TEST BANK FOR Evidence-
n n n
Based Physical Examination for Health & Well-
n n n n n
Being Assessment2nd Edition
n n n
Ansemiconsciousnwomannisnbroughtntonthenemergencyndepartmentnafternshenwasnfoundnonn
thenfloorninnhernkitchen.nHernface,nnailnbeds,nlips,nandnoralnmucosanarenanbrightncherryrednc
olor.nThennursensuspectsnthatnthisncoloringnisnduento:na.
Polycythemia.n
b.
Carbonnmonoxidenpoisoning.n
c.
Carotenemia.
d.nUremia.
-nb
Anpatientnhasnbeennadmittedntonanhospitalnafternthenstaffninnthennursingnhomennoticednanpre
ssurenulcerninnhisnsacralnarea.nThennursenexaminesnthenpressurenulcernandndeterminesnth
atnitnisnanstagenIInulcer.nWhichnofnthesenfindingsnarencharacteristicnofnanstagenIInpressurenul
cer?nSelectnallnthatnapply.na.
Intactnskinnappearsnrednbutnisnnotnbroken.nb.
Partialnthicknessnskinnerosionnisnobservednwithnanlossnofnepidermisnorndermis.nc.nUlcern
extendsnintonthensubcutaneousntissue.nd.
Localizednrednessninnlightnskinnwillnblanchnwithnfingertipnpressure.ne.nOpenn
blisternareasnhavenanred-pinknwoundnbed.
f.
Patchesnofnescharncovernpartsnofnthenwound.n-nb,ne
Whichnstatementnaboutnthenapicesnofnthenlungsnisntrue?nThenapicesnofnthenlungs:na.nAre
natnthenlevelnofnthensecondnribnanteriorly.nb.
Extendn3nton4ncmnaboventheninnernthirdnofnthenclavicles.nc.
Arenlocatednatnthensixthnribnanteriorlynandntheneighthnribnlaterally.nd.
Restnonnthendiaphragmnatnthenfifthnintercostalnspaceninnthenmidclavicularnlinen(MCL).n-nb
Whennauscultatingnthenlungsnofnannadultnpatient,nthennursennotesnthatnlow-
pitched,nsoftnbreathnsoundsnarenheardnovernthenposteriornlowernlobes,nwithninspirationnbe
ingnlongernthannexpiration.nThennurseninterpretsnthatnthesensoundsnare:na.
Normallynauscultatednovernthentrachea.nb.
Bronchialnbreathnsoundsnandnnormalninnthatnlocation.nc.
,Vesicularnbreathnsoundsnandnnormalninnthatnlocation.nd.nBronchovesi
cularnbreathnsoundsnandnnormalninnthatnlocationn-nc
Whenninspectingnthenanteriornchestnofnannadult,nthennursenshouldnincludenwhichnassessme
nt?
a.
Diaphragmaticnexcursionn
b.
Symmetricnchestnexpansionn
c.
Presencenofnbreathnsounds
d.
Shapenandnconfigurationnofnthenchestnwalln-nd
Anmannhasncomeninntonthenclinicnfornanskinnassessmentnbecausenhenisnworriednhenmightnha
venskinncancer.nDuringnthenskinnassessmentnthennursennoticesnseveralnareasnofnpigmentat
ionnthatnlookngreasy,ndark,nandnstucknonnhisnskin.nWhichnisnthenbestnprediction?na.
Senilenlentigines,nwhichndonnotnbecomencancerousnb.
Actinicnkeratoses,nwhichnarenprecursorsntonbasalncellncarcin omanc.
Acrochordons,nwhichnarenprecursorsntonsquamousncellncarcinomand.n
Seborrheicnkeratoses,nwhichndonnotnbecomencancerousn-nd
Thennursenjustnnotednfromnthenmedicalnrecordnthatnthenpatientnhasnanlesionnthatnisnconfluent
ninnnature.nOnnexamination,nthennursenexpectsntonfind:na.
Lesionsnthatnrunntogether.nb.
Annularnlesionsnthatnhavengrownntogether.
c.
Lesionsnarrangedninnanlinenalongnannervenroute.nd.nLesion
snthatnarengroupednornclusteredntogether.n-na
Anpatientnhasnhadnanterriblenitchnfornseveralnmonthsnthatnhenhasnbeenncontinuouslyns
cratching.nOnnexamination,nthennursenmightnexpectntonfind:na.nAnkeloid.nb.nAnfissure.n
c.
Keratosis.nd.nLich
enification.n-nd
Lichenificationnresultsnfromnprolonged,nintensenscratchingnthatneventuallynthickensnthenski
nnandnproducesntightlynpackednsetsnofnpapules.nAnkeloidnisnanhypertrophicnscar.nAnfissureni
snanlinearncracknwithnabruptnedges,nwhichnextendsnintonthendermis;nitncannbendry
ornmoist.nKeratosesnarenlesionsnthatnarenraised,nthickenednareasnofnpigmentationnthat
appearncrusted,nscaly,nandnwarty.
,Anphysiciannhasndiagnosednanpatientnwithnpurpura.nAfternleavingnthenroom,nannursingns
tudentnasksnthennursenwhatnthenphysiciannsawnthatnledntonthatndiagnosis.nThennursensh
ouldnsay,nThenphysiciannisnreferringntonthe:na.
Bluendilationnofnbloodnvesselsninnanstar-
shapednlinearnpatternnonnthenlegs.nb.nFierynred,nstar-
shapednmarkingnonnthencheeknthatnhasnansolidncircularncenter.nc.nConfluentnandnext
ensivenpatchnofnpetechiaenandnecchymosesnonnthenfeet.nd.
Tinynareasnofnhemorrhagenthatnarenlessnthann2nmm,nround,ndiscrete,nandndarknredninnc
olor.n-nc
An45-year-
oldnfarmerncomesninnfornanskinnevaluationnandncomplainsnofnhairnlossnonnhisnhead.nHisnhairn
seemsntonbenbreakingnoffninnpatches,nandnhennoticesnsomenscalingnonnhisnhead.nThennursen
beginsnthenexaminationnsuspecting:na.
Tineancapitis.nb.
Folliculitis.nc.
Toxicnalopecia.nd.
Seborrheic dermatitis.n-na
Thennursenisnexaminingnanpatientnwhontellsnthennurse,nInsurensweatnanlot,nespeciallynonnm
ynfacenandnfeetnbutnitndoesntnhavenannodor.nThennursenknowsnthatnthisnconditionncouldnb
enrelatednto:na.
Eccrinenglands.nb.
Apocrinenglands.
c.
Disordernofnthenstratumncorneum.nd.nDisor
dernofnthenstratumngerminativum.n-na
Annewbornninfantnisninnthenclinicnfornanwell-
babyncheckup.nThennursenobservesntheninfantnfornthenpossibilitynofnfluidnlossnbecausenofnw
hichnofnthesenfactors?na.
Subcutaneousnfatndepositsnarenhighninnthennewborn.nb.neb
Saceousnglandsnarenoverproductiveninnthennewborn.nc.
Thennewbornsnskinnisnmorenpermeablenth annthatnofnthenadult.nd.
Thenamountnofnvernixncaseosandramaticallynrisesninnthennewborn.n-nc
Duringnannexamination,nthennursenfindsnthatnanpatientnhasnexcessivendrynessnofnthenskin.nT
henbestntermntondescribenthisnconditionnis:na.
Xerosis.nb.n
Pruritus.nc
.
Alopecia.nd.nS
eborrhea.n-na
, Anpatientncomesninnfornanphysicalnexaminationnandncomplainsnofnfreezingntondeathnwhile
waitingnfornhernexamination.nThennursennotesnthatnhernskinnisnpalenandncoolnandnattri
butesnthisnfindingnto:na.
Venousnpooling.
b.
Peripheralnvasodilation.nc.
n
Peripheralnvasoconstriction.nd.nD
ecreasednarterialnperfusion.n-nc
Anpatientncomesntonthenclinicnandnstatesnthatnhenhasnnoticednthatnhisnskinnisnreddernthan
normal.nThennursenunderstandsnthatnthisnconditionnisnduentonhyperemianandnknowsnthatnitnc
annbencausednby:
a.
Decreasednamountsnofnbilirubinninnthenbloodnb .
E xcessnbloodninnthenunderlyingnbloodnvessels
c.
Decreasednperfusionntonthensurroundingntissuesnd.nE
xcessnbloodninnthendilatednsuperficialncapillariesn-nd
AnnewbornninfantnhasnDownnsyndrome.nDuringnthenskinnassessment,nthennursennoticesnantr
ansientnmottlingninnthentrunknandnextremitiesninnresponsentonthencoolntemperatureninnthenex
aminationnroom.nTheninfantsnmothernalsonnoticesnthenmottlingnandnasksnwhatnitnis.nThennur
senknowsnthatnthisnmottlingnisncalled:na.
Cafnaunlait.nb.n
Carotenemia.n
c.
Acrocyanosis.n
d.
Cutisnmarmorata.n-nd
An35-year-
oldnpregnantnwomanncomesntonthenclinicnfornanmonthlynappointment.nDuringnthenassessm
ent,nthennursennoticesnthatnshenhasnanbrownnpatchnofnhyperpigmentationnonnhernface.nThen
nursencontinuesnthenskinnassessmentnawarenthatnanothernfindingnmaynbe:na.
Keratoses.nb.n
Xerosis.nc.
Chloasma.n
d.
Acrochordons.n-nc
Duringnauscultationnofnthenlungsnofnannadultnpatient,nthennursennoticesnthenpresencenofnbro
nchophony.nThennursenshouldnassessnfornsignsnofnwhichncondition?na.
n n n
Based Physical Examination for Health & Well-
n n n n n
Being Assessment2nd Edition
n n n
Ansemiconsciousnwomannisnbroughtntonthenemergencyndepartmentnafternshenwasnfoundnonn
thenfloorninnhernkitchen.nHernface,nnailnbeds,nlips,nandnoralnmucosanarenanbrightncherryrednc
olor.nThennursensuspectsnthatnthisncoloringnisnduento:na.
Polycythemia.n
b.
Carbonnmonoxidenpoisoning.n
c.
Carotenemia.
d.nUremia.
-nb
Anpatientnhasnbeennadmittedntonanhospitalnafternthenstaffninnthennursingnhomennoticednanpre
ssurenulcerninnhisnsacralnarea.nThennursenexaminesnthenpressurenulcernandndeterminesnth
atnitnisnanstagenIInulcer.nWhichnofnthesenfindingsnarencharacteristicnofnanstagenIInpressurenul
cer?nSelectnallnthatnapply.na.
Intactnskinnappearsnrednbutnisnnotnbroken.nb.
Partialnthicknessnskinnerosionnisnobservednwithnanlossnofnepidermisnorndermis.nc.nUlcern
extendsnintonthensubcutaneousntissue.nd.
Localizednrednessninnlightnskinnwillnblanchnwithnfingertipnpressure.ne.nOpenn
blisternareasnhavenanred-pinknwoundnbed.
f.
Patchesnofnescharncovernpartsnofnthenwound.n-nb,ne
Whichnstatementnaboutnthenapicesnofnthenlungsnisntrue?nThenapicesnofnthenlungs:na.nAre
natnthenlevelnofnthensecondnribnanteriorly.nb.
Extendn3nton4ncmnaboventheninnernthirdnofnthenclavicles.nc.
Arenlocatednatnthensixthnribnanteriorlynandntheneighthnribnlaterally.nd.
Restnonnthendiaphragmnatnthenfifthnintercostalnspaceninnthenmidclavicularnlinen(MCL).n-nb
Whennauscultatingnthenlungsnofnannadultnpatient,nthennursennotesnthatnlow-
pitched,nsoftnbreathnsoundsnarenheardnovernthenposteriornlowernlobes,nwithninspirationnbe
ingnlongernthannexpiration.nThennurseninterpretsnthatnthesensoundsnare:na.
Normallynauscultatednovernthentrachea.nb.
Bronchialnbreathnsoundsnandnnormalninnthatnlocation.nc.
,Vesicularnbreathnsoundsnandnnormalninnthatnlocation.nd.nBronchovesi
cularnbreathnsoundsnandnnormalninnthatnlocationn-nc
Whenninspectingnthenanteriornchestnofnannadult,nthennursenshouldnincludenwhichnassessme
nt?
a.
Diaphragmaticnexcursionn
b.
Symmetricnchestnexpansionn
c.
Presencenofnbreathnsounds
d.
Shapenandnconfigurationnofnthenchestnwalln-nd
Anmannhasncomeninntonthenclinicnfornanskinnassessmentnbecausenhenisnworriednhenmightnha
venskinncancer.nDuringnthenskinnassessmentnthennursennoticesnseveralnareasnofnpigmentat
ionnthatnlookngreasy,ndark,nandnstucknonnhisnskin.nWhichnisnthenbestnprediction?na.
Senilenlentigines,nwhichndonnotnbecomencancerousnb.
Actinicnkeratoses,nwhichnarenprecursorsntonbasalncellncarcin omanc.
Acrochordons,nwhichnarenprecursorsntonsquamousncellncarcinomand.n
Seborrheicnkeratoses,nwhichndonnotnbecomencancerousn-nd
Thennursenjustnnotednfromnthenmedicalnrecordnthatnthenpatientnhasnanlesionnthatnisnconfluent
ninnnature.nOnnexamination,nthennursenexpectsntonfind:na.
Lesionsnthatnrunntogether.nb.
Annularnlesionsnthatnhavengrownntogether.
c.
Lesionsnarrangedninnanlinenalongnannervenroute.nd.nLesion
snthatnarengroupednornclusteredntogether.n-na
Anpatientnhasnhadnanterriblenitchnfornseveralnmonthsnthatnhenhasnbeenncontinuouslyns
cratching.nOnnexamination,nthennursenmightnexpectntonfind:na.nAnkeloid.nb.nAnfissure.n
c.
Keratosis.nd.nLich
enification.n-nd
Lichenificationnresultsnfromnprolonged,nintensenscratchingnthatneventuallynthickensnthenski
nnandnproducesntightlynpackednsetsnofnpapules.nAnkeloidnisnanhypertrophicnscar.nAnfissureni
snanlinearncracknwithnabruptnedges,nwhichnextendsnintonthendermis;nitncannbendry
ornmoist.nKeratosesnarenlesionsnthatnarenraised,nthickenednareasnofnpigmentationnthat
appearncrusted,nscaly,nandnwarty.
,Anphysiciannhasndiagnosednanpatientnwithnpurpura.nAfternleavingnthenroom,nannursingns
tudentnasksnthennursenwhatnthenphysiciannsawnthatnledntonthatndiagnosis.nThennursensh
ouldnsay,nThenphysiciannisnreferringntonthe:na.
Bluendilationnofnbloodnvesselsninnanstar-
shapednlinearnpatternnonnthenlegs.nb.nFierynred,nstar-
shapednmarkingnonnthencheeknthatnhasnansolidncircularncenter.nc.nConfluentnandnext
ensivenpatchnofnpetechiaenandnecchymosesnonnthenfeet.nd.
Tinynareasnofnhemorrhagenthatnarenlessnthann2nmm,nround,ndiscrete,nandndarknredninnc
olor.n-nc
An45-year-
oldnfarmerncomesninnfornanskinnevaluationnandncomplainsnofnhairnlossnonnhisnhead.nHisnhairn
seemsntonbenbreakingnoffninnpatches,nandnhennoticesnsomenscalingnonnhisnhead.nThennursen
beginsnthenexaminationnsuspecting:na.
Tineancapitis.nb.
Folliculitis.nc.
Toxicnalopecia.nd.
Seborrheic dermatitis.n-na
Thennursenisnexaminingnanpatientnwhontellsnthennurse,nInsurensweatnanlot,nespeciallynonnm
ynfacenandnfeetnbutnitndoesntnhavenannodor.nThennursenknowsnthatnthisnconditionncouldnb
enrelatednto:na.
Eccrinenglands.nb.
Apocrinenglands.
c.
Disordernofnthenstratumncorneum.nd.nDisor
dernofnthenstratumngerminativum.n-na
Annewbornninfantnisninnthenclinicnfornanwell-
babyncheckup.nThennursenobservesntheninfantnfornthenpossibilitynofnfluidnlossnbecausenofnw
hichnofnthesenfactors?na.
Subcutaneousnfatndepositsnarenhighninnthennewborn.nb.neb
Saceousnglandsnarenoverproductiveninnthennewborn.nc.
Thennewbornsnskinnisnmorenpermeablenth annthatnofnthenadult.nd.
Thenamountnofnvernixncaseosandramaticallynrisesninnthennewborn.n-nc
Duringnannexamination,nthennursenfindsnthatnanpatientnhasnexcessivendrynessnofnthenskin.nT
henbestntermntondescribenthisnconditionnis:na.
Xerosis.nb.n
Pruritus.nc
.
Alopecia.nd.nS
eborrhea.n-na
, Anpatientncomesninnfornanphysicalnexaminationnandncomplainsnofnfreezingntondeathnwhile
waitingnfornhernexamination.nThennursennotesnthatnhernskinnisnpalenandncoolnandnattri
butesnthisnfindingnto:na.
Venousnpooling.
b.
Peripheralnvasodilation.nc.
n
Peripheralnvasoconstriction.nd.nD
ecreasednarterialnperfusion.n-nc
Anpatientncomesntonthenclinicnandnstatesnthatnhenhasnnoticednthatnhisnskinnisnreddernthan
normal.nThennursenunderstandsnthatnthisnconditionnisnduentonhyperemianandnknowsnthatnitnc
annbencausednby:
a.
Decreasednamountsnofnbilirubinninnthenbloodnb .
E xcessnbloodninnthenunderlyingnbloodnvessels
c.
Decreasednperfusionntonthensurroundingntissuesnd.nE
xcessnbloodninnthendilatednsuperficialncapillariesn-nd
AnnewbornninfantnhasnDownnsyndrome.nDuringnthenskinnassessment,nthennursennoticesnantr
ansientnmottlingninnthentrunknandnextremitiesninnresponsentonthencoolntemperatureninnthenex
aminationnroom.nTheninfantsnmothernalsonnoticesnthenmottlingnandnasksnwhatnitnis.nThennur
senknowsnthatnthisnmottlingnisncalled:na.
Cafnaunlait.nb.n
Carotenemia.n
c.
Acrocyanosis.n
d.
Cutisnmarmorata.n-nd
An35-year-
oldnpregnantnwomanncomesntonthenclinicnfornanmonthlynappointment.nDuringnthenassessm
ent,nthennursennoticesnthatnshenhasnanbrownnpatchnofnhyperpigmentationnonnhernface.nThen
nursencontinuesnthenskinnassessmentnawarenthatnanothernfindingnmaynbe:na.
Keratoses.nb.n
Xerosis.nc.
Chloasma.n
d.
Acrochordons.n-nc
Duringnauscultationnofnthenlungsnofnannadultnpatient,nthennursennoticesnthenpresencenofnbro
nchophony.nThennursenshouldnassessnfornsignsnofnwhichncondition?na.
