Physical Assessment--Midterm Exam Part 2

A 52-year-old pt with myopia calls the ophthalmology clinic very upset. She tells the nurse, "I keep seeing semi-clear spots floating across my vision. What is wrong with me?" What would be the most appropriate response by the nurse?

"It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'."

A pt calls the clinic and tells the nurse that the doctor told her that she has "otalgia." This pt cannot remember what the doctor explained this to be. How would he nurse most appropriately respond?

"Otalgia is pain in the ear."

A pt comes to the clinic, reporting that he woke up this morning with a painful right eye. What would be the most appropriate response from the nurse?

"You will need to see the doctor to have you eye checked."

The nurse is assessing a child's language development. How old would the nurse expect the child to be if she was using her first word and had a receptive vocabulary of 50 words?

10 to 15 months

A nurse is caring for a 22-year-old man and a 75-year-old man. If the nurse gave both pts the same simple comparison task, how much faster would the nurse expect the 22-year-old to finish it than the 75-year-old?

50%

Upon examination, the Advanced Practice Nurse finds that a pt has otitis media with effusion. What assessment finding is most clearly indicative of this diagnosis?

A diffuse cone of light

coining

A practice among Southeast Asians in which a coin or other object is rubbed across the skin in a specific manner to treat various health concerns.

The nurse assesses a 67-year-old man new to the mental health clinic. The following is the nurse's documentation of the encounter: Pt appears stated age and normal weight; no obvious deformity. Posture erect and relaxed. Movements symmetrical, voluntary, deliberate, coordinated, smooth, and even. Gait is steady and even. Activity moderate and relaxed. Well-groomed pt with no unusual body odors. Clothing clean and appropriate. Pt awake, alert, calm, and expressive, responding appropriately to voice cues. Converses with eyes closed and no eye contact. Facial expressions congruent with subjects. speech of slow pace and low volume, with few fluctuations; it is unorganized and incongruent with behavior and nonverbal communication. Words slurred and indistinct. A&OX3. Pt follows conversation and events; normal attention span. Short- and long-term memory intact. Mini-mental status examination (MMSE) completed with no deficits. Pt takes responsibility for actions. Thought processes easy to follow, logical, and relevant. With which of the following is the documentation most consistent?

A pt who has had a recent stroke

A pt has Darwin tubercle. What is this?

A small painless nodule on the helix

When assessing a pt, the nurse notes a brownish ridge along the gum line. This finding would be considered normal in a pt from what background?

African American

The incidence of infant mortality varies in the United States. What group has 1.4 times the number of infant deaths than Whites and is more likely to begin prenatal care in the third trimester?

American Indians

What group of people have a lower HIV/AIDS rate than do Whites and are less likely to die from it?

Asian Americans

A new nurse on the long-term care unit is learning how to assess a pt's risk for skin breakdown. What would be the most likely instrument this nurse would use?

Braden Scale

Crystallized intelligence is also called what?

Cognitive pragmatics

A pt asks a nurse if any foods promote eye health. What food would the nurse include as a response?

Deep-water fish

When assessing a pt for human violence, what basic technique would the nurse need to apply?

Demonstrating compassion

A nurse has performed a head and neck assessment of an adult pt and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?

Document this as an expected assessment finding

An anatomy and physiology instructor is discussing the lymphatic system of the head and neck. Why would the instructor emphasize the importance of the drainage pattern of the lymph?

Enlargement of the node may be a sign of pathology that is distant from that nodule

A pt has been found to have abnormal vision. What would be the nurse's next step?

Facilitate a referral to an ophthalmologist

A pt comes to the clinic complaining of waking during the night with sudden shortness of breath. She is diagnosed with paroxysmal nocturnal dyspnea. Before leaving the clinic, the pt asks the nurse what causes paroxysmal nocturnal dyspnea. What would be the nurse's best response?

Fluid overload from elevation of the legs

A community health nurse is planning an educational event for the parent-teacher association of the local elementary school. In discussing chickenpox, how would the nurse describe the rash?

Fluid-filled lesions less than 1 cm in diameter

A staff educator from the hospital is providing an event for the hospital staff. The educator is talking about health promotion activities for people with diseases of the nose, mouth, throat, and sinuses. What would the educator include in the presentation?

How to reduce periodontal disease

A pt comes to the clinic and reports nosebleeds. What area of the nose is the bleeding most likely coming from?

Kiesselbach plexus

A pt comes to the clinic and reports pain when he touches his ear. With what is this finding most consistent?

Otitis externa

Which of the following statements best describes alternative medicine?

Particular treatments are undertaken instead of biomedical treatments

A pt with a nursing diagnosis of disturbed sensory perception would be expected to exhibit what characteristics?

Poor concentration, irritability, agitation, change in behavior

A nurse in a dermatology clinic cares for an adolescent pt with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this pt?

Pustular acne

primary lesions

Reddened lesions that arise from previously normal skin and include maculae, papules, nodules, tumors, polyps, wheals, blisters, cysts, pustules, and abscesses. May be further described as nonelevated, elevated-solid, or fluid-filled.

A nurse is discussing memory with students. What type of memory would the nurse be explaining if he was talking about retrieval of facts, vocabulary, and general knowledge?

Semantic long-term memory

secondary lesions

Skin changes that appear following a primary lesion (e.g., formation of scar tissue, crusts from dried burn vesicles).

The nurse is caring for a 63-year-old client who can neither read nor speak English. What would be the appropriate chart to use to assess this pt's vision

Snellen E

A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches?

Stiff neck

A pt has a nursing diagnosis of ineffective airway clearance. What intervention would be most appropriate?

Teach deep breathing and coughing

Healthy People identifies a goal of reducing the annual rate of rape or attempted rape, and other sexual assaults. What action best facilitates this goal?

Teaching children about healthy touch

The staff educator form the hospital's respiratory unit is providing a public educational event. The educator is talking about health promotion activities for people with respiratory diseases or those who are at high risk for respiratory complications. What would the educator include in the presentation?

Teaching strategies to reduce complications of existing diagnoses

An anatomy instructor is discussing the nose with the nursing class. How would the instructor identify the ostiomeatal complex?

The middle turbinate and inferior meatus area

The nurse is caring for a pt who comes to the clinic reporting a lump by her ear. What are the symptoms of a cancerous lymph node?

The node is fixed and rubbery

The nurse is admitting a 79-year-old man for outpatient surgery. The pt has bruises in various stages of healing all over his body. Why is it important for the nurse to promptly document and report these findings?

The pt may have been abused

A nurse is writing a care plan for a pt who has been found to have a progressive hearing loss. What would be an appropriate outcome for this pt?

The pt will explain a plan to accommodate hearing impairment

What outcome should the nurse prioritize when addressing a pt's social, cultural, and spiritual issues?

The pt will express meaning and purpose in life

A pt has a nursing diagnosis of disturbed visual sensory perception. Which of the following is the most appropriate outcome for this pt's care planning?

The pt will remain free from harm resulting from a loss of vision

A 52-year-old pt fails the Romberg test. The nurse explains that this might indicate a dysfunction in what part of the ear?

The vestibular portion of the inner ear

Which of the following assessment findings of the mouth, nose, and throat of an older adult client would the nurse attribute to the aging process?

Tongue fissures

The nurse is admitting a 23-year-old woman to the acute care mental health unit. Physical examination reveals vertical cuts on the pt's forearms approximately 6 inches long bilaterally. On the care plan, the nurse enters a nursing diagnosis of Risk for Self Mutilation. What would be the most immediate nursing intervention for this pt?

Treat medical injuries

A pt is found to have a smooth, glossy tongue. What vitamin deficiency might this indicate?

Vitamin B12 deficiency

the nurse is conducting a MMSE on a 77-year-old woman brought to the emergency department by her daughter. What is one of the first questions the nurse would ask this pt?

What day of the week is it?

A pt with advanced COPD is very fatigued and has minimal stamina. Clustering of care has become necessary. When should the nurse auscultate this pt's lungs?

When turning the pt

a nurse is caring for several pts in an outpatient setting. which of the following pts is most likely to experience a weight gain?

a 33-year-old athlete on steroids

Spirituality can best be described as

a source of inner strength

laceration

a superficial or deep skin tear, often requiring suturing to heal correctly

lichenification

accentuation of normal skin lines resembling tree bark, commonly caused by excessive scratching

polyp

an abnormal growth of tissue originating on a mucous membrane

dysplastic nevus

an atypical mole

A 37-year-old man presents at the emergency department complaining that he is having trouble breathing. What would the nurse prioritize in this pt's acute assessment?

assessing pulse

Adventitious sounds related to atelectasis and pulmonary edema are first evident when auscultating what area of the respiratory system?

bases

The nurse in an ED is caring for a minimally responsive 27-year-old victim of a motorcycle accident. The pt was not wearing a helmet. When assessing the pt's head and neck, the nurse should prioritize the assessment for which of the following?

bleeding

a nursing student is caring for a male pt who has been admitted in a severely malnourished state. for what signs of malnutrition would the student observe?

bleeding of the gums

ecchymosis

bruise or brusing

cachexia is characterized by i highly catabolic state with accelerated muscle loss. what is another component of cachexia?

chronic inflammatory response

The instructor is discussing Uri Bronfenbrenner. This instructor explains that Brofenbrenner's theory of development is what?

continuous

a nurse is teaching a nutrition class to pts with obesity. what would be the most appropriate topic to teach these patient?

decreasing intake of foods with low nutrient density

The nurse is caring for and 88-year old man hospitalized with a fractured hip and asks for a dietary consult because assessment findings indicate that the pt is malnourished. the pt has a diagnosis of early-stage Alzheimer disease. in conducting a comprehensive dietary assessment, what would be the method of choice for determining this patient's dietary intake?

direct observation

The nurse is providing pt teaching to the mother of a 3-month-old with otitis media. What would the nurse explain is a risk factor for otitis media?

exposure to cigarette smoke

macule

flat, distinct, colored area of skin that is less than 10mm in diameter and does not include a change in skin texture or thickness

vesicle

fluid-filled lesion less than 1cm in diameter

the nurse is doing a research project on the frequency with wich certain foods have been eaten by several pts during the last trimester of pregnancy. what would the be the most appropriate tool to use in this research?

food-frequency questionnaires

A child who is 10 months old would be expected to be at what stage of language development?

gesturing such as showing and pointing

When assessing the head and neck, the nurse should realize that variations in skull or neck shape or size relate most to what?

height and weight

Which of the following is a priority pt teaching topic r/t the ears?

how to prevent skin cancer

A mother brings her 6-month-old to the clinic for a well-baby checkup. She tells the nurse that she is concerned that her baby is not crawling yet. What would be important for the nurse to explain to this mother?

individuals develop at different rates

A patient has a nursing diagnosis of impaired social interaction. What is a common characteristic of this diagnosis?

insufficient quantity or quality of social exchange

A pt with zosteriform rash has a rash that

is distributed along a dermatome

pruritus

itching

A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?

lacrimal apparatus

When documenting that a pt has freckles, the appropriate term to use is

macules

A nurse is caring for a pt admitted with neck pain. This pt is febrile. What is the most likely medical diagnosis for this pt?

meningitis

uremic frost

precipitation of renal urea and nitrogen waste products through sweat onto the skin

pustule

purulent fluid-filled raised lesion of any size

Avulsion

ragged wound that occurs when trauma forces the skin to separate from underlying structures

plaque

raised, defined lesion of any color, greater than 1 cm in diameter

papule

raised, defined lesion of any color, less than 1 cm in diameter

wheal

raised, flesh-colored or reddened edematous papules or plaques, varying in size and shape

A psychology professor is explaining language development to students. The professor explains that the understanding of spoken or written words and sentences is

receptive language

malar rash

red macular lesions distributed over the forehead, cheeks, and chin, resembling the pattern of a butterfly

purpura

red or purple discolorations on the skin that do not blanch on applying pressure. they are caused by bleeding underneath the skin. purpura measure 0.3 to 1 cm

rubor

redness of the skin, commonly as a result of inflammation

When assessing for human violence in pts, it is important for the nurse to

reexamine assumptions and stereotypes

A mother brings her 4-year-old daughter to the clinic and reports that the child has developed a rash that she is constantly scratching on her abdomen. On examination, the nurse finds that the rash is serpiginous. The nurse would know that the rash is most probably caused by

scabies

cyst

skin lesion that is distinct and walled-off and which contains fluid or semisolid material

brawny skin

skin that is dark and leathery

nodule

solid palpable lesion greater than 1 cm in diameter, often with some depth

A pt has been diagnosed with stomach cancer and has a comorbidity of depression. For what would it be important to assess in this pt?

suicide

A person with a barrel chest has a problem doing what?

taking a deep breath

a nurse is conducting a comprehensive nutritional assessment on a pt with suspected malnutrition. why would it be important to assess this pt's ability to cook?

to assess if the pt has the ability to obtain or prepare food

a nurse is providing care for a pt who has a hx of alcoholism. what would be appropriate to include in this pt's discharge teaching?

to increase fruit and vegetable intake

Abrasion

wound caused by shear force or friction against the skin, removing several layers and exposing the dermis