Chapter 21 Physical Assessment

Chapter 21  Physical Assessment

Multiple Choice

Identify the choice that best completes the statement or answers the question.

____ 1. 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?
1)
Have the mother remain outside the room.

2)
Ask the mother to remove the infant’s clothing and diaper. 3)
Weigh the infant wearing only the diaper.
4)
Place the infant supine on the scale with his knees extended.

ANS: 2
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.

PTS: 1 DIF: Moderate REF: p. 517
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application

____ 2. Where should the nurse assess skin color changes in the dark-skinned patient?
1)
Nailbeds

2)
Any exposed area 3)
Oral mucosa
4)
Palms of the hands

ANS: 3
In dark-skinned patients, look for color changes in the conjunctiva or oral mucosa. They should be pink and moist. In dark-skinned patients, skin color changes may not be apparent in nailbeds, palms of the hands, and other exposed areas.

PTS: 1 DIF: Easy REF: pp. 497-498, 519
KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall

Treas Fundamentals TB21-2 Test Bank, Chapter 21.

____ 3. 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?
1)
“I’ll ask the physician to look at the spot.”
2)
“Those spots are quite common and typically fade with time.”
3)
“You may want a plastic surgeon to look at that.”
4)
“That spot is benign so it’s nothing you need to worry about.”

ANS: 2
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.

PTS: 1 DIF: Moderate REF: p. 497
KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application

____ 4. 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?
1)

Venous insufficiency 2)
Hyperthyroidism
3)

Arterial insufficiency 4)
Dehydration

ANS: 3
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.

PTS: 1 DIF: Moderate REF: p. 498

Treas Fundamentals TB21-3 Test Bank, Chapter 21.

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application