Grading Summary
Grade Details - All Questions
Question 1. 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 and
Explanation: 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.
Question 2. 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.
Question 3. 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 rash
Explanation: 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.
Question 4. Question : The nurse notices that a patient has a solid, elevated, circumscribed
lesion that is less than 1 cm in diameter. When documenting this
finding, the nurse would report this as a
Student
Answer: bulla.
wheal.
nodule.
papule.
Instructor A papule is something one can feel, is solid, elevated, circumscribed, less than 1
Explanation: cm in diameter, and is due to superficial thickening in the epidermis. A bulla is
larger than 1 cm, superficial, and thin walled. A wheal is superficial, raised,
transient, erythematous, and irregular in shape due to edema. A nodule is solid,
elevated, hard or soft, and larger than 1 cm.
Question 5. 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?
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