Health Assessment Exam 1

2. Risk factors for osteoarthritis include ________ (Select all that apply.) a) Older age b) Chronic carpel tunnel syndrome c) Genetics d) Being male e) Obesity

A, C, E Rationale: Osteoarthritis is more common with aging due to the cumulative effects of wear and tear on the joints over time. Individuals with a family history of Osteoarthritis are more susceptible for developing the condition. Excess body weight places increased stress on weight-bearing joints.

19. A patient is prescribed benzodiazepine, alprazolam for the management of panic attacks. Which action by the patient makes the nurse confident that the medication information discussed has been understood? a) The patient removes pizza from their diet b) The patient asks for an extra bottle of grape juice to drink with dinner c) The patient requests a prescription for oral contraceptives before being discharged d) The patient states that chewable antacids may be taken to relieve heartburn

C Rationale: Benzodiazepines increase the risk of congenital anomalies and so should not be taken by pregnant women.

15. Which stage of pressure ulcer would the nurse document for a patient who has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia? a) Stage II b) Stage V c) Stage IV d) Unstageable

D Rationale: A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged.

34. Which nursing action is most important for a client with urinary retention related to benign prostatic hyperplasia who has a secondary diagnosis of delirium related to urosepsis and a prescription for the insertion of an indwelling urinary retention catheter? a) Secure a prescription for wrist restraints b) Orient the client to time, place, and person c) Involve family members in the client's care d) Determine whether any unsafe behavior patterns exist

D Rationale: The nurse should determine whether the client is a danger to self or others before planning and implementing care.

42. Which reason would an intravenous infusion of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium be prescribed for a patient with a nasogastric tube set to low intermittent suction? a) Prevent constipation b) Prevent dehydration c) Prevent vomiting d) Prevent electrolyte imbalance

D Rationale: When patient do not receive nutrients or fluids by mouth and have a loss of electrolytes through the removal of gastric secretions via an NG tube, electrolyte imbalance is a primary concern.

11. Which finding(s) in the older adult patient is associated with a urinary tract infection (UTI)? (Select all that apply.) a) Dysuria b) Urgency c) Confusion d) Incontinence e) Slight rise in temperature

11. C, D, E Rationale: An older adult patient with a UTI is likely to appear confused and may experience incontinence. The older adult patient may develop only a slight rise in temperature.

17. Which condition requires airborne precautions? a) Measles b) Influenza c) Clostridium difficile (C.diff) d) Bacterial meningitis

17. A Rationale: Varicella, measles, and tuberculosis require airborne precautions because these infections spread through small particles in the air.

10. Which stage would the nurse document for a client with a pressure injury that has exposed bone and tendons? a) Stage IV b) Stage I c) Stage II d) Stage III

A Rationale: A stage IV (4) pressure injury involves full-thickness tissue loss and the tendons, bones, or muscle are exposed.

39. The nurse would assess the respiratory status of the patient at 2-hour intervals as a safety priority for which condition? a) Hypokalemia b) Hyperkalemia c) Hyponatremia d) Hypernatremia

A Rationale: In hypokalemia, low potassium levels in the blood, can lead to muscle weakness, including respiratory muscles.

6. Which component of skin maintains optimal barrier function? a) Keratin b) Melanin c) Collagen d) Adipose Tissue

A Rationale: Keratin is a protein produced by keratinocytes that helps maintain optimal barrier function.

31. Which environment would be conducive to reducing emotional stress and providing safety for a patient diagnosed with generalized anxiety disorder? a) One in which realistic limits and controls are set b) One where all needs are met c) One where the patient's environment is kept neat and orderly d) One in which the patient's requests are met promptly

A Rationale: Setting realistic limits and control makes the environment as emotionally nonthreatening as is realistically possible.

32. Which factors are unique to delirium when distinguishing between dementia and delirium? (Select all that apply.) a) Slurred speech b) Lability of mood c) Long-term memory loss d) Visual or tactile hallucinations e) Insidious deterioration of cognition f) A fluctuating level of consciousness

A, D, F Rationale: Delirium results in sparse or rapid speech that may be slurred/incoherent. Visual or tactile hallucinations/illusions may occur with delirium because of altered cerebral function. Patients with delirium fluctuate from hyperalert to difficult to arouse; they may lost orientation to time and place.

4. What is the difference between evisceration and dehiscence? a) Evisceration is the separation of wound edges, while dehiscence involves protrusion of organs b) Dehiscence is the separation of wound edges and evisceration is the protrusion of organs c) Evisceration and dehiscence both refer to the same surgical complication d) Evisceration involves the incomplete closure of a wound, while dehiscence is the displacement of internal organs

B

41. Which action is the function of Antidiuretic Hormone (ADH)? a) Reduces blood volume b) Decreases water loss in urine c) Increases urine output d) Initiates the thirst mechanism

B Rationale: ADH is released mainly in response to a decrease in blood volume or an increased concentration of sodium or other substances in the plasma. ADH acts to decrease the production of urine by increasing the reabsorption of water by renal tubules.

25. A patient has been robbed, beaten, and sexually assaulted. The primary health care provider prescribed 0.25mg of alprazolam for agitation. Which event would alert the nurse to administer this medication? a) The patient's crying increases b) The patient requests something to calm her c) The nurse determines a need to reduce her anxiety d) The primary health care provider is getting ready to perform a vaginal examination

B Rationale: Because a sexual assault is a threat to the sense of control over one's life, some control should be given back to the patient as soon as possible.

48. Which factor is a likely cause of hyponatremia? (Select all that apply.) a) Diabetes insipidus b) Profuse diaphoresis c) Excess sodium intake d) Removal of the parathyroid glands e) Rapid IV infusion of 5% dextrose in water (D5W)

B, E Rationale: Perspiration contains high levels of sodium and inappropriate use of sodium-free or hypotonic IV fluids like D5W causes hyponatremia from water excess.

44. A patient is admitted with severe diarrhea that resulted in hypokalemia. The nurse would monitor for which clinical manifestation of the electrolyte deficiency? (Select all that apply.) a) Diplopia b) Skin rash c) Leg cramps d) Tachycardia e) Muscle weakness

C, E Rationale: Legs cramps occur with hypokalemia because of potassium deficit. Muscle weakness occurs because of the alteration in the sodium potassium pump mechanism.

28. Which action would the nurse take first for a patient with a generalized anxiety disorder? a) Remove as many stimuli from the patient's environment as possible b) Encourage the client to exercise on a daily basis c) Administer as-needed medications prescribed by the primary health care provider d) Have the patient list the behaviors used to reduce anxiety

A Rationale: Removing as many stimuli from the patient's environment helps reduce the patient's anxiety by limiting the factors that must be confronted; decreasing stimuli usually decreases anxiety.

23. Which approach would the nurse use for a patient with Alzheimer disease who expresses fear and anxiety upon admission to a long-term care facility? a) Reassuring the patient with the presence of 1-2 staff members b) Exploring the reasons for the concerns c) Providing the patient with a written schedule of planned interactions d) Explaining to the patient why the admission to the facility is necessary

A Rationale: The patient needs reassurance, because forgetfulness blocks previous explanations; the presence of 1-2 staff members serves as a support system.

37. Which principle explains how loop diuretics promote diuresis? a) Osmosis b) Filtration c) Diffusion d) Active transport

A Rationale: Loop diuretics inhibit the reabsorption of sodium and water in the ascending loop of Henle. The increased sodium load in the distal tubule causes the passive transfer of water from the glomerular filtrate to urine through the process of osmosis.

45. Which action is the nurse's priority when caring for a patient admitted for dehydration on an IV infusion of normal saline at 125 mL/hr who begins screaming, "I can't breathe!" one hour after the IV is initiated? a) Elevate the head of the bed and obtain vital signs b) Discontinue the IV and contact the primary health care provider c) Change the IV to an intermittent infusion device d) Contact the primary health care provider to obtain a prescription for a sedative

A Rationale: Normal saline will not cause an allergic reaction and a mere 125 mL in a dehydrated client will not cause pulmonary edema, so it is important to further assess the patient to determine the cause of the patient's distress. Elevating the head of the bed facilitates breathing by decreasing pressure against the diaphragm.

46. Which action would the nurse take after identifying that a patient's urinary output is less than 40 mL/hr over the past 3 hours? a) Assess breath sounds and obtain vital signs b) Decrease the IV flow rate and increase oral fluids c) Insert an indwelling catheter to facilitate emptying of the bladder d) Check for dependent edema by assessing the lower extremities

A Rationale: The imbalance in intake/output, with a decreasing urinary output, may indicate kidney failure. The retention of excess body fluid can precipitate the development of heart failure. Assessing breath sounds and obtaining vital signs are necessary when monitoring for these complications.

13. Which action(s) would the nurse instruct an older patient to implement to ensure antibody-mediated immunity? (Select all that apply.) a) Obtain a shingles vaccination b) Receive a tetanus booster injection c) Obtain the pneumococcal vaccination d) Receive annual testing for tuberculosis e) Receive an annual influenza vaccination f) Avoid obtaining the pertussis vaccination

A, B, C, E Rationale: Because older adults are less able to make new antibodies in response to the presence of new antigens, they should receive the shingles vaccination. Older adults may not have sufficient antibodies present to provide protection when re-exposed to microorganisms, thus booster shots are encouraged. The pneumococcal and influenza vaccinations help create antibodies in response to new antigens.

35. What physiological factor(s) alters the pharmacokinetic properties of medication in the breast-feeding neonate? (Select all that apply.) a) Decreased fat content b) Increased protein binding c) Immature blood-brain barrier d) Increased first pass elimination e) Decreased glomerular filtration rate f) All The Above

A, C, E Rationale: In neonates, the fat content is low because of a large amount of total body water. As a result, the medication readily enters the bran because of the neonates' immature blood-brain barrier. Neonates have immature kidneys; therefore the glomerular filtration rate is decreased.

3. What distinguishes acute pain from chronic pain? a) Chronic pain typically has a sudden onset, while acute pain develops gradually b) Acute pain is short-lived and decreases with healing, chronic pain persists and serves no useful purpose c) Acute pain is generally more severe than chronic pain d) Chronic pain is always associated with an identifiable injury or illness whereas acute pain is not

B Rationale: Acute pain is typically a response to a specific injury, illness or tissue damage and decreases as the injury heals. Chronic pain persists over an extended period, often beyond the expected time for healing, and does not serve a clear protective function.

33. Which intravenous (IV) solution would the nurse anticipate administering when caring for a patient with a history of severe diarrhea for the past 3 days who is admitted for dehydration? a) 3% sodium chloride b) 0.9% sodium chloride c) 5% dextrose and lactated ringer solution d) 5% dextrose and 0.9% sodium chloride

B Rationale: An IV solution of 0.9% sodium chloride is the most appropriate initial IV fluid for this patient because it is an isotonic solution that will act as a volume expander to quickly replace volume losses.

43. Which clinical finding would the nurse anticipate when admitting a patient with an extracellular fluid volume excess? a) Rapid, thready pulse b) Distended jugular veins c) Elevated hematocrit level d) Increased serum sodium level

B Rationale: Because of fluid overload in the intravascular space, the neck veins become visibly distended.

16. ______ is a condition associated with fever, redness, skin breakdown, and inflammation on an area that is tender and edematous with diffused borders a) Shingles b) Cellulitis c) Folliculitis d) Onychomycosis

B Rationale: Fever and redness due to inflammation are followed by skin breakdown in cellulitis.

47. While changing a newborn girl's diaper the nurse observes a brick-red stain on the diaper. How would the nurse interpret this clinical finding? a) A sign of low iron excretion b) An uncommon benign occurrence c) An expected occurrence in female newborns d) The result of a medication administered during labor

B Rationale: The brick-red color in the urine is caused by albumin and urates that are found in the first week of life.

Which information will the nurse share with a patient who sustained a burn and asks, "What is the difference between my full-thickness and deep partial-thickness burns?" a) "Full-thickness burns extend into the subcutaneous tissue; deep partial-thickness burns effect only the epidermis." b) "Full-thickness burns extend into the subcutaneous tissue; deep partial-thickness burns extend through the epidermis and involve only part of the dermis." c) "Full-thickness burns involves superficial layers of the epidermis; deep partial-thickness burns extend through the epidermis." d) "Full-thickness burns extend through the epidermis and only part of the dermis; deep partial-thickness burns extend into the subcutaneous tissue."

B Rationale: The response that full-thickness burns extend into the subcutaneous tissue and deep partial-thickness burns extend through the epidermis and involve only part of the dermis correctly describes the difference.

21. Which statement about benzodiazepines requires correction? a) They are indicated for ethanol withdraw b) These medications increase the activity of gamma-aminobutyric acid (GABA) c) Benzodiazepines are the first-line medications used in chronic anxiety disorders d) These medications depress activity in the brain stem

B Rationale: Benzodiazepines act by *decreasing* the activity of gamma-aminobutyric acid, which is an inhibitory neurotransmitter.

36. As the nurse is conducting the discharge assessment, the 2-day-old neonate expels a large amount of meconium. Which would the nurse conclude regarding this occurrence? a) It is the precursor of newborn diarrhea b) It is a common finding in a 2-day-old neonate c) It is a pathological condition of the digestive system d) It reflects immaturity of the autonomic nervous system

B Rationale: Passage of meconium is desirable in the newborn because it indicates patency of the colon and a perforate anus. Meconium is passed usually during the first several days of life, it is typically dark green or black in color.

5. Which of the following regarding acne are correct? (Select all that apply.) a) Acne is a hormonal disease b) Acne may be caused by stress c) Family history could be a reason for acne d) Propionibacterium acnes causes acne e) Acne is commonly found on the face, chest, upper back, and neck

B, C, D, E Rationale: Stress and family history may cause acne formation. The causative organism is Propionibacterium acnes. Acne is commonly found on the face, chest, upper back, and neck where there are a higher number of sebaceous glands. Acne is not a hormonal disease, rather it is a skin disease due to a hormonal imbalance.

14. Which immune function change places older patients at risk for bacterial and fungal infections? a) Decline in natural antibodies b) Reduction of neutrophil function c) Decrease in circulating T lymphocytes d) Reduction of colony-forming B lymphocytes

C Rationale: A decrease in circulating T lymphocytes occurs with cell-mediated immunity, resulting in increased risk of bacterial and fungal infections.

1. A patient complains of pain during a dressing change. What would be the most effective interventions the nurse could initiate at the next dressing change in order to reduce the patient's pain? a) Thoroughly explain the procedure to the patient b) Use a distraction technique to divert the patient's attention during the procedure c) Premedicate the patient with a prescribed analgesic 30 minutes before the intervention d) Position the patient comfortably before the intervention

C Rationale: Administration of a prescribed analgesic would directly control the patient's pain level during the dressing change. This intervention is more likely to be effective than the other options listed.

26. Which medication would the nurse anticipate developing a teaching plan for when a patient reports becoming panicked and having an irrational fear of talking in public? a) Buspirone b) Diazepam c) Alprazolam d) Lorazepam

C Rationale: Alprazolam (benzodiazepine) is a short-acting anxiolytic medication used to treat those clients with panic disorders and the irrational fear of public speaking (agoraphobia).

7. Which action would the nurse take first after learning that sputum cultures for a patient with a chronic cough were positive for tuberculosis? a) Notify the patient's health care provider b) Auscultate the patient's breath sounds c) Place the client on airborne precautions d) Notify the public health department

C Rationale: The initial action by the nurse after learning the patient has active tuberculosis would be to assure the safety of other patients, visitors, and staff by implementing airborne precautions.

20. _______, __________, and __________ are all clinical manifestation of a patient diagnosed with Alzheimer disease a) Focused attention span, incontinence, and difficulty learning something new b) Loss of recent memory, perceptual disturbances, and heightened long-term memory c) Loss of recent memory, perceptual disturbances, and difficulty learning something new d) Pruritis, cloudy vision, and dry mouth

C Rationale: Neurofibrillary tangles attack the hippocampus, impairing recent memory. As dementia progresses, sensory-perceptual alterations occur (hallucinations). Alzheimer disease is associated with learning, thinking, and language impairment.

22. A patient is prescribed alprazolam. Which action must the nurse include in the patient assessment during the initiation of therapy? a) Measure the patient's urine output b) Examine the patient's pupils daily c) Check the patient's blood pressure d) Assess the abdomen for distention

C Rationale: Orthostatic hypotension is a common side effect of alprazolam that occurs early in therapy, so checking the patient's blood pressure is the appropriate action.

40. Which action would the nurse take for an older adult patient with Alzheimer disease who has intermittent episodes of urinary incontinence? a) Point out the behavior to the patient b) Obtain incontinence pads for the patient c) Take the patient to the bathroom at regular intervals d) Encourage the patient to call for help when there is an urge to urinate

C Rationale: Taking the patient to the bathroom at regular intervals will facilitate elimination needs. Patients with Alzheimer disease have difficulty recognizing and remembering to follow through on basic needs; routinely emptying the bladder may reduce episodes of incontinence.

49. Which action would be most important for the nurse to take when caring for a patient who started furosemide 2 days ago and has a serum potassium level of 2.8 mEq/L? a) Hold the morning dose of the diuretic b) Continue to monito the level to ensure that it stays within the normal limits c) Notify the primary health care provider of the critically low result d) Anticipate a prescription for an increase in the dosage of the furosemide

C Rationale: The healthcare provider should be notified because a potassium level of 2.8 is critically low.

38. Which finding of a patient several hours after removal of a catheter inserted a week prior after pelvic surgery indicates a need for reinsertion of the catheter? a) Anuria b) Polyuria c) Retention d) Incontinence

C Rationale: The inability of the patient to urinate in spite of the bladder being filled with urine is called retention. Generally, patients who have undergone pelvic surgery and have the catheter removed experience urinary retention. The catheter should be reinserted if the patient is unable to void.

30. Which assessments are priority for a disturbed patient who is brought to the emergency department by the police? a) Recollection of past events and events preceding police involvement b) Previous history of incarceration or hospitalization for psychiatric disorders c) Current behavior, appearance, cognitive function, orientation d) Cultural background, family history, developmental level, and verbal skills

C Rationale: The priority is a brief mental assessment that includes appearance, behavior, judgment, orientation, recent memory, and cognition. The other assessment are detailed histories.

8. Which combination of patient responses would the nurse determine represents the highest risk for the development of pressure injuries? a) Spending extensive time in a chair; body mass index of 23 b) Minimal reaction to painful stimuli; receiving tube feedings c) Periodic diaphoresis; occasional sliding down in bed d) Incontinence; inability to move independently

D Rationale: Constant exposure to moisture (urine) and prolonged pressure that compresses capillary beds place a patient at high risk for pressure injuries.

27. Which cognitive development is seen in early adolescence? a) Having established abstract thoughts b) Developing capacity for abstract thinking c) Exploring the ability to attract the opposite sex d) Exploring a newfound ability for limited abstract thoughts

D Rationale: Formal operational thought includes being able to think in abstract terms, think about possibilities, and think through hypotheses, which are characteristics of cognitive development during adolescence.

29. Which medication class is preferred for managing anxiety disorders? a) Anticholinergics b) Lithium carbonate c) Antipsychotic medications d) Selective serotonin reuptake inhibitors (SSRIs)

D Rationale: SSRIs have better safety profiles and do not carry the risk of substance abuse and tolerance.

18. Which patient is at an increased risk for hospital-acquired pneumonia? a) Patient who was admitted yesterday with hypoxia and fever b) Patient who has been on mechanical ventilation for 5 days c) Patient who reports being on an airplane with other sick individuals d) Patient who was admitted to the hospital 5 days ago for abdominal pain

D Rationale: Hospital-acquired pneumonia occurs in non-intubated clients and begins 48 hours after admission.

12. Which laboratory test will be elevated in a patient with inflammatory arthritis? a) Leukocyte count b) Hemoglobin and hematocrit c) Blood urea nitrogen (BUN) and creatinine d) Erythrocyte sedimentation rate (ESR)

D Rationale: The ESR measures the rate at which red blood cells fall through plasma. The rate is most significantly affected by an increased number of acute-phase reactants, which occur with inflammation.

50. Which clinical manifestation indicates a need for the nurse to contact the health care provider to increase the IV fluid infusion rate for an older patient with an infection? a) Pruritus b) Erythema c) General malaise d) Acute confusion

D Rationale: The nurse would consider the development of dehydration if acute confusion occurs in an older patient with an infection and contact the healthcare provider.

24. Which intervention would the nurse use when a patient with dementia tries to open the door and says, "I want to leave now."? a) Ask the patient where they are going and how they plan to get there b) Allow the patient to leave; they have the right to refuse treatment c) Explain that the family and doctor want them to stay for safety d) Invite the patient to attend an activity program that they enjoy

D Rationale: The nurse would use distraction to direct the patient away from the door. This intervention provides safety without confrontation.