Advanced Physical Assessment Quiz 3
,Advanced Physical Assessment quiz 3
1. Question :
A 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 would pay special attention to the danger signs for
pigmented lesions and would be concerned with which
additional finding?
Student Answer: Color variation
Border regularity
Symmetry of lesions
Diameter less than 6 mm
Instructor Abnormal characteristics of pigmented lesions are summarized in the
Explanation: mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color
variation, and diameter greater than 6 mm.
Points Received: 2 of 2
Comments:
Question 2.Question :
The nurse is bathing an 80-year-old man and notices that his skin
is wrinkled, thin, lax, and dry. This finding would be related to
which factor?
Student Answer: Increased vascularity of the skin in the elderly
Increased numbers of sweat and sebaceous glands in the elderly
An increase in elastin and a decrease in subcutaneous fat in the
elderly
An increased loss of elastin and a decrease in subcutaneous fat
in the elderly
Instructor An accumulation of factors place the aging person at risk for skin disease
Explanation: and breakdown: the thinning of the skin, the decrease in vascularity and
nutrients, the loss of protective cushioning of the subcutaneous layer, a
lifetime of environmental trauma to skin, the social changes of aging, the
increasingly sedentary lifestyle, and the chance of immobility.
Points Received: 2 of 2
, Comments:
Question 3.Question :
A patient comes to the clinic and tells the nurse that he has been
confined to his recliner chair for about three days with his feet
down and he wants the nurse to evaluate his feet. During the
assessment, the nurse might expect to find
Student Answer: pallor.
coolness.
distended veins.
prolonged capillary filling time.
Instructor Keeping the feet in a dependent position causes venous pooling, resulting in
Explanation: redness, warmth, and distended veins. Prolonged elevation would cause pallor
and coolness. Immobilization or prolonged inactivity would cause prolonged
capillary filling time. See Table 12-1.
Points Received: 2 of 2
Comments:
Question 4.Question :
A 65-year-old man with emphysema and bronchitis has come to the
clinic for a follow-up appointment. On assessment, the nurse might
expect to see which assessment finding?
Student Answer: Anasarca
Scleroderma
Pedal erythema
Clubbing of the nails
Instructor Clubbing of the nails occurs with congenital cyanotic heart disease,
Explanation: neoplastic, and pulmonary diseases. The other responses are assessment
findings not associated with pulmonary diseases.
Points Received: 2 of 2
Comments:
, Question 5.Question :
The nurse notices that a school-aged child has bluish-white,
red- based spots in her mouth that are elevated about 1 mm to 3
mm. What other signs would the nurse expect to find in this
patient?
Student Answer: A pink, papular rash on the face and neck
Pruritic vesicles over her trunk and neck
Hyperpigmentation on the chest, abdomen, and the back of the
arms
A red-purple, maculopapular, blotchy rash behind the ears and
on the face
Instructor With measles (rubeola), the examiner would assess a red-purple, blotchy
Explanation: rash on the third or fourth day of illness that appears first behind the ears
and spreads over the face and then over the neck, trunk, arms and legs. It
looks coppery and does not blanch. The bluish-white, red-based spots in the
mouth are known as Koplik’s spots.
Points Received: 2 of 2
Comments:
Question 6.Question :
During an examination, the nurse knows that Paget’s disease
would be indicated by which of these assessment findings?
Student Answer: Positive Macewen sign
Premature closure of the sagittal suture
Headache, vertigo, tinnitus, and deafness
Elongated head with heavy eyebrow ridge
,Advanced Physical Assessment quiz 3
1. Question :
A 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 would pay special attention to the danger signs for
pigmented lesions and would be concerned with which
additional finding?
Student Answer: Color variation
Border regularity
Symmetry of lesions
Diameter less than 6 mm
Instructor Abnormal characteristics of pigmented lesions are summarized in the
Explanation: mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color
variation, and diameter greater than 6 mm.
Points Received: 2 of 2
Comments:
Question 2.Question :
The nurse is bathing an 80-year-old man and notices that his skin
is wrinkled, thin, lax, and dry. This finding would be related to
which factor?
Student Answer: Increased vascularity of the skin in the elderly
Increased numbers of sweat and sebaceous glands in the elderly
An increase in elastin and a decrease in subcutaneous fat in the
elderly
An increased loss of elastin and a decrease in subcutaneous fat
in the elderly
Instructor An accumulation of factors place the aging person at risk for skin disease
Explanation: and breakdown: the thinning of the skin, the decrease in vascularity and
nutrients, the loss of protective cushioning of the subcutaneous layer, a
lifetime of environmental trauma to skin, the social changes of aging, the
increasingly sedentary lifestyle, and the chance of immobility.
Points Received: 2 of 2
, Comments:
Question 3.Question :
A patient comes to the clinic and tells the nurse that he has been
confined to his recliner chair for about three days with his feet
down and he wants the nurse to evaluate his feet. During the
assessment, the nurse might expect to find
Student Answer: pallor.
coolness.
distended veins.
prolonged capillary filling time.
Instructor Keeping the feet in a dependent position causes venous pooling, resulting in
Explanation: redness, warmth, and distended veins. Prolonged elevation would cause pallor
and coolness. Immobilization or prolonged inactivity would cause prolonged
capillary filling time. See Table 12-1.
Points Received: 2 of 2
Comments:
Question 4.Question :
A 65-year-old man with emphysema and bronchitis has come to the
clinic for a follow-up appointment. On assessment, the nurse might
expect to see which assessment finding?
Student Answer: Anasarca
Scleroderma
Pedal erythema
Clubbing of the nails
Instructor Clubbing of the nails occurs with congenital cyanotic heart disease,
Explanation: neoplastic, and pulmonary diseases. The other responses are assessment
findings not associated with pulmonary diseases.
Points Received: 2 of 2
Comments:
, Question 5.Question :
The nurse notices that a school-aged child has bluish-white,
red- based spots in her mouth that are elevated about 1 mm to 3
mm. What other signs would the nurse expect to find in this
patient?
Student Answer: A pink, papular rash on the face and neck
Pruritic vesicles over her trunk and neck
Hyperpigmentation on the chest, abdomen, and the back of the
arms
A red-purple, maculopapular, blotchy rash behind the ears and
on the face
Instructor With measles (rubeola), the examiner would assess a red-purple, blotchy
Explanation: rash on the third or fourth day of illness that appears first behind the ears
and spreads over the face and then over the neck, trunk, arms and legs. It
looks coppery and does not blanch. The bluish-white, red-based spots in the
mouth are known as Koplik’s spots.
Points Received: 2 of 2
Comments:
Question 6.Question :
During an examination, the nurse knows that Paget’s disease
would be indicated by which of these assessment findings?
Student Answer: Positive Macewen sign
Premature closure of the sagittal suture
Headache, vertigo, tinnitus, and deafness
Elongated head with heavy eyebrow ridge
