The nurse asks a 50-year-old female client what her natural hair color is. The client replies, "I've been dyeing my hair for so long, I'm not even sure... I just know that this month it's ravishing red." Based on this information, the nurse expects to obtain which finding when palpating this client's scalp hair?

Excess vellus hair.

Fine, thin, limp texture.

Receding front hairline.

Coarse, dry, brittle texture.

Answer and Explanation

The Correct Answer is D

A. Vellus hair is fine, short, and lightly pigmented hair that covers most of the body. It is not typically associated with the effects of hair dye or chemical treatments. Excess vellus hair would be unusual in this context and is not related to the typical outcomes of hair dyeing.
B. Fine, thin, and limp hair can be a result of chemical damage from hair dyeing and other treatments. Hair that has been subjected to frequent dyeing and chemical processing can lose its strength and texture, becoming weaker and less resilient. This finding is consistent with the impact of repeated hair dyeing.
C. A receding front hairline is typically associated with genetic factors and androgenic alopecia (pattern baldness) rather than the effects of hair dyeing. Although hair loss can be influenced by various factors, including chemicals, a receding hairline is not a direct consequence of dyeing hair.
D. Coarse, dry, and brittle hair is a common result of frequent chemical treatments, including hair dyeing. Chemicals in hair dyes can strip moisture from the hair, leading to a rough texture, breakage, and brittleness. This finding is consistent with long-term use of hair dye and chemical processing.

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Correct Answer is D

Explanation

A. A painful ulcerated mucosal area inside the cheek that has been present for only 1 day is concerning but less alarming in the short term compared to chronic lesions. Acute ulcers can be caused by minor trauma, infections, or canker sores. While it is important to monitor and evaluate these lesions, especially if they persist or worsen, a duration of only 1 day typically suggests it might be related to a transient condition.
B. Stippled gingival margins that adhere firmly to the teeth can indicate gingival hyperplasia or certain systemic conditions like vitamin deficiencies. While this finding can be concerning and warrants further investigation into oral health or potential systemic issues, it is generally less urgent compared to other findings that may indicate malignancy or severe chronic conditions.

C. Small yellowish-white lesions on the buccal mucosa could be oral leukoplakia or aphthous ulcers, which can be benign or related to underlying conditions. While these lesions need to be assessed to determine their cause, they are usually less immediately concerning than persistent ulcers that could indicate more serious issues.
D. An ulceration under the tongue that has been present for three weeks is the most concerning finding. Chronic oral ulcers, especially those persisting for more than two weeks, can be indicative of serious conditions such as oral cancer or other malignancies. Persistent lesions warrant thorough investigation to rule out or address potential malignancy or other significant pathologies.

A. Ask about pain while bearing weight. B. Determine level of consciousness. C. Observe for deformity of the spine. D. Measure orthostatic blood pressure.

Correct Answer is A

Explanation

A. A limping gait can be a sign of pain or discomfort while walking. By asking about pain while bearing weight, the nurse can get a better understanding of the underlying cause of the limp.
B. A limping gait is not typically associated with changes in level of consciousness. This assessment is not relevant in this situation.

C. While a spinal deformity can cause a limping gait, it is not the most likely cause in this case. The nurse should first assess for pain while bearing weight to get a better understanding of the underlying issue.
D. Orthostatic blood pressure is a measure of blood pressure changes when a person stands up. It is not typically associated with a limping gait and is not relevant in this situation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which finding should raise the greatest concern for a nurse who is performing an ear nose and throat (ENT) examination?

Correct Answer is D

Explanation

During the admission assessment, the nurse observes that a client has a limping gait. Which assessment should the nurse complete next?

Correct Answer is A

Explanation

The nurse reorients a male client to the correct time, day, date, and location, but he is only able to remember his name and where he is. Based on these findings, which should the nurse document?

The nurse is completing an assessment for a client with uncontrolled diabetes mellitus (DM) who came to the clinic reporting frequent, painful urination. Which screening test should the nurse perform first?

During a routine health screening of an adult female, the nurse notes several changes that have occurred over the past year. Which change indicates the need for a bone density screening?

A client who recently underwent a routine surgical procedure made a dinic appointment. To elicit the most information, which question is best for the nurse to ask this client?

The nurse assesses a client with a sleep pattern disturbance. In developing a plan of care, what assessment data should the nurse obtain first?

During a routine physical examination of a middle-aged female client, chest palpation is determined to be normal except for a 2 inch diameter area of crepitus over the upper right anterior chest. Which is the most accurate interpretation of this finding?

The nurse is assessing the visual acuity of a client who reports changes in vision. How many feet away from the Snellen chart should the client stand? (Enter a whole number only.)

While the nurse is taking a health history, the client announces, "I don't have time for this. This is a waste of time. I need treatment." Which response is best for the nurse to provide?