Correct Answers (Verified Update)
38 questions with answers
Topic: nurs307 ch13 skin, hair, nails
1. After completing an initial assessment of a patient, the nurse has charted that his
respirations are eupneic and his pulse is 58 beats per minute. What type of
assessment data is this? -Introspective -Reflective -Subjective -Objective
Answer: Objective Objective data is what the health professional observes by inspecting,
percussing, palpating, and auscultating during the physical examination. Subjective data is
what the person says about him or herself during history taking. The terms reflective and
introspective are not used to describe data.
2. The nurse is reviewing data collected after an assessment. Of the data listed
below, which would be considered related cues that would be clustered together
during data analysis? (Select all that apply.)
a. Hypoactive bowel sounds
b. Patient reports dyspnea upon exertion
c. Edema, +2, noted on left hand
d. Rate of respirations 16 breaths per minute
e. Nonproductive cough f. Inspiratory wheezes noted in left lower lobes
Answer: b. pt reports dyspnea upon excretion d. 16 RR per min e. nonproductive cough f.
inspiratory wheezes noted in left lower lobes
3. A patient tells the nurse that he is very nervous, nauseous, and "feels hot." What
type of assessment data is this? -Reflective -Objective -Introspective -Subjective
Answer: Subjective Subjective data is what the person says about him or herself during
history taking. Objective data is what the health professional observes by inspecting,
percussing, palpating, and auscultating during the physical examination. The terms reflective
and introspective are not used to describe data.
4. The nurse is conducting a class on priority setting for a group of new graduate
nurses. Which is an example of a first-level priority problem?
a. Individual with a small laceration on the sole of the foot
b. Individual with shortness of breath and respiratory distress
c. Newly diagnosed patient with diabetes who needs diabetic teaching
d. Patient with postoperative pain
Answer: b. Individual with shortness of breath and respiratory distress
5. A newly admitted patient is in acute pain, has not been sleeping well lately, and is
having difficulty breathing. How should the nurse prioritize these problems?
a. Breathing, pain, and sleep
b. Sleep, breathing, and pain
c. Breathing, sleep, and pain
d. Sleep, pain, and breathing
Answer: a. Breathing, pain, and sleep
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, 6. A patient comes in for a physical examination in late July and states that she was
"freezing to death" while waiting for her examination. The nurse notes that her skin
is pale and cool. What would the nurse understand is the likely cause?\
a. Decreased arterial perfusion
b. Peripheral vasoconstriction
c. Venous pooling
d. Peripheral vasodilation
Answer: b. Peripheral vasoconstriction A chilly or air-conditioned environment causes
vasoconstriction, which results in false pallor and coolness.
7. During the aging process, the hair can look gray or white and begin to feel thin
and fine. What would the nurse understand causes this?
a. Increase in the vascularity of the scalp
b. Decrease in the number of functioning phagocytes
c. Increased adipose tissue
d. Decrease in the number of functioning melanocytes
Answer: d. Decrease in the number of functioning melanocytes
8. A semiconscious woman is brought to the emergency department after she was
found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a
bright cherry-red color. What should the nurse suspect is the likely cause of these
findings?
a. Uremia
b. Polycythemia
c. Carbon monoxide poisoning
d. Carotenemia
Answer: c. Carbon monoxide poisoning A bright cherry-red coloring in the face, upper torso,
nail beds, lips, and oral mucosa appears in cases of carbon monoxide poisoning. Uremia
presents as an orange-green or gray pallor, not bright red.
9. The nurse is preparing for a certification course on skin care and needs to be
familiar with the various lesions that may be identified on assessment of the skin.
Which definitions of lesions are correct? (Select all that apply.)
a. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple,
or brown in color.
b. Bulla: Larger than 1 cm also known as a friction blister.
c. Bulla: Elevated, circumscribed lesion filled with turbid fluid (pus).
d. Papule: Hypertrophic scar.
e. Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm.
Answer: a. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red,
purple, or brown in color. b. Bulla: Larger than 1 cm also known as a friction blister. e.
Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm.
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