Exam 2: NSG121/ NSG 121 (Latest 2024/ 2025 Update) Health Assessment | Review with Questions and Verified Answers| 100% Correct| Grade A- Herzing
Exam 2: NSG121/ NSG 121 (Latest 2024/
2025 Update) Health Assessment | Review
with Questions and Verified Answers| 100%
Correct| Grade A- Herzing
Q: Clean-contaminated wound
Answer:
Are those that are made under sterile conditions, like
surgical incisions
Q: A bowel resection
Answer:
is a surgical removal of a portion of the small or large intestine, is an example of a cleancontaminated wound.
Q: What does the nurse do during burn classification
Answer:
The nurse attempts to blanch the burned area by applying pressure with a sterile, cotton-tipped
applicator, and then observes capillary refill
Q: What would be included in the documentation of a pressure injury?
Answer:
the size in depth and diameter, color
and texture of the tissue, amount, color, consistency, and odor of any exudate (drainage)
Q: ABCDEs melanoma
Answer:
asymmetry, border, color, diameter, and evolution
Q: A patient is using the sternocleidomastoid and the trapezius muscles for breathing what
action by the nurse?
Answer:
complete a full respiratory assessment.
Q: When assessing a 6-month-old client’s head and neck what finding would you document?
Answer:
You should expect the sutures of the cranium to be soft and loose at this age.
Q: When assessing the mouth of an older adult client what finding would you report?
Answer:
The nurse should report a lesion that changes or persists because a biopsy should be done to rule
out oral cancer.
Q: Risk factors of cancer of the neck
Answer:
Tobacco use and alcohol consumption
Q: When assessing a client’s lifestyle and habits for risk factors the nurse must keep in mind
that this includes risk factors that can be controlled by the client.
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Largest organ of the body Skin
Three layers of the skin epidermis, dermis, subcutaneous
Epidermis First line of defenseSpecialized cells for perception of pain, touch, temperature
Dermis supports the epidermis and has blood vessels (it protects Epidermis)
Subcutaneous layer Innermost layer of the skin, containing fat tissueProvides insulation and contributes to skins mobility
If the body doesn’t have Subcutaneous layer The organs would be damage because it cushions and insulates the body.
Aging factors Decrease Skin turgor, thin skin, bruise easily and dry.
What affect does cultural consideration of the skin, hair and nails? the exposure to sun, some people skin is smoother or thicker. We do not have the same textureAsian culture- coning and cupping of the skin.Different marking on the body(Tell me how you care for your skin?Do you take vitamins?)If you see marking – ask them, how did you get that on your skin
Skin findings indicating burn History of severe sunburn or skin cancerLifestyle/occupation/hobbies – sunburn or frostbite, hygiene, moisturizer useDetermine risk for skin breakdown
Your patient has sunburn, what should you ask them? How did you get your burn, how long were you in the sun?
Medications can cause photosensitivity or phototoxicity Photosensitivity is a side effect of some antibiotics. The questions in the distractors do not assess risk factors for or medical history associated with sunburn.
You’re looking at an older individual what I would notice that could be a problem. Moles (melanoma)
Risk factors of skin cancer Sun Exposure, Moles, Occupation
Dermatologic Signs and Symptoms Changes in mole or lesion – Color change and evolution of a skin lesion can be signs of melanoma. A small, black mole not a concern.
A client of Southeast Asian descent and observes a linear pattern of purple lesions on the client’s back The nurse must consider that a client’s culture might influence how the client self-treats at home. Assessment is the first step.
Skin assessment finding wheals on the back Wheals are raised lesions. The lesions are of various sizes, some papules (less than 1 cm in diameter) and some patches (greater than 1 cm in diameter).
Different types of wounds Clean, Clean Contaminated, Contaminated, Surgical
Clean-contaminated wound surgical incisions, genitourinary, gastrointestinal tracts, A bowel resection, gun shot
Contaminated wound gunshot wound in the abdomen
Vascular assessment of the burned area is necessary to determine depth of tissue destruction The nurse attempts to blanch the burned area by applying pressure with a sterile, cotton-tipped applicator, and then observes capillary refill when the pressure is released.
What would be included in the documentation of a pressure injury The size in depth and diameter, color and texture of the tissue, amount, color, consistency, and odor of any exudate (drainage), condition of surrounding tissue, location using appropriate landmarks, and any associated pain.
How to document stage 4 Size, Depth and Diameter, Color, Consistency, Odor
ABCDEs melanoma asymmetry, border, color, diameter, evolution
A patient client is using the sternocleidomastoid and the trapezius muscles for breathing
Risk factor for cancer in neck Alcohol Use, Tobacco, Smoking, certain medication we take
What health promotion would you tell your patient to reduce or help with skin cancer Sunscreen, Wear hats, Don’t smoke or don’t drink
6-month-old client’s head and neck: you should expect the sutures, soft spots, fontanels
When assessing the mouth of an older adult report a lesion that changes or persists because a biopsy should be done to rule out oral cancer
Risk factors of cancer of the neck male gender over the age of 50. Tobacco use and alcohol consumption
Assessing the lymph nodes of a runny nose and an ear infection patient where do people have infection of the ear was connected too Otitis Media (inner ear)Palpate The lymph node is posterior Auricular lymph node
Lifestyle risk factors for wellness and function of the ears Examples are exposure to the sun, Certain medications can cause adverse effects on the ears, like tinnitus, vertigo, ect. Hearing loss from loud noises is a major worldwide health issue. Air pressure changes with altitude from flying or diving can cause damage to the eustachian tube.
Assessing the head and neck of a client with loss of vision when the loss started, if it was gradual or sudden and when it stopped.
You’re assessing your patient ear; they’re dizzy and difficult hearing at times Vertigo
Assessing the thyroid gland from the posterior Stand behind the client and palpate the client’s thyroid, cricoid cartilages, and the thyroid isthmus
If a person has face sunburn ask if they are using an antimicrobial
Assessing a healthy client’s neck for any discernible lymph nodes
History of breast cancer, what should you identify as this person is talking, related to risk factors? Birth control
Person has fever and a sore Throat
When you have a patient touch their shoulder, their ears touch their shoulder you’re testing for Lateral flexion motion
Visual acuity Snellen eye chart. a client with 20/30 vision, the client can read at 20 feet what a normal eye can read at 30 feet.
Whisper test Cover or plug one ear at a time and speak away from the patient.
Assessing Vision using a unilateral cover test ocular deviation (eyes stay steady, don’t move)
Nose inspection technique Nose appears symmetrical, midline, and proportionally shaped to facial features. Skin surface is smooth without lesions; coloration is consistent with other facial complexion. Use a light to illuminate the nares. Observe the color of the mucous membranes. Inspect any mucus. Note the color and character of the nasal mucosa
When assessing the client’s uvula “When the client says “”ah””. The nurse should recognize that if there is no upward movement of the uvula there is a dysfunction of the vagus nerve and is common when a client has a stroke.”
You’re looking at the head and neck of an elderly person High risk for Thyroid dysfunction (common over age 60).
In head and neck assessment
Testing peripheral vision Confrontation test. Cover one eye, while the nurse covers the opposite eye.
Extraocular muscle movements with the cardinal fields of gaze test Symmetrical movements of the eyes in all nine cardinal fields of gaze.
The eyes of an older adult Observe Unequal pupillary response to light is abnormal finding that could indicate trauma or increased intracranial pressure in the brain. Unequal pupillary response is a medical emergency.
Abnormal findings when performing the Rinne test with a client who reports hearing loss Feels the bone conduction longer than hearing the sound conduction.
Male with enlarged breast, soft tissue no nodes in assessment, an appropriate statement is ask him has he started lifted weights
When you’re assessing the ear of the child down and back
When you’re assessing the ear of the adult up and back
Anterior thorax landmarks
How can an individual obtain a cervical vertebrae spine injury. Whiplash
Patient has a history of tinnitus, what question would I ask my patient When did it start? How long?
What does the Rhine test look for Conductive hearing loss.
Assessing an older patient mouth, what finding do I need to tell or notify the doctor Pain. Open, painful sores or lesions.
You are assessing posterior approach palpating what gland Parathyroid
When you’re looking in the throat anterior and posterior what landmark are you looking for Tonsil (key word is sticking their tongue out)
When you want the uvula to rinse or look at motion Have the patient open mouth and say ah- NO TONGUE
What is the test for peripheral vision??? Confrontation
When you’re assessing extra oculomotor for the cardinal field of gaze? Make an XDocument the eye moves smoothly, no deviation, and symmetrical. *Assess for any deviation and consider if patient is paralyzed, had a stroke, or bells palsy
Youre checking an older person eye, what is the priority Deviation, unequal eyes
Teaching patient about respiratory tract and respiration The diaphragm contracts and flattens pulling the lungs down.
What occupation would you find people who are at higher risk for respiratory problems
When talking a comprehensive assessment the patient states they smoke 40 packs and they are trying to stop What have you done to try and stop
Subjective Data for a patient with asthma or COPD “””It takes longer to catch my breath”””
Patient has pneumonia what are the breath sounds that you would hear Wheezing
You are inspecting the anterior thoracic transverse diameter of a patient who smokes and comparing to a patient who is healthy. You know that the ratio is 1.2 is normal.1.1 is the smokers one. the findings are abnormal. You would assess for hyperinflation
You are teaching a post-menopausal woman about breast examination, which statement tells the nurse that theyre teaching was successful. If you teach a younger person, they should assess after their cycle. Post-menopausal can check whenever they want anytime during the month.
Technique for screening a patient for nipple retraction Arms at the side then tell the patient to slowly rise their hands above your head to see the nipple retract
Breast development for a preadolescent One breast can be bigger than the other one.
You’re testing visual acuity- you notice its 20/30 what does that mean Patient can read 20 feet away from the chart, but most people can read 30 feet away from the chart.
Patient has a nasal infection- I diagnose them with asomina. What does this mean This patient cannot smell
To document stage two pressure ulcer, how would you know that the nurse needs further teaching If you left out the size of the wound, the depth and diameter are crucial to the staging a bed sore. This is what is needed to say they need further teaching.
Patient reports SOB, what would I report to the physician immediately – The answer is the high pitched crowning sound. This is an emergency (ITS STRIDOR)
Assessing a male client with enlarged breast tissue. You notes that the breast tissue is soft, with no nodules. What would you ask the patient? Do you have a family history of breast cancer?
Braden Scale is used to measure what? Who are at high risk? Pressure ulcers. Incontinence patients
Gynecomastia enlarged breast tissue in men
Assessing the skin of a darker skin patient- excessive growth on the ear They have a keloid
White patches in mouth in an older white person Oral Candidiasis, thrush
Patient had a stroke and reports that they recently lost their denture and have been choking, they are at risk for Nutritional Deficit
Most painful burn superficial burn
Corneal light reflex test Hirshberg test
An intentional wound surgical incision
Egophony test normal findings repeat letter e sounds
What does a wheel look like? Raised red bubble fluid ex: positive tb test
Burn classifications, how should you assess/inspect the depth? Capillary refil
Health promotion risk reduction, what type of questions would you ask fora pilot? Do you wear sunscreen or protective clothing? Do you take anymedications? Do you wear sunscreen
You are teaching about the respiratory trac and respirations, what shouldyou be including in your conference? Diaphragm contracts and flattens, pulls the lungs down
A client smokes 20 packs of cigarettes per year, they just can’t seem tostop. Tell me more about how you feel
Your client has pneumonia and you’re listening to their chest, the breathsounds are low pitched with a gurgling sound that clears with a cough. Rhonchi
Patient reports fever & sore throat Anterior cervical nodes, pharyngitis
Whispered pectoriloquy “Recognition of whispered words “”1,2,3″””
When looking at anterior and posterior pillars Assessing tonsils