Font size
WorksheetsMM - HeadtoToe and Integumentary
Total questions: 53
Worksheet time: 28mins
The very first thing a nurse will assess when doing a head to toe examination is what?
Head
Vital Signs
Skin
General appearance
What could the nurse assess based soley on the way the patients walk into the room?
Gender and age
Signs of illness
Gait and posture
Signs of illness, well nourished
What does AO in AOX4 stand for?
(a)
What does PERRL stand for?
(a)
A nurse is inspecting the patient’s ears with an otoscope. Which of the following findings would be considered normal?
A small plastic bead
Brownish black tympanic membrane
Perforation of the tympanic membrane
Small amount of cerumen
A nurse is assessing a patient’s neck with the patient seated. Which of the following is considered an unexpected finding?
Jugular vein distention
Midline Trachea
Lack of bruits in carotid arteries
Thyroid symmetry bilaterally
In which arteries are bruits considered normal?
Carotid arteries
Temporal arteries
Aortic artery
None of the above
What is the purpose of auscultating the abdomen before palpation and percussion?
To get a baseline of bowel sounds
To prevent alteration of bowel sounds
To assess for any masses or lesions
To check for tenderness or pain
Techniques of assessment include interviewing, inspection, palpation, percussion, auscultation, percussion, and olfaction.
true
false
What should be assessed during the inspection of the chest?
Respiratory rate, skin color, abnormal movements
Hygiene, posture, abnormal smell
Heart sounds, lung sounds, chest symmetry
Hair condition, beard abnormalities, skin breakdown
Data such as headache, nasal stuffiness, and sore throat are example of what type of data?
Subjective Data
Objective Data
Secondary Data
Signs
The signs experienced by the patient are a type of what data?
Objective Data
Subjective Data
Secondary Data
Diagnostic Data
Where is the apical impulse located?
In the second left intercostal space at the midclavicular line
In the fifth left intercostal space at the midclavicular line
In the ninth left intercostal space at the midclavicular line
In the third left intercostal space at the midclavicular line
identify the sign given in image
Jugular vein distension
Subclavian vein distension
Carotid artery thrombosis
Pulmonary artery hypertension
Identify the image in which nurse place left hand finger in the ICS and right hand finger taps the left hand finger with movement from the right wrist?
Inspection
Percussion
Palpation
Auscultation
When auscultating over the lung fields the nurse hears a high-pitched, musical sound like a "squeak" on expiration. What is the proper documentation of this sound?
crackles
a squeak
rhonchi
wheezes
What is the functional reflex allowing the eyes to focus on near objects?
Corneal Light Reflex
Near Visual Acuity
Cover Test
Accommodation
What is b?
Right Upper Quadrant
Left Upper Quadrant
Right Lower Quadrant
Left Lower Quadrant
Stepphie's metformin bottle says to take one tablet b.i.d. What does that mean
take one tablet once a day
take one tablet twice a day
take one tablet at bedtime
take one tablet at two meals each day
Activities of Daily Living
(a)
intra-
within
under
over
trans-
near
across
minor
blast
study of
embryonic cell
causing death
excision
-graph
study of
record
pain
instrument to record
Lab values: pH 7.50, paCO2 32, HCO3 24
compensated respiratory alkalosis
uncompensated respiratory alkalosis
compensated metabolic acidosis
compensated metabolic alkalosis
pH 7.37 PaCO2 65 HCO3 35
Compensated Respiratory Acidosis
Uncompensated Respiratory Acidosis
Compensated Metabolic Acidosis
Compensated Metabolic Acidosis
Which letter refers to the dermis?
A
B
C
D
E
What is #9 pointing to?
sebaceous gland
sudoriferous gland
messiner's corpuscle
pacinian corpuscle
Which of the following is a warning sign of melanoma in a mole?
symmetrical shape
smooth border
small diameter
different colors
Why can you often not feel third-degree burns?
Because they damage the nerve ending in your skin
Because they aren't very damaging
Because they cause scabs to form
Because they only affect the inner part of your skin
1st degree burn
superficial; involves the epidermis
2nd-degree burn
partial thickness; involves the epidermis and dermis
3rd degree burn
full-thickness; involves the epidermis, dermis, and subcutaneous
A student reaches into a container of corrosive chemicals without gloves and burns the anterior and posterior of their left arm. What % of their body is burned?
4.5%
9%
18%
36%
Which of the following terms is a minor wound resulting from rubbing or friction to the epidermal layer of the skin?
Laceration
Abrasion
Thermal burn
Sunburn
Which of the following is the treatment of choice for reducing further trauma for a burn-induced skin injury?
Saline Wound Wash
Liquid Adhesive Bandages
Chilled Refrigerated Water
Tap Water
Hydrogen Peroxide
These medications reduce friction and rubbing irritation to the wounded area and promote moist healing:
Systemic Analgesics
Local Anesthetics
First Aid Antiseptics
Skin Protectants
Which pressure ulcer stage includes exposure of bone, muscle or tendons?
Stage I
Stage II
Stage III
Stage IV
Stage IV
Stage I pressure ulcer includes which of the following?
full thickness tissue loss
exposed bone, tendon and/or muscle
non-blanchable erythema of intact skin
unstageable
When slough and/or eschar is present, the wound is identified as unstageable when____?
the base of the wound cannot be determined
the periwound is blanch able
you can see tendon, bone and/or muscle
To prevent bed sores, ___________
Don't move the patient at all
Actively move and turn the patient
Place the patient sitting upright in a chair
Which Condition is not a risk factor for developing pressure damage
Diabetes
Stroke
Peripheral Arterial Disease
Allergic Rhinitis
What stage pressure ulcer is this?
Unstageable
Stage I
Stage II
Deep tissue injury (DTI)
Acne and folliculitis are filled with pus and are examples of .....
Papule
Pustule
Black Head
Wheal
select the high risk score for skin assessment scale
12
15-16
13-14
12 OR LESS
If there is a mole that has grown and changed over time and the mole is reddish, brown with blue specks, indentations on the edge and 10 mm. Should the person be concerned?
No, this is a basal cell carcinoma most likely with a high successful cure rate.
Yes, this is most likely a squamous cell carcinoma, which needs to be removed and treated.
No, this is merely a irregular mole, but nothing unusual.
Yes, this is most likely a melanoma, which needs to be removed and treated.
A postoperative patient arrives at an ambulatory care center and states, "I am not feeling well." upon assessment, the nurse notes an elevated temperature. An indication that the wound is infected would be.
There is no odor
The wound is approximated
The wound is draining purulent exudate
The are two stitches missing
How many guests attended the first Thanksgiving?
200
1500
150
20
Which President made Thanksgiving a national holiday?
Washington
Truman
Lincoln
Franklin
What pie is the most popular on Thanksgiving?
Apple Pie
Pecan Pie
Chocolate Pie
Pumpkin Pie
