A patient reports chronic itching of the ankles and continuously scratches the area. Which assessment finding will the nurse expect?
a. Hypertrophied scars on both ankles
b. Thickening of the skin around the ankles
c. Yellowish-brown skin around both ankles
d. Complete absence of melanin in both ankles
ANS: B
Lichenification is likely to occur in areas where the patient scratches the skin frequently. Lichenification results in thickening of the skin with accentuated normal skin markings. Vitiligo is the complete absence of melanin in the skin. Keloids are hypertrophied scars. Yellowish-brown skin indicates jaundice. Vitiligo, keloids, and jaundice do not usually occur as a result of scratching the skin.
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A pregnant woman's mother is worried that her daughter is not "big enough" at 20 weeks. The nurse palpates and measures the fundal height at 20 cm, which is even with the woman's umbilicus
What should the nurse report to the woman and her mother? a. "The body of the uterus is at the belly button level, just where it should be at this time." b. "You're right. We'll inform the practitioner immediately." c. "When you come for next month's appointment, we'll check you again to make sure that the baby is growing." d. "Lightening has occurred, so the fundal height is lower than expected."
A client is admitted with the diagnosis of fever of unknown origin. Which of the following diagnostic tests will the nurse expect the client to have performed? (Select all that apply.)
1. Complete blood count 2. Urinalysis 3. Chest x-ray 4. Bone scan 5. CT scan of the abdomen
The nurse is assessing a child admitted to the hospital for abdominal pain. Which of the following findings by the nurse would be typical of those seen in appendicitis?
a. anorexia, nausea, and vomiting preceded the pain according to the history provided by the caregivers b. a subnormal temperature for the last 2 days c. pain that was vague and somewhat localized to the periumbilical area and gradually migrated to the right lower quadrant d. night time chills for 1 week
Bonding between mother and child usually
a. Occurs soon after birth b. Occurs gradually over the first weeks c. Builds over the first year d. Occurs at the same time as attachment