Health Assessment exam 2

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When the patient's chart includes a notation that petechiae are present what finding does the nurse expect during inspection?
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Terms in this set (48)
When the patient's chart includes a notation that petechiae are present what finding does the nurse expect during inspection?
Purplish-red pinpoint lesions
When performing a skin assessment of an adult patient the nurse expects what finding?
Return of skin to its original position when pinched up slightly
What findings does a nurse expect when inspecting and palpating a patient's nails?
Nail surface is smooth and rounded
During an examination the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is:
Xerosis
During inspection of a patient's upper back the nurse notices three small, elevated superficial lesions filled with purulent fluid. How does the nurse document this finding?
As three pustules on the upper back
A nurse is inspecting the nails of a patient with chronic hypoxemia and notices enlargement of the ends of the fingers and the angle of the nail base is greater than 180 degrees. How does the nurse document these findings?
Clubbing
A nurse notices multiple lesions on a patient's left hand that are 0.5cm in width elevated, circular, and filled with serous fluid. What kind of primary lesions are these?
Vesicles
A patient expresses concern that a new lesion may be melanoma. Which finding suggests a malignant melanoma?
Irregular border
An older patient has developed age spots and is concerned about skin cancer. How would the nurse instruct the patient to check him/herself?
"Monitor spots for color change."
An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days: she is extremely dehydrated. What would the nurse expect to see during the examination?
Dry mucous membranes and cracked lips
While inspecting the skin a nurse notices lesions on the patient's upper right arm. What is the best way to document the size of the lesion?Use a cm ruler to measure the lesionA patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding?Color variationA patient has had a "terrible itch" for several months that he has been continuously scratching. On examination the nurse might expect to findLichenificationDuring shift report a nurse learns that a patient has a macular rash. As the nurse inspects the patient's skin, what finding will confirm the rash consists of macules?Flat, well-defined, small lesions less than 1cm in diameterThe nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination the nurse expects to find:Lesions that run togetherThe nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition?Severe dehydrationThe nurse is assessing a patient who has liver disease for jaundice. Which of these assessment findings is indicative of true jaundice?Yellow color of the sclera that extends up to the irisThe nurse is assessing for inflammation and redness in a dark-skinned person. Which technique is the best?Palpating the skin for edema and increased warmthA mole is an example of a small raised spot on the skin called:PapuleWhich is the term for a sharply elevated irregularly shaped, progressively enlarging scar caused by excessive collagen during tissue repair?KeloidWhich of the following is a blister smaller than 0.5cm?VesicleThe term urticaria means a(n):Allergic skin reactionA bluish discoloration of the skin and mucous membranes is called:CyanosisWhich term means a visible collection of pus beneath the epidermis?PustuleWhich of the following skin lesions is described as a non raised discolored spot?MaculeA 24yr old woman develops an allergic skin eruption characterized by elevated and irregularly shaped lesions. These skin lesions are called:WhealsWhile taking a history the nurse observes that the patient's facial cranial nerves (CN VII) are intact based on which behaviors of the patient?The sides of the mouth are symmetric when the patient smilesThe nurse notices that a patient's nasolabial folds are not symmetric. On examination the nurse may find that damage has occurred to which cranial nerve?VII (7)How does the nurse test the function of the patient's spinal accessory nerve (CN XI)?Ask the patient to shrug the shoulders against the resistance of the nurse's handsA mother brings her 2mo daughter in for an examination and says "my daughter rolled over against the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is something terribly wrong?" The nurse's best response would be:,"That soft spot is normal and actually allows for growth of the brain during the first year of your baby's life.To assess the TMJ of an adult patient the nurse uses which technique?Placing two fingers in front of each ear and asking the patient to slowly open and close the mouthWhich cranial nerve is assessed by using the Snellen visual acuity chart?Optic cranial nerve (CN II)A nurse shines a light in the right pupil to test constriction and notices that the left pupil constricts as well. Based on these data the nurse should take what action?Document this finding as a consensual reactionA patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that:Constriction of both pupils occurs in response to bright lightA patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:The patient can read 20ft what a person with normal vision can read at 30ftA patient's vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient:Has poor visionWhen performing the corneal light reflex assessment the nurse notes that the light is reflected at 2PM in each eye. The nurse should:Consider this a normal findingWhen assessing the pupillary light reflex the nurse should use which technique?Shine a light across the pupil from the side, and observe for direct and consensual pupillary constrictionThe nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true?The image formed on the retina is upside down and reversed from its actual appearance in the outside worldWhat instructions does the nurse give the patient before using the Snellen visual acuity chart?"Hold a white card over one eye and read the smallest possible line."The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction?Air conduction is the normal pathway for hearingThe nurse is preparing to administer ear drops to a 2yr old child. Which one of these reflects the correct procedure?Pulling pinna downDuring an examination the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" The nurse recognizes that this symptom indicates:TinnitusA patient with presbycusis is in the clinic for a physical exam. The nurse knows that presbycusis:A type of sensorineural hearing lossThe nurse is assessing a patient who may have hearing loss. Which of these behaviors does NOT indicate hearing loss?Makes eye contact with the nurse during conversationWhen inspecting a patient's nasal mucous membrane which finding does the nurse expect to see?Deep pink turbinatesWhen inspecting a patient's posterior wall of the pharynx and tonsils a nurse documents which finding as abnormal?Left and right tonsils meet at midlineThe nurse is obtaining a health history on a 3mo infant. During the interview the mother states, "I think she is getting her first tooth because she has started drooling a lot." The nurse's best response would be"She is just starting to salivate and hasn't learned to swallow the saliva."