TWU nursing assessment final review
A nurse is inspecting the client's skin and observes a .5 cm freckle on the client's
abdomen. How will the nurse document this in the chart?
a. patch
b. macule
c. papule
d. plaque
e. bulla
B. macule- freckle (solely a flat color change)
patch- macules >1cm
papule- something you can feel (raised) <1cm (like a wart)
plaque- a flock of papules, >1cm
bulla- like a vesicle but bigger, ex. friction blister or burn
When inspecting a client's arm, the nurse notes a mosquito bite on the skin. How should
the nurse document this in the chart?
a. pustule
b. vesicle
c. bulla
d. wheal
D. wheal (raised, transient, erythematous)
pustule- pus in a cavity (ex. acne)
vesicle- elevated cavity with free fluid ("blister")
bulla- like a vesicle but bigger, > 1cm
Which of the following are not examples of ADL's? (select all that apply)
a. personal hygiene
b. feeding
c. cooking
d. managing finances
e. toileting
c. cooking
d. managing finances
, ADL's are basic self care
IADL's are not necessary for fundamental functioning but let someone live
independently
Which of the following is an expected change in regard to the older client?
a. oral temp of 96 F
b. respiratory rate of 29
c. BP of 90/70
d. BMI of 18
a. oral temp of 96
Normal temp for elderly is 95-97.5
normal elderly respiratory rate is 15-22
elderly client BP normally has a higher systolic than younger people
BMI of 18 is underweight and abnormal
A BMI of ____ is underweight and a BMI of _____ is obese
BMI 18
BMI 30
A nurse is inspecting a clients abdomen and notes a small, smooth slightly raised bright
red dot. What should the nurse do in response to this finding?
a. document the cherry angioma as a normal finding
b. document the spider angioma as a normal finding
c. notify the healthcare provider immediately
d. ask the client if the spot is painful
a. this is a cherry angioma and is a normal finding
spider angioma- fiery red, star shaped marking with a solid center
The nurse is assessing a client with cardiac disease. When assessing the client's nails, she
observes spoon shaped nails. How should the nurse document this finding in the chart?
a. paronychia
b. telangiectasis
c. nail clubbing
d. koilonychia
D. koilonychia are spoon-shaped nails related to iron deficiency anemia, endocrine or
cardiac disease.
paronychia- red, swollen tender inflammation of nail folds
telangiectasis- caused by vascular dilation, permanently enlarged vessels visible on the
A nurse is inspecting the client's skin and observes a .5 cm freckle on the client's
abdomen. How will the nurse document this in the chart?
a. patch
b. macule
c. papule
d. plaque
e. bulla
B. macule- freckle (solely a flat color change)
patch- macules >1cm
papule- something you can feel (raised) <1cm (like a wart)
plaque- a flock of papules, >1cm
bulla- like a vesicle but bigger, ex. friction blister or burn
When inspecting a client's arm, the nurse notes a mosquito bite on the skin. How should
the nurse document this in the chart?
a. pustule
b. vesicle
c. bulla
d. wheal
D. wheal (raised, transient, erythematous)
pustule- pus in a cavity (ex. acne)
vesicle- elevated cavity with free fluid ("blister")
bulla- like a vesicle but bigger, > 1cm
Which of the following are not examples of ADL's? (select all that apply)
a. personal hygiene
b. feeding
c. cooking
d. managing finances
e. toileting
c. cooking
d. managing finances
, ADL's are basic self care
IADL's are not necessary for fundamental functioning but let someone live
independently
Which of the following is an expected change in regard to the older client?
a. oral temp of 96 F
b. respiratory rate of 29
c. BP of 90/70
d. BMI of 18
a. oral temp of 96
Normal temp for elderly is 95-97.5
normal elderly respiratory rate is 15-22
elderly client BP normally has a higher systolic than younger people
BMI of 18 is underweight and abnormal
A BMI of ____ is underweight and a BMI of _____ is obese
BMI 18
BMI 30
A nurse is inspecting a clients abdomen and notes a small, smooth slightly raised bright
red dot. What should the nurse do in response to this finding?
a. document the cherry angioma as a normal finding
b. document the spider angioma as a normal finding
c. notify the healthcare provider immediately
d. ask the client if the spot is painful
a. this is a cherry angioma and is a normal finding
spider angioma- fiery red, star shaped marking with a solid center
The nurse is assessing a client with cardiac disease. When assessing the client's nails, she
observes spoon shaped nails. How should the nurse document this finding in the chart?
a. paronychia
b. telangiectasis
c. nail clubbing
d. koilonychia
D. koilonychia are spoon-shaped nails related to iron deficiency anemia, endocrine or
cardiac disease.
paronychia- red, swollen tender inflammation of nail folds
telangiectasis- caused by vascular dilation, permanently enlarged vessels visible on the
