Health & Physical Assessment in Nursing, Canadian Edition By Donita T D’Amico – Test Bank

Chapter 11

MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.

1) A nurse is assessing a client with liver disease and notes that the skin, mucous membranes, and sclerae are yellowish in colour. How should the nurse document this finding?
1) Cyanosis
2) Jaundice
3) Carotenemia
4) Uremia
1) 2
Explanation:
1. Cyanotic skin is bluish in colour.
2. The nurse’s findings indicate jaundice, which is due to increased levels of bilirubin in the blood.
3. Carotenemic skin has a yellow-orange tinge.
4. Uremic skin is pale and yellow, but is associated with renal, and not liver, disease.
Assessment
Application
Objective – 11
Page –176, 177 (Table 11.1)
Difficulty – 1

2) What assessment finding of a 2 to 3-day-old newborn’s skin may require treatment?
1) Tiny white facial bumps
2) Dark spots on the sacral area
3) Irregular red patches on the back of the neck
4) Yellow skin colour

2) 4
Explanation:
1. Milia are tiny white facial papules due to sebum and will resolve within a few weeks of birth.
2. Harmless skin markings requiring no intervention include gray, blue, or purple spots (Mongolian spots) on the buttocks or sacral area .
3. Vascular markings also called stork bites on the back of the neck and disappear within the first year.
4. Yellowing of skin and mucous membranes in an infant who is 3-4 days old is physiological jaundice, but may require treatment with fluids and phototherapy.,
Evaluation
Application
Objective – 9
Page – 173
Difficulty – 1

3) A nurse is admitting a client with skin vitiligo, which is highly visible even from a distance. The client asks you to put a ‘No Visitors’ sign on the door and has called the family to tell them not to visit. What primary problem may occur with this client?
1) Risk for loneliness
2) Decrease in self-esteem
3) Defensive coping
4) Disturbed body image
3) 4
Explanation:
1. A visible skin disorder may trigger psychosocial problems. Due to a disturbed body image the client is asking to be alone.
2. A disturbance in self-esteem may occur, but the primary problem is a disturbance in body image.
3. There is no evidence that the client is defensive or highly anxious.
4. The client with vitiligo, a skin condition with patchy depigmented areas over some or all of the following body areas: face, neck hands, feet, and body folds, may suffer a severe disturbance in body image.
Diagnosis
Analysis
Objective – 8
Page – 176 (Table 11.1), 186 (Figure 11.16)
Difficulty – 2

4) A nurse is performing a skin assessment on a client and notes a round, elevated, fluid-filled mass approximately 0.5cm in size. How should the nurse document this finding?
1) Papule
2) Tumor
3) Macule
4) Vesicle
4) 4
Explanation:
1. A papule is an elevated, solid, palpable mass.
2. Tumors are elevated, but solid, hard, or soft palpable and extend deeper into the dermis.
3. A macule is a flat, nonpalpable change in skin colour.
4. The area described is a vesicle and may be caused by herpetic lesions, poison ivy, and small burn blisters.
Assessment
Analysis
Objective – 11
Page – 199, 200 (Figure 11.40)
Difficulty – 1

5) A nurse is conducting a health history on a client’s integumentary status and wants to obtain data related to risk factors. What would be an appropriate question?
1) “Does your skin itch?”
2) “Have you noticed a change in the colour or size of a mole?”
3) “Have you noticed any pain around your cuticles?”
4) “How much time do you spend outdoors?”

5) 4
Explanation:
1. This question is related to concerns or injuries the client may have.
2. Changes in moles may be a result of being outdoors, but it is not a risk factor.
3. This question will learn about a symptom but not a risk factor.
4. Health behaviours that may increase risk for health issues include exposure to the sun, failure to use a sun block, use of soaps and chemicals on the body, tattoos and body piercings.
Assessment
Application
Objective – 4
Page – 181, 182
Difficulty – 2

6) How should the nurse assess for jaundice in a client with dark skin?
1) Use a bright lamp and a magnifying glass
2) Inspect the lips, oral mucosa, sclera, conjunctivae, and palms
3) Assess the skin the same way you would inspect any client
4) Document “unable to assess” for jaundice
6) 2
Explanation:
1. A bright light and magnifying glass will not help. Jaundice is difficult to detect in people with dark skin.
2. Changes in skin colour may be difficult to evaluate in clients with dark skin. Inspect areas of the body with less pigmentation such as the lips, oral mucosa, sclera, palms of the hand, and conjunctivae.
3. Jaundice is more difficult to detect in people with dark skin.
4. The nurse can assess the lips, oral mucosa, sclera, palms of the hand, and conjunctivae and thus it is not appropriate to state “unable to assess”.
Assessment
Analysis
Objective – 7
Page – 176 (Table 11.1)
Difficulty – 2

7) A nurse is planning to do a head to toe assessment of the skin, hair, and nails of a client from Vietnam. The interpreter, a relative who speaks Vietnamese and English, has been authorized by the client to be present to translate. What should the nurse do first?
1) Perform hand hygiene and don gloves.
2) Ask the client to remove all clothing, put on a gown, and lie down.
3) Tell the client that an official interpreter needs to be present.
4) Explain the procedure and ask if you may touch the client’s head.
7) 4
Explanation:
1. Before donning gloves the nurse should explain the procedure to reduce client anxiety.
2. Before having the client undress the nurse should explain what is included in the assessment.
3. The client has authorized the family member to be the interpreter. Asking the family member to leave may increase the client’s anxiety.
4. Explaining the procedure reduces anxiety in the client. The client’s cultural beliefs may be such that the client does not want you to touch their head. You must seek clarification on this issue before proceeding to examine the scalp for lesions.
Assessment
Analysis
Objective – 5
Page – 177, 185
Difficulty – 2

8) A nurse is caring for a client who is a long-time smoker and notes clubbing of the fingers. What technique would the nurse utilize to validate this assessment? 1) Place the hands out straight with the palm sides down
2) Place two of the same fingers from each hand together
3) Place two index fingers together tip to tip
4) Place two thumbs touching side by side
8) 2
Explanation:
1. This will not validate clubbing.
2. To assess clubbing you can use the Schamroth technique in which you ask the client to bring the dorsal aspect of corresponding fingers together and if there is clubbing a diamond is not formed and the distance increases at the fingertip.
3. Two corresponding fingers are used.
4. Two fingers should be placed together to create a diamond to assess for clubbing.
Assessment
Application
Objective – 6
Page – 192, 215 (Figure 11.86)
Difficulty – 2

9) A nurse is performing an assessment of a client’s skin, hair, and nails when the client becomes pale and diaphoretic. What action should the nurse take first?
1) Call the physician
2) Ask about anxiety and explain procedures
3) Lower the client’s head
4) Give the client orange juice with extra sugar
9) 2
Explanation:
1. The nurse would not call the physician before taking vital signs and reducing the client’s anxiety. If the blood pressure drops and there is an increase in pulse the physician should be called.
2. Anxiety can cause the client to have pallor and be diaphoretic. This can often be resolved by recognizing the anxiety and explaining the procedure(s).
3. The client is anxious and the nurse should try to reduce anxiety by explaining the assessment procedure.
4. There is no indication at there is a drop in blood sugar.

Implementation
Application
Objective – 3
Page – 185
Difficulty – 2

10) A nurse is assessing a female client and notes facial hirsutism. The client asks the nurse why this has happened to her. How should the nurse respond?
1) “You need to take vitamins.”
2) “There is no known cause for this condition.”
3) “Your diet is not nutritionally balanced.”
4) “You may have some hormone imbalances.”
10) 4
Explanation:
1. This is not an appropriate response.
2. Hirsutism is generally due to an endocrine disorder.
3. Hirsutism is not related to diet.
4. Hirsutism is excess body hair in females on the face, chest, abdomen, arms, and legs, following the male pattern. It is typically due to endocrine or metabolic dysfunction, but may be idiopathic in nature.
Diagnosis
Application
Objective – 8
Page – 213 (Figure 11.81)
Difficulty – 2