Test 2 Review

Question 1

To which patient will the nurse plan to provide teaching on managing acute pain?

a. Patient with arthritis
b. Patient with fibromyalgia
c. Patient with kidney stones
d. Patient with low back pain

Answer 1

ANS: C
Acute pain is of short duration and dissipates after the injured tissue has healed, for example, in a patient with kidney stones. The other conditions are examples of chronic pain during which the pain continues for 6 months or longer and does not stop even after the injured tissue has healed.

Question 2

The nurse is teaching students about the older adult population and normal aging. Which statement by a nursing student indicates an understanding of older adults and pain?

a. “Older adults must learn to tolerate pain.”
b. “Pain is a normal process of aging and is to be expected.”
c. “Pain is not a normal process of aging and can indicate injury.”
d. “Older adults perceive pain to a lesser degree compared with younger individuals.”

Answer 2

ANS: C
Pain indicates a pathological condition or an injury and should never be considered something that an older adult should expect or tolerate. Pain is not a normal part of aging, and no evidence suggests that pain perception is reduced with aging.

Question 3

A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, “It hurts so bad.” Which pain assessment tool would be the best choice when assessing this child’s pain?

a. Descriptor Scale
b. Numeric rating scale
c. Brief Pain Inventory
d. Faces Pain Scale—Revised (FPS-R)

Answer 3

ANS: D
Rating scales can be introduced at age 4 or 5 years. The FPS-R is designed for use with children and asks the child to choose a face that shows “how much hurt (or pain) you have now.” Young children should not be asked to rate pain by using numbers.

Question 4

A patient states that the pain medication is “not working” and rates his postoperative pain at a 10 on a 1-to-10 scale. Which of these assessment findings indicates an acute pain response to poorly controlled pain?

a. Confusion
b. Hyperventilation
c. Increased blood pressure and pulse
d. Depression

Answer 4

ANS: C
Responses to poorly controlled acute pain include tachycardia, elevated blood pressure, and hypoventilation. Confusion and depression are associated with poorly controlled chronic pain.

Question 5

During assessment, a 68-year-old patient informs the nurse about the analgesics she uses to manage her arthritis pain. What should the nurse caution the patient about?

a. Use of warm packs
b. Dislike of using ibuprofen
c. Occasional use of a multivitamin
d. Frequent combined use of acetaminophen and prescribed Tylenol 3

Answer 5

ANS: D
Many medications are combined with acetaminophen to achieve a synergistic effect (Percocet,
which contains both acetaminophen and oxycodone; Tylenol 1, 2, and 3, which contain
combinations of acetaminophen with varying amounts of codeine; and Tramacet, which
contains paracetamol and tramadol). Acetaminophen is well tolerated; however, the maximum
daily dosage in a healthy patiNentRshoIuldGnotBex.cCeedM4 g per day from all sources combined. USNT O
The maximum daily dosage is best decreased for older patients and for those with impaired liver function.

Question 6

When assessing a patient’s pain, the nurse knows that the most reliable indicator of pain would be the:

a. Patient’s vital signs.
b. Physical examination findings.
c. Results of a computed tomography (CT) scan.
d. Subjective report by the patient.

Answer 6

ANS: D
The subjective report by the patient is the most reliable indicator of pain. Physical examination findings can lend support, but the clinician cannot base the diagnosis of pain solely on physical assessment findings.

Question 7

A patient has had arthritic pain in her hips for several years since she suffered a hip fracture. She is walking around in her room with no sign of discomfort. However, when asked, she states that her pain is “bad this morning” and rates it at an 8 on a 1-to-10 scale. What does the nurse suspect? The patient:

a. Is addicted to her pain medications and cannot obtain pain relief.
b. Does not want to trouble the nursing staff with her complaints.
c. Is not in pain but rates it high to receive pain medication.
d. Has experienced chronic pain for years and has adapted to it.

Answer 7

ANS: D
Persons with chronic pain typically try to give little indication that they are in pain and, over time, adapt to the pain. As a result, they are at risk for underdiagnosis.

Question 8

The nurse is reviewing the principles of pain. Which type of pain is caused by an abnormal processing of the pain impulse through the peripheral or central nervous system?

a. Visceral
b. Referred
c. Cutaneous
d. Neuropathic

Answer 8

ANS: D
Neuropathic pain implies an abnormal processing of the pain message. The other types of pain are named according to their sources.

Question 9

When assessing the quality of a patient’s pain, which question should the nurse ask?

a. “When did the pain start?”
b. “Is the pain a stabbing pain?”
c. “Is it a sharp pain or dull pain?”
d. “What does your pain feel like?”

Answer 9

ANS: D

To assess the quality of a person’s pain, the patient should be asked to describe the pain in his or her own words.

Question 10

When assessing a patient’s pain, the nurse knows that an example of visceral pain would be:

a. Hip fracture.
b. Cholecystitis.
c. Second-degree burns.
d. Pain after a leg amputation.

Answer 10

ANS: B

Visceral pain originates from the larger interior organs, such as the gallbladder, liver, or kidneys.

Question 11

The nurse is reviewing the principles of nociception. During which phase of nociception does the conscious awareness of a painful sensation occur?

a. Perception
b. Modulation
c. Transduction
d. Transmission

Answer 11

ANS: A
Perception is the third phase of nociception and indicates the conscious awareness of a painful sensation. During this phase, the sensation is recognized by higher cortical structures and identified as pain.

Question 12

When assessing the intensity of a patient’s pain, which question by the nurse is appropriate?

a. “What makes your pain better or worse?”
b. “How much pain do you have now?”
c. “How does pain limit your activities?”
d. “What does your pain feel like?”

Answer 12

ANS: B
Asking the patient “How much pain do you have?” is an assessment of the intensity of a patient’s pain; various intensity scales can be used. Asking what makes one’s pain better or worse assesses alleviating or aggravating factors. Asking whether pain limits one’s activities assesses the degree of impairment and quality of life. Asking “What does your pain feel like” assesses the quality of pain.

Question 13

A patient is complaining of severe knee pain after twisting it during a basketball game and is requesting pain medication. Which action by the nurse is appropriate?
a. Completing the physical examination first and then giving the pain medication
b. Telling the patient that the pain medication must wait until after the x-ray images
are completed
c. Evaluating the full range of motion of the knee and then medicating for pain
d. Administering pain medication and then proceeding with the assessment

Answer 13

ANS: D
The American Pain Society (1992) has stated: “In cases in which the cause of acute pain is uncertain, establishing a diagnosis is a priority, but symptomatic treatment of pain should be given while the investigation is proceeding. With occasional exceptions, (e.g., the initial examination of the patient with an acute condition of the abdomen), it is rarely justified to defer analgesia until a diagnosis is made. In fact, a comfortable patient is better able to cooperate with diagnostic procedures.”

Question 14

The nurse is assessing a 6-month-old infant. What does the nurse know to be true regarding the pain experienced by infants?
a. Pain in infants can only be assessed by physiological changes, such as an increased
heart rate.
b. The FPS-R can be used to assess pain in infants.
c. A procedure that induces pain in adults will also induce pain in the infant.
d. Infants feel pain less compared with adults.

Answer 14

ANS: C
If a procedure or disease process causes pain in an adult, then it will also cause pain in an infant. Physiological changes cannot be exclusively used to confirm or deny pain because other factors, such as medications, fluid status, or stress, may cause physiological changes. The FPS-R can be used starting at age 4 years.

Question 15

A patient has been admitted to the hospital with vertebral fractures related to osteoporosis. She is in extreme pain. This type of pain would be classified as:

a. Referred
b. Cutaneous
c. Visceral
d. Deep somatic

Answer 15

ANS: D
Deep somatic pain comes from such sources as the blood vessels, joints, tendons, muscles, and bone. Referred pain is felt at one site but originates from another location. Cutaneous pain is derived from the skin surface and subcutaneous tissues. Visceral pain originates from the larger, interior organs.

Question 16

During assessment of a patient’s pain, the nurse is aware that certain nonverbal behaviours are associated with chronic pain. Which of these behaviours are associated with chronic pain? (Select all that apply.)

a. Sleeping
b. Moaning
c. Diaphoresis
d. Bracing
e. Restlessness
f. Rubbing

Answer 16

ANS: A, D, F
Behaviours that have been associated with chronic pain include bracing, rubbing, diminished activity, sighing, and changes in appetite. In addition, those with chronic pain may sleep in an attempt at distraction. The other behaviours are associated with acute pain.

Question 17

During an admission assessment of a patient with dementia and recent falls, the nurse will assess for pain by: (Select all that apply.)

a. Asking the family to identify any patterns the patient demonstrates to express pain.
b. Examining the patient’s facial expressions and behaviours for pain cues.
c. Asking the patient to describe the pain.
d. Having the patient rate pain on a 1-to-10 scale.
e. Assessing for sudden onset of acute confusion in the patient.

Answer 17

ANS: A, B, E
Intellectually/cognitively impaired persons, such as patients with dementia, may have a limited ability to communicate information about pain, which places them at high risk for undertreatment of pain. Discussion with the family or other health care team members can help you identify patterns that may indicate that a patient is experiencing pain. Be attentive to behavioural cues of pain, by examining facial expressions or changes in appetite, daily activities, involvement in social activities, or sleep–wake cycles. Assess any sudden onset of acute confusion or delirium because it may indicate poor control of pain.

Question 18

When working with Indigenous children, the nurse recognizes that they: (Select all that apply.)

a. Express pain through their facial expressions.
b. Silently suffer through their pain.
c. Cry easily when in pain.
d. Are reluctant to express their pain vocally.
e. Are at increased risk for pain.

Answer 18

ANS: B, D, E
Indigenous children and youth feel and experience pain just like anyone else, but many tend not to express it outwardly through words, facial expressions, or crying. They just manage it and suffer silently. This response to pain is thought to be a result of cultural traditions and the effects of the residential school system. Indigenous children have higher rates of dental pain, ear infections, and juvenile rheumatoid arthritis. Understanding that this population is at a higher risk for pain and is also more likely to be stoic about pain expression should prompt health care providers to have open discussions with Indigenous patients about experiences that may cause them pain: both bodily and spiritually.

Question 19

During an examination, the nurse can assess mental status by which activity?

A. Examining the patient’s electroencephalogram
B. Observing the patient as he or she performs an intelligence quotient (IQ) test
C. Observing the patient and inferring health or dysfunction
D. Examining the patient’s response to a specific set of questions

Answer 19

ANS:C
Mental status cannot be directly scrutinized like the characteristics of skin or heart sounds. Its functioning is inferred through an assessment of an individuals behaviors, such as consciousness, language, mood and affect ,and other aspects

Question 20

The nurse is assessing the mental status of a child. Which statement about children and mental status is true?

A. All aspects of mental status in children are interdependent.
B. Children are highly labile and unstable until the age of 2 years.
C. Childrens mental status is largely a function of their parents level of functioning until the age of 7 years.
D. A childs mental status is impossible to assess until the child develops the ability to concentrate.

Answer 20

ANS: A
Separating and tracing the development of only one aspect of mental status is difficult. All aspects are interdependent. For example, consciousness is rudimentary at birth because the cerebral cortex is not yet developed. The infant cannot distinguish the self from the mothers body. The other statements are not true.

Question 21

The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient:

a. Will have no decrease in any of his abilities, including response time.
b. Will have difficulty on tests of remote memory because this ability typically decreases with age.
c. May take a little longer to respond, but his general knowledge and abilities should not have declined.
d. Will exhibit had a decrease in his response time because of the loss of language and a decrease in general knowledge.

Answer 21

ANS: C
The aging process leaves the parameters of mental status mostly intact. General knowledge does not decrease, and little or no loss in vocabulary occurs. Response time is slower than in a youth. It takes a little longer for the brain to process information and to react to it. Recent memory, which requires some processing, is somewhat decreased with aging, but remote memory is not affected.

Question 22

When assessing aging adults, the nurse knows that one of the first things that should be assessed before making judgments about their mental status is:

a. Presence of phobias
b. General intelligence
c. Presence of irrational thinking patterns
d. Sensory-perceptive abilities

Answer 22

ANS: D
Age-related changes in sensory perception can affect mental status. For example, vision loss (as detailed in Chapter 15) may result in apathy, social isolation, and depression. Hearing changes are common in older adults, which produces frustration, suspicion, and social isolation and makes the person appear confused.

Question 23

The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination?

a. A patients family is the best resource for information about the patients coping skills.
b. Gathering mental status information during the health history interview is usually sufficient.
c. Integrating the mental status examination into the health history interview takes an enormous amount of extra time.
d. To get a good idea of the patients level of functioning, performing a complete mental status examination is usually necessary.

Answer 23

ANS: B
The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described, however, rarely need to be taken in their entirety. Usually, one can assess mental status through the context of the health history interview.

Question 24

A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurses best course of action?

a. Perform a complete mental status examination.
b. Refer him to a psychometrician.
c. Plan to integrate the mental status examination into the history and physical examination.
d. Reassure his wife that memory loss after a physical shock is normal and will soon subsi

Answer 24

ANS: A
Performing a complete mental status examination is necessary when any abnormality in affect or behavior is discovered or when family members are concerned about a persons behavioral changes (e.g., memory loss, inappropriate social interaction) or after trauma, such as a head injury.

Question 25

The nurse is conducting a patient interview. Which statement made by the patient should the nurse more
fully explore during the interview?
a. I sleep like a baby.
b. I have no health problems.
c. I never did too good in school.
d. I am not currently taking any medications.

Answer 25

ANS: C
In every mental status examination, the following factors from the health history that could affect the findings should be noted: any known illnesses or health problems, such as alcoholism or chronic renal disease; current medications, the side effects of which may cause confusion or depression; the usual educational and behavioral level, noting this level as the patients normal baseline and not expecting a level of performance on the mental status examination to exceed it; and responses to personal history questions, indicating current stress, social interaction patterns, and sleep habits.

Question 26

A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and is lethargic. The nurses best approach regarding this examination is to:

a. Plan to defer the rest of the mental status examination.
b. Skip the language portion of the examination, and proceed onto assessing mood and affect.
c. Conduct an in-depth speech evaluation, and defer the mental status examination to another time.
d. Proceed with the examination, and assess the patient for suicidal thoughts because dysarthria is often accompanied by severe depression.

Answer 26

ANS: A
In the mental status examination, the sequence of steps forms a hierarchy in which the most basic functions (consciousness, language) are assessed first. The first steps must be accurately assessed to ensure validity of the steps that follow. For example, if consciousness is clouded, then the person cannot be expected to have full attention and to cooperate with new learning. If language is impaired, then a subsequent assessment of new learning or abstract reasoning (anything that requires language functioning) can give erroneous conclusions.

Question 27

A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes that:

a. She probably does not have any problems.
b. She is only trying to shock people and that her dress should be ignored.
c. She has a manic syndrome because of her abnormal dress and grooming.
d. More information should be gathered to decide whether her dress is appropriate.

Answer 27

ANS: D
Grooming and hygiene should be notedthe person is clean and well groomed, hair is neat and clean, women have moderate or no makeup, and men are shaved or their beards or moustaches are well groomed. Care should be taken when interpreting clothing that is disheveled, bizarre, or in poor repair because these sometimes reflect the persons economic status or a deliberate fashion trend.

Question 28

A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. During the tests of cognitive function, the nurse would expect that he:

a. May display some disruption in thought content.
b. Will state, I am so relieved to be out of intensive care.
c. Will be oriented to place and person, but the patient may not be certain of the date.
d. May show evidence of some clouding of his level of consciousness.

Answer 28

ANS: C
The nurse can discern the orientation of cognitive function through the course of the interview or can directly and tactfully ask, Some people have trouble keeping up with the dates while in the hospital. Do you know todays date? Many hospitalized people have trouble with the exact date but are fully oriented on the remaining items.

Question 29

During a mental status examination, the nurse wants to assess a patients affect. The nurse should ask the patient which question?

a. How do you feel today?
b. Would you please repeat the following words?
c. Have these medications had any effect on your pain?
d. Has this pain affected your ability to get dressed by yourself?

Answer 29

ANS: A
Judge mood and affect by body language and facial expression and by directly asking, How do you feel today? or How do you usually feel? The mood should be appropriate to the persons place and condition and should appropriately change with the topics.

Question 30

12. The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to:
    a. Administer the FACT test.
    b. Ask him to describe his first job.
    c. Give him the Four Unrelated Words Test.
    d. Ask him to describe what television show he was watching before coming to the clinic.

Answer 30

ANS: C
Ask questions that can be corroborated, which screens for the occasional person who confabulates or makes up answers to fill in the gaps of memory loss. The Four Unrelated Words Test tests the persons ability to lay down new memories and is a highly sensitive and valid memory test.

Question 31

A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not ____ four unrelated words ____.

a. Invent; within 5 minutes
b. Invent; within 30 seconds
c. Recall; after a 30-minute delay
d. Recall; after a 60-minute delay

Answer 31

ANS: C
The Four Unrelated Words Test tests the persons ability to lay down new memories. It is a highly sensitive and valid memory test. It requires more effort than the recall of personal or historic events. To the person say, I am going to say four words. I want you to remember them. In a few minutes I will ask you to recall them. After 5 minutes, ask for the four words. The normal response for persons under 60 years is an accurate three- or four- word recall after a 5-, 10-, and 30-minute delay.

Question 32

During a mental status assessment, which question by the nurse would best assess a persons judgment?

a. Do you feel that you are being watched, followed, or controlled?
b. Tell me what you plan to do once you are discharged from the hospital.
c. What does the statement, People in glass houses shouldnt throw stones, mean to you?
d. What would you do if you found a stamped, addressed envelope lying on the sidewalk?

Answer 32

ANS: B
A person exercises judgment when he or she can compare and evaluate the alternatives in a situation and reach an appropriate course of action. Rather than testing the persons response to a hypothetical situation (as illustrated in the option with the envelope), the nurse should be more interested in the persons judgment about daily or long-term goals, the likelihood of acting in response to delusions or hallucinations, and the capacity for violent or suicidal behavior.

Question 33

Which of these individuals would the nurse consider at highest risk for a suicide attempt?

a. Man who jokes about death
b. Woman who, during a past episode of major depression, attempted suicide
c. Adolescent who just broke up with her boyfriend and states that she would like to kill herself
d. Older adult man who tells the nurse that he is going to join his wife in heaven tomorrow and plans to use a gun

Answer 33

ANS: D
When the person expresses feelings of sadness, hopelessness, despair, or grief, assessing any possible risk of physical harm to him or herself is important. The interview should begin with more general questions. If the nurse hears affirmative answers, then he or she should continue with more specific questions. A precise suicide plan to take place in the next 24 to 48 hours with use of a lethal method constitutes high risk.

Question 34

The nurse is performing a mental status assessment on a 5-year-old girl. Her parents are undergoing a bitter divorce and are worried about the effect it is having on their daughter. Which action or statement might lead the nurse to be concerned about the girls mental status?

a. She clings to her mother whenever the nurse is in the room.
b. She appears angry and will not make eye contact with the nurse.
c. Her mother states that she has begun to ride a tricycle around their yard.
d. Her mother states that her daughter prefers to play with toddlers instead of kids her own age while in daycare.

Answer 34

ANS: D
The mental status assessment of infants and children covers behavioral, cognitive, and psychosocial
development and examines how the child is coping with his or her environment. Essentially, the nurse should
follow the same Association for Behavioral and Cognitive Therapies (ABCT) guidelines as those for the adult, with special consideration for developmental milestones. The best examination technique arises from a thorough knowledge of the developmental milestones (described in Chapter 2). Abnormalities are often problems of omission (e.g., the child does not achieve a milestone as expected).

Question 35

The nurse is assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented?

A. I know my name is John. I couldnt tell you where I am. I think it is 2010, though.
B. I know my name is John, but to tell you the truth, I get kind of confused about the date.
C. I know my name is John; I guess Im at the hospital in Spokane. No, I dont know the date.
D. I know my name is John. I am at the hospital in Spokane. I couldnt tell you what date it is, but I know that it is February of a new year2010.

Answer 35

ANS: D
Many aging persons experience social isolation, loss of structure without a job, a change in residence, or some short-term memory loss. These factors affect orientation, and the person may not provide the precise date or complete name of the agency. You may consider aging persons oriented if they generally know where they are and the present period. They should be considered oriented to time if the year and month are correctly stated. Orientation to place is accepted with the correct identification of the type of setting (e.g., hospital) and the name of the town.

Question 36

The nurse is performing the Denver II screening test on a 12-month-old infant during a routine well-child visit. The nurse should tell the infants parents that the Denver II:

a. Tests three areas of development: cognitive, physical, and psychological
b. Will indicate whether the child has a speech disorder so that treatment can begin.
c. Is a screening instrument designed to detect children who are slow in development.
d. Is a test to determine intellectual ability and may indicate whether problems will develop later in school.

Answer 36

ANS: C
The Denver II is a screening instrument designed to detect developmental delays in infants and preschoolers. It tests four functions: gross motor, language, fine motor-adaptive, and personal-social. The Denver II is not an intelligence test; it does not predict current or future intellectual ability. It is not diagnostic; it does not suggest treatment regimens.

Question 37

A patient drifts off to sleep when she is not being stimulated. The nurse can easily arouse her by calling her. name, but the patient remains drowsy during the conversation The best description of this patients level of
consciousness would be:

a. Lethargic
b. Obtunded
c. Stuporous
d. Semialert

Answer 37

ANS: A
Lethargic (or somnolent) is when the person is not fully alert, drifts off to sleep when not stimulated, and can be aroused when called by name in a normal voice but looks drowsy. He or she appropriately responds to questions or commands, but thinking seems slow and fuzzy. He or she is inattentive and loses the train of thought. Spontaneous movements are decreased

Question 38

A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, I buy obie get spirding and take my train. What is the best description of this patients problem?

a. Global aphasia
b. Brocas aphasia
c. Echolalia
d. Wernickes aphasia

Answer 38

ANS: D
This type of communication illustrates Wernickes or receptive aphasia. The person can hear sounds and words but cannot relate them to previous experiences. Speech is fluent, effortless, and well articulated, but it has many paraphasias (word substitutions that are malformed or wrong) and neologisms (made-up words) and often lacks substantive words. Speech can be totally incomprehensible. Often, a great urge to speak is present. Repetition, reading, and writing also are impaired. Echolalia is an imitation or the repetition of another persons words or phrases.

Question 39

A patient repeatedly seems to have difficulty coming up with a word. He says, I was on my way to work, and when I got there, the thing that you step into that goes up in the air was so full that I decided to take the stairs. The nurse will note on his chart that he is using or experiencing:

a. Blocking
b. Neologism
c. Circumlocution
d. Circumstantiality

Answer 39

ANS: C

Circumlocution is a roundabout expression, substituting a phrase when one cannot think of the name of the object.

Question 40

During an examination, the nurse notes that a patient is exhibiting flight of ideas. Which statement by the patient is an example of flight of ideas?

a. My stomach hurts. Hurts, spurts, burts.
b. Kiss, wood, reading, ducks, onto, maybe.
c. Take this pill? The pill is red. I see red. Red velvet is soft, soft as a babys bottom.
d. I wash my hands, wash them, wash them. I usually go to the sink and wash my hands.

Answer 40

ANS: C
Flight of ideas is demonstrated by an abrupt change, rapid skipping from topic to topic, and practically continuous flow of accelerated speech. Topics usually have recognizable associations or are plays on words.

Question 41

23. A patient describes feeling an unreasonable, irrational fear of snakes. His fear is so persistent that he can no longer comfortably look at even pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. The nurse recognizes that he:
    a. Has a snake phobia.
    b. Is a hypochondriac; snakes are usually harmless.
    c. Has an obsession with snakes.
    d. Has a delusion that snakes are harmful, which must stem from an early traumatic incident involving snakes.

Answer 41

ANS: A

A phobia is a strong, persistent, irrational fear of an object or situation; the person feels driven to avoid it.

Question 42

A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the

content. This behavior is a display of:
a. Confusion
b. Ambivalence
c. Depersonalization
d. Inappropriate affect

Answer 42

ANS: D

An inappropriate affect is an affect clearly discordant with the content of the persons speech.

Question 43

During reporting, the nurse hears that a patient is experiencing hallucinations. Which is an example of a hallucination?

a. Man believes that his dead wife is talking to him.
b. Woman hears the doorbell ring and goes to answer it, but no one is there.
c. Child sees a man standing in his closet. When the lights are turned on, it is only a dry cleaning bag.
d. Man believes that the dog has curled up on the bed, but when he gets closer he sees that it is a blanket.

Answer 43

ANS: A
Hallucinations are sensory perceptions for which no external stimuli exist. They may strike any sense: visual, auditory, tactile, olfactory, or gustatory.

Question 44

A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. For the mental status examination, the nurse should first assess the patients:

a. Affect and mood
b. Memory and affect
c. Language abilities
d. Level of consciousness and cognitive abilities

Answer 44

ANS: D
Delirium is a disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. Delirium is not an alteration in mood, affect, or language abilities.

Question 45

A patient states, I feel so sad all of the time. I cant feel happy even doing things I used to like to do. He also states that he is tired, sleeps poorly, and has no energy. To differentiate between a dysthymic disorder and a major depressive disorder, the nurse should ask which question?

a. Have you had any weight changes?
b. Are you having any thoughts of suicide?
c. How long have you been feeling this way?
d. Are you having feelings of worthlessness?

Answer 45

ANS: C
Major depressive disorder is characterized by one or more major depressive episodes, that is, at least 2 weeks of depressed mood or loss of interest accompanied by at least four additional symptoms of depression. Dysthymic disorder is characterized by at least 2 years of depressed mood for more days than not, accompanied by additional depressive symptoms.

Question 46

A 26-year-old woman was robbed and beaten a month ago. She is returning to the clinic today for a follow- up assessment. The nurse will want to ask her which one of these questions?

a. How are things going with the trial?
b. How are things going with your job?
c. Tell me about your recent engagement!
d. Are you having any disturbing dreams?

Answer 46

ANS: D
In posttraumatic stress disorder, the person has been exposed to a traumatic event. The traumatic event is persistently reexperienced by recurrent and intrusive, distressing recollections of the event, including images, thoughts, or perceptions; recurrent distressing dreams of the event; and acting or feeling as if the traumatic event were recurring.

Question 47

The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status?

a. Mental status assessment diagnoses specific psychiatric disorders.
b. Mental disorders occur in response to everyday life stressors.
c. Mental status functioning is inferred through the assessment of an individuals behaviors.
d. Mental status can be directly assessed, similar to other systems of the body (e.g., heart sounds, breath sounds).

Answer 47

ANS: C
Mental status functioning is inferred through the assessment of an individuals behaviors. It cannot be directly assessed like the characteristics of the skin or heart sounds.

Question 48

A 23-year-old patient in the clinic appears anxious. Her speech is rapid, and she is fidgety and in constant motion. Which of these questions or statements would be most appropriate for the nurse to use in this situation to assess attention span?

a. How do you usually feel? Is this normal behavior for you?
b. I am going to say four words. In a few minutes, I will ask you to recall them.
c. Describe the meaning of the phrase, Looking through rose-colored glasses.
d. Pick up the pencil in your left hand, move it to your right hand, and place it on the table.

Answer 48

ANS: D
Attention span is evaluated by assessing the individuals ability to concentrate and complete a thought or task without wandering. Giving a series of directions to follow is one method used to assess attention span.

Question 49

The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident (stroke) and has aphasia. Which of these questions is most important to use when assessing mental status in this patient?

a. Please count backward from 100 by seven.
b. I will name three items and ask you to repeat them in a few minutes.
c. Please point to articles in the room and parts of the body as I name them.
d. What would you do if you found a stamped, addressed envelope on the sidewalk?

Answer 49

ANS: C
Additional tests for persons with aphasia include word comprehension (asking the individual to point to articles in the room or parts of the body), reading (asking the person to read available print), and writing

Question 50

A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self- mutilation and has a history of suicide attempts. She describes difficulty sleeping at night and has lost 10 pounds in the past month. Which of these statements or questions is the nurses best response in this situation?

a. Do you have a weapon?
b. How do other people treat you?
c. Are you feeling so hopeless that you feel like hurting yourself now?
d. People often feel hopeless, but the feelings resolve within a few weeks.

Answer 50

ANS: C
When the person expresses feelings of hopelessness, despair, or grief, assessing the risk of physical harm to him or herself is important. This process begins with more general questions. If the answers are affirmative, then the assessment continues with more specific questions.

Question 51

The nurse is providing instructions to newly hired graduates for the minimental state examination (MMSE). Which statement best describes this examination?

a. Scores below 30 indicate cognitive impairment.
b. The MMSE is a good tool to evaluate mood and thought processes.
c. This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness.
d. The MMSE is useful tool for an initial evaluation of mental status. Additional tools are needed to evaluate cognition changes over time.

Answer 51

ANS: C
The MMSE is a quick, easy test of 11 questions and is used for initial and serial evaluations and can demonstrate a worsening or an improvement of cognition over time and with treatment. It evaluates cognitive functioning, not mood or thought processes. MMSE is a good screening tool to detect dementia and delirium and to differentiate these from psychiatric mental illness.

Question 52

The nurse discovers speech problems in a patient during an assessment. The patient has spontaneous speech, but it is mostly absent or is reduced to a few stereotypical words or sounds. This finding reflects which type of aphasia

a. Global
b. Brocas
c. Dysphonic
d. Wernickes

Answer 52

ANS: A
Global aphasia is the most common and severe form of aphasia. Spontaneous speech is absent or reduced to a few stereotyped words or sounds, and prognosis for language recovery is poor. Dysphonic aphasia is not a valid condition.

Question 53

A patient repeats, I feel hot. Hot, cot, rot, tot, got. Im a spot. The nurse documents this as an illustration of:

a. Blocking
b. Clanging
c. Echolalia
d. Neologism

Answer 53

ANS: B

Clanging is word choice based on sound, not meaning, and includes nonsense rhymes and puns.

Question 54

During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This behavior is an example of:

a. Social phobia
b. Compulsive disorder
c. Generalized anxiety disorder
d. Posttraumatic stress disorder

Answer 54

ANS: B
Repetitive behaviors, such as handwashing, are behaviors that the person feels driven to perform in response to an obsession. The behaviors are aimed at preventing or reducing distress or preventing some dreaded event or situation.

Question 55

The nurse is administering a Mini-Cog test to an older adult woman. When asked to draw a clock showing the time of 10:45, the patient drew a clock with the numbers out of order and with an incorrect time. This result indicates which finding?

a. Cognitive impairment
b. Amnesia
c. Delirium
d. Attention-deficit disorder

Answer 55

ANS: A
The Mini-Cog is a newer instrument that screens for cognitive impairment, often found with dementia. The result of an abnormal drawing of a clock and time indicates a cognitive impairment.

Question 56

During morning rounds, the nurse asks a patient, How are you today? The patient responds, You today, you today, you today! and mumbles the words. This speech pattern is an example of:

a. Echolalia
b. Clanging
c. Word salad
d. Perseveration

Answer 56

ANS: A
Echolalia occurs when a person imitates or repeats anothers words or phrases, often with a mumbling, mocking, or a mechanical tone.

Question 57

The nurse is assessing a patient who is admitted with possible delirium. Which of these are manifestations of delirium? Select all that apply.

a. Develops over a short period.
b. Person is experiencing apraxia.
c. Person is exhibiting memory impairment or deficits.
d. Occurs as a result of a medical condition, such as systemic infection.
e. Person is experiencing agnosia.

Answer 57

ANS: A, C, D
Delirium is a disturbance of consciousness that develops over a short period and may be attributable to a medical condition. Memory deficits may also occur. Apraxia and agnosia occur with dementia.

Question 58

The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is:

a. Highly vascular.
b. Thick and tough.
c. Thin and nonstratified.
d. Replaced every 4 weeks.

Answer 58

ANS: D

The epidermis is thin yet tough, replaced every 4 weeks, avascular, and stratified into several zones.

Question 59

The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis:

a. Contains mostly fat cells.
b. Consists mostly of keratin.
c. Is replaced every 4 weeks.
d. Contains sensory receptors.

Answer 59

ANS: D
The dermis consists mostly of collagen, elastic tissue that allows the skin to stretch, and contains nerves, sensory receptors, blood vessels, and lymphatic vessels. It is not replaced every 4 weeks.

Question 60

The nurse is examining a patient who tells the nurse, “I sure sweat a lot, especially on my face and feet but it doesn’t have an odour.” The nurse knows that this condition could be related to:

a. Eccrine glands.
b. Apocrine glands.
c. Disorder of the stratum corneum.
d. Disorder of the stratum germinativum.

Answer 60

ANS: A
The eccrine glands are coiled tubules that directly open onto the skin surface and produce a dilute saline solution called sweat. Apocrine glands are primarily located in the axillae, anogenital area, nipples, and naval area and mix with bacterial flora to produce the characteristic musky body odour. The patient’s statement is not related to disorders of the stratum corneum or the stratum germinativum.

Question 61

A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors?

a. Subcutaneous fat deposits are high in the newborn.
b. Sebaceous glands are overproductive in the newborn.
c. The newborn’s skin is more permeable than that of the adult.
d. The amount of vernix caseosa dramatically rises in the newborn.

Answer 61

ANS: C
The newborn’s skin is thin, smooth, and elastic and is relatively more permeable than that of the adult; consequently, the infant is at greater risk for fluid loss. The subcutaneous layer in the infant is inefficient, not thick, and the sebaceous glands are present but decrease in size and production. Vernix caseosa is not produced after birth.

Question 62

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult?

a. Increased vascularity of the skin
b. Increased numbers of sweat and sebaceous glands
c. An increase in elastin and a decrease in subcutaneous fat
d. An increased loss of elastin and a decrease in subcutaneous fat

Answer 62

ANS: D
An accumulation of factors place the aging person at risk for skin disease and breakdown: the thinning of the skin, a decrease in vascularity and nutrients, the loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, the social changes of aging, an increasingly sedentary lifestyle, and the chance of immobility.

Question 63

During the aging process, the hair can look grey or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning:

a. Metrocytes.
b. Fungacytes.
c. Phagocytes.
d. Melanocytes.

Answer 63

ANS: D
In the aging hair matrix, the number of functioning melanocytes decreases; as a result, the hair looks grey or white and feels thin and fine. The other options are not correct.

Question 64

During an examination, the nurse finds that a patient has excessive dryness of the skin. When charting, the nurse describes this condition as:

a. Xerosis.
b. Pruritus.
c. Alopecia.
d. Seborrhea.

Answer 64

ANS: A
Xerosis is the term used to describe skin that is excessively dry. Pruritus refers to itching, alopecia refers to hair loss, and seborrhea refers to oily skin.

Question 65

A 22-year-old woman comes to the clinic because of severe sunburn and states, “I was out in the sun for just a couple of minutes.” The nurse begins a medication review with her, paying special attention to which class of medications?

a. Nonsteroidal anti-inflammatory drugs for pain
b. Tetracyclines for acne
c. Proton pump inhibitors for heartburn
d. Thyroid replacement hormone for hypothyroidism

Answer 65

ANS: B
Drugs that may increase sunlight sensitivity and give a burn response include sulphonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.

Question 66

A woman is leaving on a trip to Hawaii and has come in for a checkup. During the health history interview, the patient informs the nurse that she takes an oral hypoglycemic medication for diabetes. The nurse provides teaching about the medication and:

a. Increased possibility of bruising.
b. Skin sensitivity as a result of exposure to salt water.
c. Lack of availability of glucose-monitoring supplies.
d. Importance of sunscreen and avoiding direct sunlight.

Answer 66

ANS: D
Drugs that may increase sunlight sensitivity and give a burn response include sulphonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.

Question 67

A 13-year-old girl is interested in obtaining information about the cause of her acne. The nurse should inform her that acne:

a. Is contagious.
b. Has no known cause.
c. Is caused by increased sebum production.
d. Has been found to be related to poor hygiene.

Answer 67

ANS: C
Approximately 90% of males and 80% of females will experience acne; causes are increased sebum production and epithelial cells that do not desquamate normally.

Question 68

A 75-year-old woman with a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse encourages her to stop trying to remove the corn with scissors because:
a. Her actions could increase her risk for infection and lesions because of her chronic disease.
b. She has increased circulation to her foot because of her diabetes, and it could cause severe bleeding.
c. She is 75 years old and has vision issues, which places her at greater risk for
self-injury with the scissors.
d. Her range of motion is limited because of her peripheral vascular disease, and she may not be able to reach the corn safely.

Answer 68

ANS: A
A personal history of diabetes and peripheral vascular disease increases a person’s risk for skin lesions in the feet or ankles. The patient needs to seek professional assistance for corn removal.

Question 69

While assessing a patient’s skin, the nurse notes multiple skin fissures on the hands. The nurse recognizes this as:

a. Diaphoresis in the patient.
b. Potential openings for bacterial infection.
c. Poor temperature regulation.
d. Impaired perception to pain.

Answer 69

ANS: B
The skin is a barrier that stops invasion of microorganisms and loss of water and electrolytes from within the body. Fissures or cracks in the skin result from extreme dryness. These fissures are openings in the skin which can allow bacteria to enter the body.

Question 70

A patient comes in for a physical examination and complains of “freezing to death” while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to:

a. Venous pooling.
b. Peripheral vasodilation.
c. Peripheral vasoconstriction.
d. Decreased arterial perfusion.

Answer 70

ANS: C
A chilly or air-conditioned environment causes vasoconstriction, which results in false pallor and coolness (see Table 13-1).

Question 71

A 62-year-old patient with heart failure comes to the clinic for his annual examination. During skin assessment, the nurse notes slight swelling to the patient’s feet, and indentations which quickly fade when both feet are palpated. The nurse will chart this finding as:

a. No edema noted.
b. Unilateral deep pitting 3+ edema.
c. Bilateral moderate pitting 2+ edema.
d. Mild pitting 1+ edema.

Answer 71

ANS: C
Some problems, such as heart failure or kidney failure, can cause bilateral edema in the extremities. Edema is graded on a four-point scale:
1+: Mild pitting, slight indentation, no perceptible swelling of the leg
2+: Moderate pitting, indentation subsides rapidly
3+: Deep pitting, indentation remains for a short time, swelling of leg
4+: Very deep pitting, indentation lasts a long time, gross swelling and distortion of leg

Question 72

A patient is especially worried about the white coloration of an area of skin on her feet, and she has been told it is vitiligo. The nurse explains that vitiligo is:

a. Caused by an excess of melanin pigment.
b. Caused by an excess of apocrine glands in her feet.
c. Caused by the complete absence of melanin pigment.
d. Related to impetigo and can be treated with an ointment.

Answer 72

ANS: C
Vitiligo is the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orifices—otherwise, the depigmented skin is normal.

Question 73

A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding?

a. Colour variation
b. Border regularity
c. Symmetry of lesions
d. Diameter of less than 6 mm

Answer 73

ANS: A
Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, colour variation, and diameter greater than 6 mm.

Question 74

A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition results from hyperemia and knows that it can be caused by:

a. Decreased amounts of bilirubin in the blood.
b. Excess blood in the underlying blood vessels.
c. Decreased perfusion to the surrounding tissues.
d. Excess blood in the dilated superficial capillaries.

Answer 74

ANS: D

Erythema is an intense redness of the skin caused by excess blood (hyperemia) in the dilated superficial capillaries.

Question 75

During a skin assessment, the nurse initially is concerned that the patient who is of East Asian origin has skin that is yellowish-brown. On further assessment, the nurse notes that the skin on the hard and soft palate is pink and the patient’s sclerae are not yellow. From this finding, the nurse recognizes that the patient likely does not have:

a. Pallor.
b. Jaundice.
c. Cyanosis.
d. Iron deficiency.

Answer 75

ANS: B
Jaundice is exhibited by yellow coloration, which indicates rising levels of bilirubin in blood. Jaundice is first noticed in the junction of the hard and soft palate in the mouth and in the sclerae.

Question 76

A patient of African origin is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patient’s skin?

a. Ruddy blue
b. Generalized pallor
c. Ashen, grey, or dull
d. Patchy areas of pallor

Answer 76

ANS: C
Pallor attributable to shock, with decreased perfusion and vasoconstriction, in dark-skinned people will cause the skin to appear ashen, grey, or dull (see Table 13-2).

Question 77

An older adult woman is brought to the emergency department after she was found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination?

a. Smooth mucous membranes and lips
b. Dry mucous membranes and cracked lips
c. Pale mucous membranes
d. White patches on the mucous membranes

Answer 77

ANS: B
With dehydration, mucous membranes appear dry and the lips look parched and cracked. The other responses are not found in dehydration.

Question 78

A 42-year-old woman is concerned about several small, slightly raised, bright red dots that have appeared on her chest. On examination, the nurse explains that the spots are probably:

a. Anasarca.
b. Scleroderma.
c. Senile angiomas.
d. Latent myeloma.

Answer 78

ANS: C
Cherry (senile) angiomas are small, smooth, slightly raised bright red dots that commonly appear on the trunk of adults over 30 years old.

Question 79

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse notes:

a. Anasarca.
b. Scleroderma.
c. Pedal erythema.
d. Clubbing of the nails.

Answer 79

ANS: D
Clubbing of the nails occurs with congenital cyanotic heart disease and neoplastic and pulmonary diseases. The other responses are assessment findings not associated with pulmonary diseases.

Question 80

A newborn infant has Down’s syndrome. During the skin assessment, the nurse notices a transient mottling in the trunk and extremities in response to the cool temperature in the examination room. The infant’s mother also notices the mottling and asks what it is. The nurse knows that this mottling is called:

a. Café au lait.
b. Carotenemia.
c. Acrocyanosis.
d. Cutis marmorata.

Answer 80

ANS: D
Persistent or pronounced cutis marmorata occurs with infants born with Down’s syndrome or those born prematurely and is a transient mottling in the trunk and extremities in response to cool room temperatures. A café au lait spot is a large round or oval patch of light-brown pigmentation. Carotenemia produces a yellow-orange coloration in light-skinned persons. Acrocyanosis is bluish coloration around the lips, hands and fingernails, and feet and toenails.

Question 81

A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During the assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse will chart this finding as:

a. Keratoses.
b. Xerosis.
c. Chloasma.
d. Acrochordons.

Answer 81

ANS: C
In pregnancy, skin changes can include striae, linea nigra (a brownish-black line down the midline), chloasma which is an irregular brown patch of hyperpigmentation on the face, and vascular spiders. Keratoses are raised, thickened areas of pigmentation that look crusted, scaly, and warty. Xerosis is dry skin. Acrochordons, or skin tags, occur more often in the aging adult.

Question 82

A man has come into the clinic because he’s worried he might have
skin cancer. During the skin assessment, the nurse notices several areas of pigmentation that look greasy, dark, and “stuck on” his skin. The nurse informs the patient that they are:
a. Senile lentigines, which do not become cancerous.
b. Actinic keratoses, which are precursors to basal cell carcinoma.
c. Acrochordons, which are precursors to squamous cell carcinoma.
d. Seborrheic keratoses, which do not become cancerous.

Answer 82

ANS: D
Seborrheic keratoses appear like dark, greasy, “stuck-on” lesions that primarily develop on the trunk. These lesions do not become cancerous. Senile lentigines are commonly called liver spots and are not precancerous. Actinic (senile or solar) keratoses are lesions that are red-tan scaly plaques that increase over the years to become raised and roughened. They may have a silvery-white scale adherent to the plaque. They occur on sun-exposed surfaces and are directly related to sun exposure. They are premalignant and may develop into squamous cell carcinoma. Acrochordons are skin tags and are not precancerous.

Question 83

A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, “What causes these liver spots?” The nurse tells her, “They are:

a. “Signs of decreased hematocrit related to anemia.”
b. “Caused by the destruction of melanin in your skin from exposure to the sun.”
c. “Clusters of melanocytes that appear after extensive sun exposure.”
d. “Areas of hyperpigmentation related to decreased perfusion and vasoconstriction.”

Answer 83

ANS: C
Liver spots, or senile lentigines, are clusters of melanocytes that appear on the forearms and dorsa of the hands after extensive sun exposure. The other responses are not correct.

Question 84

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. The nurse documents this finding as a:

a. Bulla.
b. Wheal.
c. Nodule.
d. Papule.

Answer 84

ANS: D
A papule is something one can feel, is solid, elevated, circumscribed, less than 1 cm in diameter, and is caused by superficial thickening in the epidermis. A bulla is larger than 1 cm, superficial, and thin walled. A wheal is superficial, raised, transient, erythematous, and irregular in shape attributable to edema. A nodule is solid, elevated, hard or soft, and larger than 1 cm.

Question 85

From reviewing the patient’s medical record, the nurse notes that the patient has a lesion that is confluent in nature. During assessment, the nurse observes:

a. Lesions that run together.
b. Annular lesions that have grown together.
c. Lesions arranged in a line along a nerve route.
d. Lesions that are grouped or clustered together.

Answer 85

ANS: A
Confluent lesions (as with urticaria [hives]) run together. Grouped lesions are clustered together. Annular lesions are circular in nature. Zosteriform lesions are arranged along a nerve route.

Question 86

A patient has had a “terrible itch” for several months and states that he has been continuously scratching it. During examination, the nurse finds:

a. A keloid.
b. A fissure.
c. Keratosis.
d. Lichenification.

Answer 86

ANS: D
Lichenification results from prolonged, intense scratching that eventually thickens the skin and produces tightly packed sets of papules. A keloid is a hypertrophic scar. A fissure is a linear crack with abrupt edges, which extends into the dermis; it can be dry or moist. Keratoses are lesions that are raised, thickened areas of pigmentation that appear crusted, scaly, and warty.

Question 87

A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse replies, “The physician is referring to the:

a. “Blue dilation of blood vessels in a star-shaped linear pattern on the legs.”
b. “Fiery red, star-shaped marking on the cheek that has a solid circular centre.”
c. “Merging extensive patch of red dots and larger bruises on the feet.”
d. “Tiny areas of bruising that are less than 2 mm, round, discrete, and dark red in colour.”

Answer 87

ANS: C
Purpura is a confluent and extensive patch of petechiae and ecchymoses [small and large areas of bleeding from broken blood vessels under the skin] and a flat macular hemorrhage observed in generalized disorders, such as thrombocytopenia and scurvy. The blue dilation of blood vessels in a star-shaped linear pattern on the legs indicates a venous lake. The fiery red, star-shaped marking on the cheek that has a solid circular centre indicates a spider or star angioma. The tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in colour indicate petechiae.

Question 88

A mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a red base and suspects:

a. Eczema.
b. Impetigo.
c. Herpes zoster.
d. Diaper dermatitis.

Answer 88

ANS: B
Impetigo is moist, thin-roofed vesicles with a thin erythematous (red) base and is a contagious bacterial infection of the skin and most common in infants and children. Eczema is characterized by erythematous papules and vesicles with weeping, oozing, and crusts. Herpes zoster (i.e., chickenpox or varicella) is characterized by small, tight vesicles that are shiny with an erythematous base. Diaper dermatitis is characterized by red, moist maculopapular patches with poorly defined borders.

Question 89

The nurse notices that a school-aged child has bluish-white, red-based spots in her mouth and that the lesions are raised approximately 1 to 3 mm. The nurse will assess the child for:

a. A pink, papular rash on the face and neck.
b. Pruritic vesicles over her trunk and neck.
c. Hyperpigmentation on the chest, abdomen, and back of the arms.
d. A red-purple, maculopapular, blotchy rash behind the ears and on the face.

Answer 89

ANS: D
With measles (rubeola), the examiner observes a red-purple, blotchy rash on the third or fourth day of illness that appears first behind the ears, spreads over the face, and then over the neck, trunk, arms, and legs. The rash appears coppery and does not blanch. The bluish-white, red-based spots in the mouth are known as Koplik’s spots.

Question 90

The nurse is assessing the skin of a patient who has AIDS and notices multiple patchlike lesions on the temple and beard area that are faint pink in colour. The nurse recognizes these lesions as:

a. Measles (rubeola).
b. Kaposi’s sarcoma.
c. Angiomas.
d. Herpes zoster.

Answer 90

ANS: B
Kaposi’s sarcoma is a vascular tumour that, in the early stages, appears as multiple, patchlike, faint pink lesions over the patient’s temple and beard areas. Measles is characterized by a red-purple maculopapular blotchy rash that appears on the third or fourth day of illness.

Question 91

A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. His hair seems to be breaking off in patches, and he notices some scaling on his head. The nurse begins the examination suspecting:

a. Tinea capitis.
b. Folliculitis.
c. Toxic alopecia.
d. Seborrheic dermatitis.

Answer 91

ANS: A
Tinea capitis is rounded patchy hair loss on the scalp, leaving broken-off hairs, pustules, and scales on the skin, and is caused by a fungal infection. Lesions are fluorescent under Wood’s light and are usually observed in children and farmers; tinea capitis is highly contagious. (See Table 13-13, Abnormal Conditions of Hair, for descriptions of the other terms.)

Question 92

36. The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition?
    a. Severe obesity
    b. Childhood growth spurts
    c. Severe dehydration
    d. Connective tissue disorders, such as scleroderma

Answer 92

ANS: C

Decreased skin turgor is associated with severe dehydration or extreme weight loss.

Question 93

While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in colour. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition?

a. Heart failure
b. Venous thrombosis
c. Local inflammation
d. Blockage of lymphatic drainage

Answer 93

ANS: A
Bilateral edema or edema that is generalized over the entire body is caused by a central problem, such as heart failure or kidney failure. Unilateral edema usually has a local or peripheral cause.

Question 94

A 40-year-old woman reports a change in mole size, accompanied by colour changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would:

a. Tell the patient to watch the lesion and report back in 2 months.
b. Refer the patient for further assessment because of the risk for melanoma based on signs and symptoms.
c. Ask additional questions regarding environmental irritants that may have caused this condition.
d. Tell the patient that these signs suggest a compound nevus, which is very common in young to middle-aged adults.

Answer 94

ANS: B
The ABCD danger signs of melanoma are asymmetry, border irregularity, colour variation, and diameter. In addition, individuals may report a change in size, the development of itching, burning, and bleeding, or a new-pigmented lesion. Any one of these signs raises the suggestion of melanoma and warrants immediate referral.

Question 95

The nurse is assessing a patient with emphysema for clubbing of the fingernails, which is confirmed by:

a. Nail bases that are firm and slightly tender.
b. Curved nails with a convex profile and ridges across the nails.
c. Nail bases that feel spongy with an angle of the nail base of 150 degrees.
d. Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy.

Answer 95

ANS: D
The normal nail is firm at its base and has an angle of 160 degrees. In clubbing, the angle straightens to 180 degrees or greater and the nail base feels spongy.

Question 96

The nurse is performing an assessment for jaundice in a patient who has liver disease. Which of these assessment findings is indicative of true jaundice?

a. Yellow patches in the outer sclera
b. Yellow coloration of the sclera that extends up to the iris
c. Skin that appears yellow when examined under low light
d. Yellow deposits on the palms and soles of the feet where jaundice first appears

Answer 96

ANS: B
The yellow sclera of jaundice extends up to the edge of the iris. Calluses on the palms and soles of the feet often appear yellow but are not classified as jaundice. Scleral jaundice should not be confused with the normal yellow subconjunctival fatty deposits that are common in the outer sclera of dark-skinned persons.

Question 97

The nurse is assessing for inflammation in a dark-skinned person. Which technique is the best?

a. Assessing the skin for cyanosis and swelling
b. Assessing the oral mucosa for generalized erythema
c. Palpating the skin for edema and increased warmth
d. Palpating for tenderness and local areas of ecchymosis

Answer 97

ANS: C
Because inflammation cannot be seen in dark-skinned persons, palpating the skin for increased warmth, for taut or tightly pulled surfaces that may be indicative of edema, and for a hardening of deep tissues or blood vessels is often necessary.

Question 98

A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash consists of small, red, flat skin spots with a “bull’s eye” pattern across his midriff and behind his knees. The nurse suspects:

a. Rubeola.
b. Lyme disease.
c. Allergy to mosquito bites.
d. Rocky Mountain spotted fever.

Answer 98

ANS: B
Lyme disease occurs in people who spend time outdoors in May through September. The first disease state exhibits the distinctive “bull’s eye” and a red macular (small, flat skin spots) or papular (small solid bumps) rash that radiates from the site of the tick bite with some central clearing. The rash spreads 5 cm or larger and is usually in the axilla, midriff, inguinal area, or behind the knee, with regional lymphadenopathy.

Question 99

A 52-year-old woman has a small solid bump on her nose that has rounded, pearly borders and a central red ulcer. She states that she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition?

a. Acne
b. Basal cell carcinoma
c. Melanoma
d. Squamous cell carcinoma

Answer 99

ANS: B
Basal cell carcinoma usually starts as a skin-coloured papule (small solid bump) that develops rounded, pearly borders with a central red ulcer. It is the most common form of skin cancer and grows slowly. This description does not fit acne lesions. (See Table 13-11 for descriptions of melanoma and squamous cell carcinoma.)

Question 100

A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the past 24 hours. He says his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration and tests skin mobility and turgor over the infant’s:

a. Sternum.
b. Forehead.
c. Forearms.
d. Abdomen.

Answer 100

ANS: D
Mobility and turgor are tested over the abdomen in an infant. Poor turgor, or tenting, indicates dehydration or malnutrition. The other sites are not appropriate for checking skin turgor in an infant.

Question 101

A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red colour. The nurse suspects that this colouring is caused by:

a. Polycythemia.
b. Carbon monoxide poisoning.
c. Carotenemia.
d. Uremia.

Answer 101

ANS: B
A bright cherry-red colouring in the face, upper torso, nail beds, lips, and oral mucosa appears in cases of carbon monoxide poisoning.

Question 102

46. A patient has been admitted for severe psoriasis. The nurse expects to see what finding in the patient’s fingernails?
    a. Splinter hemorrhages
    b. Paronychia
    c. Pitting
    d. Beau’s lines

Answer 102

ANS: C
Sharply defined pitting and crumbling of the nails, each with distal detachment characterize pitting nails and are associated with psoriasis. (See Table 13-14 for Abnormal Conditions of the Nails.)

Question 103

The nurse is assessing a 50-year-old patient who is restricted to the bed. The patient has limited mobility and needs to be frequently repositioned. The nurse will use the Braden Scale to assess for:

a. Mobility and positioning needs.
b. Risk for developing pressure ulcers.
c. Progression of limitations.
d. Cognitive status and functioning.

Answer 103

ANS: B

The Braden Scale is used for predicting the risk for pressure sores, (See Table 13-1.)

Question 104

The nurse is performing a Braden Scale assessment on a 65-year-old bedbound patient with limited mobility. The patient is unable to communicate needs or discomfort but does respond to verbal commands. The nurse notes that the patient’s skin is moist and will likely require a linen change each shift. The patient is confined to the bed with no ability to walk and makes very limited changes to body extremities occasionally. The patient requires frequent repositioning with maximum assistance. The patient eats about half of the food offered. The nurse charts the findings as:

a. At risk for pressure ulcers.
b. Low risk for pressure ulcer development.
c. Moderate risk for pressure ulcers.
d. High Risk for developing pressure ulcers.

Answer 104

ANS: D

Question 105

The nurse initiates a Braden Scale assessment of the 85-year-old patient who is independent with activities of daily living and frequently ambulates around the unit. The patient scores a 23 which the nurse documents as:

a. At increased risk for pressure ulcers.
b. No risk for pressure ulcer development.
c. Requires monthly Braden Scale assessment.
d. Initiate a weekly assessment schedule.

Answer 105

ANS: B
The full score attainable is 23, indicating that the patient is not at risk for pressure ulcer development. See Table 13-1 For Braden Scale Assessment for Predicting Pressure Ulcer Risk.

Question 106

1. The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct? (Select all that apply.)
   a. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in colour
   b. Bulla: Elevated, circumscribed lesion filled with turbid fluid (pus)
   c. Papule: Hypertrophic scar
   d. Vesicle: Known as a friction blister
   e. Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm

Answer 106

ANS: A, D, E
A pustule is an elevated, circumscribed lesion filled with turbid fluid (pus). A hypertrophic scar is a keloid. A bulla is larger than 1 cm and contains clear fluid. A papule is solid and elevated but measures less than 1 cm.

Question 107

A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer. Which of these findings are characteristic of a stage II pressure ulcer? (Select all that apply.)

a. Intact skin appears red but is not broken.
b. Partial thickness skin erosion is observed with a loss of epidermis or dermis.
c. Ulcer extends into the subcutaneous tissue.
d. Localized redness in light skin will blanch with fingertip pressure.
e. Open blister areas have a red-pink wound bed.
f. Patches of eschar cover parts of the wound.

Answer 107

ANS: B, E
Stage I pressure ulcers have intact skin that appears red but is not broken, and localized redness in intact skin will blanch with fingertip pressure. Stage II pressure ulcers have partial thickness skin erosion with a loss of epidermis or also the dermis; open blisters have a red-pink wound bed. Stage III pressure ulcers are full thickness, extending into the subcutaneous tissue; subcutaneous fat may be seen but not muscle, bone, or tendon. Stage IV pressure ulcers involve all skin layers and extend into supporting tissue, exposing muscle, bone, and tendon. Slough (stringy matter attached to the wound bed) or eschar (black or brown necrotic tissue) may be present. (See Table 13-6.)

Question 108

The nurse is working with the older adult population, and recognizes that the aging process can increase: (Select all that apply.)

a. Heat stroke risk.
b. Skin vascularity.
c. Occurrence of skin tear injuries.
d. Muscle tone.
e. Time for a wound to heal.
f. Skin elasticity.

Answer 108

ANS: A, C, E
Elastin, collagen, and subcutaneous fat are lost, as is muscle tone. The loss of collagen increases the risk for shearing and tearing injuries. The vascularity of the skin diminishes while the vascular fragility increases. When skin breakdown does occur, subsequent cell replacement is slower, and wound healing is delayed.

Question 109

The nurse recognizes the importance of assessing the patient’s skin as the skin has many protective and adaptive functions which include: (Select all that apply.)

a. Protection from bacterial intrusion.
b. Increasing dehydration through water loss.
c. Regulation of body temperature.
d. Supporting wound healing.
e. Decreasing the wastes excreted.

Answer 109

ANS: A, C, D
The skin is a waterproof, highly resilient covering that has protective and adaptive properties. Some of the functions include:
• Protection: the skin protects the body from injury from physical, chemical, thermal, and light wave sources.
• Barrier: the skin stops the invasion of microorganisms and loss of water and electrolytes from within the body.
• Temperature regulation: the skin allows heat dissipation through sweat glands and heat storage through subcutaneous insulation.
• Wound repair: the skin allows cell replacement of surface wounds.
• Absorption and excretion: the skin allows limited excretion of some metabolic wastes, by-products of cellular decomposition such as minerals, sugars, amino acids, cholesterol, uric acid, and urea.
(See Function of the Skin).

Question 110

A physician tells the nurse that a patient’s vertebra prominens is tender and asks the nurse to re-evaluate the area in 1 hour. The area of the body the nurse will assess is:

a. Just above the diaphragm.
b. Just lateral to the knee cap.
c. At the level of the C7 vertebra.
d. At the level of the T11 vertebra.

Answer 110

ANS: C

The C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable when the head is flexed.

Question 111

A mother brings her 2-month-old daughter in for an examination and says, “My daughter rolled over against the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is something terribly wrong?” The nurse’s best response would be:

a. “Perhaps that is a result of your dietary intake during pregnancy.”
b. “Your baby may have craniosynostosis, a disease of the sutures of the brain.”
c. “That ‘soft spot’ may be an indication of cretinism or congenital hypothyroidism.”
d. “That ‘soft spot’ is normal, and actually allows for growth of the brain during the first year of your babies life

Answer 111

ANS: D
Membrane-covered “soft spots” allow for growth of the brain during the first year of life. They gradually ossify; the triangular-shaped posterior fontanelle is closed by 1 to 2 months, and the diamond-shaped anterior fontanel closes between 9 months and 2 years.

Question 112

The nurse notices that a patient’s palpebral fissures are unequal. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)?

a. III
b. V
c. VII
d. VIII

Answer 112

ANS: C
Facial muscles are mediated by CN VII; asymmetry of palpebral fissures may be attributable to damage to CN VII (Bell’s palsy).

Question 113

A patient is unable to differentiate between sharp and dull stimulations to both sides of her face. The nurse suspects:

a. Bell’s palsy.
b. Damage to the trigeminal nerve.
c. Frostbite with resultant paresthesia to the cheeks.
d. Scleroderma.

Answer 113

ANS: B
Facial sensations of pain or touch are mediated by cranial nerve V, which is the trigeminal nerve. Bell palsy is associated with cranial nerve VII damage. Frostbite and scleroderma are not associated with this problem.

Question 114

When examining the face of a patient, the nurse is aware that the two pairs of salivary glands that are accessible for examination are the ___________ and ___________ glands.

a. Occipital; submental
b. Parotid; jugulodigastric
c. Parotid; submandibular
d. Submandibular; occipital

Answer 114

ANS: C
Two pairs of salivary glands accessible to examination on the face are the parotid glands, which are in the cheeks over the mandible, anterior to and below the ear; and the submandibular glands, which are beneath the mandible at the angle of the jaw. The parotid glands are normally nonpallapable

Question 115

A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to cranial nerve ______ and proceeds with the examination by ________________________.

a. XI; palpating the anterior and posterior triangles
b. XI; asking the patient to shrug her shoulders against resistance
c. XII; percussing the sternomastoid and submandibular neck muscles
d. XII; assessing for a positive Romberg sign

Answer 115

ANS: B
The major neck muscles are the sternomastoid and the trapezius. They are innervated by cranial nerve XI, the spinal accessory. The innervated muscles assist with head rotation and head flexion, movement of the shoulders, and extension and turning of the head.

Question 116

When examining a patient after a biopsy of the cervical lymph nodes, to ensure there is no damage to the major neck muscles, the nurse should check the function of cranial nerve:

a. V; trigeminal nerve.
b. XI; spinal accessory nerve.
c. VII; facial nerve.
d. VI; abducens nerve.

Answer 116

ANS: B
The major neck muscles are the sternomastoid and the trapezius. They are innervated by cranial nerve XI, the spinal accessory. Injury or surgery to the neck region can cause trauma to the nerve.

Question 117

A patient’s laboratory data reveal an elevated thyroxine (T4) level. The nurse would proceed with an examination of the _____ gland.

a. Thyroid
b. Parotid
c. Adrenal
d. Parathyroid

Answer 117

ANS: A
The thyroid gland is a highly vascular endocrine gland that secretes T4 and triiodothyronine (T3). The other glands do not secrete T4.

Question 118

A patient says that she has recently noticed a lump in the front of her neck below her “Adam’s apple” that seems to be getting bigger. During assessment, the nurse suspects a noncancerous finding as the lump:

a. Is singular and firm.
b. Consists of multiple nodules.
c. Disappears when the patient smiles.
d. Is hard and fixed to the surrounding structures.

Answer 118

ANS: B
Multiple nodules usually indicate inflammation or a multinodular goitre, rather than a neoplasm. Any rapidly enlarging or firm nodule should be further investigated.
Painless, rapidly growing nodules may be cancerous, especially the appearance of a single nodule in a young person. Cancerous nodules tend to be hard and fixed to surrounding structures.

Question 119

A patient who is 7 months pregnant is at the clinic for her routine checkup. During assessment the nurse notes that the patient’s thyroid is palpable. The nurse will:

a. Refer the patient to a thyroid specialist.
b. Send the patient for laboratory tests for thyroid hormones.
c. Document the findings as normal.
d. Ask a colleague to check the findings.

Answer 119

ANS: C

Usually the normal adult thyroid is not palpable. However, the thyroid gland may be palpable normally during pregnancy.

Question 120

The nurse notices that a patient’s submental lymph nodes are enlarged. To identify the cause of the enlargement of the patient’s nodes, the nurse assesses the:

a. Infraclavicular area.
b. Supraclavicular area.
c. Area distal to the enlarged node.
d. Area proximal to the enlarged node.

Answer 120

ANS: D
When nodes are abnormal, the nurse should check the area into which they drain for the source of the problem. The area proximal (upstream) to the location of the abnormal node should be explored.

Question 121

The nurse is aware that the four areas in the body where lymph nodes are accessible are the:

a. Head, breasts, groin, and abdomen.
b. Arms, breasts, inguinal area, and legs.
c. Head and neck, arms, breasts, and axillae
d. Head and neck, arms, inguinal area, and axillae.

Answer 121

ANS: D
Nodes are located throughout the body, but they are accessible to examination only in four areas: head and neck, arms, inguinal region, and axillae.

Question 122

A mother brings her newborn in for an assessment and asks, “Is there something wrong with my baby? His head seems so big.” Which statement is true regarding the relative proportions of the head and trunk of the newborn?
a. At birth, the head is one-fifth the total length.
b. Head circumference should be greater than chest circumference at birth.
c. The head size reaches 90% of its final size when the child is 3 years old.
d. When the anterior fontanelle closes at 2 months, the head will be more
proportionate to the body.

Answer 122

ANS: B
The nurse recognizes that during the fetal period, head growth predominates. Head size is greater than chest circumference at birth, and the head size grows during childhood, reaching 90% of its final size when the child is 6 years of age.

Question 123

A patient, an 85-year-old woman, is concerned that the bones in her face have become more noticeable. The nurse tells her that:

a. Diets low in protein and high in carbohydrates may cause enhanced facial bones.
b. Bones can become more noticeable if the person does not use a dermatologically approved moisturizer.
c. More noticeable facial bones are probably caused by a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin.
d. Facial skin becomes more elastic with age. This increased elasticity causes the skin to be more taught, drawing attention to the facial bones.

Answer 123

ANS: C
The facial bones and orbits appear more prominent in the aging adult, and the facial skin sags, which is attributable to decreased elasticity, decreased subcutaneous fat, and decreased moisture in the skin.

Question 124

A patient reports to the nurse that he has been experiencing excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that lasts approximately one-half to 2 hours, occurring once or twice each day. The nurse suspects that he is having:

a. Hypertension.
b. Cluster headaches.
c. Tension headaches.
d. Migraine headaches.

Answer 124

ANS: B
Cluster headaches produce pain around the eye, temple, forehead, and cheek and are unilateral and always on the same side of the head. They are excruciating and occur once or twice per day and last one-half to 2 hours each.

Question 125

A patient is concerned that while studying for an examination he began to notice a severe headache in the left front and side of his head that was throbbing and was relieved when he lay down. He tells the nurse that his mother also had these headaches. The nurse suspects that he may be suffering from:

a. Hypertension.
b. Cluster headaches.
c. Tension headaches.
d. Migraine headaches.

Answer 125

ANS: D
Migraine headaches tend to be supraorbital, retro-orbital, or frontotemporal with a throbbing quality. They are severe in quality and are relieved by lying down. Migraines are associated with a family history of migraine headaches.

Question 126

A 19-year-old college student is brought to the emergency department with a severe headache he describes as, “Like nothing I’ve ever had before.” His temperature is 40° C, and he has a stiff neck. The nurse recognizes that he needs testing for:

a. A head injury.
b. Cluster headaches.
c. Migraine headaches.
d. Meningeal inflammation.

Answer 126

ANS: D
The acute onset of neck stiffness and pain along with headache and fever occurs with meningeal inflammation. A severe headache in an adult or child who has never had it before is a red flag. Head injury and cluster or migraine headaches are not associated with a fever or stiff neck.

Question 127

The nurse needs to palpate the temporomandibular joint for crepitation. This joint is located just below the temporal artery and anterior to the:

a. Hyoid bone.
b. Vagus nerve.
c. Tragus.
d. Mandible.

Answer 127

ANS: C

The temporomandibular joint is just below the temporal artery and anterior to the tragus.

Question 128

A patient has come in for an examination and states, “I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is?” The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his:

a. Thyroid gland.
b. Parotid gland.
c. Occipital lymph node.
d. Submental lymph node.

Answer 128

ANS: B
Swelling of the parotid gland is evident below the angle of the jaw and is most visible when the head is extended. Painful inflammation occurs with mumps, and swelling also occurs with abscesses or tumours. Swelling occurs anterior to the lower ear lobe.

Question 129

A male patient with a history of AIDS has come in for an examination and he states, “I think that I have the mumps.” The nurse would begin by examining the:

a. Thyroid gland.
b. Parotid gland.
c. Cervical lymph nodes.
d. Mouth and skin for lesions.

Answer 129

ANS: B
The parotid gland may become swollen with the onset of mumps, and parotid enlargement has been found with human immunodeficiency virus (HIV).

Question 130

22. The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patient’s T4 and T3 levels are elevated. During assessment, the nurse will likely find the patient has:
    a. Tachycardia.
    b. Constipation.
    c. Rapid dyspnea.
    d. Atrophied nodular thyroid gland.

Answer 130

ANS: A
T4 and T3 are thyroid hormones that stimulate the rate of cellular metabolism, resulting in tachycardia. With an enlarged thyroid gland as in hyperthyroidism, the nurse might expect to find diffuse enlargement (goitre) or a nodular lump but not an atrophied gland. Dyspnea and constipation are not findings associated with hyperthyroidism.

Question 131

A visitor from Poland, who does not speak English, seems to be somewhat apprehensive about the nurse examining his neck. He would probably be more comfortable with the nurse examining his thyroid gland from:
a. Behind with the nurse’s hands placed firmly around his neck.
b. The side with the nurse’s eyes averted toward the ceiling and thumbs on his neck.
c. The front with the nurse’s thumbs placed on either side of his trachea and his head
tilted forward.
d. The front with the nurse’s thumbs placed on either side of his trachea and his head tilted backward.

Answer 131

ANS: C
Examining this patient’s thyroid gland from the back may be unsettling for him. It would be best to examine his thyroid gland using the anterior approach, asking him to tip his head forward and to the right and then to the left.

Question 132

A patient’s thyroid gland is enlarged and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a __________ sound that is heard best with the __________ of the stethoscope.

a. Low gurgling; diaphragm
b. Loud, whooshing, blowing; bell
c. Soft, whooshing, pulsatile; bell
d. High-pitched tinkling; diaphragm

Answer 132

ANS: C
If the thyroid gland is enlarged, then the nurse should auscultate it for the presence of a bruit, which is a soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope.

Question 133

The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is very concerned. She tells the nurse that she noticed the lump approximately 8 hours after her baby’s birth and that it seems to be getting bigger. The nurse explains that this likely is:

a. Hydrocephalus.
b. Craniosynostosis.
c. Cephalhematoma.
d. Caput succedaneum.

Answer 133

ANS: C
A cephalhematoma is a subperiosteal hemorrhage that is the result of birth trauma. It is soft, fluctuant, and well defined over one cranial bone. It appears several hours after birth and gradually increases in size.

Question 134

A mother brings in her newborn infant for an assessment and tells the nurse that she has noticed that whenever her newborn’s head is turned to the right side, she straightens out the arm and leg on the same side and flexes the opposite arm and leg. After observing this on examination, the nurse tells her that this reflex is:

a. Abnormal and is called the atonic neck reflex.
b. Normal and should disappear by the first year of life.
c. Normal and is called the tonic neck reflex, which should disappear between 3 and 4 months of age.
d. Abnormal and the baby should be flexing the arm and leg on the right side of his body when the head is turned to the right.

Answer 134

ANS: C
By 2 weeks, the infant shows the tonic neck reflex when supine and the head is turned to one side (extension of same arm and leg, flexion of opposite arm and leg). The tonic neck reflex disappears between 3 and 4 months of age.

Question 135

During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and assesses the patient for:

a. Exophthalmos.
b. Sunken eyes.
c. Coarse facial features.
d. Rounded moonlike face.

Answer 135

ANS: C
Acromegaly is excessive secretion of growth hormone that creates an enlarged skull and thickened cranial bones. Patients have elongated heads, massive faces, prominent noses and lower jaws, heavy eyebrow ridges, and coarse facial features. Exophthalmos is associated with hyperthyroidism. A round moonlike face is seen with Cushing’s syndrome. Sunken eyes are reflective of a cachectic appearance. (See Table 14-4; 14-5).

Question 136

When examining children affected with Down’s syndrome (trisomy 21), the nurse looks for the possible presence of:

a. Misshapen ears.
b. Long, thin neck.
c. Thin tongue sticking out.
d. Narrow and raised nasal bridge.

Answer 136

ANS: A
With the chromosomal aberration trisomy 21, also known as Down’s syndrome, head and face characteristics may include upslanting eyes with inner epicanthal folds (small folds of skin at the inner corners), a flat nasal bridge, a small broad flat nose, a protruding thick tongue, ear dysplasia (misshapen ears), a short broad neck with webbing, and small hands with a single palmar crease. (See Table 14-2.)

Question 137

A patient is admitted to the hospital with paralysis to the left side of his mouth. On assessment, the nurse notes that the patient can close his eyes but is not able to whistle or smile when asked to. The nurse recognizes that the patient needs additional assessment for:

a. Cushing’s syndrome.
b. Parkinson’s disease.
c. Lower motor lesion.
d. Upper motor lesion.

Answer 137

ANS: D
With an upper motor neuron lesion that can occur with a cerebrovascular accident (CVA), the patient will have paralysis of lower facial muscles, but the upper half of the face will not be affected owing to the intact nerve from the unaffected hemisphere. The person is still able to wrinkle the forehead and close the eyes. (See Table 14-4, Abnormal Facial Appearances with Chronic Illnesses, for descriptions of the other responses.)

Question 138

A woman comes to the clinic and states, “I’ve been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry.” The nurse will assess for other signs and symptoms of:

a. Cachexia.
b. Parkinson’s disease.
c. Myxedema.
d. Scleroderma.

Answer 138

ANS: C
Myxedema (hypothyroidism) is a deficiency of the thyroid hormone that, when severe, causes a nonpitting edema or myxedema. The patient has a puffy edematous face, especially around the eyes (periorbital edema); coarse facial features; dry skin; and dry, coarse hair and eyebrows. (See Table 14-5 Thyroid Hormone Disorders.)

Question 139

During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be:

a. Clumped.
b. Unilateral.
c. Firm but freely movable.
d. Firm and nontender.

Answer 139

ANS: C
Acutely infected lymph nodes are bilateral, enlarged, warm, tender, and firm but freely movable. Unilaterally enlarged nodes that are firm and nontender may indicate cancer.

Question 140

The physician reports that a patient with a neck tumour has a tracheal shift. The nurse is aware that this means that the patient’s trachea is:

a. Pulled to the affected side.
b. Pushed to the unaffected side.
c. Pulled downward.
d. Pulled downward in a rhythmic pattern.

Answer 140

ANS: B
The trachea is pushed to the unaffected side with an aortic aneurysm, a tumour, unilateral thyroid lobe enlargement, or a pneumothorax. The trachea is pulled to the affected side with large atelectasis, pleural adhesions, or fibrosis. Tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm.

Question 141

During an assessment of an infant, the nurse notes that the fontanelles are depressed and sunken. The nurse suspects which condition?

a. Rickets
b. Dehydration
c. Mental retardation
d. Increased intracranial pressure

Answer 141

ANS: B
Depressed and sunken fontanels occur with dehydration or malnutrition. Mental retardation and rickets have no effect on the fontanels. Increased intracranial pressure would cause tense or bulging and possibly pulsating fontanelles.

Question 142

The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. These findings are characteristic of:

a. Allergies.
b. Sinus infection.
c. Nasal congestion.
d. Upper respiratory infection.

Answer 142

ANS: A
Chronic allergies often develop chronic facial characteristics and include blue shadows below the eyes, a double or single crease on the lower eyelids, open-mouth breathing, and a transverse line on the nose.

Question 143

While performing a well-child assessment on a 5-year-old, the nurse notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5 cm in size, round, mobile, and nontender. The nurse documents that the child:

a. Has chronic allergies.
b. Has an infection.
c. Has normal findings for a 5-year-old child.
d. Should be referred for additional evaluation

Answer 143

ANS: C
Palpable lymph nodes are normal in children until puberty when the lymphoid tissue begins to atrophy. Lymph nodes may be up to 1 cm in size in the cervical and inguinal areas but are discrete, movable, and nontender.

Question 144

The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally:

a. Shotty
b. Nonpalpable.
c. Large, firm, and fixed to the tissue.
d. Rubbery, discrete, and mobile.

Answer 144

ANS: B
Most lymph nodes are nonpalpable in adults. The palpability of lymph nodes decreases with age. Normal nodes feel movable, discrete, soft, and nontender.

Question 145

During an examination of a patient in her third trimester of pregnancy, the nurse notices that the patient’s thyroid gland is slightly enlarged. No enlargement had been previously noticed. The nurse recognizes that the patient:

a. Has an iodine deficiency.
b. Is exhibiting early signs of goitre.
c. Is exhibiting a normal enlargement of the thyroid gland during pregnancy.
d. Needs further testing for possible thyroid cancer.

Answer 145

ANS: C

The thyroid gland enlarges slightly during pregnancy because of hyperplasia of the tissue and increased vascularity.

Question 146

During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is by:

a. Using gentle pressure and palpating with both hands to compare the two sides.
b. Using strong pressure and palpating with both hands to compare the two sides.
c. Gently pinching each node between one’s thumb and forefinger and then moving down the neck muscle.
d. Using the index and middle fingers and gently palpating by applying pressure in a rotating pattern.

Answer 146

ANS: A
Using gentle pressure is recommended because strong pressure can push the nodes into the neck muscles. Palpating with both hands to compare the two sides symmetrically is usually most efficient.

Question 147

During a well-baby checkup, a mother is concerned because her 2-month-old infant cannot hold her head up when she is pulled to a sitting position. Which response by the nurse is appropriate?

a. “Head control is usually achieved by 4 months of age.”
b. “You shouldn’t be trying to pull your baby up like that until she is older.”
c. “Head control should be achieved by this time.”
d. “This inability indicates possible nerve damage to the neck muscles.”

Answer 147

ANS: A
Head control is achieved by 4 months when the baby can hold the head erect and steady when pulled to a vertical position. The other responses are not appropriate.

Question 148

During an examination of a 3-year-old child, the nurse notices a bruit over the left temporal area. The nurse should:

a. Continue the examination because a bruit is a normal finding for this age.
b. Check for the bruit again in 1 hour.
c. Notify the parents that a bruit has been detected in their child.
d. Stop the examination, and notify the physician.

Answer 148

ANS: A
Bruits are common in the skull in children under 4 or 5 years of age and in children with anemia. They are systolic or continuous and are heard over the temporal area.

Question 149

During an examination, the nurse finds that a patient’s left temporal artery is tortuous and feels hardened and tender, compared with the right temporal artery. The nurse suspects which condition?

a. Crepitation
b. Mastoiditis
c. Temporal arteritis
d. Bell’s palsy

Answer 149

ANS: C
With temporal arteritis, the artery appears more tortuous and feels hardened and tender. These assessment findings are not consistent with the other responses.

Question 150

The nurse is providing an educational session to parents in the community on concussions. The nurse shares some of the signs and symptoms to watch for after a head injury which can indicate a concussion and the need to seek medical attention: (Select all that apply.)

a. Fatigue
b. Calmness
c. Photophobia
d. Happiness
e. Feeling woozy
f. Insomnia

Answer 150

ANS: A, C, E
Signs and symptoms of a concussion are headache, dizziness/feeling woozy, feeling dazed, “seeing stars,” sensitivity to light/photophobia, ringing in ears/tinnitus, tiredness/fatigue, nausea, vomiting, irritability, confusion, and disorientation.