Cumulative Exam: Physical Assessment
While assessing edema on a male patient's lower leg, the nurse notices that there is a slight (2 mm) imprint of his fingers where he palpated the patient's leg. How does the nurse document this finding?
1+ edema
Which patient would be expected to experience acute pain? a. A patient who had abdominal surgery 8 hours ago b. A patient who has cancer and has been receiving treatment for 4 months c. A patient who states that he or she has lived with severe pain for many years d. A patient who has been treated unsuccessfully over the past year for back pain
A. A patient who had abdominal surgery 8 hours ago
Which question is the most appropriate to learn about a patient's religious practices? a. "How often do you go to church?" b. "Where is your church located?" c. "Do you mind telling me about your religion?" d. "Do you have any specific religious or spiritual practices or beliefs?"
d. "Do you have any specific religious or spiritual practices or beliefs?"
A nurse dorsiflexes a patient's right ankle 90 degrees and then uses a reflex hammer to strike the appropriate tendon. What is the expected response for this deep tendon reflex? a. Extension of the right lower leg b. Plantar flexion of the right toes c. Dorsiflexion of the right foot d. Plantar flexion of the right foot
D
A nurse is having difficulty auscultating a patient's heart sounds because the lung sounds are too loud. What does the nurse ask the patient to do to improve hearing the heart sounds? Lie in a supine position Hold his or her breath for a few seconds. Sit up and lean forward. Cough.
Hold his or her breath for a few seconds.
A nurse is auscultating the lungs of a healthy male patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding?
Hold stethoscope firmly to prevent movement when placed over chest hair.
How does a nurse assess the eversion and inversion of a patient's ankle? a. For eversion, ask the patient to turn the sole of the foot away from the body and for inversion turn the sole of the foot toward the midline. b. For eversion, ask the patient to turn the sole of the inward toward the midline and for inversion turn the sole of the foot away from the body. c. For eversion, ask the patient to walk on his toes and, for inversion, to walk on his heels. d. For eversion, ask the patient to point the toes forward and, for inversion, to point the toes backward.
A This is the correct maneuver for eversion and inversion of the ankle.
When auscultating the heart of a patient with pericarditis, the nurse expects to hear which sound? a. A systolic murmur b. An S3 heart sound c. A friction rub d. An S4 heart sound
A friction rub
A nurse assesses a patient with a head injury who has slowing intellectual functioning, personality changes, and emotional lability. The nurse correlates these findings with which area of the brain? a. Frontal lobe b. Parietal lobe c. Thalamus d. Temporal lobe
A frontal lobe
During a physical examination, the nurse notes that the patient's skin is dry and flaking, with patches of eczema. Which nutritional deficiency might be present? A. Protein B. Essential fatty acid C. Vitamin B D. Vitamin C
Answer: B Dry and scaly skin is a manifestation of essential fatty acid deficiency. Vitamin C deficiency causes bleeding gums, arthralgia, and petechiae. Vitamin B deficiency is too large a category to consider. Specific categories of vitamin B deficiency have been identified, such as pyridoxine and thiamine. Protein deficiency causes decreased pigmentation and lackluster hair.
Which characteristics are risk factors for cerebrovascular accident? (Select all that apply.) A. hypertension B. hypocholesterolemia C. smoking D. history of coronary artery diseases E. diabetes melitus
Answers: A, C, D, and E
A nurse is caring for a woman who has given birth to a healthy baby. The woman's husband and mother are in the room, and more family members are in the lobby. Which comment by the nurse demonstrates culturally competent care?
Are there any ceremonies or other practices that are important to you at at this time
A nurse auscultates low-pitched, coarse snoring sounds in a patient's lungs during inhalation. What is the most appropriate action for the nurse to take at this time?
Ask the patient to cough and repeat auscultation
After collecting the data, the nurse begins data analysis with which action?
clustering data
What sound does a nurse expect to hear when using the bell of the stethoscope over the epigastric area of the abdomen of a healthy patient? a. Bowel sounds b. Venous hum c. Soft, low-pitched murmur d. No sounds
d. No sounds
To document the palpation of a pulse, the nurse is correct in making which notation about the rhythm? "Rhythm noted at +2" "Bounding rhythm" "Rhythm 100 beats/min" "Irregular rhythm"
irregular rhythm
A patient tells the nurse that she has smoked 2 packs of cigarettes a day for 20 years. The nurse records this as how many pack-years?
40 pack-years
Which patient has the least risk for unhealthy fat distribution?
?
With the patient lying supine, a nurse raises the patient's leg to flex the hip. The patient complains of pain when the leg is raised to 40 degrees. The nurse correlates this finding with which disorder? a. Lumbar nerve compression b. Cervical disk herniation c. Osteoarthritis d. Bursitis
A
A nurse is assessing a patient who complains of awful abdominal pain and rates it as a 9 on a scale of 0 to 10. Which of the following physiologic signs may accompany acute pain? (Select all that apply.) a. Tachycardia b. Irritability c. Increased blood pressure d. Depression e. Insomnia f. Sweating
A C F
Which patient needs to be taught about how diet and exercise can lower lipids to reduce the risk for coronary artery disease?
A patient with Elevated low-density lipoproteins (LDL) Elevated LDLs contain more cholesterol than any of the other lipoproteins and have an affinity for arterial walls. Elevated LDL levels correlate most closely with an increased incidence of atherosclerosis and CAD.b.
In teaching the group of patients about osteoporosis, the nurse identifies which one of these participants as having the highest risk for this disease?
A small boned, thin white American woman
Which action by the nurse results in the patient's blood pressure measurement being falsely high?Select all that apply. a. Using a blood pressure cuff that is too narrow for the patient's upper arm b. Deflating the blood pressure cuff too rapidly c. Wrapping the blood pressure cuff too loosely d. Reinflating the blood pressure cuff before it completely deflates e. Positioning the patient's arm above the level of the heart
A,C,D
Match the term to the characteristics of the adventitious lung sound. 1. Discontinuous sound. Due to airways and alveoli popping open. Most often heard during inspiration. If fine crackles: atelectasis. If harsh crackles (bubbling): CHF/secretions. Lung Collapse. 2.Continuous sound. High pitched whistle. Usually heard on expiration. Prolongs the expiratory sound. Common with: asthma, COPD, CHF (cardiac asthma). 3. Continuous sound. Often during expiration. Prolongs expiratory sound. Considered to be central airway sounds. Low pitch wheeze. A snoring/groaning type of sound, harsh - sonorous wheeze. 4. Due to inflammation of the visceral and parietal pleurae - the two membranes rub together. Leather-on-leather sound. Heard on I and E. Intensity increases with deeper breaths. A.Crackles B.Wheeze C. Rhonchi D. Pleural friction rub
A. 1 B. 2 C. 3 D. 4
Match the following term to the appropriate definition of primary skin lesions. 1. A flat, small (1 centimeter or less) lesion with color change. Seen in rubeola, rubella, scarlet fever, roseola infantum. 2. An elevated, sharply circumscribed, small (1 centimeter), colored lesion. May be pink, tan, red, or any variation. Seen in ringworm and psoriasis. 3. A bulging, small (under 1 centimeter), sharply defined lesion filled with clear, free fluid. Seen as groups in herpes simplex, varicella, poison ivy, and herpes zoster. 4. A palpable, solid lesion, greater than 1 cm in diameter. These are usually found in the dermal or subcutaneous tissue, and the lesion may be above, level with, or below the skin surface. 5. A well-circumscribed, elevated, superficial, solid lesion, greater than 1 cm in diameter. A. Macule B. Papule C. Plaque D. Nodule E. Vesicle
A. 1 B. 2 C. 5 D. 4 E. 3
In the labor and delivery department, the nurse notices that two women who are in labor are responding differently to their contractions. The first woman, who is having her first baby, has rated her pain as a "7," seems agitated, and has asked for pain medication. The second woman, who is having her third baby, has also rated her pain as a "7," but is calmer and says she does not need anything for pain at this time. What explains the differences in the outward responses to pain between these women? a. Pain tolerance b. Pain threshold c. Nociception d. Physiologic stress
A. Pain Tolerance
Which questions are appropriate to ask a patient when performing a symptom analysis for a rash? (Select all that apply.) A. When did the rash first start? B. Do you have a family history of rashes? C. What makes the rash worse? D. Describe the sensation from the rash, does it burn or itch? E. Describe what the rash looked like initially? F. What do you do to make your rash better?,
A. When did the rash first start?, C. What makes the rash worse?, D. Describe the sensation from the rash, does it burn or itch?, E. Describe what the rash looked like initially? F. What do you do to make your rash better?,
An Asian woman comes to the clinic with a complaint of back pain. During the history, she tells the nurse that she usually uses acupuncture for her pain. What is the nurse's best response? a. "When have you used acupuncture, and what effects did it have?" b. "Acupuncture is good for some problems, but for major illnesses it's best to see a doctor." c. "Why did you use acupuncture?" d. "I hear that lots of Asian people use acupuncture."
A. When have you used acupuncture and what effects did it have
Which findings are expected from a musculoskeletal assessment of a left-handed healthy adult? (Select all that apply.) a. Cervical concave, thoracic convex, and lumbar concave contours of the spine b. Muscle strength of 3/5 bilaterally c. Circumference of left upper arm larger than right upper arm d. Lumbar and thoracic spine flexion of 75 degrees e. External rotation and abduction of left arm of 90 degrees f. Flexion of right and left knees of 90 degrees
ANS: A, C, D, E Correct: Cervical concave, thoracic convex, and lumbar concave contours of the spine are expected findings of the spine. The circumference of the left upper arm larger than the right upper arm is considered an expected finding because this patient is left-handed, which may account for the increase in circumference. Lumbar and thoracic spine flexion of 75 degrees is an expected finding of the spine. Ninety-degree external rotation and abduction of the left arm is an expected finding of the spine.
A patient is put on an 1800-calorie a day diet plan. During discharge teaching, the nurse explains to this patient how to use nutrition labels to determine the amount of carbohydrates in the product. The nurse explains, however, that the label is based on 2000 calories. Which is the appropriate formula to teach this patient of the maximum grams of carbohydrates she can eat on her prescribed diet? a.1800 calories x0.45 = 810/4 calories/gram = 202.5 g b.1800 calories x0.60 = 1080/4 calories/gram = 270 g c.1800 calories x0.55 = 990/9 calories/gram = 110 g d.1800 calories x0.50 = 900/9 calories/gram = 100 g
B. 1800 calories x0.60 = 1080/4 calories/gram =270 g
A patient has had chronic back pain for several years. On assessment, the nurse notes that the patient sits quietly in a chair, reads a book, talks with a companion, and does not appear to be in pain. When questioned, the patient rates the pain as a 6 on a scale of 0 to 10. How does the nurse interpret these data? a. Many patients cannot be believed when they complain of severe pain lasting many months. b. Patients may not have the same objective responses to chronic pain because of compensation over time. c. The patient probably has already taken a very effective pain medication. d. This patient is probably not having as much pain as reported initially, and more assessment is required.
B. Patients may not have the same objective responses to chronic pain because of compensation over time.
A patient with gout is complaining of severe, throbbing pain in the great toe. What type of pain is this patient experiencing? a. Neuropathic pain b. Somatic pain c. Referred pain d. Visceral pain
B. Somatic Pain
A nurse is performing an admission physical examination on a patient who has been bedridden for a month. The nurse notices a pressure ulcer on the patient's left trochanter area that involves partial-thickness skin loss through dermal layer. The nurse reports this ulcer at what stage? A. Stage I B. Stage II C. Stage III D. Stage IV
B. Stage II
Which patient has pain caused by abnormal processing of sensory input from the peripheral nervous system? a. The patient who has aching pain from muscle strain b. The patient who has burning pain along the sciatic nerve c. The patient who has cramping pain from a tumor in the colon d. The patient who has throbbing pain from arthritis
B. The patient who has burning pain along the sciatic nerve
A patient complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what findings will suggest that the cause of this patient's dyspnea is due to heart disease rather than respiratory disease? a. Increased anteroposterior diameter b. Clubbing of the fingers c. Bilateral peripheral edema d. Increased tactile fremitus
Bilateral peripheral edema
On inspection of a patient's hands, the nurse notices ulnar deviation and swan-neck deformities bilaterally and correlates this finding with which disorder? a. Osteoarthritis b. Osteoporosis c. Rheumatoid arthritis d. Gout
C.
A nurse is inspecting the nails of a patient with chronic hypoxemia and notices enlargements of the ends of the fingers and angles of the nail base greater than a straight line (exceeding 180 degrees). How does the nurse document these findings? a. An expected finding b. Koilonychia (spoon nail) c. Clubbing d. Leukonychia
C. Clubbing is present when the angle of the nail base exceeds 180 degrees. It is caused by proliferation of the connective tissue resulting in an enlargement of the distal fingers and is most commonly associated with chronic respiratory or cardiovascular disease.
On inspection of a female patient's abdomen, the nurse asks the patient to raise her head without using her arms and notes a midline bulge. What is the appropriate response of the nurse at this time? a. Ask the patient to cough to see if the bulge reappears. b. Auscultate the patient's abdomen for hypoactive bowel sounds. c. Document this as a normal finding and continue the examination. d. Perform light and deep palpation of the abdomen.
C. Document this as a normal finding and continue the examination. (p 273)
A patient reports the mole on the scalp has started itching and it bleeds when scratching it. What other finding is a danger sign for pigmented skin lesions? a. Symmetry of the lesion b. Rounded border c. Color variation d. Size less than 6 mm wide
C. Uneven, variegated color is an early sign of malignant melanoma.
After two separate office visits, the nurse suspects that a patient is developing Stage 1 hypertension based on which consecutive blood pressure readings? A. Visit 1 : 118/78 Visit 2: 116/76 B. Visit 1: 130/88 Visit 2: 134/88 C. Visit 1: 144/92 Visit 2: 150/90 D. Visit 1: 162/100 Visit 2: 166/104
C. Visit 1: 144/92 Visit 2: 150/90
A nurse is assessing a patient who was diagnosed with emphysema and chronic bronchitis 5 years ago. During the assessment of this patient's integumentary system, what finding should the nurse correlate to this respiratory disease?
Clubbing of the fingers
The nurse asks the patient to hold the arms straight out, perpendicular to the floor, and the nurse tries to push the patient's arms down. This procedure tests the strength of which muscles? a. Triceps b. Biceps c. Trapezius d. Deltoid
D The patient uses the deltoid muscles to resist the action of the nurse.
The nurse asks the patient to rest the left arm on a table and to move the lower arm so that the palm of the hand is up and then down. What motion is the nurse testing? a. Adduction and abduction of the wrist b. Supination and pronation of the wrist c. Adduction and abduction of the elbow d. Supination and pronation of the elbow
D supination and pronation of the elbow
A nurse is conducting an assessment of an American Indian woman who has come to the clinic complaining of persistent headaches. The patient tells the nurse that the medicines prescribed by the tribal healer have done "some good." What is the appropriate response of the nurse at this time? A) Advise the client to stop taking any non-prescription medicines. B)Tell the physician that the client probably has headaches caused by the healer's medicines. C)Tell the client to increase the frequency of the healer's medicines. D)Ask the client about these medicines and how often the client uses them.
D)Ask the client about these medicines and how often the client uses them.
A patient with a partial small bowel obstruction describes the pain as "cramping, off-and-on pain that spreads over my stomach." What type of pain is this patient experiencing? a. Referred pain b. Phantom pain c. Somatic pain d. Visceral pain
D. Visceral Pain
The nurse notes that there is an audible clicking sound when the patient opens and closes the mouth. What is the appropriate response of the nurse at this time? a. Recording this as an abnormal finding, requiring additional assessment b. Measuring the distance between each side of the mandible and the eyes c. Applying resistance to the maxilla and asking the patient to repeat the motion d. Documenting this finding as expected if no other signs or symptoms are found
Documenting this finding as expected if no other signs or symptoms are found
While taking a history, a nurse learns that this patient experiences shortness of breath (dyspnea). If the cause of the dyspnea is a cardiovascular problem, the nurse expects which abnormal finding on examination? a. Flat jugular neck veins b. Red, shiny skin on the legs c. Weak, thready peripheral pulses d. Edema of the feet and ankles
Edema of the feet and ankles
A nurse is assessing a patient's peripheral circulation. Which finding indicates venous insufficiency of this patient's legs? a. Paresthesias and weak, thin peripheral pulses b. Leg pain that can be relieved by walking c. Edema that is worse at the end of the day d. Leg pain that increases when the legs are lowered
Edema that is worse at the end of the day
Facilitation is a communication technique used while obtaining a health history and is used when inconsistencies are noted between what the patient reports and observations noted. True or Flase
False- confrontation
What findings does the nurse expect when assessing the cardiovascular system of a healthy adult? (Select all that apply.) Pulse of smooth contour with 2+ amplitude Capillary refill greater than 3 seconds Warm, elastic turgor Blood pressure of 134/86 Heart rate of 112 beats/min S1 and S2 present with regular rhythm
Pulse of smooth contour with 2+ amplitude Warm, elastic turgor S1 and S2 present with regular rhythm
Which nurse is performing the technique of light palpation appropriately? a. Nurse A applies the bimanual technique to determine size and location of the patient's heart. b. Nurse B uses the fingertips to feel for temperature differences on the patient's legs. c. Nurse C places the ulnar surface of the hands on the patient's thorax to detect vibrations. d. Nurse D depresses the patient's abdomen approximately 4 cm to assess pulsations.
Nurse C places the ulnar surface of the hands of the patients thorax to detect vibrations
A patient reports that he has coronary artery disease with ventricular hypertrophy. Based on these data, what finding should the nurse expect during assessment? a. S4 heart sound b. Clubbing of fingers c. Splitting of the S1 heart sound d. Pericardial friction rub
S4 Heart Sound
A nurse learns from a report that a patient has aortic stenosis. Where does the nurse place the stethoscope to hear this stenotic valve? Fifth intercostal space, left midclavicular line Second intercostal space, left sternal border Second intercostal space, right sternal border Fourth intercostal space, left sternal border
Second intercostal space, right sternal border
A patient asks, "Why is touching my toes necessary? This is a sports physical examination, not exercise class." What is the most appropriate response by the nurse?
This allows me to see how straight your spinal column is.
During an interview, a patient begins to cry and appears angry. Which response by the nurse is most therapeutic?
This topic prompted an emotional response, tell me what you are feeling
A nurse calculates a patient's body mass index (BMI) as 33. This measurement indicates the weight classification to be Obesity class I. True or False?
True
As a nurse conducts a health assessment, he or she includes the health history, physical examination and documentation. True or False
True
The 24-hour recall is the best choice for a nurse to use as a quick screening tool to assess a patient's dietary intake. True or False
True
Which method of temperature measurement does a nurse choose when assessing school-aged children in a wellness clinic? Select all that apply. A. Tympanic B. Oral C. Axillary D. Rectal E. Temporal
Tympanic, temporal, axillary
While assessing a patient's lower extremities, the nurse suspects the lower extremities feel cooler than the upper extremities. To confirm this suspicion, how does the nurse compare the temperatures of the lower extremities with the upper extremities?
Using the backs (dorsum) of the hands to detect differences
A nurse had previously heard crackles over both lungs of a patient. As the patient improves, what lung sounds does the nurse expect to hear in the patient's lungs?
Vesicular breath sounds heard in the peripheral lung fields.
During a health fair, which recommendation is appropriate as a primary prevention measure to reduce the risk for skin cancer? Use sunscreen with a sun protection except on overcast days. Use a tanning booth instead of sunning outside if a tan is desired. Perform self-examination of skin monthly. Wear protective clothing and sunblock while in the sun.
Wear protective clothing and sunblock while in the sun.
When examining a patient, the nurse remembers to follow which principle of Standard Precautions?
Wearing gloves when contact with the client's mucous membranes is possible Rationale: Standard precautions apply to more than protection from mucus membranes; hand hygiene is required after all patient contact regardless if gloves are worn; eye protection is not needed for standard precautions.
Which question is an example of an open-ended question?
a broadly stated question that encourages a free-flowing, open response. the goal is to get a response that is more than 1 or 2 words, but keep it focused on the patient's health and refocus if the pt is unable to stay on topic ex: what were you doing when you felt the pain?
The nurse is performing a symptom analysis of a patient with pain. Which questions below are appropriate for a symptom analysis? (Select all that apply.) a. "Have you had any other symptoms such as nausea, vomiting, and sweating?" b. "Where is the pain located?" c. "Have you had a pain like this before?" d. "What does the pain feel like?" e. "What do you do to make your pain better?" f. "In your culture, how are you encouraged to express your pain?"
a. "Have you had any other symptoms such as nausea, vomiting, and sweating?" b. "Where is the pain located?" d. "What does the pain feel like?" e. "What do you do to make your pain better?"
During the history, the patient states that she does not use many drugs. What is the nurse's appropriate response to this statement? a. "Tell me about the drugs you are using currently." b. "To some people six or seven is not many." c. "Do you mean prescription drugs or illicit drugs?" d. "How often are you using these drugs?"
a. "Tell me about the drugs you are using currently."
In assessing a patient's deep tendon reflexes, a nurse finds a patient has a 4+ triceps response. How does the nurse interpret this finding? a. A hyperactive response b. A diminished response c. An absent response d. An expected response
a. A hyperactive response (p 342-343, 349-350)
What does the nurse say to obtain more data about a patient's vague statement about diet such as, "My diet's okay"? a. "Eating a variety of meats, fruits, and vegetables each day is important." b. "Give me an example of the foods you eat in a typical day." c. "Go on." d. "Does your diet meet your needs or does it need improvement?"
b. "Give me an example of the foods you eat in a typical day."
In assessing a patient with renal disease, the nurse palpates edema in both ankles and feet. Based on this finding, what question does the nurse ask the patient? a. "Have you had any pain in your abdomen?" b. "Have you had an unexpected weight gain?" c. "Have you noticed a change in the color of your skin?" d. "Have you had any nausea or vomiting?"
b. "Have you had an unexpected weight gain?" (p. 270-271)
A patient tells the nurse, "I've been having pain in my belly for several days that gets worse after eating." Which datum from the symptom analysis is consistent with the nurse's suspicion of peptic ulcer disease? a. Gnawing epigastric pain radiates to the back or shoulder that worsens after eating. b. Sharp midepigastric pain radiates to the jaw. c. Intermittent cramping pain in the left lower quadrant is relieved by defecation. d. Colicky pain is felt near the umbilicus with vomiting and constipation.
a. Gnawing epigastric pain radiates to the back or shoulder that worsens after eating.
A nurse notices abdominal distention when inspecting a patient's abdomen. What action does the nurse take next to gain further objective data? a. Place a measuring tape around the superior iliac crests. b. Assist the patient to turn on to the left side and then the right side. c. Ask the patient to cough while lying supine. d. Use the fingertips to sharply strike one side of the abdomen.
a. Place a measuring tape around the superior iliac crests.
What movement from the patient does a nurse request to assess for hyperextension of the hip? a. Raise one leg at a time while lying prone. b. Raise one leg at a time while lying supine. c. Move one leg at a time laterally, away from midline, while lying prone. d. Move one leg at a time medially, toward midline, while lying supine
a. Raise one leg at a time while lying prone
A nurse asks the patient to stand with feet together, arms resting at the sides, with eyes open and then with the eyes closed. Which response by the patient indicates an expected cerebellar function? a. Sways slightly and maintains upright posture with feet together b. Is unable to stand upright after turning around in a circle once c. Steps sideways when standing with feet together and eyes closed d. Has to move arms horizontally to maintain balance
a. Sways slightly and maintains upright posture with feet together
A nurse assessing a patient who had a cerebrovascular accident involving the Broca area suspects expressive or nonfluent aphasia. What communication abilities does the nurse anticipate from this patient? a. The patient understands speech but is unable to translate ideas into meaningful speech. b. The patient is unable to comprehend speech and thus does not respond verbally. c. The patient is able to understand speech but has difficulty forming words, creating muffled speech. d. The patient is unable to comprehend speech and responds inappropriately to conversation.
a. The patient understands speech but is unable to translate ideas into meaningful speech.
How do nurses prevent a latex allergy?
a. use non-powdered latex or non-latex b. avoid oil-based lotions when wearing latex c. remove and wash hands after removing gloves
How does the nurse detect an extra heart sound in an adult? a. Using the bell of a stethoscope b. With a pulse oximeter c. Using the diaphragm of a stethoscope d. With a Doppler ultrasound probe
a. using the bell of a stethescope
A nurse is assessing the respiratory system of a healthy adult. Which findings does this nurse expect to find? (Select all that apply.) a. Thoracic expansion that is symmetric bilaterally b. Respiratory rate of 24 breaths/min c. Bronchophony revealing clear voice sounds d. Breath sounds clear with vesicular breath sounds heard over most lung fields e. Anteroposterior diameter of the chest about a 1:2 ratio of anteroposterior to lateral diameter f. Symmetric thorax with ribs sloping downward at about 45 degrees relative to the spine
aThoracic expansion that is symmetric bilaterally. dBreath sounds are clear with vesicular breath sounds heard over most lung fields. eAnteroposterior diameter of the chest about a 1:2 ratio of the anteroposterior to lateral diameter. fSymmetric thorax with ribs sloping downward at about 45 degrees relative to the spine.
Which questions are pertinent to ask when obtaining a symptom analysis from a patient who reports a headache? a. "Describe what the headache feels like?" b. "When was your last eye examination?" c. "What makes the headaches worse?" d. "How do you rate the headaches on a scale of 0 (meaning no pain) to 10 (meaning the worse pain ever)?" e. "Do you have any symptoms with the headaches, such as nausea?" f. "When did you first notice the headaches?"
all but B
Which questions are pertinent to ask when obtaining a symptom analysis from a patient who reports breathing problems? a. "How long have you had this problem with your breathing?" b. "Do you have a family history of breathing problems?" c. "Does this breathing problem come and go or is it constant?" d. "What do you do to make your breathing better?" e. "How does this breathing problem affect your work or daily activities?" f. "How many packs of cigarettes do you smoke a day?"
all but b
When inspecting a patient's abdomen, the nurse notes which finding as abnormal? a. Protruding abdomen with skin that is lighter in color than the arms and legs b. Marked rhythmic pulsation to the left of the midline c. Faint, fine vascular network d. Small shadows created by changes in contour
b
Nurses inquire about lifestyle behaviors of patients with risk factors for osteoarthritis. Which risk factors for osteoarthritis does the nurse ask about? (Select all that apply.) a. Estrogen deficiency b. Physical inactivity c. Overuse of joints d. Smoking e. Obesity f. Age
b c e
A nurse suspects appendicitis in a patient with abdominal pain. Which findings are suggestive of appendicitis? (Select all that apply.) a. Pain radiating to the right shoulder b. Pain around the umbilicus c. Pain relieved by lying still d. Right lower quadrant pain e. Increased peristalsis
b,c, d
A nurse informs a patient that her blood pressure is 128/78. The patient asks what the number 128 means. What is the nurse's appropriate response? The 128 represents the pressure in your blood vessels when: a. "The ventricles relax and the aortic and pulmonic valves open." b. "The ventricles contract and the mitral and tricuspid valves close." c. "The ventricles contract and the mitral and tricuspid valves open." d. "The ventricles relax and the aortic and pulmonic valves close."
b. "The ventricles contract and the mitral and tricuspid valves close."
Which statement is appropriate to use when beginning an interview with a new patient? a. "Have you ever been a patient in this clinic before?" b. "What is your purpose for coming to the clinic today?" c. "Tell me a little about yourself and your family." d. "Did you have any difficulty finding the clinic?"
b. "What is your purpose for coming to the clinic today?"
The nurse holds the patient's relaxed arm with elbow flexed at a 90-degree angle, places a thumb over a tendon in the antecubital fossa, and strikes the thumb with the pointed end of the reflex hammer. Which deep tendon reflex is the nurse assessing? a. Brachioradialis b. Biceps c. Triceps d. Deltoid
b. Biceps (p 342-343, 349-350)
A male nurse is assigned to the care of a gay male with alcoholism. This sexual orientation is inconsistent with the beliefs of the nurse. What actions, if any, can the nurse take to provide patient-centered care to this patient? a. No action is necessary at this time. b. Examine his own feelings about alcoholism and homosexuality. c. Determine the patient's degree of risk for contracting the human immunodeficiency virus. d. Discuss homosexuality and alcoholism with the patient.
b. Examine his own feelings about alcoholism and homosexuality
During a history, the patient reports having gout. Based on this information, what findings does the nurse anticipate during a focused assessment? a. Warm, tender, and deformed wrists and peripheral interphalangeal (PIP) joints bilaterally b. Edema, warmth, and redness of one great toe and pea-like nodules in the ear lobes c. Enlarged and tender PIP or distal interphalangeal (DIP) joints on one or several fingers d. Tenderness with pronation and supination of the elbow and point tenderness on the lateral epicondyle
b. Edema, warmth, and redness of one great toe and pea-like nodules in the ear lobes
The nurse is unable to hear the patient's breath sounds. What checks does the nurse make of the stethoscope to determine the cause of this problem? a. Ensure the stethoscope tubing is at least 20 inches long. b. Ensure the valve is open to the diaphragm on the head of the stethoscope. c. Ensure the earpieces are pointed toward the back of the ears. d. Ensure the bell is placed firmly against the patient's skin.
b. Ensure the valve is open to the diaphragm on the head of the stethoscope.
A patient reports having abdominal distention. The nurse observes that the patient's sclerae are yellow. Which abnormal finding does the nurse anticipate on examination of this patient's abdomen ? a. Decreased bowel sounds in all quadrants b. Glistening or taut skin of the abdomen c. Bulge in the abdomen when coughing d. Bruit around the umbilicus
b. Glistening or taut skin of the abdomen
How does the nurse accurately assess bowel sounds? a. Press the diaphragm of the stethoscope firmly against the abdomen in each quadrant. b. Hold the diaphragm of the stethoscope lightly against the abdomen in each quadrant. c. Press the bell of the stethoscope firmly against the abdomen in each quadrant. d. Hold the bell of the stethoscope lightly against the abdomen in each quadrant.
b. Hold the diaphragm of the stethoscope lightly against the abdomen in each quadrant. (p 273)
A patient reports having difficulty swallowing. Based on this information, how does the nurse assess the cranial nerve related to swallowing? a. Ask the patient about feeling the blunt end of a paper clip along the jaw line. b. Observe the rising of the soft palate when the patient says "Ahh." c. Observe the symmetry of the face when the patient talks. d. Assess taste on the anterior part of the tongue.
b. Observe the rising of the soft palate when the patient says "Ahh."
A nurse who is assessing a patient's eyes finds that the pupils are equal, round, and react to light and accommodation (PERRLA). These findings verify the expected functioning of which cranial nerve? a. Optic cranial nerve (CN II) b. Oculomotor cranial nerve (CN III) c. Trochlear cranial nerve (CN IV) d. Abducens cranial nerve (CN VI)
b. Oculomotor cranial nerve (CN III)
A patient admitted with pneumonia reports that she takes insulin for diabetes mellitus. In which section of the history does the nurse document the insulin and diabetes? a. Past health history b. Present health status c. Reason for seeking care (chief complaint) d. History of present illness
b. Present Health Status
When the patient's chart includes a notation that petechiae are present, what finding does a nurse expect during inspection? a. Generalized reddish discoloration of an area of skin b. Purplish-red pinpoint lesions c. Deep purplish red patches of skin d. Small raised fluid-filled pinkish nodules
b. Purplish-red pinpoint lesions
What does the S2 heart sound represent? a. The beginning of systole. b. The closure of the aortic and pulmonic valves. c. The closure of the tricuspid and mitral values d. A split heard sound on exhalation
b. The closure of the aortic and pulmonic valves.
To assess the triceps and biceps muscle strength, the nurse applies resistance to the patient's arm. What should be done to ensure the appropriate muscle is being assessed? a. The patient pushes up against the nurse's hand to abduct the triceps muscle and pushes down against the nurse's hand to adduct the biceps muscle. b. The patient pushes forward against the nurse's hand to extend the triceps muscle and pulls backward against the nurse's hand to flex the biceps muscle. c. The patient pulls backward against the nurse's hand to flex the triceps muscle and pushes forward against the nurse's hand to extend the biceps muscle. d. The patient pushes up against the nurse's hand to abduct the biceps muscle and pushes down against the nurse's hand to adduct the triceps muscle.
b. The patient pushes forward against the nurses hand to extend the triceps muscle and pulls backward against the nurses hand to flex the biceps muscle
A nurse inspects the abdomen for skin color, surface characteristics, and surface movement. What part of the abdominal assessment does the nurse perform next? a. Palpate lightly for tenderness and muscle tone. b. The tip of the middle finger of the dominant hand strikes the nail of the middle finger touching the skin of the abdomen. c. Palpate deeply for masses or aortic pulsation. d. Percuss for tones.
b. The tip of the middle finger of the dominant hand strikes the nail of the middle finger touching the skin of the abdomen.
In assessing a patient with damage to the occipital lobe, the nurse correlates which clinical manifestation to this injury? a. Intentional tremors b. Visual changes c. Decreased hearing d. Inability to formulate words
b. Visual changes
During the first prenatal visit for a 20-year-old Hispanic woman, the nurse assesses the patient's health beliefs and practices. Which questions are appropriate as part of this assessment? a. You are Hispanic, do you need me to find an interpreter? b. What is the language that is usually spoken in your home? c. How do you define health and illness? d. Which Catholic church do you attend? e. Do you have specific beliefs or preferences concerning food or food preparation? f. Do you or the members of your family have certain beliefs and practices surrounding pregnancy and childbirth?
b. What is the language that is usually spoken in your home? c. How do you define health and illness? e. Do you have specific beliefs or preferences concerning food or food preparation? f. Do you or the members of your family have certain beliefs and practices surrounding pregnancy and childbirth?
A patient reports having abdominal distention. The nurse notices that the patient's sclerae are yellow. What question is appropriate for the nurse to ask in response to this information? a. Decreased bowel sounds in all quadrants b. Glistening or taut skin of the abdomen c. Bulge in the abdomen when coughing d. Bruit around the umbilicus
b.Glistening or taut skin of the abdomen
Which nursing behaviors indicate culturally competent care? a. Recognizing that there are different definitions of health and illness b. Complying with the stated plan of treatment, despite the client's differing opinion c. Understanding that there is diversity even among people of the same cultural group d. Helping clients of different cultures adopt the beliefs and behaviors of the dominant culture
c. Understanding that there is diversity even among people of the same cultural group
A patient who had an amputation of his lower leg comes to the clinic with a complaint of pain. He asks, "How I can be feeling pain in my foot—my foot is gone?" What is the appropriate response from the nurse? a. "After your amputation, pain perception increases." b. "Amputating your leg caused abnormal processing of sensory input by the peripheral nervous system." c. "Stimulation of nerves from your leg sends impulses to the brain so that you feel pain even though your leg is no longer there." d. "When sensory nerves enter the spinal cord, they stimulate nerves from unaffected organs in the same spinal cord segment as those neurons in areas where injury or disease is located
c. "Stimulation of nerves from your leg sends impulses to the brain so that you feel pain even though your leg is no longer there."
A 75-year-old male patient asks how to reduce his risk of esophageal cancer. What is the nurse's most appropriate response? a. "Don't worry about it, esophageal cancers have a low incidence in men." b. "You should not be concerned about esophageal cancer at your age." c. "You should consider limiting your alcohol intake to two drinks per day." d. "Increasing the fiber and protein in your diet can help you lower your risk."
c. "You should consider limiting your alcohol intake to two drinks per day."
The nurse suspects an irregularity in the rhythm of the patient's radial pulse. What is the most appropriate action for this nurse to take at this time? a. Document this rhythm as normal for the patient. b. Use a Doppler to check the brachial pulse. c. Count the patient's apical pulse for a full minute. d. Count the radial pulse again for 15 seconds and multiply by 4.
c. Count the patient's apical pulse for a full minute.
What signs of cyanosis does a nurse inspect for in a dark-skinned patient?
cyanosis may present as gray or whitish (not bluish) skin around the mouth, and the conjunctivae may appear gray or bluish.
A patient tells the nurse at the clinic, "I can never seem to get warm lately and feel tired all the time." The nurse records these data under which section of the health history? a. Past health history b. Present health status c. Reason for seeking care (chief complaint) d. Subjective assessment data
c. Reason for seeking care (chief complaint)
When auscultating a patient's abdomen using the bell of the stethoscope, the nurse hears soft, low-pitched murmurs over the right and left upper midline. What do these sounds indicate? a. Expected peristalsis b. Femoral artery stenosis c. Renal artery stenosis d. Hyperactive bowel sounds
c. Renal artery stenosis
For which person is a comprehensive assessment indicated? a. The person who had abdominal surgery yesterday b. The person who is unaware of his high serum glucose levels. c. The person who is being admitted to a long-term care facility. d. The person who is beginning rehabilitation after a knee replacement
c. The person who is being admitted to a long-term care facility
Which patient behavior indicates to the nurse that the patient's facial cranial nerve (CN VII) is intact? a. The patient's eyes move to the left, right, up, down, and obliquely. b. The patient moistens the lips with the tongue. c. The sides of the mouth are symmetric when the patient smiles. d. The patient's eyelids blink periodically.
c. The sides of the mouth are symmetric when the patient smiles.
When assessing the neck rotation of a healthy adult, a nurse expects which findings? a. A convex contour of the posterior cervical spine b. Bending of the head to the right and left (ear to shoulder) 15 degrees c. Turning the chin to the right shoulder and then the left shoulder d. Hyperextension of the head 30 degrees from midline
c. Turning the chin to the right shoulder and then the left
Health promotion is important to reduce a person's risk of cancer. Which of the following recommendations will reduce the risk of colorectal cancer? (Select all that apply.) consume a diet high in fruits,vegetables,wholegrain food, limit intake of high fat food participate in moderate to activity 5 days/week attain and maintain healthy weight dont smoke limit alcohol to 2 drinks day and one for women FOBT annually flexible sigmoidoscopy every 5 yr colonoscopy every 10 year enema every 5 year
consume a diet high in fruits,vegetables,wholegrain food, limit intake of high fat food participate in moderate to activity 5 days/week attain and maintain healthy weight dont smoke limit alcohol to 2 drinks day and one for women FOBT annually flexible sigmoidoscopy every 5 yr colonoscopy every 10 year enema every 5 year
A female Korean patient accompanied by her husband and son comes to the emergency department (ED) complaining of abdominal pain. The patient speaks and understands Korean only. Which person is the appropriate choice for the nurse to use to get a history from this patient? a. The patient's husband who speaks Korean and English b. The patient's son who speaks Korean and English c. A male technician who works in the ED who speaks Korean and English d. A female interpreter who speaks Korean and English and is available by phone
d. A female interpreter who speaks Korean and English and is available by phone
During a history, a nurse notices a patient is short of breath, is using pursed-lip breathing, and maintains a tripod position. Based on these data, what abnormal finding should the nurse expect to find during the examination? a. Increased tactile fremitus b. Inspiratory and expiratory wheezing c. Tracheal deviation d. An increased anteroposterior diameter
d. An increased anteroposterior diameter
A patient reports a history of compression of the left cranial nerve XI (spinal accessory nerve) from an old sports injury. Based on this information, what technique does the nurse include in the focused assessment? a. Asking the patient to rotate the head against resistance of the nurse's hand on the patient's chin b. Asking the patient to flex the chin to the chest against resistance of the nurse's hand on the patient's forehead c. Asking the patient to extend the head back against resistance of the nurse's hand on the back of the patient head d. Asking the patient to shrug the shoulders while the nurse attempts to push them down
d. Asking the patient to shrug the shoulders while the nurse attempts to push them down
A patient reports having leg pain while walking that is relieved with rest. Based on these data, the nurse expects which finding on inspection and palpation of this patient? a. 1+ edema of the feet and ankles bilaterally b. The circumference of the right leg is larger than the left leg c. Patchy petechiae and purpura of the lower extremities d. Cool feet with capillary refill of toes greater than 3 seconds
d. Cool feet with capillary refill of toes greater than 3 seconds
A nurse holds the patient's relaxed arm with the elbow flexed at a 90-degree angle, places a thumb over the appropriate tendon in the antecubital fossa, and strikes the thumb with the pointed end of the reflex hammer. What is the expected response for this deep tendon reflex? a. Extension of the right lower leg b. Plantar flexion of the right toes c. Dorsiflexion of the right foot d. Plantar flexion of the right foot
d. Plantar flexion of the right foot (p
When inspecting a patient's abdomen, which finding does the nurse note as normal? a. Engorgement of veins around the umbilicus b. Sudden bulge at the umbilicus when coughing c. Visible peristalsis in all quadrants d. Silver-white striae extending from the umbilicus
d. Silver-white striae extending from the umbilicus (p. 272)
The nurse records the following general inspection findings on a patient: "56-year-old Hispanic male in no distress, very thin, skin tone slightly jaundiced, disheveled appearance, and appears older than his stated age. Patient with flat affect and makes minimal eye contact." What additional information should be added to this general inspection?
movement
Nurses understand that a patient's diastolic pressure represents which physiologic function? a. The pressure needed to open the aortic and pulmonic valves b. The pressure in blood vessels when the ventricles contract c. The pressure of the blood returning to the heart from the venous system d. The pressure in blood vessels when the ventricles are relaxed
d. The pressure in blood vessels when the ventricles are relaxed
A patient has been complaining of abdominal cramping and gas; the nurse notes that his abdomen is slightly distended. Which sound does the nurse expect to hear during percussion of this patient's abdomen? a. Flatness b. Dullness c. Resonance d. Tympany
d. Tympany
When performing a skin assessment of an adult with no complaints or problems, the nurse expects what finding? a. reddened area does not blanch when gentle pressure is applied b. indentation of the finger in the skin after palpation c. flaking or scaling of the skin d. retern of skin to its original position when pinched up slightly
d. return of skin to its original position when pinched up slightly
A Hispanic patient tells an African-American nurse, "You are African-American and can't possibly understand how a person like me feels." What is an appropriate response by the nurse at this time? a.Find a nurse who is not African-American to interview the patient. b.Ask the patient, "Why do you think that, since we just met?" c.Note that the patient is very defensive about being racially different. d.Encourage the patient to describe what he means by his statement.
d.Encourage the patient to describe what he means by his statement.
A 36-year-old woman comes to the clinic for a screening exam. Her medical history is negative and she states she is in good health. Her blood pressure measures 66/40 using an automated blood pressure device. What nursing action is most appropriate?
go get another bp cuff, and ask patient what her normal is?
An example of a health promotion question included in the health history is:
how often do you exercise?
Which cranial nerve is assessed when a nurse asks a patient to stick out the tongue and move it side to side? a. Vagus nerve (CN X) b. Facial nerve (CN VII) c. Abducens nerve (CN VI) d. Hypoglossal nerve (CN XII)
hypoglossal nerve (CN XII)
What findings does a nurse expect when inspecting and palpating a patient's nails? a. Whitish to clear nails in darker-skinned patients b. Transverse depression running across the nails c. Nail surface is smooth and rounded d. A nail base angle of not more than 90 degrees.
less than 3 seconds capillary refill Nail surface is smooth and rounded
Which statement by the nurse demonstrates a patient-centered interview? a. "I need to complete this questionnaire about your medical and family history." b. "The hospital requires me to complete this assessment as soon as possible." c. "Tell me about the symptoms you've been having." d. "I've had the same symptoms that you've described."
tell me about the symptoms you've been having
Which is an example of data a nurse collects during a physical examination? a. The patient's lack of hair and shiny skin over both shins b. The patient's stated concern about lack of money for prescriptions c. The patient's complaints of tingling sensations in the feet d. The patient's mother's statements that the patient is very nervous lately
the patient's lack of hair and shiny skin over both shins
The nurse will document which information for a patient's health history?
vaccinations surgeries past hospitalizations everything
