TEST BANK FOR Evidence-
g g g
Based Physical Examination for Health & Well-
g g g g g
Being Assessment 2nd Edition
g g g
Agsemiconsciousgwomangisgbroughtgtogthegemergencygdepartmentgaftergshegwasgfoundg
ongthegfloorginghergkitchen.gHergface,gnailgbeds,glips,gandgoralgmucosagaregagbrightgcher
ryredgcolor.gThegnursegsuspectsgthatgthisgcoloringgisgduegto:ga.
Polycythemia.g
b.
Carbongmonoxidegpoisoning.g
c.
Carotenemia.
d.gUremia.
-gb
Agpatientghasgbeengadmittedgtogaghospitalgaftergthegstaffgingthegnursingghomegnoticedgag
pressuregulcerginghisgsacralgarea.gThegnursegexaminesgthegpressuregulcergandgdetermi
nesgthatgitgisgagstagegIIgulcer.gWhichgofgthesegfindingsgaregcharacteristicgofgagstagegIIgpr
essuregulcer?gSelectgallgthatgapply.ga.
Intactgskingappearsgredgbutgisgnotgbroken.gb.
Partialgthicknessgskingerosiongisgobservedgwithgaglossgofgepidermisgorgdermis.gc.gUl
cergextendsgintogthegsubcutaneousgtissue.gd.
Localizedgrednessginglightgskingwillgblanchgwithgfingertipgpressure.ge.gOp
engblistergareasghavegagred-pinkgwoundgbed.
f.
Patchesgofgeschargcovergpartsgofgthegwound.g-gb,ge
Whichgstatementgaboutgthegapicesgofgtheglungsgisgtrue?gThegapicesgofgtheglungs:ga.
gAregatgtheglevelgofgthegsecondgribganteriorly.gb.
Extendg3gtog4gcmgabovegtheginnergthirdgofgthegclavicles.gc.
Areglocatedgatgthegsixthgribganteriorlygandgthegeighthgribglaterally.gd.
Restgongthegdiaphragmgatgthegfifthgintercostalgspacegingthegmidclavicularglineg(MCL).g-gb
Whengauscultatinggtheglungsgofgangadultgpatient,gthegnursegnotesgthatglow-
pitched,gsoftgbreathgsoundsgaregheardgovergthegposteriorglowerglobes,gwithginspiration
gbeingglongergthangexpiration.gThegnurseginterpretsgthatgthesegsoundsgare:ga.
Normallygauscultatedgovergthegtrachea.gb.
Bronchialgbreathgsoundsgandgnormalgingthatglocation.gc.
,Vesiculargbreathgsoundsgandgnormalgingthatglocation.gd.gBronchovesic
ulargbreathgsoundsgandgnormalgingthatglocationg-gc
Whenginspectinggtheganteriorgchestgofgangadult,gthegnursegshouldgincludegwhichgassess
ment?
a.
Diaphragmaticgexcursion
gb.
Symmetricgchestgexpansion
gc.
Presencegofgbreathgsounds
d.
Shapegandgconfigurationgofgthegchestgwallg-gd
Agmanghasgcomegingtogthegclinicgforgagskingassessmentgbecauseghegisgworriedghegmight
ghavegskingcancer.gDuringgthegskingassessmentgthegnursegnoticesgseveralgareasgofgpig
mentationgthatglookggreasy,gdark,gandgstuckgonghisgskin.gWhichgisgthegbestgprediction?ga
.
Senileglentigines,gwhichgdognotgbecomegcancerousgb.
Actinicgkeratoses,gwhichgaregprecursorsgtogbasalgcellgcarci omagc.
n
Acrochordons,gwhichgaregprecursorsgtogsquamousgcellgcarcinomagd.g
Seborrheicgkeratoses,gwhichgdognotgbecomegcancerousg-gd
Thegnursegjustgnotedgfromgthegmedicalgrecordgthatgthegpatientghasgaglesiongthatgisgconfl
uentgingnature.gOngexamination,gthegnursegexpectsgtogfind:ga.
Lesionsgthatgrungtogether.gb.
Annularglesionsgthatghaveggrowngtogether.
c.
Lesionsgarrangedgingaglinegalonggagnervegroute.gd.gLesio
nsgthatgareggroupedgorgclusteredgtogether.g-ga
Agpatientghasghadgagterriblegitchgforgseveralgmonthsgthatgheghasgbeengcontinuousl
ygscratching.gOngexamination,gthegnursegmightgexpectgtogfind:ga.gAgkeloid.gb.gAgfi
ssure.gc.
Keratosis.gd.gLichenificat
ion.g-gd
Lichenificationgresultsgfromgprolonged,gintensegscratchinggthatgeventuallygthickensgthegs
kingandgproducesgtightlygpackedgsetsgofgpapules.gAgkeloidgisgaghypertrophicgscar.gAgfiss
uregisgaglineargcrackgwithgabruptgedges,gwhichgextendsgintogthegdermis;gitgcangbegdry
orgmoist.gKeratosesgareglesionsgthatgaregraised,gthickenedgareasgofgpigmentationgtha
t
appeargcrusted,gscaly,gandgwarty.
,Agphysicianghasgdiagnosedgagpatientgwithgpurpura.gAftergleavinggthegroom,gagnursin
ggstudentgasksgthegnursegwhatgthegphysiciangsawgthatgledgtogthatgdiagnosis.gThegnu
rsegshouldgsay,gThegphysiciangisgreferringgtogthe:ga.
Bluegdilationgofgbloodgvesselsgingagstar-
shapedglineargpatterngongtheglegs.gb.gFierygred,gstar-
shapedgmarkinggongthegcheekgthatghasgagsolidgcirculargcenter.gc.gConfluentgand
gextensivegpatchgofgpetechiaegandgecchymosesgongthegfeet.gd.
Tinygareasgofghemorrhagegthatgareglessgthang2gmm,ground,gdiscrete,gandgdarkgredgi
ngcolor.g-gc
Ag45-year-
oldgfarmergcomesgingforgagskingevaluationgandgcomplainsgofghairglossgonghisghead.gHisg
hairgseemsgtogbegbreakinggoffgingpatches,gandghegnoticesgsomegscalinggonghisghead.gTh
egnursegbeginsgthegexaminationgsuspecting:ga.
Tineagcapitis.gb.
Folliculitis.gc.
Toxicgalopecia.gd.gSeborrhe
icgdermatitis.g-ga
Thegnursegisgexamininggagpatientgwhogtellsgthegnurse,gIgsuregsweatgaglot,gespeciallygo
ngmygfacegandgfeetgbutgitgdoesntghavegangodor.gThegnursegknowsgthatgthisgconditiong
couldgbegrelatedgto:ga.
Eccrinegglands.gb.
gApocrinegglands.
gc.
Disordergofgthegstratumgcorneum.gd.gDiso
rdergofgthegstratumggerminativum.g-ga
Agnewbornginfantgisgingthegclinicgforgagwell-
babygcheckup.gThegnursegobservesgtheginfantgforgthegpossibilitygofgfluidglossgbecausegof
gwhichgofgthesegfactors?ga.
Subcutaneousgfatgdepositsgareghighgingthegnewborn.gb.g
Sebaceousgglandsgaregoverproductivegingthegnewborn.gc.
Thegnewbornsgskingisgmoregpermeablegthangthatgofgthegadult.gd.
Thegamountgofgvernixgcaseosagdramaticallygrisesgingthegnewborn.g-gc
Duringgangexamination,gthegnursegfindsgthatgagpatientghasgexcessivegdrynessgofgthegski
n.gThegbestgtermgtogdescribegthisgconditiongis:ga.
Xerosis.gb.
gPruritus.g
c.
Alopecia.gd.gSebo
rrhea.g-ga
, Agpatientgcomesgingforgagphysicalgexaminationgandgcomplainsgofgfreezinggtogdeathgwhil
egwaitinggforghergexamination.gThegnursegnotesgthatghergskingisgpalegandgcoolgandgattri
butesgthisgfindinggto:ga.
Venousgpooling.
b.
gPeripheralgvasodilation.gc.
Peripheralgvasoconstriction.gd.gDecr
easedgarterialgperfusion.g-gc
Agpatientgcomesgtogthegclinicgandgstatesgthatgheghasgnoticedgthatghisgskingisgreddergthan
normal.gThegnursegunderstandsgthatgthisgconditiongisgduegtoghyperemiagandgknowsgthatg
itgcangbegcausedgby:
a.
Decreasedgamountsgofgbilirubingingthegbloodgb.
Excessgbloodgingthegunderlyinggbloodgvessels
c.
Decreasedgperfusiongtogthegsurroundinggtissuesgd.gExce
ssgbloodgingthegdilatedgsuperficialgcapillariesg-gd
AgnewbornginfantghasgDowngsyndrome.gDuringgthegskingassessment,gthegnursegnoticesg
agtransientgmottlinggingthegtrunkgandgextremitiesgingresponsegtogthegcoolgtemperatureging
thegexaminationgroom.gTheginfantsgmothergalsognoticesgthegmottlinggandgasksgwhatgitgis
.gThegnursegknowsgthatgthisgmottlinggisgcalled:ga.
Cafgauglait.gb.
gCarotenemia
.gc.
Acrocyanosis.
gd.
Cutisgmarmorata.g-gd
Ag35-year-
oldgpregnantgwomangcomesgtogthegclinicgforgagmonthlygappointment.gDuringgthegassess
ment,gthegnursegnoticesgthatgsheghasgagbrowngpatchgofghyperpigmentationgonghergface.g
Thegnursegcontinuesgthegskingassessmentgawaregthatganothergfindinggmaygbe:ga.
Keratoses.gb.
gXerosis.gc.
Chloasma.
gd.
Acrochordons.g-gc
Duringgauscultationgofgtheglungsgofgangadultgpatient,gthegnursegnoticesgthegpresencegofg
bronchophony.gThegnursegshouldgassessgforgsignsgofgwhichgcondition?ga.
g g g
Based Physical Examination for Health & Well-
g g g g g
Being Assessment 2nd Edition
g g g
Agsemiconsciousgwomangisgbroughtgtogthegemergencygdepartmentgaftergshegwasgfoundg
ongthegfloorginghergkitchen.gHergface,gnailgbeds,glips,gandgoralgmucosagaregagbrightgcher
ryredgcolor.gThegnursegsuspectsgthatgthisgcoloringgisgduegto:ga.
Polycythemia.g
b.
Carbongmonoxidegpoisoning.g
c.
Carotenemia.
d.gUremia.
-gb
Agpatientghasgbeengadmittedgtogaghospitalgaftergthegstaffgingthegnursingghomegnoticedgag
pressuregulcerginghisgsacralgarea.gThegnursegexaminesgthegpressuregulcergandgdetermi
nesgthatgitgisgagstagegIIgulcer.gWhichgofgthesegfindingsgaregcharacteristicgofgagstagegIIgpr
essuregulcer?gSelectgallgthatgapply.ga.
Intactgskingappearsgredgbutgisgnotgbroken.gb.
Partialgthicknessgskingerosiongisgobservedgwithgaglossgofgepidermisgorgdermis.gc.gUl
cergextendsgintogthegsubcutaneousgtissue.gd.
Localizedgrednessginglightgskingwillgblanchgwithgfingertipgpressure.ge.gOp
engblistergareasghavegagred-pinkgwoundgbed.
f.
Patchesgofgeschargcovergpartsgofgthegwound.g-gb,ge
Whichgstatementgaboutgthegapicesgofgtheglungsgisgtrue?gThegapicesgofgtheglungs:ga.
gAregatgtheglevelgofgthegsecondgribganteriorly.gb.
Extendg3gtog4gcmgabovegtheginnergthirdgofgthegclavicles.gc.
Areglocatedgatgthegsixthgribganteriorlygandgthegeighthgribglaterally.gd.
Restgongthegdiaphragmgatgthegfifthgintercostalgspacegingthegmidclavicularglineg(MCL).g-gb
Whengauscultatinggtheglungsgofgangadultgpatient,gthegnursegnotesgthatglow-
pitched,gsoftgbreathgsoundsgaregheardgovergthegposteriorglowerglobes,gwithginspiration
gbeingglongergthangexpiration.gThegnurseginterpretsgthatgthesegsoundsgare:ga.
Normallygauscultatedgovergthegtrachea.gb.
Bronchialgbreathgsoundsgandgnormalgingthatglocation.gc.
,Vesiculargbreathgsoundsgandgnormalgingthatglocation.gd.gBronchovesic
ulargbreathgsoundsgandgnormalgingthatglocationg-gc
Whenginspectinggtheganteriorgchestgofgangadult,gthegnursegshouldgincludegwhichgassess
ment?
a.
Diaphragmaticgexcursion
gb.
Symmetricgchestgexpansion
gc.
Presencegofgbreathgsounds
d.
Shapegandgconfigurationgofgthegchestgwallg-gd
Agmanghasgcomegingtogthegclinicgforgagskingassessmentgbecauseghegisgworriedghegmight
ghavegskingcancer.gDuringgthegskingassessmentgthegnursegnoticesgseveralgareasgofgpig
mentationgthatglookggreasy,gdark,gandgstuckgonghisgskin.gWhichgisgthegbestgprediction?ga
.
Senileglentigines,gwhichgdognotgbecomegcancerousgb.
Actinicgkeratoses,gwhichgaregprecursorsgtogbasalgcellgcarci omagc.
n
Acrochordons,gwhichgaregprecursorsgtogsquamousgcellgcarcinomagd.g
Seborrheicgkeratoses,gwhichgdognotgbecomegcancerousg-gd
Thegnursegjustgnotedgfromgthegmedicalgrecordgthatgthegpatientghasgaglesiongthatgisgconfl
uentgingnature.gOngexamination,gthegnursegexpectsgtogfind:ga.
Lesionsgthatgrungtogether.gb.
Annularglesionsgthatghaveggrowngtogether.
c.
Lesionsgarrangedgingaglinegalonggagnervegroute.gd.gLesio
nsgthatgareggroupedgorgclusteredgtogether.g-ga
Agpatientghasghadgagterriblegitchgforgseveralgmonthsgthatgheghasgbeengcontinuousl
ygscratching.gOngexamination,gthegnursegmightgexpectgtogfind:ga.gAgkeloid.gb.gAgfi
ssure.gc.
Keratosis.gd.gLichenificat
ion.g-gd
Lichenificationgresultsgfromgprolonged,gintensegscratchinggthatgeventuallygthickensgthegs
kingandgproducesgtightlygpackedgsetsgofgpapules.gAgkeloidgisgaghypertrophicgscar.gAgfiss
uregisgaglineargcrackgwithgabruptgedges,gwhichgextendsgintogthegdermis;gitgcangbegdry
orgmoist.gKeratosesgareglesionsgthatgaregraised,gthickenedgareasgofgpigmentationgtha
t
appeargcrusted,gscaly,gandgwarty.
,Agphysicianghasgdiagnosedgagpatientgwithgpurpura.gAftergleavinggthegroom,gagnursin
ggstudentgasksgthegnursegwhatgthegphysiciangsawgthatgledgtogthatgdiagnosis.gThegnu
rsegshouldgsay,gThegphysiciangisgreferringgtogthe:ga.
Bluegdilationgofgbloodgvesselsgingagstar-
shapedglineargpatterngongtheglegs.gb.gFierygred,gstar-
shapedgmarkinggongthegcheekgthatghasgagsolidgcirculargcenter.gc.gConfluentgand
gextensivegpatchgofgpetechiaegandgecchymosesgongthegfeet.gd.
Tinygareasgofghemorrhagegthatgareglessgthang2gmm,ground,gdiscrete,gandgdarkgredgi
ngcolor.g-gc
Ag45-year-
oldgfarmergcomesgingforgagskingevaluationgandgcomplainsgofghairglossgonghisghead.gHisg
hairgseemsgtogbegbreakinggoffgingpatches,gandghegnoticesgsomegscalinggonghisghead.gTh
egnursegbeginsgthegexaminationgsuspecting:ga.
Tineagcapitis.gb.
Folliculitis.gc.
Toxicgalopecia.gd.gSeborrhe
icgdermatitis.g-ga
Thegnursegisgexamininggagpatientgwhogtellsgthegnurse,gIgsuregsweatgaglot,gespeciallygo
ngmygfacegandgfeetgbutgitgdoesntghavegangodor.gThegnursegknowsgthatgthisgconditiong
couldgbegrelatedgto:ga.
Eccrinegglands.gb.
gApocrinegglands.
gc.
Disordergofgthegstratumgcorneum.gd.gDiso
rdergofgthegstratumggerminativum.g-ga
Agnewbornginfantgisgingthegclinicgforgagwell-
babygcheckup.gThegnursegobservesgtheginfantgforgthegpossibilitygofgfluidglossgbecausegof
gwhichgofgthesegfactors?ga.
Subcutaneousgfatgdepositsgareghighgingthegnewborn.gb.g
Sebaceousgglandsgaregoverproductivegingthegnewborn.gc.
Thegnewbornsgskingisgmoregpermeablegthangthatgofgthegadult.gd.
Thegamountgofgvernixgcaseosagdramaticallygrisesgingthegnewborn.g-gc
Duringgangexamination,gthegnursegfindsgthatgagpatientghasgexcessivegdrynessgofgthegski
n.gThegbestgtermgtogdescribegthisgconditiongis:ga.
Xerosis.gb.
gPruritus.g
c.
Alopecia.gd.gSebo
rrhea.g-ga
, Agpatientgcomesgingforgagphysicalgexaminationgandgcomplainsgofgfreezinggtogdeathgwhil
egwaitinggforghergexamination.gThegnursegnotesgthatghergskingisgpalegandgcoolgandgattri
butesgthisgfindinggto:ga.
Venousgpooling.
b.
gPeripheralgvasodilation.gc.
Peripheralgvasoconstriction.gd.gDecr
easedgarterialgperfusion.g-gc
Agpatientgcomesgtogthegclinicgandgstatesgthatgheghasgnoticedgthatghisgskingisgreddergthan
normal.gThegnursegunderstandsgthatgthisgconditiongisgduegtoghyperemiagandgknowsgthatg
itgcangbegcausedgby:
a.
Decreasedgamountsgofgbilirubingingthegbloodgb.
Excessgbloodgingthegunderlyinggbloodgvessels
c.
Decreasedgperfusiongtogthegsurroundinggtissuesgd.gExce
ssgbloodgingthegdilatedgsuperficialgcapillariesg-gd
AgnewbornginfantghasgDowngsyndrome.gDuringgthegskingassessment,gthegnursegnoticesg
agtransientgmottlinggingthegtrunkgandgextremitiesgingresponsegtogthegcoolgtemperatureging
thegexaminationgroom.gTheginfantsgmothergalsognoticesgthegmottlinggandgasksgwhatgitgis
.gThegnursegknowsgthatgthisgmottlinggisgcalled:ga.
Cafgauglait.gb.
gCarotenemia
.gc.
Acrocyanosis.
gd.
Cutisgmarmorata.g-gd
Ag35-year-
oldgpregnantgwomangcomesgtogthegclinicgforgagmonthlygappointment.gDuringgthegassess
ment,gthegnursegnoticesgthatgsheghasgagbrowngpatchgofghyperpigmentationgonghergface.g
Thegnursegcontinuesgthegskingassessmentgawaregthatganothergfindinggmaygbe:ga.
Keratoses.gb.
gXerosis.gc.
Chloasma.
gd.
Acrochordons.g-gc
Duringgauscultationgofgtheglungsgofgangadultgpatient,gthegnursegnoticesgthegpresencegofg
bronchophony.gThegnursegshouldgassessgforgsignsgofgwhichgcondition?ga.
