Chapter 08: Growth, Measurement, and Nutrition

Multiple Choice

1. The gonads begin to secrete estrogen and testosterone during: a. infancy. b. puberty. c. pregnancy. d. early adulthood.

ANS: B

At puberty, the gonads secrete testosterone and estrogen. As a result, secondary sex characteristics (e.g., genitalia growth) begin to appear. Maturation occurs at a mean age of 11.5 years in females and 13.5 years in males.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

2. Developmental changes of puberty are caused mainly by the interaction of the pituitary gland, gonads, and: a. hypothalamus. b. islet cells. c. thalamus. d. thymus.

ANS: A

Under the influence of the hypothalamus, pituitary gland, and gonads, developmental changes of puberty are established.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

3. After 50 years of age, stature: a. becomes fixed. b. begins a barely perceptible secondary increase. c. increases at a rate of 0.5 cm/year. d. declines.

ANS: D

As the individual reaches 50 years of age, the intervertebral disk begins to thin and become more compressed, which leads to a decline in stature.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

4. By 10 to 12 years of age, lymphatic tissues are about: a. 25% of adult size. b. 50% of adult size. c. the same as adult size. d. twice the size of those in the adult.

ANS: D

Lymphatic tissues are small compared with total body size, but they are almost fully developed at birth. They grow fast and are about twice the adult size by age 10 to 12 years.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

5. During adolescence, the head size normally increases as a result of: a. sinus development. b. brain mass increase. c. evolution of lymphatic tissue. d. hypertrophy of myelin.

ANS: A

As the facial sinuses grow, the head size enlarges its surface area to accommodate their growth.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

6. Gender-specific skeletal differences first occur during: a. the second stage of fetal development. b. late infancy. c. early childhood. d. adolescence.

ANS: D

During adolescence, females develop a wider pelvis and males develop broad shoulders; males transition from a slight increase in body fat to more lean muscle mass in later puberty, whereas females maintain an increase in adipose tissue throughout adolescence.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

7. Mrs. Layton is a 33-year-old patient who is obese. Most adult obesity begins: a. in adolescence. b. in childhood. c. after the skeletal growth is completed. d. once sexual maturation is complete.

ANS: A

Most adult obesity begins in adolescence.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

8. The legs are the fastest growing body part during: a. early infancy. b. late infancy. c. childhood. d. early adulthood.

ANS: C

Legs grow the fastest during childhood, whereas the trunk grows fastest in infancy, and the skeletal muscles and organs grow fastest in early adulthood.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

9. Skeletal mass and organ systems double in size during: a. infancy. b. early childhood. c. adolescence. d. early adulthood.

ANS: C

During puberty, sex steroids stimulate secretion of growth hormone, causing the organs and skeletal mass to double in size.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

10. Optimal infant birth weight is difficult for pregnant adolescents to obtain because: a. they have not completed their own growth spurt. b. there are insufficient uterine supporting structures. c. the amniotic fluid is variable in pregnant adolescents. d. blood volume has not reached adult proportions.

ANS: A

Pregnant adolescents younger than 16 years, or less than 2 years from menarche, may still be in their growth spurt. They may require higher weight gains during pregnancy to achieve an optimal infant birth weight. There are sufficient uterine supporting structures in the pregnant adolescent. The amnionic fluid is not variable in pregnant adolescents. Blood volume has reached adult proportions in the pregnant adolescent.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Less than 5 pounds b. 6 to 8 pounds c. 9 to 12 pounds d. 13 to 30 pounds

11. How much of the weight gained during a normal pregnancy is accounted for by the fetus?

ANS: B

The growing fetus accounts for only 6 to 8 pounds of the total weight gained. The remainder results from an increase in maternal tissues (e.g., placenta, amniotic fluid, uterus, blood and fluid volume, breasts, and fat reserves).

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

12. The rate of weight gain during pregnancy is expected to be: a. greatest in the first trimester. b. greatest in the second trimester. c. greatest in the third trimester. d. about the same in each trimester.

ANS: B

The rate of weight gain is slow during the first trimester, rapid during the second trimester, and less rapid during the third trimester. Maternal tissue growth accounts for most of the weight gained in the first and second trimesters, whereas fetal growth accounts for weight gained during the third trimester.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

13. During a preventive healthcare visit, Ms. G, an older patient, states that she i s getting shorter. She says that her son mentioned that her change in stature became noticeable to him during hi a i i i h he . He e a ea aigh a d a ig ed. Whe add e i g M . G. present concerns, it is most important to inquire about: a. the number of pregnancies. b. he a e heigh . c. a history of scoliosis. d. her usual height and weight.

ANS: D

Stature declines after 50 years of age because of progressive thinning of the intervertebral di k , i i i a de e i e he a ie heigh a d eigh a hi age a a ba e i e for future trending.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

14. Over the past 2 decades, there has been a trend toward: a. increased osteoporosis. b. preservation of height. c. obesity in older adults. d. preservation of muscle mass.

ANS: C

An increase in overweight and obese older adults has been documented over the past 15 to 20 years. A decrease in weight for height and body mass index has been found with increasing age in patients between 70 and 89 years of age.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

15. Milestone achievements are data most likely to appear in the history of: a. adolescents. b. infants. c. school-age children. d. young adults.

ANS: B

As part of developmental assessment in infants, milestone achievements at certain ages, such as crawling, laughing, picking up their head, and turning over, are recorded.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

16. T e i a e a i di id a f a e i e, he e a i e h d ea e: a. skull circumference. b. the length from the olecranon process to the acromion process. c. elbow breadth. d. hip circumference.

ANS: C

Wi h he a ie s right arm extended and the elbow flexed to 90 degrees, measure the elbow breadth using a measuring device or skinfold calipers, held on the same plane as the upper arm, on the two most prominent bones of the elbow.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. 3 months b. 5 months c. 9 months d. 12 months

17. Healthy term babies generally double their birth weight by what age?

ANS: B

In general, healthy infants double their birth weight by 4 to 5 months of age and triple their birth weight by 12 months of age. Formula-fed infants are heavier after the first 6 months of life than breast-fed infants; they grow faster in the first 6 months of life and experience slower growth in the second 6 months of the first year.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. 6 ounces b. 12 ounces c. 1 pound d. 2 pounds

18. Infants born to the same parents are normally within which range of weight of each other?

ANS: A

Siblings born at term to the same parents usually weigh within 6 ounces of each other.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

19. T ea e head ci c fe e ce, he a e i a ed g a d he chi d head a he occipital protuberance and the: a. supraorbital prominence. b. brow line. c. nasal bridge. d. chin.

ANS: A

The ea i g a e h d be g a ed a d he chi d head a he cci i a protuberance and supraorbital prominence, thereby documenting the largest circumference. Care should be taken to ensure that the tape does not cut the skin. Make the reading to the nearest 0.5 cm or inch, and remember to remeasure the head circumference at least once to check the accuracy of your measurement.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

20. Be ee 5 a d 24 h f ife, he i fa che ci c fe e ce i a : a. about equal to the head circumference. b. greater than head circumference by 2 inches. c. smaller than head circumference by about 4 inches. d. at least 2 inches smaller than head circumference.

ANS: A

Be ee he age f 5 h a d 2 ea , he i fa che ci c fe e ce h d c e approximate the head circumference; the ratio should be monitored so that possible microcephaly can be identified.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

21. I c i ica ac ice, he Ba a d A e e T i ed a e a e b : a. length. b. weight. c. lung maturity. d. gestational age.

ANS: D

The Ballard Assessment Tool assesses six physical and six neuromuscular characteristics and i ad i i e ed i hi 36 h f bi h c fi he e b ge a i a age.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. The child whose weight and height ratios have remained at the 50th percentile b. The child whose weight and height ratios have stayed between the 90th and 95th percentiles c. The child whose weight and height ratios have never been above the 50th percentile d. The child whose weight and height ratios have dropped 15 percentiles since the last visit

22. Which situation poses the most concern?

ANS: D

Over time, interval measurements should demonstrate that the child has establish ed a growth pattern, indicated by consistently following a percentile curve on the growth chart. Greatest concern is for the child who is trending down in a more dramatic fashion. Children who suddenly fall below or rise above their established percentile growth curve should be examined more closely to determine the cause.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

23. The upper-to-lower segment ratio should be calculated: a. bimonthly for the first year of life. b. annually for the first 5 years. c. only when a child is suspected of having a growth problem or unusual body proportions. d. in children of first-generation immigrants.

ANS: C

The upper-to-lower segment ratio is calculated when a child is suspected of having a growth problem or unusual body proportions.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Most adolescent girls will develop breasts before they develop pubic hair. b. Peak height velocity should occur after menarche. c. Breast asymmetry is an abnormal finding. d. Menarche should occur by Tanner breast stage 2.

24. Which statement regarding female pubertal changes is true?

ANS: A

In two-thirds of the population of girls, breasts begin to develop before pubic hair. Peak height velocity actually occurs about 1 year before menarche, breast asymmetry is common, and menarche occurs after Tanner breast stage 2. Peak height velocity will not occur after menarche. Breast asymmetry is not an abnormal finding. Menarche does not generally occur by Tanner breast stage 2.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. 7 years b. 8 years c. 9 years d. 10 years

25. What is the youngest age at which pubic hair growth in the male may be considered normal?

ANS: C

In males, sexual development before 9 years of age is precocious puberty and is considered an abnormal finding; sexual development after 9 years of age is considered normal puberty.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. 1 pound b. 3 pounds c. 2 pounds d. 4 pounds

26. A pregnant woman of normal prepregnancy weight should be expected to gain how much weight per week during the second and third trimesters of pregnancy?

ANS: A

Expected weight gain in the first trimester is variable, between 1 and 2 kg (2 to 4 pounds); however, in the second and third trimesters, weekly weight gain should be around 0.45 kg (1 pound) per week.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

27. A prominent forehead, large nose, large jaw, and elongation of the facial bones and extremities are signs of: a. infantile hydrocephalus. b. acromegaly. c. Cushing syndrome. d. achondroplasia.

ANS: B

A prominent forehead, large nose, large jaw, and elongation of the facial bones and extremities are all prominent characteristics of acromegaly; a prominent forehead can also occur with achondroplasia, but hypoplasia of the midface differentiates the two.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

28. R d face, ea ic a fa , h e ig e a i , a d b ffa h i he e i ce ica area are associated with: a. infantile hydrocephalus. b. acromegaly. c. Cushing syndrome. d. achondroplasia.

ANS: C

Round face, preauricular fat, hyperpigmentation, and a buffalo hump in the posterior cervical area are all commonly associated with Cushing syndrome; the buffalo hump distinguishes Cushing syndrome from the other choices.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Iron b. Thiamin c. Calcium d. Fat

29. Mrs. Raymonds is a 24-year-old patient who has presented for a routine concern over her current weight. In your patient teaching with her, you explain the importance of macronutrients. Which of the following is a macronutrient?

ANS: D

Carbohydrates, protein, and fat are referred to as macronutrients because they are required in large amounts. Iron, thiamin, and calcium are minerals.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Protein b. Carbohydrate c. Fat d. Water

30. Which is the most vital nutrient?

ANS: D

Water is the most vital nutrient. A person can exist without food for several weeks but without water for only a few days.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. 24-hour diet recall b. Food diary c. Computerized nutrient analysis d. Serum protein assay

31. Which f he f i g i he acc a e ef ec i f a i di id a f d i ake?

ANS: B

The food diary is a record of intake as it happens, making this method the most accurate ef ec i f a i di id a f d i ake.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Ascorbic acid b. Vitamin B12 c. Folate d. Fiber

32. Mrs. Hartzell is a 34-year-old patient who has presented for nutritional counseling because she is a vegetarian. Deficiency of which of the following is a concern in the vegetarian diet?

ANS: B

The nutrients that may be deficient in a vegetarian diet, if not carefully planned, include proteins, calcium, iron, vitamin B12, and vitamin D.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Diuretics b. Oral hypoglycemics c. Laxatives d. Steroids

33. Ms. Otten is a 45-year-old patient who presents with a complaint of weight gain. Which medication is frequently associated with weight gain?

ANS: D

Medications that contribute to weight gain include steroids, oral contraceptives, antidepressants, and insulin.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

34. Ms. Davis is a 27-year-old patient with a BMI of 33. Based on her BMI, your diagnosis would be: a. normal body weight. b. overweight. c. obese. d. extremely obese.

ANS: C

An obese BMI is 30 to 39.9. A normal BMI is less than 24. An overweight BMI is 25 to 29.9. An extremely obese BMI is greater than 40.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

35. A 17-year-old girl presents to the clinic for a sports physical. Physical examination findings reveal bradycardia, multiple erosions of tooth enamel, and scars on her knuckles. She appears healthy otherwise. You should ask her if she: a. binges and vomits. b. has regular menstrual periods. c. has constipation frequently. d. is cold intolerant.

ANS: A

In young adults, usually female, bradycardia, knuckle scars, and tooth decay are signs of chronic, self-induced vomiting characteristic of bulimia. Amenorrhea can occur from increased physical activity or anorexia. Constipation and cold intolerance are usu ally symptoms of anorexia nervosa.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

Multiple Response

1. Which are signs and symptoms of hydrocephalus? (Select all that apply.)

a. Early closed suture lines b. Hyperreflexia Y c. Irritable, poor feeding Y d. Does not meet expected height and weight e. Difficulty holding head up Y f. Rapidly increasing head circumference Y

ANS: B, C, E, F

Signs and symptoms of hydrocephalus include hyperreflexia, difficulty holding head up, irritability, lack of energy, rapidly increasing head circumference, and poor feeding. Early closed suture lines and inability to meet expected height and weight do not indicate hydrocephalus.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

Completion

1. An 11-year- d b i b gh i f a a a h ica e a i a i b hi he . The b heigh i 60 i che . Y ec Ma fa d e beca e he b a span is greater than _______________ inches.

ANS: 60

A a ha i g ea e ha a chi d heigh i a cia ed i h Ma fa d e. Chi d e with Marfan syndrome can have cardiovascular problems and should be thoroughly evaluated.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

2. Infants normally increase their birth length by ____% during the first year of life.

ANS: 50

Infant length generally increases by 50% in the first year of life.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

3. The term large for gestational age (LGA) indicates that an infant is larger than ____% of i fa b a he a e be f eek ge a i .

ANS: 90

LGA corresponds to an infant whose weight is classified as greater than the 90th percentile.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 09: Skin, Hair, and Nails

Multiple Choice

1. The skin repairs surface wounds by: a. exaggerating cell replacement. b. excreting lactic acid. c. producing vitamins. d. providing a mechanical barrier.

ANS: A

The skin s tissue cells have a rapid rate of turnover and constant renewal, thereb enabling the skin to repair damaged surfaces.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

2. The adipose tissue in the hypodermis serves to: a. provide sensory input. b. generate heat and insulate. c. create tensile strength. d. secrete collagen.

ANS: B

The hypodermis layer consists of adipose tissue that serves to generate heat and provide insulation, shock absorption, and a reserve of calories.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

3. The secretory activity of the sebaceous glands is stimulated by: a. body heat. b. ambient temperature. c. sex hormones. d. dietary protein.

ANS: C

The sebaceous glands, when stimulated by the sex hormones, produce a lipid-rich substance that keeps the skin moist.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Cuticle b. Perionychium c. Matrix d. Nail bed

4. Mrs. Tuber is a 36-year-old patient who comes into the health center with complaints that her fingernails are not growing. Which structure is the site of new nail growth?

ANS: C

The white crescent-shaped area beyond the proximal nail fold is called the matrix, which is the site of new nail growth.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

5. Mrs. Leonard brings her newborn infant into the pediatrician s office for a first well -baby visit. As the healthcare provider, you teach her that newborns are more vulnerable to hypothermia because of: a. the presence of coarse terminal hair. b. desquamation of the stratum corneum. c. their covering of vernix caseosa. d. a poorly developed subcutaneous fat layer.

ANS: D

Newborns have a poorly developed subcutaneous fat layer and therefore have a reduced ability to generate heat.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

6. Mrs. Mulligan brings her 16-year-old son into the office for a sports physical examination. As the healthcare provider, you explain that normal hormone-related changes of adolescence include: a. increased oil production. b. slowed hair growth. c. depleted apocrine glands. d. decreased sebaceous gland activity.

ANS: A

During adolescence, the sebaceous glands increase sebum production, which causes the skin to have an oily appearance and predisposes the individual to acne.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

7. Expected hair distribution changes in older adults include: a. increased terminal hair follicles on the scalp. b. more prominent axillary and pubic hair production. c. increased terminal hair follicles to the tragus of men s ears. d. more prominent peripheral extremity hair production.

ANS: C

The transition from a vellous to terminal hair pattern occurs in older men at the nares and tragus.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

8. Brittle nails are typical findings in: a. adolescents. b. infants. c. pregnant women. d. older adults.

ANS: D

Older adults typically have decreased peripheral circulation to the nails, causing the nails to develop longitudinal ridges that are more brittle and susceptible to splitting into layers.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

9. Mrs. Franklin is a 68-year-old patient who presents to the office with a complaint that her nails do not seem to be growing. As the healthcare provider, you explain to her that the nails of older adults grow slowly because of: a. decreased circulation. b. dietary deficiencies. c. fungal infections. d. low hormone levels.

ANS: A

Decreased circulation to the nails of older adults causes nail growth retardation.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

10. As part of your health promotion education for a new patient, you explain that the risk factors for skin cancer include: a. an olive complexion. b. repeated trauma or irritation to skin. c. history of allergic reactions to sunscreen. d. dark eyes and hair.

ANS: B

Fair-skinned persons with light eyes with repeated trauma or skin irritation have higher risk factors for skin cancer development.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

11. The type and brand of grooming products used are important to the health history of: a. adolescents. b. everyone. c. older adults. d. persons with rashes.

ANS: B

Knowledge of exposure to environmental chemicals is valid health history data for all age groups, not just adolescents, older adults, or persons with rashes.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

12. Mr. Donalds is a 45-year-old roofer. Your inspection to determine color variations of the skin is best conducted: a. using an episcope. b. under fluorescent lighting. c. with illumination provided by daylight. d. using a Wood s light.

ANS: C

Daylight provides the best illumination source for determining color variations of the skin.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

13. Tangential lighting is best used for inspecting skin: a. color. b. contour. c. exudates. d. symmetry.

ANS: B

Tangential lighting light shined laterally to the surface is best for inspecting skin contour.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

14. Unusual white areas on the skin may be caused by: a. adrenal disease. b. polycythemia. c. vitiligo. d. Down syndrome.

ANS: C

The absence of melanin produces unpigmented white areas known as vitiligo.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Native Americans b. African Americans c. Mexican Americans d. Asians

15. Which cultural group has the lowest incidence of nevi?

ANS: B

Nevi are more common in persons who burn, rather than tan; therefore, African Americans have the lowest rates of nevi.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

16. You are inspecting the lower extremities of a patient and have noted pale, shiny skin of the lower extremities. This may reflect: a. systemic disease. b. a history of vigorous exercise. c. peptic ulcer disease. d. mental retardation.

ANS: A

Pale, shiny skin of the lower extremities may reflect peripheral changes that occur with systemic disorders, such as diabetes mellitus and cardiovascular disease.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Whether she had unprotected sex b. Whether she has a history of diabetes mellitus c. Whether she had unusual bleeding problems d. Whether she eats a lot of yellow and orange vegetables

17. A 29-year-old white woman appears jaundiced. Liver disease as a cause has been excluded. What history questions should the nurse ask?

ANS: D

In the absence of liver disease, another cause of jaundice is increased carotene pigmentation. Diets high in carrots, sweet potatoes, and squash are high in carotene and can make the skin appear to be jaundiced. Whether she had unprotected sex, a history of diabetes mellitus, or unusual bleeding problems would not be relevant when assessing the jaundiced skin.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

18. Mrs. Bower is a 39-year-old patient who has come to the office for a routine physical examination. As a healthcare provider, you know that the skin temperature is best assessed with the: a dorsal surface of the e aminer s hand. b. palmar surface of the e aminer s hand. c. ulnar surface of the e aminer s hand. d. pads of the e aminer s fingers.

ANS: A

The dorsal surface of the hand is best for estimating temperature variations.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

19. You are examining a pregnant patient and have noted a vascular lesion. When you blanch over the vascular lesion, the site blanches and refills evenly from the center outward. The nurse documents this lesion as a: a. telangiectasia. b. spider angioma. c. petechiae. d. purpura.

ANS: B

Spider angiomas are dilated arterioles. A network of dilated capillaries radiate from the center arteriole, outward like a spider s legs. Spider angiomas are oft en associated with high estrogen levels, as occur in pregnancy. Blanching over the center is followed by a rapid return of redness from the center outward. Telangiectasias refill erratically. Petechiae and purpura do not blanch.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

20. Small, minute bruises are called: a. ecchymoses. b. petechiae. c. spider veins. d. telangiectasias.

ANS: B

Petechiae are smaller than 0.5 cm in diameter. Ecchymoses are larger than 0.5 cm in diameter. Spider veins and telangiectasias are vascular lesions.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

21. A flat, nonpalpable lesion is described as a macule if the diameter is: a. larger than 1 cm. b. smaller than 1 cm. c. 3 cm exactly. d. too irregular to measure.

ANS: B

A macule, by definition, is a flat, circumscribed area smaller than 1 cm in diameter and is measurable. An example of a macular rash is measles.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

22. Mrs. Britton is a 34-year-old patient who presents to the office with complaints of skin rashes. You have noted a 4.3-cm, rough, elevated area of psoriasis. This is an example of a: a. plaque. b. patch. c. macule. d. papule.

ANS: A

A plaque, by definition, is an elevated, firm, rough lesion with a flat top surface larger than 1 cm in diameter, as seen in someone with, for example, psoriasis.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

23. Skin turgor checks are performed to determine the: a. temperature of the skin. b. hydration status. c. actual age. d. extent of an ecchymosis.

ANS: B

Skin will remain tented if the patient is dehydrated or will not tent if edema is present.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

24. You have just completed a skin assessment on Mr. Baker. During your assessment, you have transilluminated a skin lesion. During the physical examination, you know that skin lesions are transilluminated to distinguish: a. vascular from nonvascular lesions. b. furuncles from folliculitis lesions. c. fluid-filled lesions from solid cysts or masses. d. herpes zoster from varicella.

ANS: C

Transillumination is used to determine the presence of fluid in cysts and masses. Fluid-filled lesions will transilluminate with a red glow, and solid masses will not transilluminate.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

25. Fluorescing lesions are best distinguished using a(n): a. incandescent lamp. b. magnifying glass. c. transilluminator. d. Wood s lamp.

ANS: D

Fluorescing lesions (e.g., some tinea lesions) show a characteristic yellow -green color under a Wood s lamp.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

26. Women with terminal hair growth in a male distribution pattern should receive further evaluation for a(n): a. circulation condition. b. endocrine disorder. c. inflammatory state. d. nutritional deficit.

ANS: B

Hirsutism in women (growth of terminal hair in a male distribution) can be a clinical sign of an endocrine disorder. Hair loss can be associated with poor circulation, inflammation, or nutritional deficits.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Dark bands seen on all fingernails of a dark-skinned person b. Yellow discoloration of the great toe of an older adult c. Single dark band in a white adult d. Pits in both index fingernails of an adult

27. Which nail change found on examination would be most alarming?

ANS: C

Dark bands in a dark-skinned person are normal; yellow in the toe of an older adult can represent a nail disease or a chronic respiratory condition; and pits are related to psoriasis. A single dark band in a white adult indicates a more serious condition melanoma.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

28. Transient mottling of the patient s skin in a cool room is a common finding in: a. menopausal women. b. newborn infants. c. pregnant women. d. sedentary adults.

ANS: B

Cutis marmorata, a mottled appearance, is part of the newborn s response to changes in temperature.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

29. A single transverse line seen in the palm of a small child may imply: a. Down syndrome. b. Turner syndrome. c. systemic sclerosis. d. profound dehydration.

ANS: A

The simian line, a single transverse crease, is seen on the palm of children with Down syndrome.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

30. Cafe au lait patches are numbered with each assessment of infants and young children because: a. the numbers are expected to increase each year. b. coalescent lesions are a more serious finding. c. the presence of six or more patches suggests neurofibromatosis. d. decreasing numbers are expected with growth.

ANS: C

The presence of six or more patches with diameters larger than 1 cm in children younger than 5 years of age suggests neurofibromatosis. Fewer than five patches is usually considered harmless. The numbers of cafe au lait patches are not expected to increase each year.

Coalescent lesions are not a more serious finding. Decreasing numbers are not expected with growth.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

31. A Dennie-Morgan fold is probably caused by: a. birth trauma. b. high fever. c. excess adipose tissue. d. chronic rubbing.

ANS: D

Persons with chronic atopic or allergic conditions tend to rub the eyes sufficiently to cause an extra crease or pleat of skin below the eye, called the Dennie-Morgan fold.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

32. Linea nigra is commonly found on the abdomens of: a. infants and children. b. adolescents. c. pregnant patients. d. older adults.

ANS: C

Pregnant patients commonly develop pigmentation of the abdomen from the symphysis pubis to the top of the fundus in the midline.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

33. Cherry angiomas are a common finding in: a. adults older than 30 years. b. newborns. c. pregnant women. d. sunbathers.

ANS: A

Cherry angiomas occur in almost everyone older than 30 years and increase numerically with age.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

34. Pigmented, raised, warty lesions over the face and trunk should be assessed by an experienced practitioner who can distinguish: a. cutaneous tags from lentigines. b. furuncles from folliculitis. c. sebaceous hyperplasia from eczema. d. seborrheic keratoses from actinic keratoses.

ANS: D

Actinic keratoses have malignant potential, and seborrheic keratoses do not. Because they can look similar, an experienced practitioner should make the determination.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

35. Age spots are also called: a. seborrheic keratoses. b. solar lentigines. c. cutaneous horns. d. acrochordon.

ANS: B

Solar lentigines are irregular, round, gray-brown lesions with a rough surface that occur in sun-exposed areas and are referred to as age spots.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

36. The most common inflammatory skin condition is: a. cutis marmorata. b. eczematous dermatitis. c. intradermal nevus. d. pityriasis rosea.

ANS: B

The most common inflammatory skin disorder is eczematous dermatitis.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Pityriasis rosea b. Psoriasis c. Tinea corporis d. Rosacea

37. Which is a noncandidal fungal infection?

ANS: C

Tinea corporis is the only listed fungal infection (noncandidal); the others are not fungal in origin.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

38. The characteristic that best differentiates psoriasis from other skin abnormalities is the: a. color of the scales. b. formation of tiny papules. c. general distribution over the body. d. recurrence.

ANS: A

Unlike other skin conditions, silvery papules and plaques characterize psoriasis.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

39. Painful vesicles are associated with: a. psoriasis. b. pityriasis rosea. c. paronychia. d. herpes zoster.

ANS: D

Herpes zoster (shingles) produces painful itching or burning of the dermatome area.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Teach infectious control measures. b. Inquire about another recent skin lesion. c. Inspect the palms and the soles. d. Inform the patient that this will resolve within a week.

40. A 17-year-old student complains of a rash for 3 da s. You note pale, er thematous oval plaques over the trunk. They have fine scales and are arranged in a fernlike pattern, with parallel alignment. What is the nurse s ne t action?

ANS: B

The described rash is the typical presentation of pityriasis rosea. The rash is not infectious or contagious, does not involve the palms and soles, and usually lasts for several weeks.

Pityriasis rosea begins with a sudden primary (herald) patch, with generalized eruption to the trunk and extremities following 1 to 3 weeks later.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Asymmetric borders b. Borders well demarcated c. Color of lesion is uniform d. Diameter less than 6 mm

41. Which of the following is an ABCDE characteristic of malignant melanoma?

ANS: A

ABCD melanoma mnemonic includes asymmetry, borders that are irregular, color that is not the same all over, diameter larger than 6 mm and growing, and evolution.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

42. The most common cutaneous neoplasm is: a. basal cell carcinoma. b. compound nevus. c. seborrheic keratosis. d. senile actinic keratosis.

ANS: A

Basal cell carcinoma is the most common form of skin cancer. It occurs more frequently on sun-exposed parts of the body.

DIF: Cognitive Level: Remembering (Knowledge)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

43. Soft, painless, bluish papules in persons who are HIV-positive are most likely: a. Kaposi sarcoma. b. malignant melanoma. c. molluscum contagiosum. d. pityriasis rosea.

ANS: A

Kaposi sarcoma is the more common malignant skin lesion of HIV-infected persons. The lesions are soft, painless, bluish purple macules or papules.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Teach infectious control measures. b. Inquire about other patterns of physical abuse. c. Inspect the buccal mucosa for Koplik spots. d. Inform the parent that this will resolve within a couple of days.

44. A 5-year-old child presents with discrete vesicles on an erythematous base that began near her scalp and are spreading to the trunk. The child has a low-grade fever and feels tired. What is the nurse s ne t action?

ANS: A

The description of this child s complaint is a varicella rash, not ph sical abuse or rubeola. Chickenpox is a highly communicable disease and can be prevented by immunization. The period of communicability lasts from 1 or 2 days before onset of the rash until all the vesicles have crusted over, which usually takes about 1 week. This is not physical abuse. Inspecting the buccal mucosa for Koplik spots will not diagnose the problem. This will not resolve within a couple of days.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Exanthem b. Impetigo c. Solar keratoses d. Trichotillomania

45. During history taking, a mother states that her son awoke in the middle of the night complaining of intense itching to his legs. Today, your inspection reveals a honey-colored exudate from the vesicular rash on his legs. Which condition is consistent with these findings?

ANS: B

Impetigo causes intense pruritus, regional lymphadenopathy, and honey -colored exudative crusting as the vesicles or bullae rupture and dry.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Recent bruising over both knees b. A healed laceration under the chin c. A bruise on the right shin with associated abrasion of tissue d. Bruises in various stages of resolution over body soft tissues

46. You are conducting a preschool examination on a 5-year-old child. Which injury would most likely raise your suspicion that the child is being abused?

ANS: D

Toddlers and older children who bruise themselves accidentally do so over bony prominences, like the knees, chin, and shin. Bruises over soft tissues are more consistent with abuse.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

47. Assessment of poor hygiene, healed fractures with deformity, or unexplained trauma in older adults indicates: a. sexual abuse. b. physical neglect. c. psychological abuse. d. violated rights.

ANS: B

Physical neglect is described as the most common form of elder abuse.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Flat b. Convex c. Concave d. Bowed

48. The nurse assesses the nail base angle using the Schamroth technique. Which nail bed shape indicates a normal expected examination finding?

ANS: C

The normal nail base angle should be 160 degrees, which results in a concave nail base that produces a diamond-shaped window with the Schamroth technique.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

Multiple Response

1. Which identify the signs and symptoms of basal cell cancer? (Select all that apply.)

a. Itching b. Reddish patch c. Starts from a nevi d. Various clinical forms cystic, nodular, pigmented e. Macule type

ANS: A, B, D

Common signs and symptoms of basal cell carcinoma include a, pink, red, tan, white, black, or brown shiny nodule, in a variety of clinical forms, which may be crusted and itching.

DIF: Cognitive Level: Applying (Application)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation