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NUR 245 / NUR245 EXAM 2. QUESTIONS WITH 100% CORRECT ANSWERS.

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While performing an assessment of a 65-year-old man with a hx 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 A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. she has a dark complexion and has no family hx of skin cancer, but she has had many blistering sunburns in the past. the nurse would... The nurse is assessing for clubbing of the fingernails and expects to find... The nurse is assessing the pt who has liver disease for jaundice. which of these assessment findings is indicative if true jaundice? The nurse is assessing for inflammation in a dark-skinned person. which technique is the best? A few days after a summer hiking trip, a 25-year-old man comes into the clinic with a rash. on exam, the nurse notes that the rash is red, macular, with a bullseye pattern across his midriff and behind his knees. the nurse suspects... A 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 month ago and that it has slowly grown larger. The nurse suspects which condition? A father brings his 2 month old infant into the clinic because the infant has had diarrhea for the last 24 hours. he says the baby has not been able to keep formula down and that the diarrhea has been about every 2 hours, the nurse suspects dehydration. the nurse should test skin mobility and turgor over the infants... A semiconscious woman is brought to the ER 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: A patient has been admitted for severe psoriasis. the nurse expects to see what finding n the pts fingernails? 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 an assessment of the skin. which of the following definitions are correct? select all that apply: 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?

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NUR 245 EXAM 2
As a mandatory reporter of elder abuse, which of these must be present before a
nurse notifies the authorities?
suspicion of elder abuse and/or neglect




During a home visit, the nurse notices that an elderly woman is caring for her
bedridden husband. The woman states that this is her duty, she does the best she
can, and her children come to help when they are in town. Her husband is unable to
care for himself, and she appears thin, weak, and exhausted. The nurse notices that
several of his prescription medication bottles are empty. This situation is best
described by the term:
unintentional physical neglect




A nurse is aware that intimate partner violence (IPV) screening should occur with
what situation?
as a routine part of each healthcare encounter




Which statement is best for the nurse to use when preparing to administer the Abuse
Assessment Screen?
we need to ask these questions because domestic violence are so common in our
society

,Which term refers to a wound produced by tearing or splitting of body tissue, usually
from blunt impact over a body surface?
laceration




During an examination, the nurse notices a patterned injury on a pts back. which of
the following would cause such an injury?
-blunt force
-friction abrasion
-stabbing from a kitchen knife
-whipping from an extension cord
whipping from an extension cord




When documenting IPV and elder abuse, the nurse should include:
photographic documentation of injuries




A female pt denies any abuse when answering abuse assessment screen, but the
nurse has noticed some other conditions that are associated with IPV. examples of
such conditions include....
-asthma

,-confusion
-depression
-frequent colds




The nurse is using the danger assessment (DA) tool to evaluate the risk of homicide.
Which of these statements best describes its use?
-the DA tool is to be administered by the law enforcement personnel
-the DA tool should be used in every assessment of suspected abuse
-the number of yes answers indicates the woman's understanding of her situation
-the higher the number of yes answers, the more serious the danger of the womans
situation




The nurse is assessing bruising on an injured patient. Which color indicates a new
bruise that is less than 24 hours old?
red




The nurse suspects abuse when a 10 y/o child is taken to the ED for a leg injury. the
best way to document the history and physical findings is to:
use the words the child used to describe how the injury occurred

, During an interview, a woman has answered yes to two of the abuse assessment
screen questions- what should the nurse say next?
"tell me about the abuse in your relationship"




The nurse is examining a 3 year old child who was brought to the emergency room
after a fall. which bruise, if found, would be of most concern?
-bruise on the knee
-bruise on the elbow
-bruise on the abdomen
-bruise on the shin
bruise on the abdomen- not a bony prominence therefore more likely to be a mark of
abuse




The nurse assesses an older woman and suspects physical abuse. which questions
are appropriate for screening for abuse? select all that apply
-has anyone made you afraid, touched you in ways you did not want, or hurt you
physically?
-are you being abused?
-have you relied on people for any of the following: bathing, dressing, shopping,
banking, meals?

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