Exam 1 Sherpath questions
Which types of play and recreation activities are evaluated as part of a child's musculoskeletal system assessment? SATA a) Ability to pick up toys b) Ability to sit still c) Movement around the room d) Ability to sit and creep e) Ability to lift heavy objects
a) Ability to pick up toys c) Movement around the room d) Ability to sit and creep
Which maneuvers are necessary to assess range of motion? SATA a) Active movement of a joint by the patient b) Passive movement of a joint by the nurse c) Passive movement of a joint by the patient d) Active movement of a joint by the nurse e) Pushing of the patient's hand against the nurse's hand
a) Active movement of a joint by the patient b) Passive movement of a joint by the nurse
Which condition is necessary for accurate inspection? a) Adequate time to complete exam b) Dark, calming room with an examination table c) Patient is quiet and motionless d) Examination room with sunny window
a) Adequate time to complete exam
In which ways can the nurse evaluate hip muscle strength? SATA a) Apply resistance during abduction and adduction b) Apply resistance as the patient uncrosses the legs while seated c) Ask the patient to swing the straightened leg behind the body d) Ask the patient to lie supine and swing the leg laterally and medially with the knee straight e) Apply resistance while patient maintains flexion of the hip with knee flexed, then extended
a) Apply resistance during abduction and adduction b) Apply resistance as the patient uncrosses the legs while seated e) Apply resistance while patient maintains flexion of the hip with knee flexed, then extended
Which characteristics of respiration are normal findings? SATA a) Breathing without effort b) Breathing with regular rhythm c) Abdominal movement with breathing d) Quiet breathing e) Shallow breathing
a) Breathing without effort b) Breathing with regular rhythm c) Abdominal movement with breathing d) Quiet breathing
Which techniques are required to conduct accurate percussion? SATA a) Downward snap the striking finger b) Tap sharply and rapidly c) Slowly lift finger to damp sound d) Use the tip of the finger to strike e) Have short fingernails
a) Downward snap the striking finger b) Tap sharply and rapidly d) Use the tip of the finger to strike e) Have short fingernails
Which steps should the nurse take to establish and maintain a good rapport with the patient? SATA a) Ensure patient comfort b) Ask students to participate in the discussion c)Use effective communication d) Use appropriate body language e) Focus on the patient
a) Ensure patient comfort c)Use effective communication d) Use appropriate body language e) Focus on the patient
Which elements of an infant's feet should be assessed as part of the musculoskeletal examination? SATA a) Flexibility b) Number of toes c) Midline of the foot d) Long bones for fractures e) Palmar and phalangeal creases
a) Flexibility b) Number of toes c) Midline of the foot
For which common lower leg deformities should the nurse assess during the musculoskeletal assessment of a child? SATA a) Genu varum b) Fractured clavicle c) Genu valgum d) Tailor sitting position e) Popliteal creases
a) Genu varum c) Genu valgum
Which auscultation techniques are correct for auscultating the heart and lungs? SATA a) Isolate each sound and listen to it separately b) Talk with the patient while auscultating c) Listen to the heart and lungs simultaneously d) Focus on the characteristics of each sound e) Anticipate the patient's next inhalation
a) Isolate each sound and listen to it separately d) Focus on the characteristics of each sound
How does the musculoskeletal examination of an adolescent differ from that of an adult? a) It does not differ. b) A parent must be present. c) The adolescent should be sitting for the examination. d) The nurse should assess passive movement, but not active
a) It does not differ.
The nurse should assess range of motion in the hand and wrist by asking the patient to perform which movements? SATA a) Touch thumb to each fingertip b) Tightly grip two of the nurse's fingers c) Lift the arms laterally up over the head d) Bend the hand up and down at the wrist e) Spread fingers apart, then touch them together
a) Touch thumb to each fingertip d) Bend the hand up and down at the wrist e) Spread fingers apart, then touch them together
During assessment of range of motion, which parts of the musculoskeletal system should be assessed? SATA a) biceps b) cervical spine c) abdominal muscles d) temporomandibular joint e) metacarpophalangeal joint
a) biceps b) cervical spine d) temporomandibular joint e) metacarpophalangeal joint
Effective communication relies on the nurse implementing which communication techniques? SATA a) courtesy b) comfort c) connection d) counsel e) confidentiality
a) courtesy b) comfort c) connection e) confidentiality
While preparing the patient room before beginning an interview, which steps should the nurse take to ensure patient comfort and establish good patient-nurse rapport? SATA a) drawing the curtains b) adjusting the room temp. c) speaking in a loud voice so the patient can hear d) addressing immediate patient needs e) asking others to leave the room
a) drawing the curtains b) adjusting the room temp. d) addressing immediate patient needs e) asking others to leave the room
Which pieces of information are pertinent to a patient history? SATA a) family diseases b) chronic diseases c) onset of symptoms d) current symptoms e) social security number
a) family diseases b) chronic diseases c) onset of symptoms d) current symptoms
During what part of the comprehensive health history does the nurse ask about the cause of death of a patient's deceased father? a) family history b) chief concern c) surgical history d) previous hospitalizations
a) family history
Which body areas are best for measuring the blood oxygen levels of an adult patient? SATA a) finger b) toe c) palm of the hand d) thumb e) pinna
a) finger b) toe e) pinna
Which part of the hand is used to palpate the patient's abdomen? a) finger pads b) ball of hand c) back of hand d) forefinger and thumb
a) finger pads
Which part of the hand would the nurse use to palpate pulsations? a) finger pads b) ball of hand c) back of hand d) forefinger and thumb
a) finger pads
When preparing a dietary meal plan for a new patient, the nurse understands that which cultural factors may play a role in the patient's food selection? SATA a) food beliefs b) food allergies c) patient tastes d) periods of required fasting e) culturally forbidden foods
a) food beliefs d) periods of required fasting e) culturally forbidden foods
What part of the history is being assessed when the nurse asks, "How does your pain affect your daily routine?" a) history of present illness b) medical and surgical history c) chronic medical conditions d) chief complaint
a) history of present illness
What components are included in a general inspection of the patient? SATA a) overall color of skin b) symmetry of body c) color of scalp d) obvious injuries e) shape of thorax
a) overall color of skin b) symmetry of body d) obvious injuries
Which patient behaviors and conditions may result in the patient's unwillingness or inability to communicate and hinder the nurse's ability to obtain a comprehensive health history? SATA a) patient withdrawal b) young age c) anxiety d) pregnancy e) serious illness
a) patient withdrawal c) anxiety e) serious illness
What information is the nurse assessing when asking the patient, "What were you doing at the time your symptoms began?" a) precipitating factors b) chief complaint c) medical history d) first symptoms
a) precipitating factors
Which actions by the nurse will help build rapport with the patient? SATA a) returning eye contact b) saying please and thank you c) speaking with the patient for several hours d) speaking to the patient from a comfortable distance e) trying to understand the concerns of the patient
a) returning eye contact b) saying please and thank you d) speaking to the patient from a comfortable distance e) trying to understand the concerns of the patient
The assessment of financial resources and health insurance is included in which element of the functional examination? a) social situation b) review of systems c) physical examination d) activities of daily living
a) social situation
How should the patient be positioned while the nurse inspects the feet and ankles? SATA a) standing b) sitting c) walking d) with legs crossed e) with legs raised
a) standing b) sitting c) walking
Why is it important for the nurse to establish a good rapport by ensuring each patient-nurse interaction is unique? a) to build trust b) so the patient feels less intimidated c) so the patient tells the truth d) so that a critically ill patient understands everything will be fine
a) to build trust
When palpating a patient's bones, joints, and surrounding muscles, which characteristics would the nurse assess? SATA a) tone b) crepitus c) symmetry d) temperature e) resistance to pressure
a) tone b) crepitus d) temperature e) resistance to pressure
Which method of temperature measurement is the most reliable? a) tympanic b) oral c) rectal d) axillary
a) tympanic
Which tone would the nurse expect to hear when percussing over the stomach? a) tympany b) dullness c) resonance d) flatness
a) tympany
The nurse is caring for a patient from an unfamiliar culture who states the intent to use an alternative therapy to treat a health condition. What is the nurse's best response? a) "Have you used alternative medicine in the past?" b) "What type of alternative treatment do you plan to use?" c) "Have you previously been treated medically for a similar problem?" d) "What are your spiritual beliefs?"
b) "What type of alternative treatment do you plan to use?"
Select the blood pressure reading that falls outside of the normal range. a) 91/61 b) 121/70 c) 118/69 d) 110/79
b) 121/70
The nurse can examine the elbow's range of motion by asking the patient to perform which movements? SATA a) Turn each hand to the right and left b) Bend and straighten the elbow c) Bend each hand at the wrist up and down d) Turn the hand from palm side down to palm side up e) Lift both arms laterally over the head
b) Bend and straighten the elbow d) Turn the hand from palm side down to palm side up
The pulse oximeter measures a patient's blood oxygen based on which properties of hemoglobin? a) Deoxygenated hemoglobin absorbs more infrared light than oxygenated blood. b) Deoxygenated hemoglobin absorbs more red light than oxygenated hemoglobin. c) Oxygenated hemoglobin allows more infrared light to pass through than deoxygenated blood. d) Deoxygenated hemoglobin allows more infrared light to pass through than oxygenated hemoglobin
b) Deoxygenated hemoglobin absorbs more red light than oxygenated hemoglobin.
Establishing a good rapport with the patient facilitates the nurse's ability to obtain which information? SATA a) How the patient thinks he or she should be treated b) Details about a patient's complaint c) How the patient has been treated in the past d) The patient's expectations e) Where the patient has been treated in the past
b) Details about a patient's complaint d) The patient's expectations
On which elements should the nurse focus when performing the physical examination component of the functional assessment? SATA a) Determining caregiver's abilities b) Evaluating coordination and gait c) Assessing for dyspnea with exertion d) Asking about use of a cane or walker e) Measuring blood pressure while the patient is seated and standing
b) Evaluating coordination and gait c) Assessing for dyspnea with exertion e) Measuring blood pressure while the patient is seated and standing
Which type of movement defines a grade 3 range of motion? a) Trace of movement b) Full range of motion against gravity, but not resistance c) Full passive range of motion d) Full range of motion against gravity with full resistance
b) Full range of motion against gravity, but not resistance
The pulse oximetry reading indicates which physiologic measure? a) The maximum oxygen the blood can carry b) How much oxygen the blood is carrying c) The amount of deoxygenated hemoglobin d) The color of the arterial blood
b) How much oxygen the blood is carrying
Which element of the assessment should be performed with the patient seated and wearing a gown? a) Percussion of the posterior chest b) Inspection of facial symmetry c) Auscultation of heart and lungs d) Palpation of axillary lymph nodes
b) Inspection of facial symmetry
The nurse is conducting a cultural assessment of a patient from an unfamiliar culture. What information would be helpful in establishing the patient's faith-based influences and rituals? a) Knowledge of the personal space preferences of the patient b) Knowledge of whether the patient belongs to a religious organization c) Knowledge of the patient's personal hygiene habits d) Knowledge of the patient's beliefs regarding eye contact
b) Knowledge of whether the patient belongs to a religious organization
Which element of the assessment should be performed after assessment of the patient's back, posterior chest, and lungs? a) Weber test b) Palpation of apical pulse c) Palpation of posterior chest d) Inspection of spine and scapula
b) Palpation of apical pulse
Which examination component should be performed while the adult patient is supine with the legs exposed? a) Palpation of breast tissue b) Palpation of popliteal pulse c) Palpation for inguinal hernia d) Palpation for aortic pulsation
b) Palpation of popliteal pulse
A necessary part of establishing a good rapport with a patient is to understand the patient's perspective on the condition and treatment plan. How does this help the history-taking process? a) Allows the patient to participate in designing the treatment plan b) Prevents miscommunication and misinterpretations c) Allows the patient to participate in identifying the diagnosis d) Provides the nurse with additional information related to patient symptoms
b) Prevents miscommunication and misinterpretations
Which findings relating to a patient's pulse are considered normal? SATA a) Pulse rate of 101 beats per minute b) Regular rhythm c) Strong amplitude d) Contour with a smooth upstroke e) Occasional variations outside the normal limits
b) Regular rhythm c) Strong amplitude d) Contour with a smooth upstroke
Which appropriate actions taken by the nurse demonstrate that body language is important in establishing and maintaining a good rapport with the patient? SATA a) Getting as close to the patient as possible b) Sitting during the interview c) Addressing immediate patient needs d) Keeping an appropriate distance e) Communicating effectively
b) Sitting during the interview d) Keeping an appropriate distance
Asking several consecutive yes/no questions should be avoided for which reason? SATA a) They encourage the patient to lie. b) They may confuse the patient. c) They may be misinterpreted as judgmental. d) They discourage the patient from providing additional information. e) They are examples of open-ended questions.
b) They may confuse the patient. d) They discourage the patient from providing additional information.
What is an important quality for a nurse to have to conduct an effective patient-centered interview? a) conciseness b) ability to adapt to the patient c) knowledge of medical terminology d) experience with the patient's presenting condition
b) ability to adapt to the patient
Which part of the hand is best used to assess for fremitus, or vibrations? a) finger pads b) ball of hand c) back of hand d) forefinger and thumb
b) ball of hand
Which aspects of a patient's life that are influenced by culture may have an impact on patient care? SATA a) desire to get well b) health beliefs and practices c) communication d) dietary practices e) treatment preferences
b) health beliefs and practices c) communication d) dietary practices e) treatment preferences
An increase in body temperature may be an indication of which condition? SATA a) hypothermia b) infection c) damage to the hypothalamus d) vasoconstriction e) inflammation
b) infection c) damage to the hypothalamus d) vasoconstriction
Palpation of the thyroid and cervical lymph nodes is included in examination of which part of the body? a) eyes b) neck c) mouth d) pharynx
b) neck
During what part of the comprehensive patient history does the nurse ask about sexual history? a) medical history b) personal and social history c) previous hospitalizations d) prior surgeries
b) personal and social history
Which reason describes the benefit to using an electric thermometer to measure an adult patient's temperature? a) ability to obtain core body temperature b) quicker to use c) preferred by patient d) most reliable to use
b) quicker to use
The nurse is taking the pulse of an adult patient. Which description of pulse amplitude is characteristic of a normal pulse? a) flat b) strong c) low d) regular
b) strong
What patient behavior, state, or action can interfere with the history-taking process and may be a manifestation of patient fear or anxiety? SATA a) depression b) talkativeness c) withdrawal d) serious illness e) asking the nurse a personal question
b) talkativeness c) withdrawal
Which is the best method by which to measure temperature in a 5-month-old patient? a) digital b) tympanic c) oral d) rectal
b) tympanic
Place the steps for indirect percussion technique in order. a) snap the wrist of the dominant hand downward b) expose patient's skin by removing gown as needed c) keep the fingers of the nondominant hand fanned out and off the surface of the skin d) place middle finger of nondominant hand firmly on patient's skin e) with dominant hand, strike the middle finger of nondominant hand
b, d, c, a, e
Which question, asked by the nurse, demonstrates an effective interview technique? a) "You aren't sexually active, are you?" b) "Are you experiencing hemoptysis?" c) "How many sexual partners do you currently have?" d) "Have you ever experienced orthopnea?"
c) "How many sexual partners do you currently have?"
The nurse is gathering a health history. Which question, asked by the nurse, would be most effective for obtaining details about the chief complaint? a) "You are still drinking, aren't you?" b) "Are your joints tender?" c) "Please describe the pain." d) "Please describe similar conditions in your family members."
c) "Please describe the pain."
What guidelines should the nurse follow to ensure that auscultation sounds are accurately heard? a) Encourage the patient to ask questions during auscultation b) Focus on counting the respiratory rate while auscultating the abdomen c) Ensure that the stethoscope endpiece is firmly held against the skin d) Place the stethoscope over a sheet while auscultating a patient who is "cold"
c) Ensure that the stethoscope endpiece is firmly held against the skin
During an abdominal assessment, palpation occurs after auscultation for what reason? a) Palpation can cause the patient to experience pain. b) Auscultation always follows inspection. c) Palpation may increase intestinal activity. d) Auscultation can be time-consuming.
c) Palpation may increase intestinal activity.
When interviewing a patient through use of an interpreter, how should the nurse adjust the interviewing process? a) Speak to the interpreter and not the patient b) Write down the questions rather than speaking c) Pause every one or two sentences to allow the interpreter to speak d) Speak quickly so that the interview is not prolonged
c) Pause every one or two sentences to allow the interpreter to speak
The nurse is communicating with a patient who recently received the diagnosis of a terminal illness. Which action by the nurse is an example of empathy? a) Assuring the patient that everything will be fine b)Leaving the patient alone c) Showing understanding and acceptance d) Asking the patient to not cry
c) Showing understanding and acceptance
When inspecting the musculoskeletal system, which elements of the patient's posture would the nurse assess? SATA a) build b) height c) erectness d) symmetry e) alignment
c) erectness d) symmetry e) alignment
When testing muscle strength, the nurse should compare the bilateral muscles using which elements? SATA a) tenderness b) tone c) resistance d) temperature e) symmetry
c) resistance e) symmetry
Which tone would the nurse expect to hear when percussing over the lungs? a) tympany b) dullness c) resonance d) flatness
c) resonance
The correct method for measuring blood pressure includes inflating the cuff to 20 to 30 mmHg above the palpable systolic pressure and then deflating at what speed to identify the systolic pressure reading? a) 20 to 30 mmHg/sec b) 10 to 15 mmHg/sec c) 5 to 10 mmHg/sec d) 2 to 3 mmHg/sec
d) 2 to 3 mmHg/sec
The nurse holds an infant in vertical suspension with hands under the axillae to assess which element of the musculoskeletal system? a) Range of motion b) Muscle pain c) Hip dislocation d) General muscle strength
d) General muscle strength
The nurse should assess which aspect of an infant's musculoskeletal system during every examination for the first year of life? a) Genu varum b) Tibial torsion c) Arch of the foot d) Hip dislocation or subluxation
d) Hip dislocation or subluxation
What auscultatory landmark, identified after the systolic sound, marks the first diastolic sound? a) Appearance of Korotkoff sounds b) Disappearance of Korotkoff sounds c) Two consecutive beats d) Muffling of sounds
d) Muffling of sounds
Which element is performed after inspection and palpation of the patient's spine while the patient is standing? a) Test abdominal reflexes b) Palpate axillary lymph nodes c) Assess radial and brachial pulses d) Observe the patient walk heel to toe
d) Observe the patient walk heel to toe
To ensure accurate findings, what information would the nurse verify prior to beginning inspection? a) A clock with a second hand is present in the room. b) The patient is completely covered with a drape at all times. c) History-taking questions have been answered. d) Overhead lighting and a lamp are available.
d) Overhead lighting and a lamp are available.
The healthcare provider palpates the prostate gland and seminal vesicles with the patient standing as part of which element of the examination? a) spinal b) rectal c) neurological d) abdominal/Genital
d) abdominal/Genital
Which tone would the nurse expect to hear when percussing over bone? a) tympany b) dullness c) resonance d) flatness
d) flatness
What patient characteristic can interfere with obtaining a comprehensive health history and can be treated with breathing or relaxation exercises? a) intoxication b) patient withdrawal c) uncooperativeness d) moderate anxiety
d) moderate anxiety
Contraction and relaxation of the skeletal muscles result in what temperature-regulating reaction? a) vasodilation b) hypothermia c) pyrexia d) shivering
d) shivering
Which element of the functional assessment should be included during the review of systems? a) blood pressure b) ability to bathe c) neurologic function d) signs of dementia
d) signs of dementia
Place the examination components in order for the adult patient who is supine. a) palpate for pedal edema b) percuss liver border c) inspect abdomen d) auscultate heart
d, c, b, a
During the health history, the patient tells the nurse he drinks four beers daily. Which statement, made by the nurse, is an example of reflecting? a) "To clarify, you said you drink four beers daily?" b) "When during the day do you drink your beers?" c) "I can appreciate wanting a beer or two after a long day." d) "What do you mean?"
a) "To clarify, you said you drink four beers daily?"
The nurse is gathering a health history. Which statement, made by the nurse, would be least effective for obtaining details about the patient's smoking habits? a) "You look like you smoke about a pack of cigarettes per day; is this accurate?" b) "How many packs of cigarettes do you smoke a week?" c) "How long have you used tobacco?" d) "What type of tobacco do you use?"
a) "You look like you smoke about a pack of cigarettes per day; is this accurate?"
Which temperature, taken rectally, is outside the normal range for a healthy adult? a) 97 F b) 36.5 C c) 37 C d) 99 F
a) 97 F
Which blood pressure response is expected when a patient rises from a sitting position? a) A rise in diastolic pressure b) A rise in systolic pressure c) No change in diastolic pressure d) An increase in pulse pressure
a) A rise in diastolic pressure
What percussion tone would indicate air-filled (emphysematous) lungs? a) Hyperresonance b) dullness c) resonance d) flatness
a) Hyperresonance
Blood pressure follows a diurnal pattern, peaking at what time during the day? a) afternoon b) midmorning c) evening d) early morning
a) afternoon
Which muscle characteristics should the nurse inspect as part of a thorough musculoskeletal examination? SATA a) tone b) atrophy c) symmetry d) hypertrophy e) fasciculations
b) atrophy c) symmetry d) hypertrophy e) fasciculations
Which respiratory rate (in breaths per minute) would the nurse characterize as bradypnea? a) 12 b) 15 c) 9 d) 20
c) 9
Which elements should be performed after light palpation of all quadrants of the abdomen in the adult patient? a) Percussion of all quadrants b) Auscultation for bowel sounds c) Deep palpation of all quadrants d) Inspection of abdominal contour
c) Deep palpation of all quadrants
Which type of movement defines a grade 2 range of motion? a) Trace of movement b) No evidence of movement c) Full passive range of motion d) Full range of motion against gravity with full resistance
c) Full passive range of motion
During which component of a comprehensive history does the nurse ask the patient about prescribed medications? a) family history b) chief concern c) medical history d) previous hospitalizations
c) medical history
Observing the patient's gait and testing balance are included in which element of the adult head-to-toe examination with patient standing? a) spinal b) abdominal c) neurologic d) musculoskeletal
c) neurologic
Place the steps for measuring blood pressure in the order in which they are performed. a) note the systolic sound b) inflate cuff until it is 20 to 30 mmHg above palpable systolic pressure c) deflate cuff to 2 to 3 mmHg per second d) note the second diastolic sound e) determine palpable systolic pressure
e, b, c, a, d
Use of a medical interpreter to take a patient history in a non-English-speaking patient is preferred over use of the patient's family member(s) for which reasons? SATA a) the ability of the interpreter to provide culturally sensitive advice b) The interpreter's knowledge of medical terminology c) A family member's possible unwillingness to interpret d) The interpreter's understanding of patient rights e) The tendency for a patient to withhold embarrassing or private information from family
a) the ability of the interpreter to provide culturally sensitive advice b) The interpreter's knowledge of medical terminology d) The interpreter's understanding of patient rights e) The tendency for a patient to withhold embarrassing or private information from family
