Nursi
ngHealthAssessmentTheFoundati
on
ofCli
nicalPr
acti
ce,3rdEdit
ion,Pat
ri
ciaM.
Di
ll
onchapter2.
wr
i
tt
enb
y
Ma
yal
i
l
y
www.
st
uv
ia
.co
m
, St
uvi
a.
com-
TheMa
rke
tpl
acet
oBu
yan
dSe
lly
ourSt
udyMa
ter
ial
Ch
apt
er02:As
ses
sin
gth
eIn
tegu
men
tar
ySy
ste
m
Mul
ti
pleChoi
ce
I
den
ti
fythec
hoic
eth
atb
estc
omp
let
est
hes
tat
eme
nto
ran
swe
rst
heq
ues
ti
on.
_
___ 1
. Whi
chisapri
maryfunct
ionoft
hei
nte
gume
nta
rys
yst
em?
Fi
rs
tli
neoftheb ody’
sd ef
ense
I
ncre
asesbodyte mperat
ure
Sy
nthesi
zesvi
tami nE
Absor
bsult
ravi
oletra
ys
_
___ 2
. Thenurs
eispr
ovi
di
ngcaretoanewb
orn.
Wh i
chi
san
orma
las
ses
sme
ntf
ind
ingt
hatof
tenoc
cur
swi
thi
nth
e
fi
rst2to3d aysofl
ifeforth
ispati
ent?
Decreasedel
asti
ci
ty
Physiol
ogicj
aundi
ce
Pronouncedbodyodor
Hyperpi
gme n
tati
onofthes k
in
_
___ 3
. Thenur
sei
sass
ess
ingas
chool
-
agep
ati
entwi
thas
kind
isor
der
.Wh
ichd
isor
deri
smos
tli
kel
ytooc
curd
uri
ng
chil
dhood?
Acne
Psori
asi
s
Vari
cel
la
Rosacea
_
___ 4
. Thenur
sei
sass
essi
ngt
hesk
incol
orf
orad
ark
-sk
inn
edp
ati
ent
.Wh
ichl
oca
tioni
smos
tap
prop
ria
tef
ort
he
nursetousef
orthi
sass
es s
me nt
?
Scl
era
Oralmucos
a
Sol
esofthefeet
Abdomina
lregi
on
_
___ 5
. Thenur
seisprovi
di
ngcaret
oanAf
ri
canAme
ric
anp
ati
ent
.Wh
ichi
sac
ommons
kina
sse
ssme
ntf
indi
ngf
ora
pati
entofthi
se th
nici
ty
?
Kel
oids
Agespots
I
ncrease
dr i
skforsunburn
Decr
easedfac i
alhai
r
_
___ 6
. Thenur
seiscondu
ctin
gas ki
nasses
smen
tforap
ati
entwh
oha
samol
e.Wh
ichqu
est
ioni
smos
tap
prop
ria
te
d u
rin
gthisa s
sessme nt?
“Doyouha v
ea nya l
lergi
es?”
“Whend i
dyouf i
rstnotic
ethis?
”
“Haveyounoticedan yrash
es?”
“Doyouo f
tenhavear u
nnyn os
e?”
_
___ 7
. Thenur
seisa
sse
ssi
ngap
ati
entwi
thas
kinc
ondi
ti
on.
Whi
chc
ond
iti
oni
sth
emos
tcommond
uri
ngt
hef
all
?
Eczema
Ti
nea
Urt
ic
a r
ia
, St
uvi
a.
com-
TheMa
rke
tpl
acet
oBu
yan
dSe
lly
ourSt
udyMa
ter
ial
4
)Imp
eti
go
_
___ 8
. Thenur
seisass
essi
nga
nadole
scen
tcli
entwh
oisex
per
ien
cin
ginc
rea
sedp
ers
pir
ati
on.
Whi
chl
oca
tionwi
l
l
thenurseassesstodet
ermineapocri
negla
ndfunct
ioni
ng?
Legs
Undera
rms
Chest
All
ofthea b
ove
_
___ 9
. Thenur
seispr
ovi
din
gcaretoapat
ie
ntwhoi
spre
scr
ibe
dval
proi
cac
idfort
het
rea
tme
ntofas
eiz
ured
isor
der
.
Wh i
chwillt
hen ur
seas s
e ssf
orduri
ngtheski
nexaminat
ion?
Alopec
ia
Prur
it
icrash
Toxi
ce pi
dermalnecr
olysis
Stev
ens-Johnso
ns yn
drome
_
___ 1
0. Thenur
sei
sprovi
di
ngcar
etoapat
ie
ntwhopr
ese
ntswi
thaf
eve
r.Wh
ichi
sth
emos
tap
prop
ria
tea
cti
onb
yth
e
nursedur
ingtheassessmen
tp r
oces
s ?
As sessforc
onfusi
on
As sessvi
talsi
gns
As sessforl
eth
a r
gy
As sessfori
rr
it
abil
it
y
_
___ 1
1.Thenur
seisass
essin
gap at
ie
nt’
sski
nandn
ote
sjau
ndi
ce,
aye
ll
owdis
color
ati
onofs
kin
.Wh
ichc
onc
lus
ionb
y
thenurseismos tappropr
iat
ebasedonthi
sassess
mentfi
nding
?
I
mp air
edc a
rdi
o v
a scu
larcir
cul
ati
on
Dimini
shedoxygenc oncent
rat
ion
Li
verimpair
me nt
Renali
mp ai
rme n
t
_
___ 1
2. Thenurs
ea s
sess
ingapat
ie
ntwhoi
sex
per
ien
cin
gre
nal
fai
l
ure
.Wh
ichc
han
get
oth
ein
teg
ume
nta
rys
yst
em
doesth enurs
ea nt
ic
ipatef
orth
ispat
ient
?
J aundi
c e
Th i
n ni
ngh ai
r
Ur emicfrost
Th i
cken ednai
ls
_
___ 1
3. Ast
uden
tnurs
esasksthen
ursi
ngin
str
uct
o rwh
yaninf
ant
’sski
nappea
rsr
e d
dened.Whi
chr
esp
ons
ebyt
he
nur
sin
gi n
struc
torismos ta
p p
ropri
ate?
“Theinf
ant’
ss ki
ncolori
sc ausedbyane xcess
ivebrea
k do
wno feryth
rocytes
.”
“Theinf
ant’
ss ki
ncolori
sc ausedbyincre
a s
edlipi
dlevel
s.”
“Theinf
ant’
ss ki
ncolori
sc ausedbyd i
minis
hedp e
rip
he r
alci
rcul
ati
on .
”
“Theinf
ant’
ss ki
ncolori
sc ausedbyloweramo unt
sofs ubcu
taneoustis
su e
.”
_
___ 1
4. Thenur
seisas
sessi
nganadole
scentp
a t
ie
ntwhopr
ese
ntswi
tha
cne
.Wh
ent
eac
hin
gth
epa
tie
ntwh
yth
is
occurs,whi
chreasonwillthenurseprovi
de?
Increasedli
pi
dlevels
Increasedsebump rodu
ct i
on
Increasedcardi
aco u
tput
Increasedhemoglobinproduct
ion
ngHealthAssessmentTheFoundati
on
ofCli
nicalPr
acti
ce,3rdEdit
ion,Pat
ri
ciaM.
Di
ll
onchapter2.
wr
i
tt
enb
y
Ma
yal
i
l
y
www.
st
uv
ia
.co
m
, St
uvi
a.
com-
TheMa
rke
tpl
acet
oBu
yan
dSe
lly
ourSt
udyMa
ter
ial
Ch
apt
er02:As
ses
sin
gth
eIn
tegu
men
tar
ySy
ste
m
Mul
ti
pleChoi
ce
I
den
ti
fythec
hoic
eth
atb
estc
omp
let
est
hes
tat
eme
nto
ran
swe
rst
heq
ues
ti
on.
_
___ 1
. Whi
chisapri
maryfunct
ionoft
hei
nte
gume
nta
rys
yst
em?
Fi
rs
tli
neoftheb ody’
sd ef
ense
I
ncre
asesbodyte mperat
ure
Sy
nthesi
zesvi
tami nE
Absor
bsult
ravi
oletra
ys
_
___ 2
. Thenurs
eispr
ovi
di
ngcaretoanewb
orn.
Wh i
chi
san
orma
las
ses
sme
ntf
ind
ingt
hatof
tenoc
cur
swi
thi
nth
e
fi
rst2to3d aysofl
ifeforth
ispati
ent?
Decreasedel
asti
ci
ty
Physiol
ogicj
aundi
ce
Pronouncedbodyodor
Hyperpi
gme n
tati
onofthes k
in
_
___ 3
. Thenur
sei
sass
ess
ingas
chool
-
agep
ati
entwi
thas
kind
isor
der
.Wh
ichd
isor
deri
smos
tli
kel
ytooc
curd
uri
ng
chil
dhood?
Acne
Psori
asi
s
Vari
cel
la
Rosacea
_
___ 4
. Thenur
sei
sass
essi
ngt
hesk
incol
orf
orad
ark
-sk
inn
edp
ati
ent
.Wh
ichl
oca
tioni
smos
tap
prop
ria
tef
ort
he
nursetousef
orthi
sass
es s
me nt
?
Scl
era
Oralmucos
a
Sol
esofthefeet
Abdomina
lregi
on
_
___ 5
. Thenur
seisprovi
di
ngcaret
oanAf
ri
canAme
ric
anp
ati
ent
.Wh
ichi
sac
ommons
kina
sse
ssme
ntf
indi
ngf
ora
pati
entofthi
se th
nici
ty
?
Kel
oids
Agespots
I
ncrease
dr i
skforsunburn
Decr
easedfac i
alhai
r
_
___ 6
. Thenur
seiscondu
ctin
gas ki
nasses
smen
tforap
ati
entwh
oha
samol
e.Wh
ichqu
est
ioni
smos
tap
prop
ria
te
d u
rin
gthisa s
sessme nt?
“Doyouha v
ea nya l
lergi
es?”
“Whend i
dyouf i
rstnotic
ethis?
”
“Haveyounoticedan yrash
es?”
“Doyouo f
tenhavear u
nnyn os
e?”
_
___ 7
. Thenur
seisa
sse
ssi
ngap
ati
entwi
thas
kinc
ondi
ti
on.
Whi
chc
ond
iti
oni
sth
emos
tcommond
uri
ngt
hef
all
?
Eczema
Ti
nea
Urt
ic
a r
ia
, St
uvi
a.
com-
TheMa
rke
tpl
acet
oBu
yan
dSe
lly
ourSt
udyMa
ter
ial
4
)Imp
eti
go
_
___ 8
. Thenur
seisass
essi
nga
nadole
scen
tcli
entwh
oisex
per
ien
cin
ginc
rea
sedp
ers
pir
ati
on.
Whi
chl
oca
tionwi
l
l
thenurseassesstodet
ermineapocri
negla
ndfunct
ioni
ng?
Legs
Undera
rms
Chest
All
ofthea b
ove
_
___ 9
. Thenur
seispr
ovi
din
gcaretoapat
ie
ntwhoi
spre
scr
ibe
dval
proi
cac
idfort
het
rea
tme
ntofas
eiz
ured
isor
der
.
Wh i
chwillt
hen ur
seas s
e ssf
orduri
ngtheski
nexaminat
ion?
Alopec
ia
Prur
it
icrash
Toxi
ce pi
dermalnecr
olysis
Stev
ens-Johnso
ns yn
drome
_
___ 1
0. Thenur
sei
sprovi
di
ngcar
etoapat
ie
ntwhopr
ese
ntswi
thaf
eve
r.Wh
ichi
sth
emos
tap
prop
ria
tea
cti
onb
yth
e
nursedur
ingtheassessmen
tp r
oces
s ?
As sessforc
onfusi
on
As sessvi
talsi
gns
As sessforl
eth
a r
gy
As sessfori
rr
it
abil
it
y
_
___ 1
1.Thenur
seisass
essin
gap at
ie
nt’
sski
nandn
ote
sjau
ndi
ce,
aye
ll
owdis
color
ati
onofs
kin
.Wh
ichc
onc
lus
ionb
y
thenurseismos tappropr
iat
ebasedonthi
sassess
mentfi
nding
?
I
mp air
edc a
rdi
o v
a scu
larcir
cul
ati
on
Dimini
shedoxygenc oncent
rat
ion
Li
verimpair
me nt
Renali
mp ai
rme n
t
_
___ 1
2. Thenurs
ea s
sess
ingapat
ie
ntwhoi
sex
per
ien
cin
gre
nal
fai
l
ure
.Wh
ichc
han
get
oth
ein
teg
ume
nta
rys
yst
em
doesth enurs
ea nt
ic
ipatef
orth
ispat
ient
?
J aundi
c e
Th i
n ni
ngh ai
r
Ur emicfrost
Th i
cken ednai
ls
_
___ 1
3. Ast
uden
tnurs
esasksthen
ursi
ngin
str
uct
o rwh
yaninf
ant
’sski
nappea
rsr
e d
dened.Whi
chr
esp
ons
ebyt
he
nur
sin
gi n
struc
torismos ta
p p
ropri
ate?
“Theinf
ant’
ss ki
ncolori
sc ausedbyane xcess
ivebrea
k do
wno feryth
rocytes
.”
“Theinf
ant’
ss ki
ncolori
sc ausedbyincre
a s
edlipi
dlevel
s.”
“Theinf
ant’
ss ki
ncolori
sc ausedbyd i
minis
hedp e
rip
he r
alci
rcul
ati
on .
”
“Theinf
ant’
ss ki
ncolori
sc ausedbyloweramo unt
sofs ubcu
taneoustis
su e
.”
_
___ 1
4. Thenur
seisas
sessi
nganadole
scentp
a t
ie
ntwhopr
ese
ntswi
tha
cne
.Wh
ent
eac
hin
gth
epa
tie
ntwh
yth
is
occurs,whi
chreasonwillthenurseprovi
de?
Increasedli
pi
dlevels
Increasedsebump rodu
ct i
on
Increasedcardi
aco u
tput
Increasedhemoglobinproduct
ion
