N125 EXAM 2 STUDY QUESTIONS WITH ACCURATE
ANSWERS
. The nurse is testing superficial reflexes on an adult patient. When stroking up
the lateral side of the sole and across the ball of the foot, the nurse notices the
plantar flexion of the toes. How should the nurse document this finding?
a.
Positive Babinski sign
b.
Plantar reflex abnormal
c.
Plantar reflex present
d.
Plantar reflex 2+ on a scale from 0 to 4+ correct answer ANS: C
With the same instrument, the nurse should draw a light stroke up the lateral side
of the sole of the foot and across the ball of the foot, similar to an upside-down J.
The normal response is plantar flexion of the toes and sometimes of the entire
foot. A positive Babinski sign is abnormal and occurs with the response of
dorsiflexion of the big toe and fanning of all toes. The plantar reflex is not graded
on a 0 to 4+ scale.
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:
a.
Tinea capitis.
b.
Folliculitis.
,c.
Toxic alopecia.
d.
Seborrheic dermatitis. correct answer ANS: A
Tinea capitis is rounded patchy hair loss on the scalp, leaving broken-off hairs,
pustules, and scales on the skin, and is caused by a fungal infection. Lesions are
fluorescent under a Wood light and are usually observed in children and farmers;
tinea capitis is highly contagious.
A 13-year-old girl is interested in obtaining information about the cause of her
acne. The nurse should share with her that acne:
a.
Is contagious.
b.
Has no known cause.
c.
Is caused by increased sebum production.
d.
Has been found to be related to poor hygiene. correct answer ANS: C
Approximately 90% of males and 80% of females will develop acne; causes are
increased sebum production and epithelial cells that do not desquamate
normally.
A 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?
,a. Head injury
b. Cluster headache
c. Migraine headache
d. Meningeal inflammation correct answer ANS: D
The acute onset of neck stiffness and pain along with headache and fever occurs
with meningeal inflammation. A severe headache in an adult or child who has
never had it before is a red flag. Head injury and cluster or migraine headaches
are not associated with a fever or stiff neck.
A 21-year-old patient has a head injury resulting from trauma and is unconscious.
There are no other injuries. During the assessment what would the nurse expect
to find when testing the patients deep tendon reflexes?
a.
Reflexes will be normal.
b.
Reflexes cannot be elicited.
c.
All reflexes will be diminished but present.
d.
Some reflexes will be present, depending on the area of injury. correct answer
ANS: A
A reflex is a defense mechanism of the nervous system. It operates below the
level of conscious control and permits a quick reaction to potentially painful or
damaging situations.
, A 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?
a.
Nonsteroidal antiinflammatory drugs for pain
b.
Tetracyclines for acne
c.
Proton pump inhibitors for heartburn
d.
Thyroid replacement hormone for hypothyroidism correct answer ANS: B
Drugs that may increase sunlight sensitivity and give a burn response include
sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.
A 25-year-old woman in her fifth month of pregnancy has a blood pressure of
100/70 mm Hg. In reviewing her previous examination, the nurse notes that her
blood pressure in her second month was 124/80 mm Hg. In evaluating this
change, what does the nurse know to be true?
a.
This decline in blood pressure is the result of peripheral vasodilatation and is an
expected change.
b.
Because of increased cardiac output, the blood pressure should be higher at this
time.
c.
This change in blood pressure is not an expected finding because it means a
decrease in cardiac output.
ANSWERS
. The nurse is testing superficial reflexes on an adult patient. When stroking up
the lateral side of the sole and across the ball of the foot, the nurse notices the
plantar flexion of the toes. How should the nurse document this finding?
a.
Positive Babinski sign
b.
Plantar reflex abnormal
c.
Plantar reflex present
d.
Plantar reflex 2+ on a scale from 0 to 4+ correct answer ANS: C
With the same instrument, the nurse should draw a light stroke up the lateral side
of the sole of the foot and across the ball of the foot, similar to an upside-down J.
The normal response is plantar flexion of the toes and sometimes of the entire
foot. A positive Babinski sign is abnormal and occurs with the response of
dorsiflexion of the big toe and fanning of all toes. The plantar reflex is not graded
on a 0 to 4+ scale.
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:
a.
Tinea capitis.
b.
Folliculitis.
,c.
Toxic alopecia.
d.
Seborrheic dermatitis. correct answer ANS: A
Tinea capitis is rounded patchy hair loss on the scalp, leaving broken-off hairs,
pustules, and scales on the skin, and is caused by a fungal infection. Lesions are
fluorescent under a Wood light and are usually observed in children and farmers;
tinea capitis is highly contagious.
A 13-year-old girl is interested in obtaining information about the cause of her
acne. The nurse should share with her that acne:
a.
Is contagious.
b.
Has no known cause.
c.
Is caused by increased sebum production.
d.
Has been found to be related to poor hygiene. correct answer ANS: C
Approximately 90% of males and 80% of females will develop acne; causes are
increased sebum production and epithelial cells that do not desquamate
normally.
A 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?
,a. Head injury
b. Cluster headache
c. Migraine headache
d. Meningeal inflammation correct answer ANS: D
The acute onset of neck stiffness and pain along with headache and fever occurs
with meningeal inflammation. A severe headache in an adult or child who has
never had it before is a red flag. Head injury and cluster or migraine headaches
are not associated with a fever or stiff neck.
A 21-year-old patient has a head injury resulting from trauma and is unconscious.
There are no other injuries. During the assessment what would the nurse expect
to find when testing the patients deep tendon reflexes?
a.
Reflexes will be normal.
b.
Reflexes cannot be elicited.
c.
All reflexes will be diminished but present.
d.
Some reflexes will be present, depending on the area of injury. correct answer
ANS: A
A reflex is a defense mechanism of the nervous system. It operates below the
level of conscious control and permits a quick reaction to potentially painful or
damaging situations.
, A 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?
a.
Nonsteroidal antiinflammatory drugs for pain
b.
Tetracyclines for acne
c.
Proton pump inhibitors for heartburn
d.
Thyroid replacement hormone for hypothyroidism correct answer ANS: B
Drugs that may increase sunlight sensitivity and give a burn response include
sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.
A 25-year-old woman in her fifth month of pregnancy has a blood pressure of
100/70 mm Hg. In reviewing her previous examination, the nurse notes that her
blood pressure in her second month was 124/80 mm Hg. In evaluating this
change, what does the nurse know to be true?
a.
This decline in blood pressure is the result of peripheral vasodilatation and is an
expected change.
b.
Because of increased cardiac output, the blood pressure should be higher at this
time.
c.
This change in blood pressure is not an expected finding because it means a
decrease in cardiac output.
