Advanced Physical Assessment quiz 3

Advanced Physical Assessment quiz 3 1. Question : 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 would pay special attention to the danger signs for pigmented lesions and would be concerned with which additional finding? Student Answer: Color variation Border regularity Symmetry of lesions Diameter less than 6 mm Instructor Explanation: Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm. Points Received: 2 of 2 Comments: Question 2.Question : 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? Student Answer: Increased vascularity of the skin in the elderly Increased numbers of sweat and sebaceous glands in the elderly An increase in elastin and a decrease in subcutaneous fat in the elderly An increased loss of elastin and a decrease in subcutaneous fat in the elderly Instructor Explanation: An accumulation of factors place the aging person at risk for skin disease and breakdown: the thinning of the skin, the 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, the increasingly sedentary lifestyle, and the chance of immobility. Points Received: 2 of 2 Comments: Question 3.Question : A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for about three days with his feet down and he wants the nurse to evaluate his feet. During the assessment, the nurse might expect to find Student Answer: pallor. coolness. distended veins. prolonged capillary filling time. Instructor Explanation: Keeping the feet in a dependent position causes venous pooling, resulting in redness, warmth, and distended veins. Prolonged elevation would cause pallor and coolness. Immobilization or prolonged inactivity would cause prolonged capillary filling time. See Table 12-1. Points Received: 2 of 2 Comments: Question 4.Question : A 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 assessment finding? Student Answer: Anasarca Scleroderma Pedal erythema Clubbing of the nails Instructor Explanation: Clubbing of the nails occurs with congenital cyanotic heart disease, neoplastic, and pulmonary diseases. The other responses are assessment findings not associated with pulmonary diseases. Points Received: 2 of 2 Comments: Question 5.Question : The nurse notices that a school-aged child has bluish-white, redbased spots in her mouth that are elevated about 1 mm to 3 mm. What other signs would the nurse expect to find in this patient? Student Answer: A pink, papular rash on the face and neck Pruritic vesicles over her trunk and neck Hyperpigmentation on the chest, abdomen, and the back of the arms A red-purple, maculopapular, blotchy rash behind the ears and on the face Instructor Explanation: With measles (rubeola), the examiner would assess a red-purple, blotchy rash on the third or fourth day of illness that appears first behind the ears and spreads over the face and then over the neck, trunk, arms and legs. It looks coppery and does not blanch. The bluish-white, red-based spots in the mouth are known as Koplik’s spots. Points Received: 2 of 2 Comments: Question 6.Question : During an examination, the nurse knows that Paget’s disease would be indicated by which of these assessment findings? Student Answer: Positive Macewen sign Premature closure of the sagittal suture Headache, vertigo, tinnitus, and deafness Elongated head with heavy eyebrow ridge Instructor Explanation: Paget’s disease occurs more often in males and is characterized by bowed long bones, sudden fractures, and enlarging skull bones that press on cranial nerves causing symptoms of headache, vertigo, tinnitus, and progressive deafness. Points Received: 2 of 2 Comments: Question 7.Question : A mother brings her newborn in for an assessment and asks, “Is there something wrong with my baby? His head seems so big.” The nurse recognizes that which statement is true regarding the relative proportions of the head and trunk of the newborn? Student Answer: At birth, the head is one fifth the total length. Head circumference should be greater than chest circumference at birth. The head size reaches 90% of its final size when the child is 3 years old. When the anterior fontanel closes at 2 months, the head will be more proportioned to the body. Instructor Explanation: 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 age 6 years. Points Received: 2 of 2 Comments: Question 8.Question : 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 Student Answer: thyroid gland. parotid gland. cervical lymph nodes. mouth and skin for lesions. Instructor Explanation: The parotid gland may become swollen with the onset of mumps, and parotid enlargement has been found with HIV. Points Received: 2 of 2 Comments: Question 9.Question : A 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 Student Answer: Cushing’s syndrome. Parkinson disease. Bell’s palsy. had a cerebrovascular accident (stroke).