Which finding, obtained during a skin assessment, should the school nurse report to the healthcare provider?

Multiple maculopapular pustules over forehead and chin on an adolescent.

Bilateral patellar abrasions with eschar formation on a preschool-aged child.

Red, swollen, painful nodule located on upper back on a school-aged boy.

Small, white flecks on the hair shafts throughout scalp on a school-aged girl.

Answer and Explanation

The Correct Answer is A

A.   Multiple maculopapular pustules over the forehead and chin are suggestive of acne vulgaris or possibly another dermatologic condition that may require medical intervention. If the pustules are widespread or persistent, it should be reported for further evaluation.
B.   Bilateral patellar abrasions with eschar formation are common in children and are usually non- threatening unless there are signs of infection. This finding may not require immediate reporting unless the condition worsens.
C.   A red, swollen, painful nodule on the upper back is likely a boil or abscess, but it’s important to consider the overall presentation and if there is a risk for systemic infection. This may not need immediate reporting unless symptoms worsen.
D.   Small, white flecks on the hair shafts indicate possible head lice, which, while needing treatment,
doesn’t require immediate reporting unless there is a larger health concern associated with it.

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Correct Answer is D

Explanation

A. Borborygmi refers to the audible rumbling sounds produced by the movement of gas through the intestines. While these sounds may be present in this case, they are more commonly described as prolonged, loud, or audible sounds, not as typical gurgles occurring at the interval described.
B. Hyperactive bowel sounds are frequent and loud, often heard in conditions like diarrhea or early bowel obstruction. The described pattern here, with sounds occurring every 5 to 10 seconds, doesn't necessarily suggest hyperactivity.
C. Hypoactive bowel sounds are reduced or absent, commonly seen in conditions like ileus or bowel obstruction. The sounds described here are not consistent with hypoactive sounds, which would be faint or absent.
D. The description provided aligns with normal bowel sounds, which are intermittent and occur every 5 to 30 seconds in a healthy individual. This pattern of gurgles with the stated frequency is typical of normal bowel function.

A. Tenting noted in subclavicular area. B. Loss of skin elasticity in the hand. C. Skin is warm and dry. D. Thinning hair in the lower extremities.

Correct Answer is A

Explanation

A. Tenting of the skin is a classic sign of dehydration. When the skin is pinched and does not return quickly to its normal position, it indicates a lack of fluid in the body. This is a common finding in dehydration, particularly in older adults.
B. Loss of skin elasticity is a natural part of the aging process and may not be directly related to dehydration. It is common in older adults and is not necessarily an indicator of fluid status.
C. Warm and dry skin can be a sign of dehydration, particularly if accompanied by other symptoms such as a dry mouth or increased heart rate. Dry skin occurs when there is insufficient moisture in the body, which is common in dehydration.
D. Thinning hair in the lower extremities is more often associated with circulation issues or aging. It is not a typical sign of dehydration and would not be used as a primary indicator for assessing hydration status.

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Which finding, obtained during a skin assessment, should the school nurse report to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While auscultating for bowel sounds in an adult client, the nurse notes a series of gurgles that last about 3 seconds and occur every 5 to 10 seconds in all quadrants. How should the nurse document this finding?

Correct Answer is D

Explanation

When assessing an older adult client, which finding is most indicative of dehydration?

Correct Answer is A

Explanation

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

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