or moist. Keratoses are lesions that are raised, thickened areas of pigmentation that
appear crusted, scaly, and warty.
TEST BANK FOR Evidence-Based Physical
Examination Best Practices for Health & Well-Being 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
Assessment 2nd Edition should say, The physician is referring to the:
a.
Blue dilation of blood vessels in a star-shaped linear pattern on the legs.
b.
A man has come in to the clinic for a skin assessment because he is worried he might Fiery red, star-shaped marking on the cheek that has a solid circular center.
have skin cancer. During the skin assessment the nurse notices several areas of c.
pigmentation that look greasy, dark, and stuck on his skin. Which is the best prediction? Confluent and extensive patch of petechiae and ecchymoses on the feet.
a. d.
Senile lentigines, which do not become cancerous Tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in
b. color. - c
Actinic keratoses, which are precursors to basal cell carcinoma
c. A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his
Acrochordons, which are precursors to squamous cell carcinoma head. His hair seems to be breaking off in patches, and he notices some scaling on his
d. head. The nurse begins the examination suspecting:
Seborrheic keratoses, which do not become cancerous - d a.
Tinea capitis.
The nurse just noted from the medical record that the patient has a lesion that is b.
confluent in nature. On examination, the nurse expects to find: Folliculitis.
a. c.
Lesions that run together. Toxic alopecia.
b. d.
Annular lesions that have grown together. Seborrheic dermatitis. - a
c.
Lesions arranged in a line along a nerve route.
d. The nurse is examining a patient who tells the nurse, I sure sweat a lot, especially on
Lesions that are grouped or clustered together. - a my face and feet but it doesnt have an odor. The nurse knows that this condition could
be related to:
A patient has had a terrible itch for several months that he has been continuously a.
scratching. On examination, the nurse might expect to find: Eccrine glands.
a. b.
A keloid. Apocrine glands.
b. c.
A fissure. Disorder of the stratum corneum.
c. d.
Keratosis. Disorder of the stratum germinativum. - a
d.
Lichenification. - d 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?
Lichenification results from prolonged, intense scratching that eventually thickens the a.
skin and produces tightly packed sets of papules. A keloid is a hypertrophic scar. A Subcutaneous fat deposits are high in the newborn.
fissure is a linear crack with abrupt edges, which extends into the dermis; it can be dry b.
,Sebaceous glands are overproductive in the newborn. Caf au lait.
c. b.
The newborns skin is more permeable than that of the adult. Carotenemia.
d. c.
The amount of vernix caseosa dramatically rises in the newborn. - c Acrocyanosis.
d.
During an examination, the nurse finds that a patient has excessive dryness of the skin. Cutis marmorata. - d
The best term to describe this condition is:
a. A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During
Xerosis. the assessment, the nurse notices that she has a brown patch of hyperpigmentation on
b. her face. The nurse continues the skin assessment aware that another finding may be:
Pruritus. a.
c. Keratoses.
Alopecia. b.
d. Xerosis.
Seborrhea. - a c.
Chloasma.
A patient comes in for a physical examination and complains of freezing to death while d.
waiting for her examination. The nurse notes that her skin is pale and cool and Acrochordons. - c
attributes this finding to:
a. A semiconscious woman is brought to the emergency department after she was found
Venous pooling. on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-
b. red color. The nurse suspects that this coloring is due to:
Peripheral vasodilation. a.
c. Polycythemia.
Peripheral vasoconstriction. b.
d. Carbon monoxide poisoning.
Decreased arterial perfusion. - c c.
Carotenemia.
A patient comes to the clinic and states that he has noticed that his skin is redder than d.
normal. The nurse understands that this condition is due to hyperemia and knows that it Uremia. - b
can be caused by:
a. A patient has been admitted to a hospital after the staff in the nursing home noticed a
Decreased amounts of bilirubin in the blood pressure ulcer in his sacral area. The nurse examines the pressure ulcer and
b. determines that it is a stage II ulcer. Which of these findings are characteristic of a stage
Excess blood in the underlying blood vessels II pressure ulcer? Select all that apply.
c. a.
Decreased perfusion to the surrounding tissues Intact skin appears red but is not broken.
d. b.
Excess blood in the dilated superficial capillaries - d Partial thickness skin erosion is observed with a loss of epidermis or dermis.
c.
A newborn infant has Down syndrome. During the skin assessment, the nurse notices a Ulcer extends into the subcutaneous tissue.
transient mottling in the trunk and extremities in response to the cool temperature in the d.
examination room. The infants mother also notices the mottling and asks what it is. The Localized redness in light skin will blanch with fingertip pressure.
nurse knows that this mottling is called: e.
a. Open blister areas have a red-pink wound bed.
,f.
Patches of eschar cover parts of the wound. - b, e During a morning assessment, the nurse notices that the patients sputum is frothy and
pink. Which condition could this finding indicate?
Which statement about the apices of the lungs is true? The apices of the lungs: a.
a. Croup
Are at the level of the second rib anteriorly. b.
b. Tuberculosis
Extend 3 to 4 cm above the inner third of the clavicles. c.
c. Viral infection
Are located at the sixth rib anteriorly and the eighth rib laterally. d.
d. Pulmonary edema - d
Rest on the diaphragm at the fifth intercostal space in the midclavicular line (MCL). - b
A patient has been admitted to the emergency department with a possible medical
When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft diagnosis of pulmonary embolism. The nurse expects to see which assessment findings
breath sounds are heard over the posterior lower lobes, with inspiration being longer related to this condition?
than expiration. The nurse interprets that these sounds are: a.
a. Absent or decreased breath sounds
Normally auscultated over the trachea. b.
b. Productive cough with thin, frothy sputum
Bronchial breath sounds and normal in that location. c.
c. Chest pain that is worse on deep inspiration and dyspnea
Vesicular breath sounds and normal in that location. d.
d. Diffuse infiltrates with areas of dullness upon percussion - c
Bronchovesicular breath sounds and normal in that location - c
During palpation of the anterior chest wall, the nurse notices a coarse, crackling
When inspecting the anterior chest of an adult, the nurse should include which sensation over the skin surface. On the basis of these findings, the nurse suspects:
assessment? a.
a. Tactile fremitus.
Diaphragmatic excursion b.
b. Crepitus.
Symmetric chest expansion c.
c. Friction rub.
Presence of breath sounds d.
d. Adventitious sounds. - b
Shape and configuration of the chest wall - d
The findings from an assessment of a 70-year-old patient with swelling in his ankles
During auscultation of the lungs of an adult patient, the nurse notices the presence of include jugular venous pulsations 5 cm above the sternal angle when the head of his
bronchophony. The nurse should assess for signs of which condition? bed is elevated 45 degrees. The nurse knows that this finding indicates:
a. a.
Airway obstruction Decreased fluid volume.
b. b.
Emphysema Increased cardiac output.
c. c.
Pulmonary consolidation Narrowing of jugular veins.
d. d.
Asthma - c Elevated pressure related to heart failure. - d
, Watch the patients respirations while listening for the effect on the sound. - d
During an assessment of a 68-year-old man with a recent onset of right-sided
weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope Which of these findings would the nurse expect to notice during a cardiac assessment
over the left carotid artery. This finding would indicate: on a 4-year-old child?
a. a.
Valvular disorder. S3 when sitting up
b. b.
Blood flow turbulence. Persistent tachycardia above 150 beats per minute
c. c.
Fluid volume overload. Murmur at the second left intercostal space when supine
d. d.
Ventricular hypertrophy. - b Palpable apical impulse in the fifth left intercostal space lateral to midclavicular line - c
During an inspection of the precordium of an adult patient, the nurse notices the chest A 70-year-old patient with a history of hypertension has a blood pressure of 180/100
moving in a forceful manner along the sternal border. This finding most likely suggests mm Hg and a heart rate of 90 beats per minute. The nurse hears an extra heart sound
a(n): at the apex immediately before the S1. The sound is heard only with the bell of the
a. stethoscope while the patient is in the left lateral position. With these findings and the
Normal heart. patients history, the nurse knows that this extra heart sound is most likely a(n):
b. a.
Systolic murmur. Split S1.
c. b.
Enlargement of the left ventricle. Atrial gallop.
d. c.
Enlargement of the right ventricle. - d Diastolic murmur.
d.
When listening to heart sounds, the nurse knows that the S1: Summation sound. - b
a.
Is louder than the S2 at the base of the heart. The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her
b. myocardial infarction (MI). Heart sounds are normal when she is supine, but when she
Indicates the beginning of diastole. is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the
c. diaphragm of the stethoscope at the apex. It disappears on inspiration. The nurse
Coincides with the carotid artery pulse. suspects:
d. a.
Is caused by the closure of the semilunar valves. - c Increased cardiac output.
b.
During the cardiac auscultation, the nurse hears a sound immediately occurring after Another MI.
the S2 at the second left intercostal space. To further assess this sound, what should c.
the nurse do? Inflammation of the precordium.
a. d.
Have the patient turn to the left side while the nurse listens with the bell of the Ventricular hypertrophy resulting from muscle damage. - c
stethoscope.
b. The nurse knows that normal splitting of the S2 is associated with:
Ask the patient to hold his or her breath while the nurse listens again. a.
c. Expiration.
No further assessment is needed because the nurse knows this sound is an S3. b.
d. Inspiration.
appear crusted, scaly, and warty.
TEST BANK FOR Evidence-Based Physical
Examination Best Practices for Health & Well-Being 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
Assessment 2nd Edition should say, The physician is referring to the:
a.
Blue dilation of blood vessels in a star-shaped linear pattern on the legs.
b.
A man has come in to the clinic for a skin assessment because he is worried he might Fiery red, star-shaped marking on the cheek that has a solid circular center.
have skin cancer. During the skin assessment the nurse notices several areas of c.
pigmentation that look greasy, dark, and stuck on his skin. Which is the best prediction? Confluent and extensive patch of petechiae and ecchymoses on the feet.
a. d.
Senile lentigines, which do not become cancerous Tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in
b. color. - c
Actinic keratoses, which are precursors to basal cell carcinoma
c. A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his
Acrochordons, which are precursors to squamous cell carcinoma head. His hair seems to be breaking off in patches, and he notices some scaling on his
d. head. The nurse begins the examination suspecting:
Seborrheic keratoses, which do not become cancerous - d a.
Tinea capitis.
The nurse just noted from the medical record that the patient has a lesion that is b.
confluent in nature. On examination, the nurse expects to find: Folliculitis.
a. c.
Lesions that run together. Toxic alopecia.
b. d.
Annular lesions that have grown together. Seborrheic dermatitis. - a
c.
Lesions arranged in a line along a nerve route.
d. The nurse is examining a patient who tells the nurse, I sure sweat a lot, especially on
Lesions that are grouped or clustered together. - a my face and feet but it doesnt have an odor. The nurse knows that this condition could
be related to:
A patient has had a terrible itch for several months that he has been continuously a.
scratching. On examination, the nurse might expect to find: Eccrine glands.
a. b.
A keloid. Apocrine glands.
b. c.
A fissure. Disorder of the stratum corneum.
c. d.
Keratosis. Disorder of the stratum germinativum. - a
d.
Lichenification. - d 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?
Lichenification results from prolonged, intense scratching that eventually thickens the a.
skin and produces tightly packed sets of papules. A keloid is a hypertrophic scar. A Subcutaneous fat deposits are high in the newborn.
fissure is a linear crack with abrupt edges, which extends into the dermis; it can be dry b.
,Sebaceous glands are overproductive in the newborn. Caf au lait.
c. b.
The newborns skin is more permeable than that of the adult. Carotenemia.
d. c.
The amount of vernix caseosa dramatically rises in the newborn. - c Acrocyanosis.
d.
During an examination, the nurse finds that a patient has excessive dryness of the skin. Cutis marmorata. - d
The best term to describe this condition is:
a. A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During
Xerosis. the assessment, the nurse notices that she has a brown patch of hyperpigmentation on
b. her face. The nurse continues the skin assessment aware that another finding may be:
Pruritus. a.
c. Keratoses.
Alopecia. b.
d. Xerosis.
Seborrhea. - a c.
Chloasma.
A patient comes in for a physical examination and complains of freezing to death while d.
waiting for her examination. The nurse notes that her skin is pale and cool and Acrochordons. - c
attributes this finding to:
a. A semiconscious woman is brought to the emergency department after she was found
Venous pooling. on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-
b. red color. The nurse suspects that this coloring is due to:
Peripheral vasodilation. a.
c. Polycythemia.
Peripheral vasoconstriction. b.
d. Carbon monoxide poisoning.
Decreased arterial perfusion. - c c.
Carotenemia.
A patient comes to the clinic and states that he has noticed that his skin is redder than d.
normal. The nurse understands that this condition is due to hyperemia and knows that it Uremia. - b
can be caused by:
a. A patient has been admitted to a hospital after the staff in the nursing home noticed a
Decreased amounts of bilirubin in the blood pressure ulcer in his sacral area. The nurse examines the pressure ulcer and
b. determines that it is a stage II ulcer. Which of these findings are characteristic of a stage
Excess blood in the underlying blood vessels II pressure ulcer? Select all that apply.
c. a.
Decreased perfusion to the surrounding tissues Intact skin appears red but is not broken.
d. b.
Excess blood in the dilated superficial capillaries - d Partial thickness skin erosion is observed with a loss of epidermis or dermis.
c.
A newborn infant has Down syndrome. During the skin assessment, the nurse notices a Ulcer extends into the subcutaneous tissue.
transient mottling in the trunk and extremities in response to the cool temperature in the d.
examination room. The infants mother also notices the mottling and asks what it is. The Localized redness in light skin will blanch with fingertip pressure.
nurse knows that this mottling is called: e.
a. Open blister areas have a red-pink wound bed.
,f.
Patches of eschar cover parts of the wound. - b, e During a morning assessment, the nurse notices that the patients sputum is frothy and
pink. Which condition could this finding indicate?
Which statement about the apices of the lungs is true? The apices of the lungs: a.
a. Croup
Are at the level of the second rib anteriorly. b.
b. Tuberculosis
Extend 3 to 4 cm above the inner third of the clavicles. c.
c. Viral infection
Are located at the sixth rib anteriorly and the eighth rib laterally. d.
d. Pulmonary edema - d
Rest on the diaphragm at the fifth intercostal space in the midclavicular line (MCL). - b
A patient has been admitted to the emergency department with a possible medical
When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft diagnosis of pulmonary embolism. The nurse expects to see which assessment findings
breath sounds are heard over the posterior lower lobes, with inspiration being longer related to this condition?
than expiration. The nurse interprets that these sounds are: a.
a. Absent or decreased breath sounds
Normally auscultated over the trachea. b.
b. Productive cough with thin, frothy sputum
Bronchial breath sounds and normal in that location. c.
c. Chest pain that is worse on deep inspiration and dyspnea
Vesicular breath sounds and normal in that location. d.
d. Diffuse infiltrates with areas of dullness upon percussion - c
Bronchovesicular breath sounds and normal in that location - c
During palpation of the anterior chest wall, the nurse notices a coarse, crackling
When inspecting the anterior chest of an adult, the nurse should include which sensation over the skin surface. On the basis of these findings, the nurse suspects:
assessment? a.
a. Tactile fremitus.
Diaphragmatic excursion b.
b. Crepitus.
Symmetric chest expansion c.
c. Friction rub.
Presence of breath sounds d.
d. Adventitious sounds. - b
Shape and configuration of the chest wall - d
The findings from an assessment of a 70-year-old patient with swelling in his ankles
During auscultation of the lungs of an adult patient, the nurse notices the presence of include jugular venous pulsations 5 cm above the sternal angle when the head of his
bronchophony. The nurse should assess for signs of which condition? bed is elevated 45 degrees. The nurse knows that this finding indicates:
a. a.
Airway obstruction Decreased fluid volume.
b. b.
Emphysema Increased cardiac output.
c. c.
Pulmonary consolidation Narrowing of jugular veins.
d. d.
Asthma - c Elevated pressure related to heart failure. - d
, Watch the patients respirations while listening for the effect on the sound. - d
During an assessment of a 68-year-old man with a recent onset of right-sided
weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope Which of these findings would the nurse expect to notice during a cardiac assessment
over the left carotid artery. This finding would indicate: on a 4-year-old child?
a. a.
Valvular disorder. S3 when sitting up
b. b.
Blood flow turbulence. Persistent tachycardia above 150 beats per minute
c. c.
Fluid volume overload. Murmur at the second left intercostal space when supine
d. d.
Ventricular hypertrophy. - b Palpable apical impulse in the fifth left intercostal space lateral to midclavicular line - c
During an inspection of the precordium of an adult patient, the nurse notices the chest A 70-year-old patient with a history of hypertension has a blood pressure of 180/100
moving in a forceful manner along the sternal border. This finding most likely suggests mm Hg and a heart rate of 90 beats per minute. The nurse hears an extra heart sound
a(n): at the apex immediately before the S1. The sound is heard only with the bell of the
a. stethoscope while the patient is in the left lateral position. With these findings and the
Normal heart. patients history, the nurse knows that this extra heart sound is most likely a(n):
b. a.
Systolic murmur. Split S1.
c. b.
Enlargement of the left ventricle. Atrial gallop.
d. c.
Enlargement of the right ventricle. - d Diastolic murmur.
d.
When listening to heart sounds, the nurse knows that the S1: Summation sound. - b
a.
Is louder than the S2 at the base of the heart. The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her
b. myocardial infarction (MI). Heart sounds are normal when she is supine, but when she
Indicates the beginning of diastole. is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the
c. diaphragm of the stethoscope at the apex. It disappears on inspiration. The nurse
Coincides with the carotid artery pulse. suspects:
d. a.
Is caused by the closure of the semilunar valves. - c Increased cardiac output.
b.
During the cardiac auscultation, the nurse hears a sound immediately occurring after Another MI.
the S2 at the second left intercostal space. To further assess this sound, what should c.
the nurse do? Inflammation of the precordium.
a. d.
Have the patient turn to the left side while the nurse listens with the bell of the Ventricular hypertrophy resulting from muscle damage. - c
stethoscope.
b. The nurse knows that normal splitting of the S2 is associated with:
Ask the patient to hold his or her breath while the nurse listens again. a.
c. Expiration.
No further assessment is needed because the nurse knows this sound is an S3. b.
d. Inspiration.
