Question 1

Small hemorrhages are noted under the nailbed of a patient with a history of intravenous drug abuse.With what should the nurse realize this finding is associated?
A) Low albumin levels
B) Zinc deficiency
C) Renal disease
D) Bacterial endocarditis

Accepted Answer

Hemorrhages under the nailbed in a patient with a history of intravenous drug abuse are often associated with bacterial endocarditis, which is an infection of the inner lining of the heart and its valves. Intravenous drug abuse increases the risk of developing bacterial infections due to the use of nonsterile needles, and the infection can spread to other parts of the body, including the nails. Low albumin levels, zinc deficiency, and renal disease are not typically associated with this finding.

Question 2

Which portion of the ear is responsible for maintaining equilibrium?
A) External ear
B) Inner ear
C) Middle ear
D) Ossicles

Accepted Answer

The inner ear is responsible for maintaining equilibrium through the vestibular system, which includes the semicircular canals, utricle, and saccule. These structures detect changes in head position and movement, and send signals to the brain to help us maintain balance. The external and middle ear are involved in hearing. The ossicles are the three small bones of the middle ear that transmit sound vibrations to the inner ear.

Question 3

Which statement best describes the procedure used to assess capillary refill?
A) Briefly press the tip of the nail with firm,steady pressure,then release and observe for changes in color.
B) Press firmly with your fingertip for 5 seconds over a bony area,release pressure,and observe the skin for the reaction.
C) Tap on the skin with short strokes from your fingers.
D) Lift a fold of skin and allow it to return to its normal position.

Accepted Answer

Capillary refill is assessed by briefly pressing the tip of the nail with firm, steady pressure, then releasing and observing for changes in color. This allows for observation of how quickly the capillaries in the nail bed refill with blood after pressure is released. Option B describes checking for skin turgor, option C describes assessing for tactile fremitus, and option D describes assessing for skin elasticity.

Question 4

A patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease.Which finding might the nurse expect when assessing the patient's nails?
A) Soft,boggy nails
B) Brittle nails
C) Thickened nails
D) Thick nails with yellowing

Accepted Answer

The answer of A patient is admitted with an acute...

Question 5

When testing near vision,the nurse should position printed text how many inches away from the patient?
A) 20
B) 18
C) 16
D) 14

Accepted Answer

When testing near vision, the standard distance to position printed text is 14 inches away from the patient. This distance simulates typical reading distance and helps in assessing the patient's ability to focus on close objects.

Question 6

Which abnormal laboratory value is associated with icteric sclerae?
A) Bleeding time
B) Bilirubin
C) Hemoglobin
D) Glucose

Accepted Answer

Icteric sclerae, or yellow discoloration of the eyes, is a classic sign of elevated bilirubin levels in the blood. Bilirubin is produced by the breakdown of red blood cells and processed by the liver, so elevated levels can indicate liver dysfunction or obstructed bile flow. Bleeding time, hemoglobin, and glucose levels are not typically associated with icteric sclerae.

Question 7

Where should the nurse assess skin color changes in the dark-skinned patient?
A) Elbow
B) Any exposed area
C) Oral mucosa
D) Behind the knee

Accepted Answer

Oral mucosa is the best place to assess skin color changes in a dark-skinned patient because the mucous membranes are less pigmented than the skin and can provide a better indication of underlying changes in skin color.

Question 8

When should the nurse instruct a new mother to expect the anterior fontanel of her infant to fuse?
A) At about 8 weeks
B) At about 14 months
C) By 6 months of age
D) Before 1 year of age

Accepted Answer

The anterior fontanel of an infant typically fuses between 12-18 months of age. Choice A is too early, choice C is too soon for complete fusion, and choice D is too wide of a range.

Question 9

While the nurse assesses a newborn of African American descent,the mother points out a blue-black Mongolian spot on the newborn's back and asks,"What's that? Is something wrong with my baby?" Which response by the nurse is best?
A) "I'll ask the physician to look at the spot."
B) "Those spots are quite common and typically fade with time."
C) "You may want a plastic surgeon to look at that."
D) "That spot is benign so it's nothing you need to worry about."

Accepted Answer

Blue-black Mongolian spots are common in infants of African American, Asian, and Native American descent. They typically fade with time and do not require any medical intervention. Assuring the mother that the spot is common and benign will alleviate her concerns. The physician does not need to be consulted unless there are other concerns related to the spot. A plastic surgeon is not needed for this type of spot.

Question 10

The nurse notes ptosis in a patient who just arrived in the emergency department.What should the nurse realize this finding might indicate?
A) Hyperthyroidism
B) Stroke
C) Glaucoma
D) Macular degeneration

Accepted Answer

Ptosis, which is drooping of the eyelid, can be a sign of a stroke as it can indicate weakness or paralysis on one side of the face or body. Other symptoms such as drooping of the mouth or slurring of speech may also be present. It is important for the nurse to report this finding to the healthcare provider immediately to facilitate timely care.

Question 11

A female patient has excessive facial hair.How should the nurse document this finding?
A) Alopecia
B) Albinism
C) Hirsutism
D) Lanugo

Accepted Answer

Hirsutism refers to excessive hair growth, particularly in areas where hair is normally absent or minimal in amount, such as on the face for women. Alopecia means hair loss, albinism refers to lack of pigment in the skin, hair, and eyes, and lanugo is fine, soft, unpigmented fetal hair.

Question 12

An older adult comes to the clinic complaining of pain in the left foot.While assessing the patient,the nurse notes smooth,shiny skin that contains no hair on the client's lower legs.Which condition does this finding suggest?
A) Venous insufficiency
B) Hyperthyroidism
C) Arterial insufficiency
D) Dehydration

Accepted Answer

Smooth, shiny skin with absence of hair on the lower legs can be an indication of arterial insufficiency. This is because inadequate blood flow to the lower extremities can lead to decreased tissue oxygenation and nutrient delivery, which can result in loss of hair and changes in skin appearance. Venous insufficiency, on the other hand, is associated with symptoms such as edema, varicose veins, and skin changes such as discoloration and ulceration. Hyperthyroidism and dehydration are not typically associated with changes in skin appearance or hair loss on the legs.

Question 13

A mother brings her 6-month-old infant to the clinic for a well-baby checkup.How should the nurse proceed when weighing the patient?
A) Have the mother remain outside the room.
B) Ask the mother to remove the infant's clothing and diaper.
C) Weigh the infant wearing only the diaper.
D) Place the infant supine on the scale with his knees extended.

Accepted Answer

To obtain an accurate weight for a 6-month-old infant, the nurse should ask the mother to remove the infant's clothing and diaper. This ensures that the weight recorded is solely that of the infant, without any additional weight from clothing or a diaper.

Question 14

The left pupil of a patient fails to accommodate.This finding may reflect an abnormality in which cranial nerve?
A) CN III
B) CN V
C) CN VIII
D) CN X

Accepted Answer

CN III, also known as the oculomotor nerve, is responsible for controlling the movements of the eye muscles that control the pupil size and accommodation. A lesion or abnormality in CN III can lead to a failure of the pupil to constrict or enlarge appropriately in response to light and accommodation.

Question 15

A patient's ankles appear swollen.When the nurse assesses the edema,the skin depresses 6 mm,and the depression lasts 2 minutes.How should the nurse document this finding?
A) Trace edema
B) +1 edema
C) +2 edema
D) +3 edema

Accepted Answer

The nurse should document this finding as +3 edema, which is characterized by a 6 mm depression that lasts more than a minute.

Question 16

What should the nurse use to assess skin temperature?
A) Dorsum of the hand
B) Pad of the fingertip
C) Palm of the hand
D) Dorsum of the wrist

Accepted Answer

The dorsum (back) of the hand is the most sensitive part to assess skin temperature because it has a thinner layer of skin compared to other parts of the hand, allowing for better perception of temperature differences.

Question 17

A 48-year-old patient comes to the physician's office complaining of diminished near vision,which the nurse confirms with testing.How should the nurse document this finding?
A) Myopia
B) Diplopia
C) Presbyopia
D) Mydriasis

Accepted Answer

Myopia refers to nearsightedness, where distant objects are blurry but near objects are clear. Diplopia refers to double vision. Mydriasis refers to pupil dilation. Presbyopia is a type of age-related farsightedness that affects near vision. Therefore, C is the correct answer.

Question 18

Which skin assessment finding would cause the nurse to suspect dehydration in a middle-aged patient admitted to the hospital with traveler's diarrhea?
A) Edema
B) Hyperhidrosis
C) Pallor
D) Tenting

Accepted Answer

Tenting of the skin occurs when there is decreased skin turgor, which can indicate dehydration. Edema, or swelling, would not be a typical finding in someone who is dehydrated. Hyperhidrosis, or excessive sweating, may indicate other conditions but not necessarily dehydration. Pallor, or paleness of the skin, may indicate anemia or other conditions but not necessarily dehydration.

Question 19

While assessing an older adult patient,the nurse notes clubbing of the fingers.What does this finding indicate to the nurse?
A) Fungal infection
B) Malnutrition
C) Iron deficiency
D) Long-term hypoxia

Accepted Answer

Clubbing of the fingers is a physical finding that is associated with long-term hypoxia, or lack of oxygen. This can be due to a variety of underlying conditions, such as chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, or congenital heart disease. It is not associated with fungal infections, malnutrition, or iron deficiency.

Question 20

Which is an abnormal capillary refill finding that the nurse should report?
A) 1 second
B) 2 seconds
C) 3 seconds
D) 4 seconds

Accepted Answer

A capillary refill time of 4 seconds or greater is an abnormal finding and indicates poor peripheral perfusion, which may be due to shock or other circulation problems. A capillary refill time of 1-3 seconds is considered normal. Therefore, the nurse should report a capillary refill time of 4 seconds or greater.

Quiz 21: Physical Assessment

Small hemorrhages are noted under the nailbed of a patient with a history of intravenous drug abuse.With what should the nurse realize this finding is associated?

Which portion of the ear is responsible for maintaining equilibrium?

Which statement best describes the procedure used to assess capillary refill?

A patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease.Which finding might the nurse expect when assessing the patient's nails?

When testing near vision,the nurse should position printed text how many inches away from the patient?

Which abnormal laboratory value is associated with icteric sclerae?

Where should the nurse assess skin color changes in the dark-skinned patient?

When should the nurse instruct a new mother to expect the anterior fontanel of her infant to fuse?

While the nurse assesses a newborn of African American descent,the mother points out a blue-black Mongolian spot on the newborn's back and asks,"What's that? Is something wrong with my baby?" Which response by the nurse is best?

The nurse notes ptosis in a patient who just arrived in the emergency department.What should the nurse realize this finding might indicate?

A female patient has excessive facial hair.How should the nurse document this finding?

An older adult comes to the clinic complaining of pain in the left foot.While assessing the patient,the nurse notes smooth,shiny skin that contains no hair on the client's lower legs.Which condition does this finding suggest?

A mother brings her 6-month-old infant to the clinic for a well-baby checkup.How should the nurse proceed when weighing the patient?

The left pupil of a patient fails to accommodate.This finding may reflect an abnormality in which cranial nerve?

A patient's ankles appear swollen.When the nurse assesses the edema,the skin depresses 6 mm,and the depression lasts 2 minutes.How should the nurse document this finding?

What should the nurse use to assess skin temperature?

A 48-year-old patient comes to the physician's office complaining of diminished near vision,which the nurse confirms with testing.How should the nurse document this finding?

Which skin assessment finding would cause the nurse to suspect dehydration in a middle-aged patient admitted to the hospital with traveler's diarrhea?

While assessing an older adult patient,the nurse notes clubbing of the fingers.What does this finding indicate to the nurse?

Which is an abnormal capillary refill finding that the nurse should report?