MCSON Health Assessment (NUR 382): material for test 1
Questions With Complete Solutions
•Complete physical examination (skin) Correct Answer •Skin
assessment integrated throughout examination
•Scrutinize the outer skin surface first before you concentrate on
underlying structures.
•Separate intertriginous areas (areas with skinfolds) such as
under large breasts, obese abdomen, and groin, and inspect them
thoroughly
•Always inspect feet, toenails, and between toes.
•Genetic attributes of dark-skinned individuals afford protection
against skin cancer due to melanin. Correct Answer
•Increased likelihood of skin cancer in whites than in black and
Hispanic populations
•Succession of genetic mutations leading to increased
chromosome sensitivity to sun damage
•Lesions: if any are present, note the following: Correct
Answer •Color
•Elevation
•Pattern or shape
•Size
•Location and distribution on body
•Any exudate: note color and odor
•Use a Wood's light (ultraviolet light filtered through special
glass) to detect fluorescing lesions.
,•Regional physical examination (skin) Correct Answer
•Individuals may seek health care for skin problems and
assessment focused on skin alone.
•Assess skin as one entity; getting overall impression helps
reveal distribution patterns.
ABCDEF Skin Assessment Correct Answer •Teach skin self-
examination using ABCDEF rule to detect suspicious lesions
•A: asymmetry
•B: border irregularity
•C: color variations
•D: diameter greater than 6 mm
•E: elevation or evolution
•F: funny looking—"ugly duckling" —different from others
Abnormal hair conditions Correct Answer AIDS-related
Kaposi sarcoma: patch stage
Toxic alopecia
Tinea capitis (scalp ringworm)
Traction alopecia
Seborrheic dermatitis (cradle cap)
Pediculosis capitis (head lice)
Folliculitis barbae ("razor bumps")
Hirsutism
Furuncle and abscess
acrochordons Correct Answer skin tags
Adult BP ( normal ) Correct Answer <120 systolic and <80
diastolic
,adult BP (hypertension stage I) Correct Answer 140-159
systolic or 90-99 diastolic
Adult BP (hypertensive Crisis) Correct Answer >180 systolic
or >110 diastolic
adult BP (prehypertension) Correct Answer 120-139 systolic
or 80-89 diastolic
adult BP (stage 2 hypertension) Correct Answer >160 systolic
or >100 diastolic
AIDS related kaposi sarcoma Correct Answer a vascular
tumor and is the most common tumor in HIV infected persons
annular or circular shape/configuration of lesion Correct
Answer begins in center and spreads to periphery
As you proceed through the health history, the measurements,
and the vital signs, consider and make note of these four areas:
Correct Answer physical appearance (skin tone, age, tattoos,
piercings, bruising, clean, kempt)
body structure (thin, frail, obese, in a wheelchair, slumped over,
walk with a limp)
mobility (are they able to walk, shuffle, gait, ROM)
behavior (facial expression, speech, pleasant, combative, appear
angry, grimacing, crying, calm, etc.).
, assess the patient with dyspnea , abnormal ascites, or advanced
pregnancy, in Correct Answer the position of greatest comfort
assessing apical-radial pulse Correct Answer subtract the
radial rate from the apical rate
assessing BP Correct Answer ensure the pt has not had
caffeine, exercised, or smoked for 30 mins before assessing BP
Assessing Pain Correct Answer ask the patient if they are
feeling any discomfort right now
Avoid the word "pain": use "discomfort" or "hurting"
assess response to prescribed pain meds (side effects)
"are you sleeping well?"
"what/how much are you eating?"
"any trouble taking care of yourself?"
assess for physical, emotional, and behavioral signs/symptoms
of pain
ask about headaches or constipation
atrophic scars Correct Answer the resulting skin level is
depressed with loss of tissue; a thinning of the epidermis
stretch marks
Questions With Complete Solutions
•Complete physical examination (skin) Correct Answer •Skin
assessment integrated throughout examination
•Scrutinize the outer skin surface first before you concentrate on
underlying structures.
•Separate intertriginous areas (areas with skinfolds) such as
under large breasts, obese abdomen, and groin, and inspect them
thoroughly
•Always inspect feet, toenails, and between toes.
•Genetic attributes of dark-skinned individuals afford protection
against skin cancer due to melanin. Correct Answer
•Increased likelihood of skin cancer in whites than in black and
Hispanic populations
•Succession of genetic mutations leading to increased
chromosome sensitivity to sun damage
•Lesions: if any are present, note the following: Correct
Answer •Color
•Elevation
•Pattern or shape
•Size
•Location and distribution on body
•Any exudate: note color and odor
•Use a Wood's light (ultraviolet light filtered through special
glass) to detect fluorescing lesions.
,•Regional physical examination (skin) Correct Answer
•Individuals may seek health care for skin problems and
assessment focused on skin alone.
•Assess skin as one entity; getting overall impression helps
reveal distribution patterns.
ABCDEF Skin Assessment Correct Answer •Teach skin self-
examination using ABCDEF rule to detect suspicious lesions
•A: asymmetry
•B: border irregularity
•C: color variations
•D: diameter greater than 6 mm
•E: elevation or evolution
•F: funny looking—"ugly duckling" —different from others
Abnormal hair conditions Correct Answer AIDS-related
Kaposi sarcoma: patch stage
Toxic alopecia
Tinea capitis (scalp ringworm)
Traction alopecia
Seborrheic dermatitis (cradle cap)
Pediculosis capitis (head lice)
Folliculitis barbae ("razor bumps")
Hirsutism
Furuncle and abscess
acrochordons Correct Answer skin tags
Adult BP ( normal ) Correct Answer <120 systolic and <80
diastolic
,adult BP (hypertension stage I) Correct Answer 140-159
systolic or 90-99 diastolic
Adult BP (hypertensive Crisis) Correct Answer >180 systolic
or >110 diastolic
adult BP (prehypertension) Correct Answer 120-139 systolic
or 80-89 diastolic
adult BP (stage 2 hypertension) Correct Answer >160 systolic
or >100 diastolic
AIDS related kaposi sarcoma Correct Answer a vascular
tumor and is the most common tumor in HIV infected persons
annular or circular shape/configuration of lesion Correct
Answer begins in center and spreads to periphery
As you proceed through the health history, the measurements,
and the vital signs, consider and make note of these four areas:
Correct Answer physical appearance (skin tone, age, tattoos,
piercings, bruising, clean, kempt)
body structure (thin, frail, obese, in a wheelchair, slumped over,
walk with a limp)
mobility (are they able to walk, shuffle, gait, ROM)
behavior (facial expression, speech, pleasant, combative, appear
angry, grimacing, crying, calm, etc.).
, assess the patient with dyspnea , abnormal ascites, or advanced
pregnancy, in Correct Answer the position of greatest comfort
assessing apical-radial pulse Correct Answer subtract the
radial rate from the apical rate
assessing BP Correct Answer ensure the pt has not had
caffeine, exercised, or smoked for 30 mins before assessing BP
Assessing Pain Correct Answer ask the patient if they are
feeling any discomfort right now
Avoid the word "pain": use "discomfort" or "hurting"
assess response to prescribed pain meds (side effects)
"are you sleeping well?"
"what/how much are you eating?"
"any trouble taking care of yourself?"
assess for physical, emotional, and behavioral signs/symptoms
of pain
ask about headaches or constipation
atrophic scars Correct Answer the resulting skin level is
depressed with loss of tissue; a thinning of the epidermis
stretch marks
