Quiz
Exam 2 Part 1
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Questions in this quiz (200)
1One of the skin's functions is to produce Vitamin D
- ATrue
- BFalse
2fine downy hair of newborn infant (more in premature babies)
- Alanugo
- BVernix caseosa
- Csebum
3thick, cheesy substance
- Alanugo
- BVernix caseosa
- Csebum
4holding water in the skin producing milia (lubricate and waterproof the skin)
- Alanugo
- BVernix caseosa
- Csebum
5Increased pigmentation midline of abdomen
- ALinea nigra
- BChloasma
- CStriae gravidarum
6Discoloration changes on face representing the “mask of pregnancy” (caused by hormonal changes, in which large brown patches form on the skin, mainly on the face).
- ALinea nigra
- BChloasma
- CStriae gravidarum
7Stretch marks, which can develop over the abdomen, breast, and thighs
- AStriae gravidarum
- BChloasma
- CLinea nigra
8The nurse is assessing a patient who has been admitted for liver failure. What finding would the nurse expect?
- Acyanosis
- Bflushing
- CRubor
- Djaundice
9Jaundice occurs because your baby's body has more bilirubin than it can get rid of. Bilirubin is a yellow substance that's made when the body breaks down old red blood cells. It leaves the body through urine and stool. When you're pregnant, your body removes bilirubin from your baby through the placenta. Normal in babies
- Aphysiologic jaundice
- Bpathologic jaundice
10 Select the best description of the secretion of the eccrine glands.
- Athick, milky
- BDilute saline solution
- CProtective lipid substance
- DKeratin
11 To assess for early jaundice, you will assess:
- ASclera and hard palate
- BNail beds
- Clips
- DAll visible skin surfaces
12 Checking for skin temperature is best accomplished by using:
- AThe palmar surface of the hands.
- BThe ventral surface of the hands.
- CThe fingertips.
- DThe dorsal surface of the hands.
13 Assessing a patient’s skin turgor is done to assess which clinical finding?
- Aedema
- BDehydration
- CVitiligo
- Dscleroderma
14 You note a lesion during a skin assessment. Which is the best way to document this finding?
- ARaised, irregular lesion the size of a quarter, located on dorsum of left hand
- BOpen lesion with no drainage or odor, approximately 14 inch in diameter
- CPedunculated lesion below left scapula with consistent red color and no drainage or odor
- DDark brown raised lesion, with irregular border, on dorsum of right foot, 3 cm in size, with no drainage
15You examine the nail beds of a patient. Which finding indicates a normal angle? _____ degrees
- A60
- B100
- C160
- D180
16 You are assessing capillary refill. The room is warm. Which finding would be considered normal?
- A<1 second
- B>2 seconds
- C2 to 3 seconds
- DTime is not significant as long as color returns.
17 During a routine visit, M.B., age 78, asks about small, round, flat, brown macules on the hands. What is your best response after assessing the areas?
- A“These are the result of sun exposure and do not require treatment.”
- B“These are related to exposure to the sun. They may become cancerous.”
- C“These are the skin tags that occur with aging. No treatment is required.”
- D“I’m glad you brought this to my attention. I will arrange for a biopsy.”
18 An area of thin shiny skin with decreased visibility of normal skin markings is most likely:
- ALichenification
- Bplaque
- CAtrophy
- Dkeloid
19 Flattening of the angle between the nail and its base is:
- AFound in subacute bacterial endocarditis.
- BA description of spoon-shaped nails.
- CRelated to calcium deficiency.
- Ddescribed as clubbing
20 A configuration of individual lesions arranged in circles or arcs, as occurs with ringworm, is described as a(n) _____ lesion
- Alinear
- Bclustered
- CAnnular
- DGyrate
21 The “A” in the ABCDE rule for skin cancer stands for:
- Aaccuracy
- Bappearance
- Casymmetry
- DAttenuated
22 A risk factor for melanoma is:
- Abrown eyes
- BDarkly pigmented skin
- CSkin that freckles or burns before tanning
- DUse of sunscreen products
23Herpes zoster infection (shingles) is characterized by:
- AA bacterial cause
- BLesion on only one side of body; does not cross midline
- CAbsence of pain or edema
- DPustular, umbilicated lesions
24Basal cell layer
- Aepidermis
- Bdermis
- Csubcutaneous layer
25Aids protection by cushioning
- Aepidermis
- Bdermis
- Csubcutaneous layer
26collagen
- Aepidermis
- Bdermis
- Csubcutaneous layer
27Adipose tissue
- Aepidermis
- Bdermis
- Csubcutaneous layer
28Uniformly thin
- Aepidermis
- Bdermis
- Csubcutaneous layer
29Stratum corneum
- Aepidermis
- Bdermis
- Csubcutaneous layer
30Elastic tissue
- Aepidermis
- Bdermis
- Csubcutaneous layer
31Intense redness of the skin due to excess blood in the dilated superficial capillaries
- Apallor
- BErythema
- Ccyanosis
- Djaundice
32Bluish mottled color that signifies decreased perfusion
- Apallor
- BErythema
- Ccyanosis
- Djaundice
33Absence of red-pink tones from the oxygenated hemoglobin in blood
- Apallor
- BErythema
- Ccyanosis
- Djaundice
34Increase in bilirubin in the blood causing a yellow color in the skin
- Apallor
- BErythema
- Ccyanosis
- Djaundice
35The 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:
- Ahighly vascular
- BThick and tough
- CThin and nonstratified
- Dreplaced every 4 weeks
36The 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:
- AContains mostly fat cells
- BConsists mostly of keratin
- CIs replaced every 4 weeks
- DContains sensory receptors
37The 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 odor.” The nurse knows that this condition could be related to:
- AEccrine glands
- BApocrine glands
- CDisorder of the stratum corneum
- DDisorder of the stratum germinativum
38A 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?
- ASubcutaneous fat deposits are high in the newborn
- BSebaceous glands are overproductive in the newborn
- CThe newborn’s skin is more permeable than that of the adult
- DThe amount of vernix caseosa dramatically rises in the newborn
39The 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?
- AIncreased vascularity of the skin
- BIncreased numbers of sweat and sebaceous glands
- CAn increase in elastin and a decrease in subcutaneous fat
- DAn increased loss of elastin and a decrease in subcutaneous fat
40During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning:
- AMetrocytes
- BFungacytes
- CPhagocytes
- DMelanocytes
41During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is:
- AXerosis
- BPruritus
- CAlopecia
- DSeborrhea
42A 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 medication class?
- ANonsteroidal antiinflammatory drugs for pain
- BTetracyclines for acne
- CProton pump inhibitors for heartburn
- DThyroid replacement hormone for hypothyroidism
43A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and takes oral hypoglycemic agents. The patient needs to be concerned about which possible effect of her medications?
- AIncreased possibility of bruising
- BSkin sensitivity as a result of exposure to salt water
- CLack of availability of glucose-monitoring supplies
- DImportance of sunscreen and avoiding direct sunlight
44A 13-year-old girl is interested in obtaining information about the cause of her acne. The nurse should share with her that acne:
- AIs contagious.
- BHas no known cause
- CIs caused by increased sebum production
- DHas been found to be related to poor hygiene
45A 75-year-old woman who has 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 will encourage her to stop trying to remove the corn with scissors because:
- AThe woman could be at increased risk for infection and lesions because of her chronic disease
- BWith her diabetes, she has increased circulation to her foot, and it could cause severe bleeding
- CShe is 75 years old and is unable to see; consequently, she places herself at greater risk for self-injury with the scissors
- DWith her peripheral vascular disease, her range of motion is limited and she may not be able to reach the corn safely
46The nurse keeps in mind that a thorough skin assessment is extremely important because the skin holds information about a person’s:
- Asupport systems
- BCirculatory status.
- Csocioeconomic status
- DPsychological wellness
47A 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:
- Avenous pooling
- BPeripheral vasodilation
- CPeripheral vasoconstriction
- DDecreased arterial perfusion
48A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find:
- Apallor
- Bcoolness
- CDistended veins
- DProlonged capillary filling time
49A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is:
- ACaused by an excess of melanin pigment
- BCaused by an excess of apocrine glands in her feet
- CCaused by the complete absence of melanin pigment
- DRelated to impetigo and can be treated with an ointment
50A 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?
- Acolor variation
- BBorder regularity
- CSymmetry of lesions
- DDiameter of less than 6 mm
51A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition is due to hyperemia and knows that it can be caused by:
- ADecreased amounts of bilirubin in the blood
- BExcess blood in the underlying blood vessels
- CDecreased perfusion to the surrounding tissues
- DExcess blood in the dilated superficial capillaries
52During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patient’s scleras are not yellow. From this finding, the nurse could probably rule out:
- Apallor
- Bjaundice
- Ccyanosis
- DIron deficiency
53A black patient 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?
- Aruddy blue
- BGeneralized pallor
- CAshen, gray, or dull
- DPatchy areas of pallor
54An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination?
- ASmooth mucous membranes and lips
- BDry mucous membranes and cracked lips
- CPale mucous membranes
- DWhite patches on the mucous membranes
55A 42-year-old woman complains that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse expects that the spots are probably:
- AAnasarca
- BScleroderma
- CSenile angiomas
- DLatent myeloma
56A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding?
- AAnasarca
- BScleroderma
- CPedal erythema
- DClubbing of the nails
57A newborn infant has Down 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:
- ACafé au lait
- BCarotenemia
- CAcrocyanosis
- DCutis marmorata
58A 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 continues the skin assessment aware that another finding may be:
- AKeratoses
- BXerosis.
- CChloasma
- DAcrochordons.
59A man has come in to the clinic for a skin assessment because he is 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. Which is the best prediction?
- ASenile lentigines, which do not become cancerous
- BActinic keratoses, which are precursors to basal cell carcinoma
- CAcrochordons, which are precursors to squamous cell carcinoma
- DSeborrheic keratoses, which do not become cancerous
60A 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“Due to 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.”
61The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a:
- Abulla
- Bwheal
- Cnodule
- Dpapule
62The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find:
- ALesions that run together
- BAnnular lesions that have grown together
- CLesions arranged in a line along a nerve route
- DLesions that are grouped or clustered together.
63A patient has had a “terrible itch” for several months that he has been continuously scratching. On examination, the nurse might expect to find:
- Aa keloid
- Ba fissure
- CKeratosis
- DLichenification
64A 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 should say, “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 center.”
- C“Confluent and extensive patch of petechiae and ecchymoses on the feet.”
- D“Tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color.”
65A 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 thin erythematous base and suspects:
- AEczema
- Bimpetigo
- CHerpes zoster
- DDiaper dermatitis
66The nurse notices that a school-aged child has bluish-white, red-based spots in her mouth that are elevated approximately 1 to 3 mm. What other signs would the nurse expect to find in this patient?
- APink, papular rash on the face and neck
- BPruritic vesicles over her trunk and neck
- CHyperpigmentation on the chest, abdomen, and back of the arms
- DRed-purple, maculopapular, blotchy rash behind the ears and on the face
67The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS) and notices multiple patchlike lesions on the temple and beard area that are faint pink in color. The nurse recognizes these lesions as:
- AMeasles (rubeola).
- BKaposi’s sarcoma
- CAngiomas.
- DHerpes zoster
68A 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:
- ATinea capitis
- BFolliculitis.
- CToxic alopecia
- DSeborrheic dermatitis
69A mother brings her child into the clinic for an examination of the scalp and hair. She states that the child has developed irregularly shaped patches with broken-off, stublike hair in some places; she is worried that this condition could be some form of premature baldness. The nurse tells her that it is:
- AFolliculitis that can be treated with an antibiotic
- BTraumatic alopecia that can be treated with antifungal medications
- CTinea capitis that is highly contagious and needs immediate attention
- DTrichotillomania; her child probably has a habit of absentmindedly twirling her hair.
70The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition?
- ASevere obesity
- BChildhood growth spurts
- CSevere dehydration
- DConnective tissue disorders such as scleroderma
71While 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 color. 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?
- ATell the patient to watch the lesion and report back in 2 months.
- BRefer the patient because of the suggestion of melanoma on the basis of her symptoms
- CAsk additional questions regarding environmental irritants that may have caused this condition
- DTell the patient that these signs suggest a compound nevus, which is very common in young to middle-aged adults
72The nurse is assessing for clubbing of the fingernails and expects to find:
- ANail bases that are firm and slightly tender
- BCurved nails with a convex profile and ridges across the nails
- CNail bases that feel spongy with an angle of the nail base of 150 degrees
- DNail bases with an angle of 180 degrees or greater and nail bases that feel spongy
73The nurse is assessing a patient who has liver disease for jaundice. Which of these assessment findings is indicative of true jaundice?
- AYellow patches in the outer sclera
- BYellow color of the sclera that extends up to the iris
- CSkin that appears yellow when examined under low light
- DYellow deposits on the palms and soles of the feet where jaundice first appears
74The nurse is assessing for inflammation in a dark-skinned person. Which technique is the best?
- AAssessing the skin for cyanosis and swelling
- BAssessing the oral mucosa for generalized erythema
- CPalpating the skin for edema and increased warmth
- DPalpating for tenderness and local areas of ecchymosis
75A 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 is red, macular, with a bull’s eye pattern across his midriff and behind his knees. The nurse suspects:
- ARubeola
- BLyme disease
- CAllergy to mosquito bites
- DRocky Mountain spotted fever
76A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition?
- Aacne
- BBasal cell carcinoma
- Cmelanoma
- DSquamous cell carcinoma
77A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the last 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. The nurse should test skin mobility and turgor over the infant’s
- Asternum
- BForehead
- Cforearms
- Dabdomen
78A 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 color. The nurse suspects that this coloring is due to:
- APolycythemia.
- BCarbon monoxide poisoning
- CCarotenemia
- Duremia
79A patient has been admitted for severe psoriasis. The nurse expects to see what finding in the patient’s fingernails?
- ASplinter hemorrhages
- BParonychia
- Cpitting
- DBeau lines
80The 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.
- APetechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color
- BBulla: Elevated, circumscribed lesion filled with turbid fluid (pus)
- CPapule: Hypertrophic scar
- DVesicle: Known as a friction blister
- ENodule: Solid, elevated, and hard or soft growth that is larger than 1 cm
81A 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.
- AIntact skin appears red but is not broken
- BPartial thickness skin erosion is observed with a loss of epidermis or dermis
- CUlcer extends into the subcutaneous tissue.
- DLocalized redness in light skin will blanch with fingertip pressure.
- EOpen blister areas have a red-pink wound bed
- FPatches of eschar cover parts of the wound
82 Tiny, punctate red macules and papules on the cheeks, trunk, chest, back, and buttocks
- AErythema toxicum
- BAcrocyanosis
- CPhysiologic jaundice
- DCarotenemia
83 Lower half of body turns red, upper half blanches
- AHarlequin
- BErythema toxicum
- CAcrocyanosis
- DPhysiologic jaundice
84Transient mottling on trunk and extremities
- ACutis marmorata
- BHarlequin
- CErythema toxicum
- DAcrocyanosis
85Bluish color around the lips, hands, fingernails, feet, and toenails
- AAcrocyanosis
- BPhysiologic jaundice
- CCarotenemia
- DCafé au lait spot
86 Large round or oval patch of light brown usually present at birth
- ACafé au lait spot
- BCutis marmorata
- CHarlequin
- DErythema toxicum
87Yellowing of skin, sclera, and mucous membranes due to increased numbers of red blood cells hemolyzed after birth
- APhysiologic jaundice
- BCarotenemia
- CCafé au lait spot
- DCutis marmorata
88 Yellow-orange color in light-skinned persons from large amounts of foods containing carotene
- ACarotenemia
- BCafé au lait spot
- CCutis marmorata
- DHarlequin
89Facial expressions formed by facial muscles, which are mediated by cranial nerve _____, the facial nerve
- AVII
- BIII
- CVI
- DV
90Bones of an adolescent skull are separated by sutures and fontanels, spaces where the sutures intersect
- ATrue
- BFalse
91_____-shaped posterior fontanel closes by 1 to 2 months, and _____-shaped anterior fontanel closes between 9 months and 2 years
- Atriangle, diamond
- Bdiamond, triangle
92Triangle-shaped posterior fontanel closes by _____, and diamond-shaped anterior fontanel closes between _____
- A1-2 months, 9 months-2 years
- B9 months-2 years, 1-2 months
93Cancerous nodules tend to be hard and are fixed to surrounding structures
- ATrue
- BFalse
94The nurse suspects that a patient has hyperthyroidism. Which of the following findings would the nurse most likely find on examination?
- AIncreased heart rate, weight loss
- BDecreased heart rate, weight gain
- CIncreased heart rate, weight gain
- DDecreased heart rate, weight loss
95A physician tells the nurse that a patient’s vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is:
- AJust above the diaphragm
- BJust lateral to the knee cap
- CAt the level of the C7 vertebra
- DAt the level of the T11 vertebra
96A 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 could be 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 baby’s life.”
97The nurse notices that a patient’s palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)?
- AIII
- BV
- CVII
- DVIII
98A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects:
- ABell palsy
- BDamage to the trigeminal nerve
- CFrostbite with resultant paresthesia to the cheeks
- DScleroderma
99When examining the face of a patient, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the ___________ and ___________ glands.
- AOccipital; submental
- BParotid; jugulodigastric
- CParotid; submandibular
- DSubmandibular; occipital
100A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN ______ and proceeds with the examination by _____________.
- AXI; palpating the anterior and posterior triangles
- BXI; asking the patient to shrug her shoulders against resistance
- CXII; percussing the sternomastoid and submandibular neck muscles
- DXII; assessing for a positive Romberg sign
101When examining a patient’s CN function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the:
- ASternomastoid and trapezius
- BSpinal accessory and omohyoid
- CTrapezius and sternomandibular
- DSternomandibular and spinal accessory
102A patient’s laboratory data reveal an elevated thyroxine (T4) level. The nurse would proceed with an examination of the _____ gland
- AThyroid
- BParotid
- CAdrenal
- DParathyroid
103A 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 the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule):
- AIs tender.
- BIs mobile and not hard
- CDisappears when the patient smiles
- DIs hard and fixed to the surrounding structures
104The nurse notices that a patient’s submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the patient’s:
- AInfraclavicular area
- BSupraclavicular area
- CArea distal to the enlarged node
- DArea proximal to the enlarged node
105The nurse is aware that the four areas in the body where lymph nodes are accessible are the:
- AHead, breasts, groin, and abdomen
- BArms, breasts, inguinal area, and legs
- CHead and neck, arms, breasts, and axillae
- DHead and neck, arms, inguinal area, and axillae
106A 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?
- AAt birth, the head is one fifth the total length
- BHead circumference should be greater than chest circumference at birth
- CThe head size reaches 90% of its final size when the child is 3 years old
- DWhen the anterior fontanel closes at 2 months, the head will be more proportioned to the body
107A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give her?
- ADiets low in protein and high in carbohydrates may cause enhanced facial bones
- BBones can become more noticeable if the person does not use a dermatologically approved moisturizer
- CMore noticeable facial bones are probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin
- DFacial skin becomes more elastic with age. This increased elasticity causes the skin to be more taught, drawing attention to the facial bones
108A patient reports excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that has lasted approximately ½ to 2 hours, occurring once or twice each day. The nurse should suspect:
- AHypertension
- BCluster headaches
- CTension headaches
- DMigraine headaches.
109A patient complains that while studying for an examination he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. The nurse suspects that he may be suffering from
- AHypertension
- BCluster headaches
- CTension headaches
- DMigraine headaches
110A 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 looks for other signs and symptoms of which problem?
- AHead injury
- BCluster headache
- CMigraine headache
- DMeningeal inflammation
111During a well-baby checkup, the nurse notices that a 1-week-old infant’s face looks small compared with his cranium, which seems enlarged. On further examination, the nurse also notices dilated scalp veins and downcast or “setting sun” eyes. The nurse suspects which condition?
- ACraniotabes
- BMicrocephaly
- CHydrocephalus
- DCaput succedaneum
112The nurse needs to palpate the temporomandibular joint for crepitation. This joint is located just below the temporal artery and anterior to the:
- AHyoid bone
- BVagus nerve
- CTragus
- DMandible
113A 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:
- AThyroid gland
- BParotid gland
- COccipital lymph node
- DSubmental lymph node
114A male patient with a history of acquired immunodeficiency syndrome (AIDS) has come in for an examination and he states, “I think that I have the mumps.” The nurse would begin by examining the:
- AThyroid gland
- BParotid gland
- CCervical lymph nodes
- DMouth and skin for lesions
115The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patient’s T4 and T3 hormone levels are elevated. Which of these findings would the nurse most likely find on examination?
- ATachycardia
- BConstipation
- CRapid dyspnea
- DAtrophied nodular thyroid gland
116A 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:
- ABehind with the nurse’s hands placed firmly around his neck
- BThe side with the nurse’s eyes averted toward the ceiling and thumbs on his neck
- CThe front with the nurse’s thumbs placed on either side of his trachea and his head tilted forward
- DThe front with the nurse’s thumbs placed on either side of his trachea and his head tilted backward
117A 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.
- ALow gurgling; diaphragm
- BLoud, whooshing, blowing; bell
- CSoft, whooshing, pulsatile; bell
- DHigh-pitched tinkling; diaphragm
118The 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. One possible explanation for this is:
- AHydrocephalus
- BCraniosynostosis
- CCephalhematoma
- DCaput succedaneum
119A 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:
- AAbnormal and is called the atonic neck reflex
- BNormal and should disappear by the first year of life
- CNormal and is called the tonic neck reflex, which should disappear between 3 and 4 months of age
- DAbnormal. The baby should be flexing the arm and leg on the right side of his body when the head is turned to the right
120During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for:
- AExophthalmos
- BBowed long bones
- CCoarse facial features
- DAcorn-shaped cranium
121When examining children affected with Down syndrome (trisomy 21), the nurse looks for the possible presence of:
- AEar dysplasia
- BLong, thin neck
- CProtruding thin tongue
- DNarrow and raised nasal bridge
122A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he has:
- ACushing syndrome
- BParkinson disease
- CBell palsy
- DExperienced a cerebrovascular accident (CVA) or stroke
123A 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:
- ACachexia
- BParkinson syndrome
- CMyxedema
- DScleroderma
124During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be:
- AClumped
- BUnilateral
- CFirm but freely movable
- DFirm and nontender
125The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is aware that this means that the patient’s trachea is:
- APulled to the affected side
- BPushed to the unaffected side
- CPulled downward
- DPulled downward in a rhythmic pattern
126During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition?
- ARickets
- BDehydration
- CMental retardation
- DIncreased intracranial pressure
127The 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:
- AAllergies
- BSinus infection
- CNasal congestion
- DUpper respiratory infection
128While 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 suspects that this child:
- AHas chronic allergies
- BMay have an infection
- CIs exhibiting a normal finding for a well child of this age
- DShould be referred for additional evaluation
129The 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:
- AShotty.
- BNonpalpable
- CLarge, firm, and fixed to the tissue
- DRubbery, discrete, and mobile
130During 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 suspects that the patient:
- AHas an iodine deficiency
- BIs exhibiting early signs of goiter
- CIs exhibiting a normal enlargement of the thyroid gland during pregnancy
- DNeeds further testing for possible thyroid cancer
131During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement?
- AUsing gentle pressure, palpate with both hands to compare the two sides
- BUsing strong pressure, palpate with both hands to compare the two sides
- CGently pinch each node between one’s thumb and forefinger, and then move down the neck muscle
- DUsing the index and middle fingers, gently palpate by applying pressure in a rotating pattern
132During 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.”
133During an examination of a 3-year-old child, the nurse notices a bruit over the left temporal area. The nurse should:
- AContinue the examination because a bruit is a normal finding for this age
- BCheck for the bruit again in 1 hour
- CNotify the parents that a bruit has been detected in their child
- DStop the examination, and notify the physician
134During 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?
- ACrepitation
- BMastoiditis
- CTemporal arteritis
- DBell palsy
135The nurse is assessing a 1-month-old infant at his well-baby checkup. Which assessment findings are appropriate for this age? Select all that apply.
- AHead circumference equal to chest circumference
- BHead circumference greater than chest circumference
- CHead circumference less than chest circumference
- DFontanels firm and slightly concave
- EAbsent tonic neck reflex
- FNonpalpable cervical lymph nodes
136 Which facial bones articulate at a joint instead of a suture?
- AZygomatic
- BMaxilla
- CNasal
- DMandible
137Identify the blood vessel that runs diagonally across the sternomastoid muscle.
- ATemporal artery
- BCarotid artery
- CExternal jugular vein
- DInternal jugular vein
138The isthmus of the thyroid gland lies just below the:
- AMandible.
- BCricoid cartilage.
- CHyoid cartilage.
- DThyroid cartilage.
139Which is true regarding cluster headaches?
- AThey may be precipitated by alcohol and daytime napping.
- BTheir usual occurrence is two per month, each lasting 1 to 3 days.
- CThey are characterized as throbbing.
- DThey tend to be supraorbital, retro-orbital, or frontotemporal.
140Which is least likely to indicate a possible malignancy?
- AHistory of radiation therapy to the head, neck, or upper chest
- BHistory of using chewing tobacco
- CHistory of large alcohol consumption
- DMarked tenderness
141 Providing resistance while the patient shrugs his or her shoulders is a test of which cranial nerve?
- AII
- BV
- CIX
- DXI
142On examination, the infant’s fontanels should feel:
- AOn examination, the infant’s fontanels should feel:
- BDepressed or sunken
- CFirm, slightly concave, and well defined
- DPulsating
143If the thyroid gland were enlarged bilaterally, which maneuver would be appropriate for you to assess?
- ACheck for deviation of the trachea.
- BListen for a bruit over the carotid arteries.
- CListen for a murmur over the aortic area.
- DListen for a bruit over the thyroid lobes.
144It is normal to palpate a few lymph nodes in the neck of a healthy person. What are the characteristics of these nodes?
- AMobile, soft, nontender
- BLarge, clumped, tender
- CMatted, fixed, tender, hard
- DMatted, fixed, nontender
145Cephalhematoma is associated with:
- ASubperiosteal hemorrhage
- BIncreased intracranial pressure
- CDown syndrome
- DCerebral palsy
146Normal cervical notes are:
- ASmaller than 1 cm
- BWarm to palpation
- CFixed
- DFirm
147A throbbing, unilateral pain associated with nausea, vomiting, and photophobia is characteristic of:
- ACluster headache
- BSubarachnoid hemorrhage
- CMigraine headache
- DTension headache
148Bell palsy is characterized by:
- AUnilateral paralysis of half of the face
- BBulging eyeballs
- CA face that appears masklike
- DA puffy, edematous face
149You suspect an infant’s head is of abnormal size and can use which procedure to verify these findings?
- APalpation
- BMeasuring tape
- CObserving for symmetry of facial features
- DNoting absence of the tonic neck reflex
150Above and behind the clavicle
- ASupraclavicular
- BPreauricular
- CPosterior auricular
- DOccipital
151Deep under the sternomastoid muscle
- ADeep cervical
- BPosterior cervical
- CSupraclavicular
- DPreauricular
152In front of the ear
- APreauricular
- BPosterior auricular
- COccipital
- DSubmental
153In the posterior triangle along the edge of the trapezius muscle
- APosterior cervical
- BSupraclavicular
- CPreauricular
- DPosterior auricular
154Superficial to the mastoid process
- APosterior auricular
- BOccipital
- CSubmental
- DSubmandibular
155At the base of the skull
- AOccipital
- BSubmental
- CSubmandibular
- DJugulodigastric
156Halfway between the angle and the tip of the mandible
- ASubmandibular
- BJugulodigastric
- CSuperficial cervical
- DDeep cervical
157Behind the tip of the mandible
- ASubmental
- BSubmandibular
- CJugulodigastric
- DSuperficial cervical
158Under the angle of the mandible
- AJugulodigastric
- BSuperficial cervical
- CDeep cervical
- DPosterior cervical
159Overlying the sternomastoid muscle
- ASuperficial cervical
- BDeep cervical
- CPosterior cervical
- DSupraclavicular
160The palpebral fissure is:
- ABorder between the cornea and sclera
- BOpen space between the eyelids
- CAngle where the eyelids meet
- DVisible on the upper and lower lids at the inner canthus
161Which retinal structures can be viewed through the ophthalmoscope?
- AThe optic disc, the retinal vessels, the general background, and the macula
- BThe cornea, the lens, the choroid, and the ciliary body
- CThe optic papilla, the sclera, the retina, and the iris
- DThe pupil, the sclera, the ciliary body, and the macula
162The examiner records “positive consensual light reflex.” This indicates:
- AConvergence of the axes of the eyeballs
- BSimultaneous constriction of the other pupil when one eye is exposed to bright light
- CReflex direction of the eye toward an object attracting a person’s attention
- DAdaptation of the eye for near vision
163The thickening and yellowing of the lens due to aging is described as:
- APresbyopia
- BFloaters
- CMacular degeneration
- DSenile cataract
164You must be alert for which eye emergency symptoms?
- AFloaters
- BEpiphora
- CSudden onset of vision change
- DPhotophobia
165Visual acuity is assessed with:
- ASnellen eye chart
- BOphthalmoscope
- CHirschberg test
- DConfrontation test
166The cover test is used to assess for:
- ANystagmus
- BPeripheral vision
- CMuscle weakness
- DVisual acuity
167When using the ophthalmoscope, you would:
- ARemove your own glasses and approach the patient’s left eye with your left eye.
- BLeave the light on in the examining room and remove glasses from the patient.
- CRemove glasses and set the diopter setting at 0.
- DUse the smaller white light and instruct the patient to focus on the ophthalmoscope.
168The 6 eye muscles that control eye movement are innervated by cranial nerves:
- AII, III, V
- BIV, VI, VII
- CIII, IV, VI
- DII, III, VI
169Conjunctivitis is associated with:
- AAbsent red reflex
- BReddened conjunctiva
- CImpairment of vision
- DFever
170A patient has blurred peripheral vision. You suspect glaucoma and assess the visual fields. A patient with normal vision would see your moving finger temporally at _____ degrees
- A50
- B60
- C90
- D180
171A patient is known to be blind in the left eye. What happens to the pupils when the right eye is illuminated by a penlight beam?
- ANo response in both pupils
- BBoth pupils constrict
- CRight pupil constricts, left has no response
- DLeft pupil constricts, right has no response
172When using the ophthalmoscope, the interruption of the red reflex occurs when:
- AThere is opacity in the cornea or lens.
- BThe patient has a pathologic process of the optic tract.
- CThe blood vessels are tortuous.
- DThe pupils are constricted.
173One of the causes of visual impairment in aging adults includes:
- AStrabismus
- BGlaucoma
- CAmblyopia
- DRetinoblastoma
174What is the cause of the red reflex?
- APetechial hemorrhages in the sclera
- BDiabetic retinopathy
- CLight reflecting from the retina
- DBlood in the vitreous
175Using the otoscope, the tympanic membrane is visualized. The color of the membrane is:
- ADeep pink
- BCreamy white
- CPearly gray
- DDependent on the ethnicity of the individual
176Sensorineural hearing loss may be related to:
- AGradual nerve degeneration
- BForeign bodies
- CImpacted cerumen
- DPerforated tympanic membrane
177Before examining a patient’s ear with the otoscope, you would palpate which for tenderness?
- AHelix, external auditory meatus, and lobule
- BMastoid process, tympanic membrane, and malleus
- CPinna, pars flaccida, and antitragus
- DPinna, tragus, and mastoid process
178During the otoscopic examination of a child younger than 3 years, the examiner:
- APulls the pinna up and back
- BPulls the pinna down
- CHolds the pinna gently but firmly in its normal position
- DTilts the head slightly toward the examiner
179 In examining the ear of an adult, the canal is straightened by pulling the auricle:
- ADown and forward
- BDown and back
- CUp and back
- DUp and forward
180Darwin’s tubercle indicates:
- AAn overgrowth of scar tissue
- BA blocked sebaceous gland
- CA sign of gout called tophi
- DA congenital, painless nodule at the helix
181 When assessing a patient’s ear with an otoscope, the patient’s head should be positioned:
- ATilted toward the examiner
- BTilted away from the examiner
- CAs vertical as possible
- DTilted down
182 The hearing receptors are located in which region?
- AVestibule
- BSemicircular canals
- CMiddle ear
- DCochlea
183 The sensation of vertigo may indicate:
- AOtitis media
- BPathology in the semicircular canals
- CPathology in the cochlea
- D4th cranial nerve damage
184A common cause of a conductive hearing loss is:
- AImpacted cerumen
- BAcute rheumatic fever
- CA CVA
- DOtitis externa
185You are assessing a patient’s tympanic membrane and suspect an infection of acute purulent otitis media. Which of the following findings supports this?
- AAbsent light reflex, bluish drum, oval dark areas
- BAbsent light reflex, reddened drum, bulging drum
- COval dark areas on drum
- DAbsent light reflex, air-fluid level, or
bubbles behind drum
186You are teaching a parent of an infant the health promotion activities to reduce the risk for acute otitis media. Which would you include in the teaching plan?
- AUsing pacifiers
- BIncreasing group daycare
- CAvoiding breastfeeding
- DEliminating smoking in the house and car
187When assessing hearing acuity in a 6-month- old child, the examiner would:
- AUse an audiometer.
- BObserve for shyness and withdrawal.
- CWatch for head turning when saying the child’s name.
- DTest the startle (Moro) reflex.
188 A patient with a head injury has clear, watery drainage from the ear. How should you proceed?
- APlace a cotton ball loosely at the entrance to the ear canal.
- BAssess for the presence of glucose in the drainage.
- CPerform pneumatic otoscopy to assess for drum hypomobility.
- DAssess for the presence of a tympanostomy tube in the ear.
189What is the most common site of nose bleeds?
- AThe turbinates
- BThe columellae
- CKiesselbach plexus
- DThe meatus
190Which sinuses can you assess through examination?
- AEthmoid and sphenoid
- BFrontal and ethmoid
- CMaxillary and sphenoid
- DFrontal and maxillary
191The frenulum is the:
- AMidline fold of tissue that connects the tongue to the floor of the mouth
- BAnterior border of the oral cavity
- CArching roof of the mouth
- DFree projection hanging down from the middle of the soft palate
192 The largest salivary gland is located:
- AWithin the cheeks in front of the ear
- BBeneath the mandible at the angle of the jaw
- CWithin the floor of the mouth under the tongue
- DAt the base of the tongue
193A 70-year-old woman reports dry mouth. The most frequent cause of this is:
- AThe aging process
- BRelated to medications she may be taking
- CThe use of dentures
- DRelated to a diminished sense of smell
194During an inspection of a patient’s nares, a deviated septum is noted. What should you do next?
- ARequest a consultation with an ear, nose, and throat specialist.
- BDocument the deviation in the medical record in case the person needs to be suctioned
- CTeach the person what to do if a nosebleed should occur.
- DExplore further because polyps frequently accompany a deviated septum.
195Oral malignancies are most likely to develop:
- AOn the soft palate.
- BOn the tongue.
- CIn the buccal cheek mucosa.
- DIn the mucosal “gutter” under the tongue.
196The tonsils are graded as 3+. The tonsils would be:
- AVisible.
- BHalfway between the tonsillar pillars and uvula.
- CTouching the uvula.
- DTouching each other.
197The function of the nasal turbinates is to:
- AWarm the inhaled air.
- BDetect odors.
- CStimulate tear formation.
- DLighten the weight of the skull bones.
198The opening of an adult’s parotid gland (Stensen’s duct) is opposite to:
- ALower 2nd molar
- BLower incisors
- CUpper incisors
- DUpper 2nd molar
199 A nasal polyp is distinguished from the nasal turbinates by 3 of the following. Which reason is FALSE?
The polyp is _____- Ahighly vascular.
- Bmovable.
- Cpale gray in color.
- Dnontender.
200 The examiner notes small, round, white, shiny papules on the hard palate and gums of a 2-month-old infant. What is the significance of this finding?
- AThese are aphthous areas or ulcers that are the result of sucking.
- BTeeth buds are beginning to appear.
- CThis is a normal finding called Epstein pearls.
- DIt indicates the presence of a monilial infection
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- Health Assessment I Quiz on Exam 2 Part 1, created by Nicole Buda on 13/09/2016.
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- Nicole Buda
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