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

Stage III

Stage II

Stage I

Stage IV

Answer and Explanation

The Correct Answer is D

A. Stage III: This stage involves full-thickness tissue loss extending through the subcutaneous layer but does not typically present as a blister-like superficial wound.

B. Stage II: This stage is characterized by partial-thickness skin loss involving the epidermis and/or dermis, often presenting as a blister or superficial ulcer.

C. Stage I: Stage I pressure ulcers involve intact skin with non-blanchable redness, not a break in the skin or blister.

D. Stage IV: This stage involves full-thickness tissue loss with extensive destruction, potentially exposing bone or muscle, not a superficial blister.

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Correct Answer is B

Explanation

A. Ears: Evaluation of the ears is primarily concerned with hearing and balance, which involve cranial nerves such as VIII (Vestibulocochlear), not IX, X, and XII.

B. Mouth and throat: Cranial nerves IX (Glossopharyngeal), X (Vagus), and XII (Hypoglossal) are assessed through the examination of the mouth and throat. CN IX and X are evaluated by checking the gag reflex and the ability to swallow, while CN XII is assessed by examining tongue movements.

C. Head and face: The assessment of the head and face generally involves cranial nerves V (Trigeminal) and VII (Facial), which control facial sensation and movement, rather than IX, X, and XII.

D. Mental status examination: While mental status is crucial for overall health assessment, it does not specifically target cranial nerves IX, X, and XII.

A. It is easiest for the client to learn B. It takes the least amount of time C. It causes the least amount of pain D. It is the best technique to detect masses

Correct Answer is D

Explanation

A. It is easiest for the client to learn: While the ease of learning is important, the primary goal is effective detection of masses.

B. It takes the least amount of time: The time taken is less critical than the effectiveness of the technique in detecting abnormalities.

C. It causes the least amount of pain: Minimizing pain is not the main reason for choosing a particular technique; effectiveness in detecting masses is more critical.

D. It is the best technique to detect masses: The recommended pattern, often the vertical strip or circular pattern, is chosen because it is the most effective way to systematically cover the breast tissue and increase the likelihood of detecting abnormalities or masses.

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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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing a head-to-toe assessment, during which part would the nurse evaluate cranial nerve (CN) IX, X, and XII?

Correct Answer is B

Explanation

The nurse instructs a female client on breast self-examination. Why does the nurse recommend the pattern shown for the client to use?

Correct Answer is D

Explanation

Before completing the physical examination, the nurse determines that the client is awake, alert, and oriented. This information would be important for which part of the general survey?

The nurse is performing the technique shown. What is the nurse assessing?

The nurse is asking the client about the health of her parents, siblings, and grandparents. This is part of the health history and is done for what reason?

The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of?

What eye function is the nurse preparing to assess when the client is asked to stand 20 feet from a specific chart that is mounted on the examination room wall?

When the nurse collects objective data, which finding requires immediate follow-up?

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply.)

A client asks the nurse about the function that the lymph system plays in the body. Which of the following would be most appropriate for the nurse to include when responding to the client?