TEST BANK FOR Evidence-
p p p
Based Physical Examination for Health & Well-
p p p p p
Being Assessment 2nd Edition
p p p
Apsemiconsciouspwomanpispbroughtptopthepemergencypdepartmentpafterpshepwaspfoundponp
thepfloorpinpherpkitchen.pHerpface,pnailpbeds,plips,pandporalpmucosaparepapbrightpcherryredpc
olor.pThepnursepsuspectspthatpthispcoloringpispduepto:pa.
Polycythemia.p
b.
Carbonpmonoxideppoisoning.pc
.
Carotenemia.
d.pUremia.
-pb
Appatientphaspbeenpadmittedptopaphospitalpafterpthepstaffpinpthepnursingphomepnoticedpappre
ssurepulcerpinphispsacralparea.pThepnursepexaminesptheppressurepulcerpandpdeterminespth
atpitpispapstagepIIpulcer.pWhichpofpthesepfindingsparepcharacteristicpofpapstagepIIppressurepul
cer?pSelectpallpthatpapply.pa.
Intactpskinpappearspredpbutpispnotpbroken.pb.
Partialpthicknesspskinperosionpispobservedpwithpaplosspofpepidermisporpdermis.pc.pUlcerp
extendspintopthepsubcutaneousptissue.pd.
Localizedprednesspinplightpskinpwillpblanchpwithpfingertipppressure.pe.pOpen
pblisterpareasphavepapred-pinkpwoundpbed.
f.
Patchespofpescharpcoverppartspofpthepwound.p-pb,pe
Whichpstatementpaboutpthepapicespofptheplungspisptrue?pThepapicespofptheplungs:pa.pAr
epatptheplevelpofpthepsecondpribpanteriorly.pb.
Extendp3ptop4pcmpabovepthepinnerpthirdpofpthepclavicles.pc.
Areplocatedpatpthepsixthpribpanteriorlypandpthepeighthpribplaterally.pd.
Restponpthepdiaphragmpatpthepfifthpintercostalpspacepinpthepmidclavicularplinep(MCL).p-pb
Whenpauscultatingptheplungspofpanpadultppatient,pthepnursepnotespthatplow-
pitched,psoftpbreathpsoundsparepheardpoverpthepposteriorplowerplobes,pwithpinspirationpb
eingplongerpthanpexpiration.pThepnursepinterpretspthatpthesepsoundspare:pa.
Normallypauscultatedpoverptheptrachea.pb.
Bronchialpbreathpsoundspandpnormalpinpthatplocation.pc.
,Vesicularpbreathpsoundspandpnormalpinpthatplocation.pd.pBronchovesicul
arpbreathpsoundspandpnormalpinpthatplocationp-pc
Whenpinspectingpthepanteriorpchestpofpanpadult,pthepnursepshouldpincludepwhichpassessme
nt?
a.
Diaphragmaticpexcursion
pb.
Symmetricpchestpexpansionp
c.
Presencepofpbreathpsounds
d.
Shapepandpconfigurationpofpthepchestpwallp-pd
Apmanphaspcomepinptopthepclinicpforpapskinpassessmentpbecausephepispworriedphepmightpha
vepskinpcancer.pDuringpthepskinpassessmentpthepnursepnoticespseveralpareaspofppigmentat
ionpthatplookpgreasy,pdark,pandpstuckponphispskin.pWhichpispthepbestpprediction?pa.
Senileplentigines,pwhichpdopnotpbecomepcancerouspb.
Actinicpkeratoses,pwhichparepprecursorsptopbasalpcellpcarcin omapc.
Acrochordons,pwhichparepprecursorsptopsquamouspcellpcarcinomapd.pSe
borrheicpkeratoses,pwhichpdopnotpbecomepcancerousp-pd
Thepnursepjustpnotedpfrompthepmedicalprecordpthatptheppatientphaspaplesionpthatpispconfluent
pinpnature.pOnpexamination,pthepnursepexpectsptopfind:pa.
Lesionspthatprunptogether.pb.
Annularplesionspthatphavepgrownptogether.
c.
Lesionsparrangedpinpaplinepalongpapnerveproute.pd.pLesions
pthatparepgroupedporpclusteredptogether.p-pa
Appatientphasphadpapterriblepitchpforpseveralpmonthspthatphephaspbeenpcontinuouslyps
cratching.pOnpexamination,pthepnursepmightpexpectptopfind:pa.pApkeloid.pb.pApfissure.
pc.
Keratosis.pd.pLichenificati
on.p-pd
Lichenificationpresultspfrompprolonged,pintensepscratchingpthatpeventuallypthickenspthepski
npandpproducesptightlyppackedpsetspofppapules.pApkeloidpispaphypertrophicpscar.pApfissurepi
spaplinearpcrackpwithpabruptpedges,pwhichpextendspintopthepdermis;pitpcanpbepdry
orpmoist.pKeratosespareplesionspthatparepraised,pthickenedpareaspofppigmentationpthat
appearpcrusted,pscaly,pandpwarty.
,Apphysicianphaspdiagnosedpappatientpwithppurpura.pAfterpleavingptheproom,papnursingps
tudentpaskspthepnursepwhatpthepphysicianpsawpthatpledptopthatpdiagnosis.pThepnursepsh
ouldpsay,pThepphysicianpispreferringptopthe:pa.
Bluepdilationpofpbloodpvesselspinpapstar-
shapedplinearppatternponptheplegs.pb.pFierypred,pstar-
shapedpmarkingponpthepcheekpthatphaspapsolidpcircularpcenter.pc.pConfluentpandpex
tensiveppatchpofppetechiaepandpecchymosesponpthepfeet.pd.
Tinypareaspofphemorrhagepthatpareplesspthanp2pmm,pround,pdiscrete,pandpdarkpredpinpc
olor.p-pc
Ap45-year-
oldpfarmerpcomespinpforpapskinpevaluationpandpcomplainspofphairplossponphisphead.pHisphairp
seemsptopbepbreakingpoffpinppatches,pandphepnoticespsomepscalingponphisphead.pThepnurse
pbeginspthepexaminationpsuspecting:pa.
Tineapcapitis.pb.
Folliculitis.pc.
Toxicpalopecia.pd.pSeborrhei
cpdermatitis.p-pa
Thepnursepispexaminingpappatientpwhoptellspthepnurse,pIpsurepsweatpaplot,pespeciallyponpm
ypfacepandpfeetpbutpitpdoesntphavepanpodor.pThepnursepknowspthatpthispconditionpcouldpb
eprelatedpto:pa.
Eccrinepglands.pb.p
Apocrinepglands.p
c.
Disorderpofpthepstratumpcorneum.pd.pDisor
derpofpthepstratumpgerminativum.p-pa
Apnewbornpinfantpispinpthepclinicpforpapwell-
babypcheckup.pThepnursepobservespthepinfantpforptheppossibilitypofpfluidplosspbecausepofpw
hichpofpthesepfactors?pa.
Subcutaneouspfatpdepositsparephighpinpthepnewborn.pb.pSe
baceouspglandsparepoverproductivepinpthepnewborn.pc.
Thepnewbornspskinpispmoreppermeablepthanpthatpofpthepadult.pd.
Thepamountpofpvernixpcaseosapdramaticallyprisespinpthepnewborn.p-pc
Duringpanpexamination,pthepnursepfindspthatpappatientphaspexcessivepdrynesspofpthepskin.pT
hepbestptermptopdescribepthispconditionpis:pa.
Xerosis.pb.
pPruritus.p
c.
Alopecia.pd.pSebo
rrhea.p-pa
, Appatientpcomespinpforpapphysicalpexaminationpandpcomplainspofpfreezingptopdeathpwhilepw
aitingpforpherpexamination.pThepnursepnotespthatpherpskinpisppalepandpcoolpandpattributespt
hispfindingpto:pa.
Venousppooling.
b.
Peripheralpvasodilation.pc.
p
Peripheralpvasoconstriction.pd.pDecre
asedparterialpperfusion.p-pc
Appatientpcomesptopthepclinicpandpstatespthatphephaspnoticedpthatphispskinpispredderpthan
normal.pThepnursepunderstandspthatpthispconditionpispdueptophyperemiapandpknowspthatpitpc
anpbepcausedpby:
a.
Decreasedpamountspofpbilirubinpinpthepbloodpb .
Excesspbloodpinpthepunderlyingpbloodpvessels
c.
Decreasedpperfusionptopthepsurroundingptissuespd.pExces
spbloodpinpthepdilatedpsuperficialpcapillariesp-pd
ApnewbornpinfantphaspDownpsyndrome.pDuringpthepskinpassessment,pthepnursepnoticespapt
ransientpmottlingpinptheptrunkpandpextremitiespinpresponseptopthepcoolptemperaturepinpthepe
xaminationproom.pThepinfantspmotherpalsopnoticespthepmottlingpandpaskspwhatpitpis.pThepnu
rsepknowspthatpthispmottlingpispcalled:pa.
Cafpauplait.pb.p
Carotenemia.
pc.
Acrocyanosis.
pd.
Cutispmarmorata.p-pd
Ap35-year-
oldppregnantpwomanpcomesptopthepclinicpforpapmonthlypappointment.pDuringpthepassessm
ent,pthepnursepnoticespthatpshephaspapbrownppatchpofphyperpigmentationponpherpface.pThep
nursepcontinuespthepskinpassessmentpawarepthatpanotherpfindingpmaypbe:pa.
Keratoses.pb.
pXerosis.pc.
Chloasma.
pd.
Acrochordons.p-pc
Duringpauscultationpofptheplungspofpanpadultppatient,pthepnursepnoticesptheppresencepofpbro
nchophony.pThepnursepshouldpassesspforpsignspofpwhichpcondition?pa.
p p p
Based Physical Examination for Health & Well-
p p p p p
Being Assessment 2nd Edition
p p p
Apsemiconsciouspwomanpispbroughtptopthepemergencypdepartmentpafterpshepwaspfoundponp
thepfloorpinpherpkitchen.pHerpface,pnailpbeds,plips,pandporalpmucosaparepapbrightpcherryredpc
olor.pThepnursepsuspectspthatpthispcoloringpispduepto:pa.
Polycythemia.p
b.
Carbonpmonoxideppoisoning.pc
.
Carotenemia.
d.pUremia.
-pb
Appatientphaspbeenpadmittedptopaphospitalpafterpthepstaffpinpthepnursingphomepnoticedpappre
ssurepulcerpinphispsacralparea.pThepnursepexaminesptheppressurepulcerpandpdeterminespth
atpitpispapstagepIIpulcer.pWhichpofpthesepfindingsparepcharacteristicpofpapstagepIIppressurepul
cer?pSelectpallpthatpapply.pa.
Intactpskinpappearspredpbutpispnotpbroken.pb.
Partialpthicknesspskinperosionpispobservedpwithpaplosspofpepidermisporpdermis.pc.pUlcerp
extendspintopthepsubcutaneousptissue.pd.
Localizedprednesspinplightpskinpwillpblanchpwithpfingertipppressure.pe.pOpen
pblisterpareasphavepapred-pinkpwoundpbed.
f.
Patchespofpescharpcoverppartspofpthepwound.p-pb,pe
Whichpstatementpaboutpthepapicespofptheplungspisptrue?pThepapicespofptheplungs:pa.pAr
epatptheplevelpofpthepsecondpribpanteriorly.pb.
Extendp3ptop4pcmpabovepthepinnerpthirdpofpthepclavicles.pc.
Areplocatedpatpthepsixthpribpanteriorlypandpthepeighthpribplaterally.pd.
Restponpthepdiaphragmpatpthepfifthpintercostalpspacepinpthepmidclavicularplinep(MCL).p-pb
Whenpauscultatingptheplungspofpanpadultppatient,pthepnursepnotespthatplow-
pitched,psoftpbreathpsoundsparepheardpoverpthepposteriorplowerplobes,pwithpinspirationpb
eingplongerpthanpexpiration.pThepnursepinterpretspthatpthesepsoundspare:pa.
Normallypauscultatedpoverptheptrachea.pb.
Bronchialpbreathpsoundspandpnormalpinpthatplocation.pc.
,Vesicularpbreathpsoundspandpnormalpinpthatplocation.pd.pBronchovesicul
arpbreathpsoundspandpnormalpinpthatplocationp-pc
Whenpinspectingpthepanteriorpchestpofpanpadult,pthepnursepshouldpincludepwhichpassessme
nt?
a.
Diaphragmaticpexcursion
pb.
Symmetricpchestpexpansionp
c.
Presencepofpbreathpsounds
d.
Shapepandpconfigurationpofpthepchestpwallp-pd
Apmanphaspcomepinptopthepclinicpforpapskinpassessmentpbecausephepispworriedphepmightpha
vepskinpcancer.pDuringpthepskinpassessmentpthepnursepnoticespseveralpareaspofppigmentat
ionpthatplookpgreasy,pdark,pandpstuckponphispskin.pWhichpispthepbestpprediction?pa.
Senileplentigines,pwhichpdopnotpbecomepcancerouspb.
Actinicpkeratoses,pwhichparepprecursorsptopbasalpcellpcarcin omapc.
Acrochordons,pwhichparepprecursorsptopsquamouspcellpcarcinomapd.pSe
borrheicpkeratoses,pwhichpdopnotpbecomepcancerousp-pd
Thepnursepjustpnotedpfrompthepmedicalprecordpthatptheppatientphaspaplesionpthatpispconfluent
pinpnature.pOnpexamination,pthepnursepexpectsptopfind:pa.
Lesionspthatprunptogether.pb.
Annularplesionspthatphavepgrownptogether.
c.
Lesionsparrangedpinpaplinepalongpapnerveproute.pd.pLesions
pthatparepgroupedporpclusteredptogether.p-pa
Appatientphasphadpapterriblepitchpforpseveralpmonthspthatphephaspbeenpcontinuouslyps
cratching.pOnpexamination,pthepnursepmightpexpectptopfind:pa.pApkeloid.pb.pApfissure.
pc.
Keratosis.pd.pLichenificati
on.p-pd
Lichenificationpresultspfrompprolonged,pintensepscratchingpthatpeventuallypthickenspthepski
npandpproducesptightlyppackedpsetspofppapules.pApkeloidpispaphypertrophicpscar.pApfissurepi
spaplinearpcrackpwithpabruptpedges,pwhichpextendspintopthepdermis;pitpcanpbepdry
orpmoist.pKeratosespareplesionspthatparepraised,pthickenedpareaspofppigmentationpthat
appearpcrusted,pscaly,pandpwarty.
,Apphysicianphaspdiagnosedpappatientpwithppurpura.pAfterpleavingptheproom,papnursingps
tudentpaskspthepnursepwhatpthepphysicianpsawpthatpledptopthatpdiagnosis.pThepnursepsh
ouldpsay,pThepphysicianpispreferringptopthe:pa.
Bluepdilationpofpbloodpvesselspinpapstar-
shapedplinearppatternponptheplegs.pb.pFierypred,pstar-
shapedpmarkingponpthepcheekpthatphaspapsolidpcircularpcenter.pc.pConfluentpandpex
tensiveppatchpofppetechiaepandpecchymosesponpthepfeet.pd.
Tinypareaspofphemorrhagepthatpareplesspthanp2pmm,pround,pdiscrete,pandpdarkpredpinpc
olor.p-pc
Ap45-year-
oldpfarmerpcomespinpforpapskinpevaluationpandpcomplainspofphairplossponphisphead.pHisphairp
seemsptopbepbreakingpoffpinppatches,pandphepnoticespsomepscalingponphisphead.pThepnurse
pbeginspthepexaminationpsuspecting:pa.
Tineapcapitis.pb.
Folliculitis.pc.
Toxicpalopecia.pd.pSeborrhei
cpdermatitis.p-pa
Thepnursepispexaminingpappatientpwhoptellspthepnurse,pIpsurepsweatpaplot,pespeciallyponpm
ypfacepandpfeetpbutpitpdoesntphavepanpodor.pThepnursepknowspthatpthispconditionpcouldpb
eprelatedpto:pa.
Eccrinepglands.pb.p
Apocrinepglands.p
c.
Disorderpofpthepstratumpcorneum.pd.pDisor
derpofpthepstratumpgerminativum.p-pa
Apnewbornpinfantpispinpthepclinicpforpapwell-
babypcheckup.pThepnursepobservespthepinfantpforptheppossibilitypofpfluidplosspbecausepofpw
hichpofpthesepfactors?pa.
Subcutaneouspfatpdepositsparephighpinpthepnewborn.pb.pSe
baceouspglandsparepoverproductivepinpthepnewborn.pc.
Thepnewbornspskinpispmoreppermeablepthanpthatpofpthepadult.pd.
Thepamountpofpvernixpcaseosapdramaticallyprisespinpthepnewborn.p-pc
Duringpanpexamination,pthepnursepfindspthatpappatientphaspexcessivepdrynesspofpthepskin.pT
hepbestptermptopdescribepthispconditionpis:pa.
Xerosis.pb.
pPruritus.p
c.
Alopecia.pd.pSebo
rrhea.p-pa
, Appatientpcomespinpforpapphysicalpexaminationpandpcomplainspofpfreezingptopdeathpwhilepw
aitingpforpherpexamination.pThepnursepnotespthatpherpskinpisppalepandpcoolpandpattributespt
hispfindingpto:pa.
Venousppooling.
b.
Peripheralpvasodilation.pc.
p
Peripheralpvasoconstriction.pd.pDecre
asedparterialpperfusion.p-pc
Appatientpcomesptopthepclinicpandpstatespthatphephaspnoticedpthatphispskinpispredderpthan
normal.pThepnursepunderstandspthatpthispconditionpispdueptophyperemiapandpknowspthatpitpc
anpbepcausedpby:
a.
Decreasedpamountspofpbilirubinpinpthepbloodpb .
Excesspbloodpinpthepunderlyingpbloodpvessels
c.
Decreasedpperfusionptopthepsurroundingptissuespd.pExces
spbloodpinpthepdilatedpsuperficialpcapillariesp-pd
ApnewbornpinfantphaspDownpsyndrome.pDuringpthepskinpassessment,pthepnursepnoticespapt
ransientpmottlingpinptheptrunkpandpextremitiespinpresponseptopthepcoolptemperaturepinpthepe
xaminationproom.pThepinfantspmotherpalsopnoticespthepmottlingpandpaskspwhatpitpis.pThepnu
rsepknowspthatpthispmottlingpispcalled:pa.
Cafpauplait.pb.p
Carotenemia.
pc.
Acrocyanosis.
pd.
Cutispmarmorata.p-pd
Ap35-year-
oldppregnantpwomanpcomesptopthepclinicpforpapmonthlypappointment.pDuringpthepassessm
ent,pthepnursepnoticespthatpshephaspapbrownppatchpofphyperpigmentationponpherpface.pThep
nursepcontinuespthepskinpassessmentpawarepthatpanotherpfindingpmaypbe:pa.
Keratoses.pb.
pXerosis.pc.
Chloasma.
pd.
Acrochordons.p-pc
Duringpauscultationpofptheplungspofpanpadultppatient,pthepnursepnoticesptheppresencepofpbro
nchophony.pThepnursepshouldpassesspforpsignspofpwhichpcondition?pa.
