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Question
A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer. Which of these findings are characteristic of a stage II pressure ulcer? Select all that apply.a. Intact skin appears red but is not broken.
b. Partial thickness skin erosion is observed with a loss of epidermis or dermis.
c. Ulcer extends into the subcutaneous tissue.
d. Localized redness in light skin will blanch with fingertip pressure.
e. Open blister areas have a red-pink wound bed.
f. Patches of eschar cover parts of the wound.
Answer
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Related questions
Q:
The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test?
a. To measure the rate of lymphatic drainage
b. To evaluate the adequacy of capillary patency before venous blood draws
c. To evaluate the adequacy of collateral circulation before cannulating the radial artery
d. To evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded
Q:
When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. Next, the nurse should:
a. Check for the presence of claudication.
b. Refer the individual for further evaluation.
c. Consider this finding as normal, and proceed with the peripheral vascular evaluation.
d. Ask the patient if he or she has experienced any unusual cramping or tingling in the arm.
Q:
When assessing a patient, the nurse notes that the left femoral pulse as diminished, 1+/4+. What should the nurse do next?
a. Document the finding.
b. Auscultate the site for a bruit.
c. Check for calf pain.
d. Check capillary refill in the toes.
Q:
A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing:
a. Claudication.
b. Sore muscles.
c. Muscle cramps.
d. Venous insufficiency.
Q:
A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient?
a. Hard and fixed cervical nodes
b. Enlarged and tender inguinal nodes
c. Bilateral enlargement of the popliteal nodes
d. Pelletlike nodes in the supraclavicular region
Q:
The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart?
a. Intraluminal valves ensure unidirectional flow toward the heart.
b. Contracting skeletal muscles milk blood distally toward the veins.
c. High-pressure system of the heart helps facilitate venous return.
d. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.
Q:
Which statement is true regarding the arterial system?
a. Arteries are large-diameter vessels.
b. The arterial system is a high-pressure system.
c. The walls of arteries are thinner than those of the veins.
d. Arteries can greatly expand to accommodate a large blood volume increase.
Q:
The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is 135 beats per minute. The nurse interprets this result as:
a. Normal for this age.
b. Lower than expected.
c. Higher than expected, probably as a result of crying.
d. Higher than expected, reflecting persistent tachycardia.
Q:
During a cardiovascular assessment, the nurse knows that a thrill is:
a. Vibration that is palpable.
b. Palpated in the right epigastric area.
c. Associated with ventricular hypertrophy.
d. Murmur auscultated at the third intercostal space.
Q:
During a cardiac assessment on a 38-year-old patient in the hospital for "chest pain," the nurse finds the following: jugular vein pulsations 4 cm above the sternal angle when the patient is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130 beats per minute, ankle edema, difficulty breathing when supine, and an S3 on auscultation. Which of these conditions best explains the cause of these findings?
a. Fluid overload
b. Atrial septal defect
c. MI
d. Heart failure
Q:
In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the:
a. Bell of the stethoscope at the base with the patient leaning forward.
b. Bell of the stethoscope at the apex with the patient in the left lateral position.
c. Diaphragm of the stethoscope in the aortic area with the patient sitting.
d. Diaphragm of the stethoscope in the pulmonic area with the patient supine.
Q:
While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse's response?
a. Talk with the patient about his intake of caffeine.
b. Perform an electrocardiogram after the examination.
c. No further response is needed because sinus arrhythmia can occur normally.
d. Refer the patient to a cardiologist for further testing.
Q:
A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous examination, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true?
a. This decline in blood pressure is the result of peripheral vasodilatation and is an expected change.
b. Because of increased cardiac output, the blood pressure should be higher at this time.
c. This change in blood pressure is not an expected finding because it means a decrease in cardiac output.
d. This decline in blood pressure means a decrease in circulating blood volume, which is dangerous for the fetus.
Q:
The direction of blood flow through the heart is best described by which of these?
a. Vena cava right atrium right ventricle lungs pulmonary artery left atrium left ventricle
b. Right atrium right ventricle pulmonary artery lungs pulmonary vein left atrium left ventricle
c. Aorta right atrium right ventricle lungs pulmonary vein left atrium left ventricle vena cava
d. Right atrium right ventricle pulmonary vein lungs pulmonary artery left atrium left ventricle
Q:
The nurse is auscultating the chest in an adult. Which technique is correct?
a. Instructing the patient to take deep, rapid breaths
b. Instructing the patient to breathe in and out through his or her nose
c. Firmly holding the diaphragm of the stethoscope against the chest
d. Lightly holding the bell of the stethoscope against the chest to avoid friction
Q:
During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:
a. Shallow breathing.
b. Normal lung tissue.
c. Decreased adipose tissue.
d. Increased density of lung tissue.
Q:
When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?
a. Between the scapulae
b. Third intercostal space, MCL
c. Fifth intercostal space, midaxillary line (MAL)
d. Over the lower lobes, posterior side
Q:
The primary muscles of respiration include the:
a. Diaphragm and intercostals.
b. Sternomastoids and scaleni.
c. Trapezii and rectus abdominis.
d. External obliques and pectoralis major.
Q:
During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the:
a. Costal angle.
b. Sternal angle.
c. Xiphoid process.
d. Suprasternal notch.
Q:
When assessing a patient's lungs, the nurse recalls that the left lung:
a. Consists of two lobes.
b. Is divided by the horizontal fissure.
c. Primarily consists of an upper lobe on the posterior chest.
d. Is shorter than the right lung because of the underlying stomach.
Q:
A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition?
a. Absent or decreased breath sounds
b. Productive cough with thin, frothy sputum
c. Chest pain that is worse on deep inspiration and dyspnea
d. Diffuse infiltrates with areas of dullness upon percussion
Q:
A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient?
a. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema
b. Rasping cough, thick mucoid sputum, wheezing, and bronchitis
c. Productive cough, dyspnea, weight loss, anorexia, and tuberculosis
d. Fever, dry nonproductive cough, and diminished breath sounds
Q:
A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse's preliminary analysis, based on this history, is that this patient may be suffering from:
a. Bronchitis.
b. Pneumonia.
c. Tuberculosis.
d. Pulmonary edema.
Q:
An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with:
a. Asthma.
b. Atelectasis.
c. Lobar pneumonia.
d. Heart failure.
Q:
A 2-year-old boy has been diagnosed with physiologic cryptorchidism. Considering this diagnosis, during assessment the nurse will most likely observe:
a. Testes that are hard and painful to palpation.
b. Atrophic scrotum and a bilateral absence of the testis.
c. Absence of the testis in the scrotum, but the testis can be milked down.
d. Testes that migrate into the abdomen when the child squats or sits cross-legged.
Q:
Which of these statements is most appropriate when the nurse is obtaining a genitourinary history from an older man?
a. "Do you need to get up at night to urinate?"
b. "Do you experience nocturnal emissions, or "wet dreams'?"
c. "Do you know how to perform a testicular self-examination?"
d. "Has anyone ever touched your genitals when you did not want them to?"
Q:
In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect?
a. Hyperreflexia
b. Fasciculations
c. Loss of muscle tone and flaccidity
d. Atrophy and wasting of the muscles
Q:
A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks, his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing?
a. Scissors gait
b. Cerebellar ataxia
c. Parkinsonian gait
d. Spastic hemiparesis
Q:
During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with plantar flexion. Which statement concerning these findings is most accurate? This patient's response:
a. Indicates a lesion of the cerebral cortex.
b. Indicates a completely nonfunctional brainstem.
c. Is normal and will go away in 24 to 48 hours.
d. Is a very ominous sign and may indicate brainstem injury.
Q:
While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: abduction and flexion of the arms and legs; fanning of the fingers, and curling of the index finger and thumb in a C position, followed by the infant bringing in the arms and legs to the body. What does the nurse know about this response?
a. This response could indicate brachial nerve palsy.
b. This reaction is an expected startle response at this age.
c. This reflex should have disappeared between 1 and 4 months of age.
d. This response is normal as long as the movements are bilaterally symmetric.