessment should the nurse wear gloves? • When palpating the texture of the patient's skin • When palpating the patient's hair • When palpating lesions on the patient's skin • When palpating the patient's nail beds for texture and capillary refill • The nurse is conducting an assessment of an adult patient who describes herself as being in good health. Inspection of the patient's nail beds reveals the presence of a bluish tone. The nurse should recognize that this finding is most likely attributable to what phenomenon? • Vasoconstriction • Hyperglycemia • Hypoxemia • Cardiopulmonary insufficiency • A nurse is providing care for a patient who has decreased mobility secondary to a recent stroke. Which of the following assessment findings would be indicative of a stage I pressure ulcer? • There is a nonblanching reddened area on the patient's coccyx region. • There is scant, frank blood present on the skin surfaces surrounding the patient's coccyx. • There is noticeable bruising on and around the patient's coccyx region. • There is a generalized rash on the patient's lower back and buttocks. • A patient has sought care because of the development of pruritic lesions between her toes, which the nurse suspects are attributable to a fungal etiology. How can the nurse best corroborate this suspicion? • Test whether gentle abrasion with an emery board is painful. • Apply hydrogen peroxide to see whether the patient's pruritus is relieved. Downloaded by: stephaniedimas | • Perform a trial with a topical antibiotic. • Illuminate the area using a Wood's light. • The nurse is assessing a middle-aged female patient who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the patient's ethnicity. What assessment question should the nurse consequently ask? • ìHas anyone in your family ever been diagnosed with skin cancer?î • ìHave you ever been assessed for diabetes?î • ìWhat dietary supplements do you usually take?î • ìDo you take steroid medications on a regular basis?î • The nurse is assessing a dark-skinned patient whose forearms are hands have distinct regions of depigmentation. The nurse should document the presence of what health problem? • Vitiligo • Striae • Angiomas • Albinism • A nurse is assessing an older adult patient's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore Risk. Which aspect of the patient's current health status would be reflected in her score on this scale? • The patient has a full-time caregiver. • The patient is consistently incontinent of urine. • The patient has a surgical diagnosis. • The patient adheres to a vegetarian diet. • A nurse is preparing for an assessment by reviewing a new patient's electronic health record, which documents the presence of macules on the patient's left flank and mid-back regions. The nurse should recognize what characteristic of these skin lesions? • The lesions will be raised and have irregular borders. • The lesions will be acutely painful. • The lesions will produce eschar. • The lesions will not be palpable. The nurse is preparing to palpate a patient's temporal artery. The nurse would place the hands at which location? • On each side of the patient's face, anterior and inferior to the ears • On each side between the top of the ear and the eye • Bilaterally, parallel to and anterior to the sternomastoid muscle • Inferior to the lower jaw beneath the patient's tongue • A nurse is preparing to assess an adult patient's carotid pulses. Which of the following actions would be contraindicated? • Asking the patient to flex his or her neck • Compressing the arteries bilaterally • Performing the examination while the patient is seated • Asking the patient to swallow water • The nurse's assessment reveals that a male patient can neither turn his head against resistance nor shrug his shoulders. The nurse should document a potential deficit in the functioning of which cranial nerve? • Abducens (VI) • Accessory (XI) • Hypoglossal (XII) • Trochlear (IV) • During the health history, a patient describes recent episodes of intermittent facial pain lasting several minutes. The nurse should recognize that this complaint is suggestive of what health problem? • Trigeminal neuralgia • Migraine headache • Meningitis • Temporomandibular joint dysfunction • A patient describes her frequent headaches as being severe and lasting for days. The patient's positive response to what question would most clearly suggest to the nurse that these headaches are migraines? • ìDo they occur after you have been tense or anxious?î • ìWhen you consume alcohol, do you get a headache?î • ìDo you have any eye symptoms, such as tearing?î • ìDo you have any visual changes before the headache?î • Which factor, if present in a patient's lifestyle and health practices assessment, would alert the nurse to the need for performing a more thorough head and neck assessment? • Alcohol abuse • Recreational drug use • Smokeless tobacco use • Multiple sex partners • A nurse is preparing a presentation for a local community group about preventing traumatic brain injury. The nurse would discuss which measure as prevention of the leading cause? • Safe use of firearms • Safe use of machinery • Falls prevention • Domestic violence prevention • A nurse is palpating the head and neck of a newly referred patient. Which of the following would the nurse suspect if assessment reveals that the patient's skull and facial bones are larger and thicker than normal? • Acromegaly • Brain tumor • Paget disease • Parkinson disease • When talking to a patient before starting the physical exam, the nurse notes that the patient consistently tilts her head to one side. Which of the following should the nurse examine first? • Hearing acuity • Thyroid gland • Mental status • Lymph nodes • The nurse assesses a patient and palpates a temporal artery that is hard, thick, and tender with absent pulsations. The nurse would gather additional information related to which aspect of health? • Mental status • Hearing • Neurologic status • Vision • A nursing educator is evaluating a colleague's examination of a patient's thyroid gland. The educator would determine that the nurse needs additional instruction when the nurse demonstrates which technique? • Inspection • Auscultation • Palpation • Percussion • A nurse is palpating the position of the patient's trachea. At which anatomic site would the nurse first position a finger for palpation? • Sternocleidomastoid muscle • Sternal notch • Submental space • Supraclavicular space