Question

Skin Assessment

Answer 1

Correct Highlights :

change in mole size
color changes
itching
burning
bleeding

Rationale :

🔸 Change in mole size can suggest dysplastic changes or malignancy 🔸 Color variation within a mole increases concern for melanoma 🔸 Itching in a mole is not normal and may indicate irritation or transformation 🔸 Burning is an unusual symptom of moles and can signal nerve involvement or inflammation 🔸 Bleeding moles often reflect ulceration or abnormal cell turnover, raising suspicion for cancer

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Answer 2

Correct Answers:

Firm but freely movable

Rationale :

🟪 Acutely infected lymph nodes are typically enlarged, tender, and movable 🟪 Firm texture reflects reactive hyperplasia in response to infection 🟪 Mobility of the node suggests it's not attached to underlying tissues, which is reassuring 🟪 Nodes become fixed in malignancy, not in infection 🟪 Palpation of symmetry, tenderness, and movement helps differentiate acute from chronic processes

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Answer 3

Correct Answers:

Crepitus.

Rationale :

🔹 Crepitus is caused by air trapped in the subcutaneous tissue, often due to trauma or pneumothorax 🔹 The crackling sensation is felt, not heard, making it a palpation-based finding 🔹 It may follow thoracic surgery, chest tube insertion, or barotrauma 🔹 It’s often non-tender but clinically significant if progressive 🔹 Confirmation often requires imaging to assess for subcutaneous emphysema

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Answer 4

Correct Answers:

Timing
Radiation
Location

Rationale :

🔺 Timing (systolic or diastolic) helps identify the affected valve 🔺 Radiation patterns help determine severity and affected areas (e.g., to neck in aortic stenosis) 🔺 Location of maximal intensity directs auscultation accuracy and guides diagnosis 🔺 These features are critical for documenting and referring cardiac abnormalities 🔺 Other findings like pitch and intensity further classify murmurs for cardiology evaluation

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Answer 5

Correct Answers:

Level of consciousness
Influenza vaccine
Fluid intake
Age

Rationale :

🟩 Older adults have reduced lung elasticity and immune response, increasing pneumonia risk 🟩 Altered LOC compromises protective airway reflexes, increasing aspiration risk 🟩 Absence of flu vaccination removes protection against viral triggers of secondary pneumonia 🟩 Low fluid intake thickens mucus and hinders airway clearance 🟩 Difficulty answering questions and flushed face support impaired gas exchange

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Answer 6

Correct Answers:

Coarse facial features

Rationale :

🟫 Excess growth hormone after puberty causes bony thickening of the face and extremities 🟫 Coarse facial features include thickened nose, brow, lips, and jaw 🟫 Changes develop slowly and are often noticed over years 🟫 Other signs include enlarged hands, feet, and spacing of teeth 🟫 Condition is diagnosed by IGF-1 levels and confirmed with MRI of the pituitary

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Answer 7

Correct Answers:

Auscultate the thyroid with the bell of the stethoscope

Rationale :

🔹 A bruit suggests increased thyroid vascularity, often found in hyperthyroidism or goiter 🔹 The bell is preferred for low-pitched vascular sounds 🔹 Breath holding during auscultation prevents interference 🔹 A thyroid bruit is a critical finding requiring endocrinology referral 🔹 It often accompanies goiters or Graves' disease

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Answer 8

Correct Answers:

When the bronchial tree is obstructed

Rationale :

🟨 Obstruction by mucus, foreign body, or mass limits airflow, reducing breath sounds 🟨 Decreased sounds may occur with atelectasis, effusion, or pneumothorax 🟨 Physical exam should include percussion and tactile fremitus for correlation 🟨 Bronchial tree blockage impairs ventilation distal to the obstruction 🟨 Recognizing silent areas is key in identifying serious pulmonary pathology

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Answer 9

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available
Order : 5 : No answer text available

Rationale :

🟧 Follows a head-to-toe approach for thoroughness and pattern comparison 🟧 Preauricular and submandibular assess facial drainage areas 🟧 Supraclavicular nodes may reveal thoracic or abdominal pathology 🟧 Axillary nodes reflect upper limb and breast drainage 🟧 Popliteal nodes complete lower extremity lymph assessment

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Answer 10

Correct Answers:

Dysphagia

Rationale :

🔻 Stroke can impair cranial nerves involved in swallowing and gag reflex 🔻 Dysphagia increases risk of aspiration pneumonia 🔻 Screening for swallowing is a safety priority before any oral intake 🔻 Signs include drooling, coughing after sips, and weak voice 🔻 Dysphagia may persist long-term and require speech therapy consult

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QLexNursing

1 :
Skin Assessment

Correct Highlights :

2 :
During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. How do acutely infected lymph nodes typically appear?

3 :
During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects:

4 :
A heart murmur should be assessed for which of the following? Select all that apply.

5 :
A nurse in an emergency department (ED) is admitting a client.

Answer Options

6 :
During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly. What additional finding would the nurse assess for to confirm this suspicion?

7 :
A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the gland for the presence of a bruit. What technique should the nurse use to assess for a bruit?

8 :
During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?

9 :
A nurse is performing a lymphatic system assessment on a client reporting fatigue and malaise for one week. In which order should the nurse perform the head to toe assessments? Indicate the correct order from first to last. All options must be used.

10 :
A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?

QLexNursing

1 : Skin Assessment

Correct Highlights :

2 : During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. How do acutely infected lymph nodes typically appear?

3 : During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects:

4 : A heart murmur should be assessed for which of the following? Select all that apply.

5 : A nurse in an emergency department (ED) is admitting a client.

Answer Options

6 : During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly. What additional finding would the nurse assess for to confirm this suspicion?

7 : A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the gland for the presence of a bruit. What technique should the nurse use to assess for a bruit?

8 : During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?

9 : A nurse is performing a lymphatic system assessment on a client reporting fatigue and malaise for one week. In which order should the nurse perform the head to toe assessments? Indicate the correct order from first to last. All options must be used.

10 : A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?

1 :
Skin Assessment

2 :
During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. How do acutely infected lymph nodes typically appear?

3 :
During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects:

4 :
A heart murmur should be assessed for which of the following? Select all that apply.

5 :
A nurse in an emergency department (ED) is admitting a client.

6 :
During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly. What additional finding would the nurse assess for to confirm this suspicion?

7 :
A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the gland for the presence of a bruit. What technique should the nurse use to assess for a bruit?

8 :
During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?

9 :
A nurse is performing a lymphatic system assessment on a client reporting fatigue and malaise for one week. In which order should the nurse perform the head to toe assessments? Indicate the correct order from first to last. All options must be used.

10 :
A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?