health assessment quiz questions

A female Korean patient comes to the ER complaining of abdominal pain. She is accompanied by her husband and son. The patient speaks only Korean, and does not understand English. Choose the appropriate mechanism below to communicate with this patient most effectively given the language barrier. 1. Use the interpreter system who has identified for you a female Korean translator 2. Have the husband interpret; he speaks both Korean and English 3. Have the patient's son interpret for you 4. Have the male technician who works with you interpret for the patient

1

After the death of a Native American man, the nurse opened the window to allow the spirits to leave. The nurse's action demonstrated the concept of cultural competence by... 1. Adapting thoughtful interventions based on the patient's cultural practices 2. To let fresh air into the room for the family 3. Complying with the family's wishes even though she did not believe in spirits

1

As nurses which of the identified body systems below do we assess primarily by inspection? 1. Integumentary/Skin 2. Cardiovascular 3. Musculoskeletal 4. Nervous System

1

Mr. M is a client who has come in for his yearly physical assessment. When you take his radial pulse you believe you notice an irregularity in the rhythm. What is the first action you would take? 1. Count Mr. M's apical pulse for 1 full minute with auscultation 2. Assume this irregularity is normal 3. Count the radial pulse again for 15 seconds and multiply by 4 4. Check Mr. M's pulse oximetry reading

1

Vital signs are ordered for Mrs. M at 6 AM, 2 PM & 10 PM. Which temperature reading is expected to be low because of normal variation in body physiology? 1. The temperature at 6 AM 2. The temperature at 2 PM 3. The temperature at 10 PM 4. All of the temperatures will be low because she is ill

1

Which is the most appropriate technique to utilize when measuring a client's blood pressure? 1. Choosing the appropriate size cuff for the patient's arm 2. Having the patient sit with his feet on the ground 3. Positioning the patient's arm above the heart 4. Wrapping the blood pressure cuff too loosely 5. Reinflating the cuff before the cuff completely deflates

1

Which of the information noted below would the nurse document as part of her/his physical assessment? 1. Slurred speech with facial drooping 2. Last tetanus immunization 3. Dietary practices 4. Allergy to latex

1

Your patient is vague about sharing information with the intake nurse. One technique that would be helpful in gaining more data is... 1. Asking the patient to explain a particular statement or point he/she made to you 2. Repeating what the patient said 3. Asking open -ended questions 4. Smiling during the interaction

1

You are the nurse caring for patients at the community women's health center today. You think your client "Laura" may be a victim of physical abuse. She nervously sits on the examination table, wringing her hands and does not make frequent eye contact with you. Which of the responses below is likely to have "Laura" begin to confide in you? 1. "Well that is a fresh bruise on your arm. Why would you stay with someone who is hurting you?" 2. "I am here to care for you. I have seen women who have been hurt by a spouse or partner. Does anyone hit you?" 3. "I suggest you get a restraining order against that creep who is hitting you Laura." 4. "Where did you get that bruise on your forehead? Did your spouse strike you?"

2

Your patient has a history of abdominal cramping and gas (flatus) over the last week or so. During your physical assessment you identify that his abdomen is slightly distended (full). Which sound do you expect to hear when you percuss his abdomen? 1. Dullness 2. Tympany 3. Bruit 4. Resonance

2

A 70 year old male is admitted to the ICU with pneumonia. Although he is short of breath he explains to you he has diabetes mellitus and takes insulin twice each day. In what section of the patient's health history would the nurse document the diabetes? 1. Reason for seeking care section 2. Medications section 3. Present health status section 4. Past health history section

3

During the health history intake, the female client states that she "does not use many drugs". What is the most appropriate response by the nurse? 1. "I am sure you mean prescription drugs?" 2. "How often do you use drugs?" 3. "Please describe for me the drugs you are currently taking" 4. "Exactly how many drugs do you take?"

3

Which is an example of data the nurse collects during the physical examination? 1. The patient states he does not have money for medications 2. The patient tells you sometimes he has ringing in his ears 3. Areas of the scalp noted to be reddened and without hair 4. The patient's son tells you that his father is becoming forgetful

3

Which set of questions is important when the client identifies that she has been having headaches? 1. Have you had any recent immunizations? What symptoms do you have when you feel the headache "coming on"? 2. Headaches may run in your family. Do you get migraines? 3. Describe what your headache feels like. When did these headaches start? What makes the headaches better or worse? 4. When was you last eye exam? Do you have high blood pressure?

3

You are going to begin interviewing a client in the outpatient health center today. Which statement is appropriate? 1. Would you describe your perception of health prevention? 2. Did you bring your insurance card with you today? 3. Good morning, what is the purpose of your visit today Mr. "B"? 4. How many times have you come to the center?

3

You are the triage nurse in the ER tonight. A female patient arrives by ambulance and you receive report from the EMT team that Mrs. "X" is having chest pains. What is your first action to prioritize her care? 1. Ask Mrs. "X" to fill out forms regarding her personal information and insurance coverage 2. Start collecting data for the comprehensive history 3. Bring Mrs. "X" to the telemetry area and begin an immediate focused assessment 4. Ask Mrs. "X" to have a seat in the holding area

3

A nurse that practices cultural sensitivity will... 1. Identify a treatment plan that is not in aaccordance with the patient's/client's religious practices 2. Assist patients/clients in adopting behaviors that they see as important 3. Indifference to other's cultural beliefs as long as it does not interfere with their job 4. Recognize the importance of and accepting diversity among patients and colleagues

4

The nurse is preparing to assess a client's ability to detect vibrations on her lower extremities. The equipment most appropriate for this assessment is a: 1. Reflex Hammer 2. Calipers 3. Goniometer 4. Tuning fork

4

When taking a family history, your patient starts to cry when you ask if his mother is still alive. Which response by the nurse is most therapeutic? 1. "Would you like a glass of water until you compose yourself again?" 2. "I will give you a few minutes to compose yourself" 3. "Please calm down, everyone loses their parents." 4. "I am so sorry if my question made you upset. Please tell me how you are feeling>"

4

Which statement by the nurse demonstrates a true patient-centered interview? 1. "The hospital requires me to ask you several, repetitive questions about your history - so please be patient." 2. "OK, lets sit down and complete this lengthy questionnaire." 3. "Sometimes I have those same aches and pains, its normal it just means we are getting older!" 4. "Good afternoon, before your exam may we sit and discuss what brought you here today? Do you have any concerns regarding your present health?"

4

A nurse can improve cultural awareness with which behavior? A. Being sensitive to differences between the cultures of the nurse and patient B. Making generalizations about various ethnic and cultural groups C. Learning everything about the various cultural groups in the nurse's city D. Taking a foreign language class

A

A nurse expects which finding when assessing the abdomen of a patient who has been unable to void for 12 hours? A. Dull tones over the suprapubic area B. Absent bowel sounds C. Hyperactive bowel sounds D. Tympanic tones over the lower abdomen

A

A nurse inspects a patient's hands and notices clubbing of the fingers. The nurse correlates this finding with what condition? A. Chronic hypoxemia B. Allergic reaction C. Trauma to the thorax D. Pulmonary infection

A

A nurse is asking questions about the present health status of a young woman who has lost weight recently. Which question is most appropriate when inquiring about present health status? A. "Describe the recent changes in your weight." B. "Do you have a family history of eating disorders?" C. "Do you have anorexia?" D. "What concerns have you had in the past regarding your weight?"

A

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? A. Hold stethoscope firmly to prevent movement when placed over chest hair. B. Ask the patient not to talk while the nurse is listening to the lungs. C. Change the patient's position to ensure accurate sounds. D. Make sure the bell of the stethoscope is used, rather than the diaphragm.

A

A nurse is using the finger pads to palpate a patient's dorsalis pedis pulses and is unable to feel any pulses. Which action is appropriate for the nurse to perform next? A. Use a Doppler to detect the presence of the pulses. B. Document that the dorsalis pedis pulses are not palpable. C. Palpate the dorsalis pedis pulses using the ulnar surface of the hand. D. Have the patient stand and try again to palpate the pulses.

A

A nurse notices a patient's chest wall moving in during inspiration and out during expiration. What additional assessment must the nurse perform immediately? A. Palpate for tracheal deviation. B. Auscultate for bronchovesicular breath sounds in the lung periphery. C. Palpate posterior thoracic muscles for tenderness. D. Auscultate for absence of breath sounds in the lung periphery.

A

A nurse performing a breast examination on a female patient places the patient in a supine position, places a pillow under the right shoulder, and asks the patient to place her right lower arm above her head. What is the reason for this position? A. Flattens the breast tissue evenly over the chest wall. B. Expose any drainage from the nipples. C. Reveal lumps deep in the breast more easily. D. Help the patient to relax and feel more comfortable.

A

A patient complains of itching, swelling, and drainage from the eyes with a postnasal drip and sneezing. What type of nasal drainage does the nurse anticipate seeing during inspection of this patient's nares? A. Clear B. Malodorous C. Yellow D. Green

A

A patient is sitting slightly forward bracing his arms on his knees in a tripod position. This position is associated with which symptom? A. Breathing difficulty B. Spinal deformity C. Abdominal pain D. Back pain

A

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. "Stimulation of nerves from your leg sends impulses to the brain so that you feel pain even though your leg is no longer there." B. "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. "Amputating your leg caused abnormal processing of sensory input by the peripheral nervous system." D. "After your amputation, pain perception increases."

A

During a physical examination, the nurse notes that the patient's skin is dry and flaking, with patches of eczema, and suspects a nutritional deficiency. What additional data should the nurse expect to find to confirm the suspicion? A. Hair loss and hair that is easily removed from the scalp B. Fissures and inflammation of the mouth C. Inflammation of peripheral nerves, and numbness and tingling in extremities D. Inflammation of the tongue and fissured tongue

A

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. "Do you mean prescription drugs or illicit drugs?" C. "To some people six or seven is not many." D. "How often are you using these drugs?"

A

How does the nurse accurately assess bowel sounds? A. Hold the stethoscope diaphragm lightly against each of the 4 quadrants of the abdomen B. Listen with his/her ear to the abdomen C. Press the diaphragm of the stethoscope firmly against the abdomen in each quadrant D. Press and hold the bell of the stethoscope on the abdomen

A

Mrs. S reports that she experiences shortness of breath and peripheral edema (swelling) in her feet. Under which category will the nurse document this data? A. Review of body systems B. Functional ability C. Present health status D. Past health history

A

Nurses understand that a patient's diastolic pressure represents which physiologic function? A. The pressure in blood vessels when the ventricles are relaxed B. The pressure in blood vessels when the ventricles contract C. The pressure needed to open the aortic and pulmonic valves D. The pressure of the blood returning to the heart from the venous system

A

What are the characteristics of one's culture? A. System of beliefs and practices B. Color of skin and hair C. Language and religion D. Food preferences

A

What instructions does the nurse give a patient before palpating the abdomen? A. Bend the knees B. Take a deep breath and cough C. Place the hands over the head D. Take a deep breath and hold it

A

What technique does a nurse use when performing a breast examination on a patient who has had a mastectomy? A. Inspects and palpates both the operative and the nonoperative sides B. Excludes palpation of the axillary area where there was lymph node dissection C. Avoids palpating the scar to prevent causing the patient any discomfort D. Palpates only the muscle tissue on the affected side

A

What tool does the nurse use to assess the patient's near vision? A. A Snellen eye chart placed about 12 inches from the patient's face B. Examination of the eyes for a red reflex C. An ophthalmoscope with the diopter set at 0 (zero) D. A newspaper held about 2 feet from the patient's face

A

When performing a skin assessment of an adult patient, the nurse expects what finding? A. Return of skin to its original position when pinched up slightly B. Reddened area does not blanch when gentle pressure is applied C. Indentation of the finger remains in the skin after palpation D. Flaking or scaling of the skin

A

Where does the nurse attach the sensor probe of the pulse oximeter to measure a patient's oxygen saturation? A. Around the patient's index finger nail B. The chest over the patient's heart C. Over the patient's radial pulse D. Over the patient's abdominal aorta

A

Where does the nurse attach the sensor probe of the pulse oximeter to measure a patient's oxygen saturation? A. Place the probe on/around the patient's index finger B. Place the probe over the radial pulse C. Place the probe over the patient's abdomen D. Place the probe over the patient's chest

A

Which manifestations does a nurse correlate with a patient with suspected meningitis? A. Severe headache, stiff neck & agitation B. Severe headache, hyper alert state & ptosis C. Lethargy, stiff neck & Bell's Palsy D. Loss of consciousness, ptosis & facial droop

A

Which patient may be experiencing severe anxiety? A. A man who phones the nurse five times asking for instructions about how to take his new medication B. A woman who reports that she is sleeping very lightly each night because her child has an ear infection C. A woman who tells the nurse she is terrified of cats D. A man who tells the nurse he feels worthless and is always tired

A

Which patient should the nurse assess first? A. The patient whose respiratory rate is 26 breaths per minute and whose trachea deviates to the right. B. The patient who has pleuritic chest pain, bilateral crackles, a productive cough of yellow sputum, and fever. C. The patient who is short of breath, using pursed-lip breathing, and in a tripod position. D. The patient whose respiratory rate is 20 breaths/min, and has 8-word dyspnea and expiratory wheezes.

A

Which situation illustrates a screening assessment? A. A hospital sponsors a health fair at a local mall and provides cholesterol and blood pressure checks to mall patrons. B. A patient newly diagnosed with Diabetes Mellitus comes to test his fasting blood glucose level. C. A patient visits an obstetric clinic for the first time and the nurse conducts a detailed history and physical examination. D. The nurse in an urgent care center checks the vital signs of a patient who is complaining of leg pain.

A

Which sound does the nurse expect to hear when percussing a patient's abdomen? A. Tympany over all 4 quadrants B. Tympany over only lower 2 quadrants C. Dull sounds over upper 2 quadrants D. Dull sounds over the bladder only

A

Which technique used by the nurse encourages a patient to continue talking during an interview? A. Using phrases such as "Go on," and "Then?" B. Repeating what the patient said, but using different words C. Asking the patient to clarify a point D. Laughing and smiling during conversation

A

While giving a history, the patient reports having carpal tunnel syndrome. Based on this information, what technique does the nurse include in a focused assessment? A. Ask the patient to flex both wrists and press the dorsal aspects of the hands together for 1 minute. B. Ask the patient to push the hand against the nurse's forearm while attempting to flex the wrist. C. Hold pressure to the radial and ulnar pulses and watch for blanching. D. Ask the patient to press the pads of the right and left fingers against each other and hold for 1 minute.

A

During a health fair to prevent the risk of skin cancer and appropriate measure to instruct participants on as a primary measure would include? 1. Perform self-examination of skin monthly 2. Wear protective clothing while in the sun 3. Use a tanning booth, its safer than sunning outside. 4. Use sunscreen only when it is bright and sunny out

2

What are the characteristics of one's race? 1. Cultural practices 2. Color of skin and hair 3. Food preferences 4. System of beliefs and practices

2

What is the most important nursing action to reduce transmission of microorganisms during a physical assessment? 1. Wear a disposable gown during the assessment. 2. Perform hand hygiene with every encounter. 3. Wear gloves when anticipating exposure to body secretions.

2

When examining a patient's nails the nurse would expect the normal appearance of the nails to be...? 1. The nail base will be flat 2. The nail surface will be smooth and rounded 3. Whitish to clear nails in patients of dark skin types 4. Nail beds will have a bluish hue

2

A 24 year old male patient "Tom" tells you he had had no energy for about 2 weeks. He has no trouble falling asleep - actually sleeps about 12-14 hours a day. "Tom" also tells you he has gained 10 pounds (lbs) in the past 2 months and has no friends. As his nurse you associate Tom's manifestions (clinical signs) with which mental health disorder? A. Schizophrenia B. Depression C. Anxiety disorder D. Bipolar disorder

B

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. Discuss homosexuality and alcoholism with the patient. D. Determine the patient's degree of risk for contracting the human immunodeficiency virus.

B

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? A. Palpate the posterior thorax for vocal fremitus. B. Ask the patient to cough and repeat auscultation. C. Auscultate the posterior thorax for vocal sounds. D. Percuss the posterior thorax for tone.

B

A nurse is assessing an 80-year-old patient who is cared for at home by his 79-year-old wife. Which data indicate this patient has malnutrition? A. Hematocrit level of 50% B. Body mass index (BMI) of 17

B

What does a nurse say to obtain more data about a patient's vague (unclear) statement about diet such as, "my diet is okay". A. "Go on..." B. "Please give me an example of the foods you eat in a typical day?" C. "Eating a variety of meats, fruits and vegetables is very important you know>" D. "Nutrition is so overrated - eat what you like!"

B

What instruction does the nurse give the patient before palpating the abdomen? A. Hold your breath please Mrs. Smith B. Please bend your knees for me Mrs. Smith C. Take a deep breath and cough for me Mrs. Smith D. Place your hands over your head Mrs. Smith

B

When assessing the neck of a healthy adult, a nurse expects which findings? A. Hyperextension of the head 30 degrees from midline B. Turning the chin to the right shoulder and then the left shoulder C. Bending of the head to the right and left (ear to shoulder) 15 degrees D. A convex contour of the posterior cervical spine

B

When examining a patient, the nurse remembers to follow which principle of Standard Precautions? A. Wear gloves to reduce the need for handwashing B. Wear gloves when in contact with the patient's mucous membranes or secretions C. Wear both eye protection and a gown during the entire exam D. Wear gloves throughout the entire physical exam

B

Which data do nurses document under the category of past health history? A. Chronic diseases B. Immunizations received C. Allergies to medications or food D. Causes of death of the patient's parents

B

Which is an example of data a nurse collects during a physical examination? A. The patient's mother's statements that the patient is very nervous lately B. The patient's lack of hair and shiny skin over both shins C. The patient's stated concern about lack of money for prescriptions D. The patient's complaints of tingling sensations in the feet

B

Which question is an example of an "open-ended question"? A. "Have you experienced this pain before?" B. "What were you doing when you felt the pain?" C. "Do you have someone to help you at home?" D. "Don't you just love Professor A?"

B

A female patient states that she has had problems with depression in the past and thinks she is depressed again. Which response by the nurse is most appropriate? A. "Do you think this is a situational depression?" B. "Did you stop taking your medication?" C. "What therapies have worked for you in the past?" D. "What do you think is causing your depression this time?"

C

A nurse is interviewing a patient who was diagnosed with type 2 diabetes mellitus 6 months ago. Since that time, the patient has gained weight and her blood glucose levels remain high. The nurse suspects that the patient is noncompliant with her diet. Which response by the nurse enhances data collection in this situation? A. "Tell me what you know about the cause of type 2 diabetes." B. "You need to follow what the doctor has prescribed to manage your disease" C. "Tell me about what foods you eat and the frequency of your meals" D. "What symptoms do you notice when your blood sugar levels are high?"

C

A nurse shines a light in the right pupil to test constriction and notices that the left pupil constricts as well. Based on these data, the nurse should take what action? A. Document this finding as an abnormal finding. B. Assess the patient for accommodation. C. Document this finding as a consensual reaction. D. Assess the patient's corneal light reflex.

C

Bowel sounds when auscultating should be heard every A. Only after a bowel movement B. Every 20 minutes C. 5-15 seconds D. 1-5 seconds

C

In assessing a patient with cardiovascular disease, the nurse palpates edema (swelling) in both ankles and feet. Based on these findings, what question does the nurse ask the patient? A. "Have you experienced any constipation in the last week or two?" B. "Have you felt any pain in your abdomen?" C. "Have you experienced any unexpected weight gain?" D. "Have you felt depressed lately?"

C

The nurse observes a patient rocking back and forth on the examination table in pain. Based on the patient's history, the nurse suspects kidney stones. What additional examination technique does the nurse perform to confirm this suspicion? A. Percussing the bladder for fullness B. Palpating McBurney point for tenderness C. Percussing the costal vertebral margins for tenderness

C

What does the S2 heart sound represent? A. The beginning of systole. B. A split heard sound on exhalation C. The closure of the aortic and pulmonic valves. D. The closure of the tricuspid and mitral values

C

Which patient would be expected to experience acute pain? A. A patient who states he has been living with severe pain for many years B. A patient with cancer who has been receiving treatment for 1 year C. A patient who had abdominal surgery 6 hours ago D. A patient who has been treated 3 years for chronic back pain

C

Which question is an example of an open-ended question? A. "How many times a day do you use your inhaler" B. "Do you have someone to help you at home?" C. "What were you doing when you felt the pain?" D. "Have you experienced pain like this before?"

C

Which valve does a nurse auscultate when the stethoscope is placed on the fourth intercostal space at the left of the sternal border? A. Pulmonic B. Aortic C. Tricuspid D. Mitral

C

While obtaining a symptom analysis from a patient who had a transient ischemic attack, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates dizziness? A. "It felt like I was on a merry-go-round." B. "The room seemed to be spinning around." C. "I felt lightheaded when I stood up." D. "My body felt like it was revolving and could not stop."

C

A nurse uses which technique to assess a patient's peripheral vision? A. The nurse asks the patient to keep the head still and by moving the eyes only, follow the nurse's finger as it moves side to side, up and down, and obliquely. B. The nurse covers one of the patient's eyes with a card and observes the uncovered eye for movement, then removes the card and observes the just uncovered eye for movement. C. With the patient and nurse facing each other and a card covering their corresponding eyes, the nurse moves an object into the visual field and the patient reports when the object is seen. D. The nurse shines a light on both corneas at the same time and notes the location of the reflection in each eye.

C

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? A. "I am assessing the flexion of your spine." B. "I am looking at the stretch of your ham strings." C. "This allows me to see how straight your spinal column is." D. "This is the best way to check for symmetry of your arms."

C

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

C

A patient is admitted to the emergency department with a tracheal obstruction. What sound does the nurse expect to hear as this patient breathes? A. Soft, muffled rhonchi heard over the trachea B. Dull sounds on percussion C. High-pitched sounds on inspiration and exhalation D. Bubbling or rasping sounds heard over the trachea

C

A patient reports having abdominal distention and having vomited several times yesterday and today. What question is appropriate for the nurse to ask in response to this information? A. "Have you noticed a change in the color of your urine or stools?" B. "Has there been a change in your usual pattern of urination?" C. "What did the vomitus look like?" D. "Did you have heartburn before the vomiting?"

C

A 24 year old male patient tells the nurse he has had no energy for 2 weeks. He does not have trouble sleeping - in fact all he wants to do is sleep. He states that he has gained 10 pounds in 2 months and does not have any friends. The nurse associates these manifestations with which mental health disorder? A. Schizophrenia B. Bipolar disorder C. Anxiety disorder D. Depression

D

A female patient states that she has had problems in the past with depression and that she believes she is becoming depressed again. Which response by the nurse is most appropriate? A. "What do you think is causing your depression this time?" B. "Did you stop taking your medications?" C. "Are you sure you are not exaggerating how you feel?" D. "What therapies have worked for you in the past?"

D

A nurse in the emergency department is assessing a patient with a moderate left pneumothorax. What does this nurse expect to find during the respiratory examination? A. Increased fremitus over the left chest B. Tracheal deviation to the left side C. Hyporesonant percussion tones over the left chest D. Distant to absent breath sounds over the left chest

D

A nurse is teaching a patient how to mange her chronic obstructive pulmonary disease (COPD). This intervention is an example of which level of health promotion? A. Risk factor prevention B. Primary prevention C. Secondary prevention D. Tertiary prevention

D

A patient asks when she can stop having Pap (Papanicolaou) tests. What is the nurse's most appropriate response? A. "Through the end of menopause." B. "Until you begin menopause." C. "Until you are no longer sexually active." D. "Through age 65".

D

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

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

During an assessment for abdominal pain, a patient reports a colicky abdominal pain and pain in the right shoulder that gets worse after eating fried foods. What question does the nurse ask to confirm the suspicion of cholelithiasis? A. "Have you experienced fever, chills, or sweating?" B. "Have you noticed any swelling in your ankles or feet at the end of the day?" C. "Have you vomited up any blood in the last 24 hours?" D. "Have you noticed a change in the color of your urine or stools?"

D

For which person is a comprehensive assessment indicated? A. The person who had abdominal surgery yesterday B. The person who is beginning rehabilitation after a knee replacement C. The person who is unaware of his high serum glucose levels D. The person who is being admitted to a long-term care facility

D

How do nurses assess a patient's pain? A. By understanding the sensory experience related to the amount of tissue damage B. By the patient's medical diagnosis or surgical procedure C. By assessing physiologic changes of the patient D. By asking the patient to rate the pain being experienced

D

How does a nurse accurately palpate carotid pulses? A. Two fingers of each hand are placed firmly over the right and left temples at the same time. B. One finger is placed gently in the space between the biceps and triceps muscles. C. Two fingers are placed at the thumb side of the forearm at the wrist. D. One finger is placed along the right and then the left medial sternocleidomastoid muscle.

D

Sometimes a patient may be overly talkative and easily distracted. One method of questions that assists the nurse in keeping the interview timely and focused for the patient includes: A. Using open ended questions B. Cut the interview short C. Request that the patient just tell you the facts D. Using closed-ended questions

D

The nurse is taking a health history on a patient who reports frequent stabbing headaches occurring once a day lasting about an hour. Which statement by the patient is most indicative of cluster headaches? A. "I usually have nausea and vomiting with my headaches." B. "My whole head is constantly throbbing." C. "It feels like my head is in a vice." D. "The pain is on the left side over my eye, forehead, and cheek."

D

What is the earliest and most sensitive indication of altered cerebral function? A. Unequal pupils B. Paralysis on one side of the body C. Loss of deep tendon reflexes D. Change in level of consciousness

D

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. Venous hum B. Soft, low-pitched murmur C. Bowel sounds D. No sounds

D

Which assessment technique does a nurse use to assess the inguinal region and femoral area of a male patient as he is standing and straining? A. Palpates the femoral artery B. Palpates the inguinal lymph nodes C. Observes for discoloration of the inguinal ring D. Observes for a bulge through the inguinal region

D

Which nurse is performing the technique of light palpation appropriately? A. Nurse D depresses the patient's abdomen approximately 4 cm to assess pulsations. B. Nurse B uses the fingertips to feel for temperature differences on the patient's legs. C. Nurse A applies the bimanual technique to determine size and location of the patient's heart. D. Nurse C places the ulnar surface of the hands on the patient's thorax to detect vibrations.

D

Which patient in the eye clinic should the nurse assess first? A. The patient who reports a gradual clouding of vision B. The patient who complains of double vision C. The patient who complains of poor night vision D. The patient who complains of sudden loss of vision

D

Which patient would be expected to experience acute pain? A. A patient who has lived with moderate pain for several years B. A patient who has cancer and has been receiving treatment for 4 months C. A patient who has been unsuccessfully treated for back pain for the past year D. A patient who had abdominal surgery 8 hours ago

D

Which statement by a 40-year old man would be most indicative of possible breast cancer? A. "My father's breasts got larger after he was older." B. "I had embarrassing breast enlargement when I was a teenager." C. "My right breast has always been a little smaller than the left." D. "I think I felt a hard spot in my left breast, but it does not hurt."

D

Professor A has stated more than once in class, "as nurses if we do not document what we have done - it is considered not done!" True False

False

The S2 heart sound is best heard at the mitral area. True False

False

The triscuspid valve is assessed on auscultation when the nurse places the stethoscope over the 7th intercostal space at the left sternal border. True False

False

When a nurse is recording data in the patient/client chart it is appropriate to document bias and opinions within the record. True False

False

When auscultating bowel sounds the nurse should press the diaphragm of the stethoscope deeply against the patient's abdomen. True False

False

A patient complains of nasal discharge and a sinus headache. The nurse anticipates that the nasal drainage is purulent green-yellow drainage. True False

True

Professor A stresses the importance of good sleep hygiene so that we are healthy nursing students. True False

True

The medical record of our patient/client serves as a legal and permanent record of the health status. True False

True

The nurse asks the patient to swallow once during palpation of the neck area/assessment of the thyroid gland. True False

True

Which questions are pertinent (important) for a nurse to ask a patient while performing a review of the cardiovascular system? Please select all that apply. A. Have you noticed any edema (swelling) in your ankles at the end of the day? B. What is your weight? C. Do you have trouble breathing when lying down in bed? D. What is your cholesterol value? E. Do you notice any coldness, numbness or color changes in your feet? F. Have you experienced any chest pain or shortness of breath?

A, C, E, F

A nurse suspects a patient has a chest wall injury and wants to collect more data about thoracic expansion. Which is the appropriate technique to use? A. Place the palmar side of each hand against the lateral thorax at the level of the waist, ask the patient to take a deep breath, and observe lateral movement of the hands. B. Place both thumbs on either side of the patient's T9 to T10 spinal processes, extend fingers laterally, ask the patient to take a deep breath, and observe lateral movement of the thumbs. C. Place both thumbs on either side of the patient's T7 to T8 spinal processes, extend fingers laterally, ask the patient to exhale deeply, and observe lateral inward movement of the thumbs. D. Place the palmar side of each hand on the shoulders of the patient, ask the patient to sit up straight and take a deep breath, and observe symmetric movement of the shoulders.

B

A nurse suspects that a large skin lesion on the patient's forearm is a fungal infection. Which device does the nurse use to confirm his suspicion? A. Pen light B. Wood lamp C. Magnification device D. Transilluminator

B

A patient complains of right ear pain. What findings does the nurse anticipate on inspecting the patient's ears? A. Report of pain when the nurse manipulates the right ear B. Bulging and red tympanic membrane in the right ear C. Increased cerumen in the right ear canal D. Redness and edema of the pinna of the right ear

B

A patient had a left radical mastectomy last year. The nurse assesses for painless and nonpitting swelling of the arm on that side. Which complication of a mastectomy is the nurse assessing for? A. Inflammation B. Lymph edema C. Infection D. Lymphoma

B

A patient has been complaining of abdominal cramping and gas (flatus); 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. Tympany C. Dullness D. Resonance

B

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

A patient reports a productive cough with yellow sputum, fever, and a sharp pain when taking a deep breath to cough. Based on these data, what abnormal finding will the nurse anticipate on examination? A. Decreased breath sounds on auscultation B. Increased tactile fremitus and dull percussion tones C. Inspiratory wheezing found on auscultation D. Muffled sounds heard when the patient says "e-e-e"

B

A patient with testicular torsion is experiencing which abnormality? A. An accumulation of fluid in the scrotum B. Twisting of the testicle and spermatic cord C. A cystic mass filled with sperm and seminal fluid in the epididymis D. Abnormal dilation and tortuosity of the veins along the spermatic cord

B

During a sports physical for a 16-year-old girl, the nurse asks which question to collect data about drug use? A. "Your high school has a reputation for drug use. Do you use drugs?" B. "Many teenagers have tried street drugs. Have you tried these drugs? " C. "Do most of your friends drink alcohol or do street drugs?" D. "Tell me which street drugs your friends have offered to you?"

B

During the history, a patient reports blurred vision, seeing double at times, and a glare from headlights from oncoming cars at night. Based on this information, what finding does the nurse expect to find on assessment of this patient's eyes? A. Anterior chamber depth is shallow. B. Red reflex is absent. C. Extraocular muscle movement is asymmetric. D. Retinal arteries are wider than retinal veins.

B

The nurse is interviewing a woman with her husband present. The husband answers the questions for the wife most of the time. What is the most appropriate therapeutic nursing action to hear the patient's viewpoint? A. Ask another nurse to complete the interview. B. Ask the husband to step out of the room. C. Continue the interview. D. Tell the woman to speak up for herself.

B

The patient describes her chest pain as "squeezing, crushing, and 12 on a scale of 10." This pain started more than an hour ago while she was resting, and she also feels nauseous. Based on these findings, the nurse should assess for which associated symptoms? A. Tachycardia, tachypnea, and hypertension B. Dyspnea, diaphoresis, and palpitations C. Hyperventilation, fatigue, anorexia, and emotional strain D. Fever, dyspnea, orthopnea, and friction rub

B

Which technique does a nurse use to palpate the patient's axillary lymph nodes? A. With the patient lying supine with arms at the sides, the nurse uses the tips of the fingers of one hand to palpate the axilla moving from the posterior to the anterior aspect of the axilla to feel for enlarged nodes. B. With the patient sitting, the nurse places fingers of both hands deep into the axilla, one hand on either side, and firmly pushes the axillary tissue toward the center to feel for enlarged nodes. C. With the patient lying supine with the hand behind the head of the side being assessed, the nurse uses the pads of fingers of one hand to systematically palpate the axilla using small circular motions to feel for enlarged nodes. D. With the patient sitting, the nurse places fingers of one hand deep into the axilla and firmly slides the fingers along the patient's middle, anterior, and posterior of the axilla to feel for enlarged nodes.

D

Which tool is the best choice for a nurse to use as a quick screening tool to assess a patient's dietary intake? A. Comprehensive diet history B. Food diary C. Calorie count D. 24-hour recall

D

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

D