NUR 309 Exam 2 Study Questions and Complete Solutions
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Course
NUR 309
Institution
NUR 309
A man has come in to the clinic for a skin assessment because he is afraid he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and "stuck on" his skin. Which is the best prediction? He probably has
a. senile lentigines, whic...
NUR 309 Exam 2 Study Questions and
Complete Solutions
A man has come in to the clinic for a skin assessment because he is afraid he might
have skin cancer. During the skin assessment the nurse notices several areas of
pigmentation that look greasy, dark, and "stuck on" his skin. Which is the best
prediction? He probably has
a. senile lentigines, which do not become cancerous
b. actinic keratoses, which are precursors to basal cell carcinoma
c. acrochordons, which are precursors to squamous cell carcinoma
d. seborrheic keratoses, which do not become cancerous ✅d. seborrheic keratoses,
which do not become cancerous
Seborrheic keratoses look like dark, greasy, "stuck-on" lesions that develop mostly on
the trunk. These lesions do not become cancerous. Senile lentigines are commonly
called liver spots and are not precancerous. Actinic (senile or solar) keratoses are
lesions that are red-tan scaly plaques that increase over the years to become raised
and roughened. They may have a silvery-white scale adherent to the plaque. They
occur on sun-exposed surfaces and are directly related to sun exposure. They are
premalignant and may develop into squamous cell carcinoma. Acrochordons are "skin
tags" and are not precancerous. Pages: 224-225
A patient tells the nurse that he has noticed that one of his moles has started to burn
and bleed. The nurse would be concerned with which additional finding?
a. Border regularity
b. Color variation
c. Symmetry of lesions
d. Diameter less than 6 mm ✅b. color cariation
Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD:
asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater
than 6 mm. Pages: 212-213
An elderly woman is brought to the emergency department after being found lying on
the kitchen floor 2 days, and she is extremely dehydrated. What would the nurse expect
to see upon examination?
a. White patches on the mucous membranes
,b. Pale mucous membranes
c. Smooth mucous membranes and lips
d. Dry mucous membranes and cracked lips ✅d. Dry mucous membranes and cracked
lips
With dehydration, mucous membranes look dry and lips look parched and cracked. The
other responses are not found in dehydration. Page: 215
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up
appointment. On assessment, the nurse might expect to see which assessment finding?
a. Clubbing of the nails
b. Pedal erythema
c. Scleroderma
d. Anasarca ✅a. clubbing of the nails
Clubbing of the nails occurs with congenital cyanotic heart disease, neoplastic, and
pulmonary diseases. The other responses are assessment findings not associated with
pulmonary diseases. Pages: 217-218
The nurse is assessing a patient who has liver disease for jaundice. Which of these
assessment findings is indicative of true jaundice?
a. Yellow patches in the outer sclera
b. Yellow color of the sclera that extends up to the iris
c. Skin that appears yellow when examined under low light
d. Yellow deposits on the palms and soles of the feet where jaundice first appears ✅b.
Yellow color of the sclera that extends up to the iris
The yellow sclera of jaundice extends up to the edge of the iris. Calluses on the palms
and soles of the feet often look yellow but are not classified as jaundice. Do not confuse
scleral jaundice with the normal yellow subconjunctival fatty deposits that are common
in the outer sclera of dark-skinned persons. Pages: 213-214
A patient complains that while studying for an examination he began to notice a severe
headache in the temporal area of his head that is throbbing and is somewhat relieved
when he lies down in a dark room. He tells the nurse that his mother also had these
headaches. The nurse suspects that he may be suffering from
,a. migraine headaches
b. tension headaches
c. hypertension
d. cluster headaches ✅a. migrane headaches
Migraine headaches tend to be supraorbital, retro-orbital, or frontotemporal with a
throbbing quality. They are of a severe quality and are relieved by lying down. Migraines
are associated with family history of migraines. Pages: 256-257
During an examination of a female patient, the nurse notes lymphadenopathy and
suspects an acute infection. Acutely infected lymph nodes would be
a. clumped
b. unilateral
c. firm and nontender
d. rubbery and freely movable ✅d. rubbery and freely movable
Acutely infected lymph nodes are bilateral, enlarged, warm, tender, and firm but freely
movable. Unilaterally enlarged nodes that are firm and nontender may indicate cancer.
Page: 262
During an assessment of an infant, the nurse notes that the fontanels are depressed
and sunken. The nurse suspects which condition?
a. Rickets
b. Dehydration
c. Mental retardation
d. Increased intracranial pressure ✅b. Dehydration
Depressed and sunken fontanels occur with dehydration or malnutrition. Mental
retardation and rickets have no effect on fontanels. Increased intracranial pressure
would cause tense or bulging, and possibly pulsating fontanels. Pages: 265-266
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. Enlarged and tender inguinal nodes
b. Hard and fixed cervical nodes
c. Bilateral enlargement of the popliteal nodes
d. "Pellet-like" nodes in the supraclavicular region ✅a. Enlarged and tender inguinal
nodes
52-year-old patient describes the presence of occasional "floaters" or "spots" moving in
front of his eyes. The nurse should
a. examine the retina to determine the number of floaters
b. presume the patient has glaucoma and refer him for further testing
c. consider this an abnormal finding and refer him to an ophthalmologist
d. know that floaters are usually not significant and are caused by condensed vitreous
fibers ✅d. know that floaters are usually not significant and are caused by condensed
vitreous fibers
Floaters are a common sensation with myopia or after middle age owing to condensed
vitreous fibers. Usually they are not significant, but acute onset of floaters may occur
with retinal detachment. Pages: 285-286
A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse
interprets these results to indicate that
a. at 30 feet the patient can read the entire chart
b. the patient can read at 20 feet what a person with normal vision can read at 30 feet
c. the patient can read the chart from 20 feet in the left eye and 30 feet in the right eye
d. the patient can read from 30 feet what a person with normal vision can read from 20
feet ✅b. the patient can read at 20 feet what a person with normal vision can read at
30 feet
The top number indicates the distance the person is standing from the chart; the
denominator gives the distance at which a normal eye can see. Page: 288
A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he
has ptosis of one eye. How should the nurse check for this?
a. Observe the distance between the palpebral fissures
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