NURS 228 Final Exam Questions| With Complete
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The nurse is assessing the skin of the client. He notices on the
right heel of the foot a red-pink wound bed. There is partial
thickness loss of the dermis with a shallow open ulcer, without
slough. What stage would the nurse rate this as? -
✔✔ANSWER✔✔-Stage II
The nurse is inspecting the client's nails and the client has a
history of emphysema. The fingernail shape that suggests on
underlying oxygen deficiency is: - ✔✔ANSWER✔✔-Early or late
clubbing
You are assessing your client and notice a circumscribed skin
elevation, less than 0.5 centimeters in diameter, containing
serous fluid. This type of skin lesion is a: - ✔✔ANSWER✔✔-
Vesicle
When inspecting the skin of an older adult client, the nurse notes
multiple small 1-2mm, flat reddish-purple macules. She also notes
this is associated with bleeding tendencies or emboli to skin. The
nurse documents this finding as which of the following? -
✔✔ANSWER✔✔-Petechiae
The nurse is working in an outpatient clinic. When examining a
client, the nurse notes asymmetric borders on a pigmented lesion.
The nurse knows this suggests: - ✔✔ANSWER✔✔-The lesion
may be cancerous
,The Braden Scale assesses six different categories. The nurse
knows all of these are on the assessment tool except: -
✔✔ANSWER✔✔-Tachypnea
The nurse notes a wound on her patient's coccyx. She notifies the
doctor and describes it as, full thickness tissue loss with exposed
bon, tendon, and muscle. Some slough is noted on the inner
wound bed. The nurse would identify this as? - ✔✔ANSWER✔✔-
Stage IV
The nurse performs a health screening on a group of people. The
nurse identifies which individual is at the greatest risk for
developing skin cancer? - ✔✔ANSWER✔✔-A 62-year old male
with light skin worked as a roofer for 40 years
The nurse is inspecting the color of the patient's nails. They
appear pale or cyanotic looking. The nurse would know this may
indicate: - ✔✔ANSWER✔✔-Hypoxia
An adult female client visits the clinic for the first time. The client
has many bruises around her neck and face, and she tells the
nurse that the bruises are the result of an accident. The nurse
suspects that the client may be experiencing - ✔✔ANSWER✔✔-
Domestic abuse
A nurse is collecting a thorough and accurate subjective history of
a client's nail problems. The client asks why this is necessary.
Which of the following should the nurse mention in response? -
✔✔ANSWER✔✔-Nail problems can be caused by an underlying
systemic illness
In which health condition would the nurse most likely expect to
assess a capillary refill time that is longer than 2 seconds? -
✔✔ANSWER✔✔-Cardiovascular Disease
, After teaching a group of students about the structure and
function of the skin, the instructor determines that the teaching
was successful when the students identify which of the following
as responsible for variations in skin color? - ✔✔ANSWER✔✔-
Melanin
The nurse's assessment of an adult female client reveals the
presence of excessive hair on her face and chest. The nurse
should plan further evaluation of which body system? -
✔✔ANSWER✔✔-Endocrine
A dark-skinned client visits the clinic because he hasn't been
feeling well. To assess the client's skin for jaundice, the nurse
should inspect the client's - ✔✔ANSWER✔✔-Sclera
Which of the following statements most accurately conveys an
aspect of the anatomy and physiology of the skin? -
✔✔ANSWER✔✔-The skin is composed of an epidermis, dermis,
and subcutaneous tissue
The nurse is speaking to a group of nursing students about health
promotion and is preparing to discuss the ABCDEs of melanoma.
Which of the following descriptions is correct for the ABCDEs? -
✔✔ANSWER✔✔-a= asymmetry, b=irregular border, c=color
changes, d=diameter > 6 mm, e=evolution
A decrease in oxyhemoglobin will result in documentation of
pallor. T or F? - ✔✔ANSWER✔✔-True
The nurse is assessing a dark-skinned client who has been
transported to the emergency room by ambulance. When the
nurse observes that the client's skin appears pale, with blue-
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