NURS 235 HEALTH CARE ASSESSMENT EXAM QUESTIONS
WITH CORRECT ANSWERS AND EXPLANATIONS
MULTIPLE CHOICE
A mother brings her 6-month-old infant to the clinic for a well-baby checkup. How should the
nurse proceed when weighing the patient?
a.
Have the mother remain outside the room.
b.
Ask the mother to remove the infant’s clothing and diaper.
c.
Weigh the infant with the diaper only.
d.
Place the infant supine on the scale with his knees extended.
ANS: B
The nurse should ask the mother to remove the infant’s clothing and diaper before weighing
and measuring the infant. An older child can be examined in his underwear; infants should be
undressed. Infants are typically more comfortable with the parent close by so the mother
should remain in the room. The infant should be supine with knees extended on the
examination table when being measured, not when being weighed.
Difficulty: Moderate
Nursing Process: Assessment
Client Need: HPM
Cognitive Level: Application
Page 488
PTS: 1
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are
most likely involved?
a.
CN V and CN VII
b.
CN VII and CN IX
c.
CN V and CN VIII
d.
CN VI and CN X
ANS: B
Cranial nerves VII and IX supply sensation to the tongue.
Difficulty: Moderate
Nursing Process: Assessment
Client Need: HPM
Cognitive Level: Application
Page 508
PTS: 1
While the nurse assesses a newborn of African American descent, the mother points out
a blue-black Mongolian spot on the newborn’s back and asks, “What’s that? Is
something wrong with my baby?” Which response by the nurse is best?
a.
“I’ll ask the physician to look at the spot.”
,NURS 235 HEALTH CARE ASSESSMENT EXAM QUESTIONS
WITH CORRECT ANSWERS AND EXPLANATIONS
b.
“Those spots are quite common and typically fade with time.”
c.
“You may want a plastic surgeon to look at that.”
d.
“That spot is benign so it’s nothing you need to worry about.”
ANS: B
The best response by the nurse is to explain that Mongolian spots are common in dark-skinned
newborns and typically fade over time. The nurse should report the finding in the patient
health record, but there is no need to notify the physician immediately. It is inappropriate for
the nurse to recommend that the mother take her newborn to a plastic surgeon; Mongolian
spots do not require treatment. Although it contains correct information, “. . . nothing you
need to worry about” is condescending.
Difficulty: Moderate
Nursing Process: Interventions
Client Need: HPM
Cognitive Level: Application
Page 489
PTS: 1
An older adult comes to the clinic complaining of pain in the left foot. While assessing
the patient, the nurse notes smooth, shiny skin that contains no hair on the client’s lower
legs. Which condition does this finding suggest?
a.
Venous insufficiency
b.
Hyperthyroidism
c.
Arterial insufficiency
d.
Dehydration
ANS: C
Peripheral arterial insufficiency is associated with smooth, thin, shiny skin with little or no
hair. Venous insufficiency leads to thick, rough skin that is commonly hyperpigmented.
Hyperthyroidism is associated with abnormally warm skin. Decreased turgor would be seen in
dehydration.
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: PHSI
Cognitive Level: Application
Page 491
PTS: 1
Which skin assessment finding would cause the nurse to suspect dehydration in a middle-aged
patient admitted to the hospital with traveler’s diarrhea?
a.
Edema
b.
Hyperhidrosis
c.
Pallor
d.
Tenting
ANS: D
, NURS 235 HEALTH CARE ASSESSMENT EXAM QUESTIONS
WITH CORRECT ANSWERS AND EXPLANATIONS
Tenting, skin that takes several seconds to return to normal after lifting up a fold, may be a
sign of dehydration. Edema, an excessive amount of fluid in the tissues, may be a sign of heart
failure, kidney disease, peripheral vascular disease, or low albumin levels. Hyperhidrosis is a
term for excessive sweating, which may be a sign of thyrotoxicosis. Pallor, abnormal loss of
skin color, may be a sign of anemia or blood loss.
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: PHSI
Cognitive Level: Analysis
Page 491
PTS: 1
A female patient has excessive facial hair. The nurse should document this finding as:
a.
Alopecia
b.
Albinism
c.
Hirsutism
d.
Lanugo
ANS: C
The nurse should document this finding as hirsutism, excess facial or trunk hair. Hair loss
should be documented as alopecia. Albinism is a condition caused by lack of pigment in
which the patient has white hair and very pale skin. Lanugo is the fine, downy growth of hair
that covers the body of a newborn.
Difficulty: Moderate
Nursing Process: Assessment
Client Need: PHSI
Cognitive Level: Comprehension
Page 492
PTS: 1
The nurse is concerned that an African American client is experiencing cyanosis. Which of
the following signs of cyanosis would the nurse look for in this client?
a.
The presence of excess interstitial fluid with a decreased elasticity or fullness of the
skin
b.
A bluish tinge in the skin, tongue, and mucous membranes that does not blanch
when pressure is applied
c.
A redness and a variety of rashes over the entire body
d.
An absence of underlying red tones in the skin most readily seen in the buccal
mucosa
ANS: B
WITH CORRECT ANSWERS AND EXPLANATIONS
MULTIPLE CHOICE
A mother brings her 6-month-old infant to the clinic for a well-baby checkup. How should the
nurse proceed when weighing the patient?
a.
Have the mother remain outside the room.
b.
Ask the mother to remove the infant’s clothing and diaper.
c.
Weigh the infant with the diaper only.
d.
Place the infant supine on the scale with his knees extended.
ANS: B
The nurse should ask the mother to remove the infant’s clothing and diaper before weighing
and measuring the infant. An older child can be examined in his underwear; infants should be
undressed. Infants are typically more comfortable with the parent close by so the mother
should remain in the room. The infant should be supine with knees extended on the
examination table when being measured, not when being weighed.
Difficulty: Moderate
Nursing Process: Assessment
Client Need: HPM
Cognitive Level: Application
Page 488
PTS: 1
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are
most likely involved?
a.
CN V and CN VII
b.
CN VII and CN IX
c.
CN V and CN VIII
d.
CN VI and CN X
ANS: B
Cranial nerves VII and IX supply sensation to the tongue.
Difficulty: Moderate
Nursing Process: Assessment
Client Need: HPM
Cognitive Level: Application
Page 508
PTS: 1
While the nurse assesses a newborn of African American descent, the mother points out
a blue-black Mongolian spot on the newborn’s back and asks, “What’s that? Is
something wrong with my baby?” Which response by the nurse is best?
a.
“I’ll ask the physician to look at the spot.”
,NURS 235 HEALTH CARE ASSESSMENT EXAM QUESTIONS
WITH CORRECT ANSWERS AND EXPLANATIONS
b.
“Those spots are quite common and typically fade with time.”
c.
“You may want a plastic surgeon to look at that.”
d.
“That spot is benign so it’s nothing you need to worry about.”
ANS: B
The best response by the nurse is to explain that Mongolian spots are common in dark-skinned
newborns and typically fade over time. The nurse should report the finding in the patient
health record, but there is no need to notify the physician immediately. It is inappropriate for
the nurse to recommend that the mother take her newborn to a plastic surgeon; Mongolian
spots do not require treatment. Although it contains correct information, “. . . nothing you
need to worry about” is condescending.
Difficulty: Moderate
Nursing Process: Interventions
Client Need: HPM
Cognitive Level: Application
Page 489
PTS: 1
An older adult comes to the clinic complaining of pain in the left foot. While assessing
the patient, the nurse notes smooth, shiny skin that contains no hair on the client’s lower
legs. Which condition does this finding suggest?
a.
Venous insufficiency
b.
Hyperthyroidism
c.
Arterial insufficiency
d.
Dehydration
ANS: C
Peripheral arterial insufficiency is associated with smooth, thin, shiny skin with little or no
hair. Venous insufficiency leads to thick, rough skin that is commonly hyperpigmented.
Hyperthyroidism is associated with abnormally warm skin. Decreased turgor would be seen in
dehydration.
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: PHSI
Cognitive Level: Application
Page 491
PTS: 1
Which skin assessment finding would cause the nurse to suspect dehydration in a middle-aged
patient admitted to the hospital with traveler’s diarrhea?
a.
Edema
b.
Hyperhidrosis
c.
Pallor
d.
Tenting
ANS: D
, NURS 235 HEALTH CARE ASSESSMENT EXAM QUESTIONS
WITH CORRECT ANSWERS AND EXPLANATIONS
Tenting, skin that takes several seconds to return to normal after lifting up a fold, may be a
sign of dehydration. Edema, an excessive amount of fluid in the tissues, may be a sign of heart
failure, kidney disease, peripheral vascular disease, or low albumin levels. Hyperhidrosis is a
term for excessive sweating, which may be a sign of thyrotoxicosis. Pallor, abnormal loss of
skin color, may be a sign of anemia or blood loss.
Difficulty: Moderate
Nursing Process: Diagnosis
Client Need: PHSI
Cognitive Level: Analysis
Page 491
PTS: 1
A female patient has excessive facial hair. The nurse should document this finding as:
a.
Alopecia
b.
Albinism
c.
Hirsutism
d.
Lanugo
ANS: C
The nurse should document this finding as hirsutism, excess facial or trunk hair. Hair loss
should be documented as alopecia. Albinism is a condition caused by lack of pigment in
which the patient has white hair and very pale skin. Lanugo is the fine, downy growth of hair
that covers the body of a newborn.
Difficulty: Moderate
Nursing Process: Assessment
Client Need: PHSI
Cognitive Level: Comprehension
Page 492
PTS: 1
The nurse is concerned that an African American client is experiencing cyanosis. Which of
the following signs of cyanosis would the nurse look for in this client?
a.
The presence of excess interstitial fluid with a decreased elasticity or fullness of the
skin
b.
A bluish tinge in the skin, tongue, and mucous membranes that does not blanch
when pressure is applied
c.
A redness and a variety of rashes over the entire body
d.
An absence of underlying red tones in the skin most readily seen in the buccal
mucosa
ANS: B
