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 Explanation: Abnormal characteristics of pigmented lesions are summarized in the 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 Explanation: An accumulation of factors place the aging person at risk for skin disease 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 Explanation: Keeping the feet in a dependent position causes venous pooling, resulting in 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 Explanation: Clubbing of the nails occurs with congenital cyanotic heart disease, neoplastic, and pulmonary diseases. The other responses are assessment findings not associated with pulmonary diseases. Points Received: 2 of 2 Comments: