During your physical examination of a 29-year-old professional volley ball player who recently completed a beach tournament, you gently pinch the skin on the chest area. The skin remains in a "tent" shape and slowly returns to its normal position. This is a sign of

Dehydration

Hypervolemia

Properly Hydrated

Infection

Answer and Explanation

The Correct Answer is A

A) Dehydration:

When the skin remains tented and returns to its normal position slowly after being pinched, it indicates decreased skin turgor, which is a clinical sign of dehydration. Dehydration can occur due to fluid loss from sweating during vigorous physical activity like a beach tournament.

B) Hypervolemia:

Hypervolemia refers to excess fluid volume in the body, which would typically manifest with signs such as peripheral edema or jugular vein distention rather than decreased skin turgor.

C) Properly Hydrated:

Properly hydrated individuals would have normal skin turgor, where the skin returns promptly to its normal position after being pinched.

D) Infection:

Skin tenting is not a specific sign of infection. Infection would typically present with localized signs such as redness, warmth, swelling, and possibly systemic signs like fever.

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Correct Answer is C

Explanation

A) Snellen chart:

The Snellen chart is used to assess distance vision, not near vision. It consists of letters or symbols arranged in rows, with the client typically asked to read from a specific distance to test visual acuity.

B) Penlight:

A penlight is primarily used to assess pupillary reactions and near vision tasks such as accommodation. It helps examine how the pupils respond to light and how well the eyes focus on near objects.

C) Magazine:

A magazine or similar reading material is commonly used to assess near vision. Clients are asked to read the text at a comfortable distance, evaluating their ability to focus on close-up objects and the clarity of their vision.

D) Ophthalmoscope:

An ophthalmoscope is used to examine the interior structures of the eye, such as the retina and optic nerve head. It is not used for assessing near vision but rather for diagnosing conditions affecting the eye's internal structures.

A. Location B. Color C. Condition of surrounding skin D. Elevation E. Distribution pattern

Correct Answer is ["A","B","C","D","E"]

Explanation

A) Location: Documenting the exact location of lesions is crucial for monitoring changes over time, assessing potential spread or resolution, and providing accurate information for future reference. This information helps in the diagnosis and in tracking the effectiveness of treatments.

B) Color: The color of lesions can provide important clues about their nature and cause. For example, red or inflamed lesions might indicate infection or irritation, while darker lesions could suggest malignancy or chronicity. Color changes can also signify healing or worsening of the lesion.

C) Condition of surrounding skin: Noting the condition of the skin around the lesions helps assess whether there is additional inflammation, infection, or other skin conditions that may be related to the primary lesion. This provides a more comprehensive understanding of the patient’s skin health and any secondary complications.

D) Elevation: Elevation refers to whether the lesion is raised, flat, or depressed compared to the surrounding skin. This characteristic helps in identifying the type of lesion, such as a papule, plaque, or ulcer. Elevated lesions might suggest certain dermatological conditions, while depressed lesions might indicate scarring or loss of tissue.

E) Distribution pattern: The pattern of how lesions are distributed on the body can provide diagnostic clues. For example, a linear distribution might suggest contact dermatitis, while a symmetrical distribution could indicate a systemic condition. Understanding the distribution pattern helps in identifying the underlying cause and planning appropriate treatment.

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During your physical examination of a 29-year-old professional volley ball player who recently completed a beach tournament, you gently pinch the skin on the chest area. The skin remains in a "tent" shape and slowly returns to its normal position. This is a sign of

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to assess a client's near vision. The nurse would use which piece of equipment for the assessment?

Correct Answer is C

Explanation

After completing an integument physical examination, the nurse is documenting information concerning observed lesions. What characteristics will the nurse include in this documentation? (Select all that apply.)

Correct Answer is ["A","B","C","D","E"]

Explanation

A nurse measures a patient height and weight and calculate his BMI. Patient BMI is 37. Classify according to this BMI results?

A nurse is assessing a client who has hypothyroidism. The nurse should expect which of the following findings?

While working in the Emergency department a Rapid response nurse is evaluating a patient in acute respiratory failure after a motor vehicle crash. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

The nurse is doing a focus assessment on a 25-year-old college student who presented to the clinic secondary to fever and lethargy. When recording the findings of the lymph glands, a nurse should note all except:

What data collected during an integumentary assessment should cause the nurse to be concerned that a client is at risk for the development of skin cancer? (Select all that apply.)

A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action/Priority should the nurse perform next?

What is the primary pathophysiology of glaucoma?

The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of pressure ulcer.