Final Exam Fundamentals 1

The patient is found to be unresponsive and not breathing. To determine the presence of central blood circulation and circulation of blood to the brain, the nurse checks the patient's _____ pulse. a. Radial b. Brachial c. Posterior tibial d. Carotid

ANS: D The heart continues to deliver blood through the carotid artery to the brain as long as possible. The carotid pulse is easily accessible during physiological shock or cardiac arrest. The radial pulse is used to assess peripheral circulation or to assess the status of circulation to the hand. The brachial site is used to assess the status of circulation to lower arm. The posterior tibial pulse is used to assess the status of circulation to the foot.

The patient requires temperatures to be taken every two hours. Which of the following cannot be delegated to nursing assistive personnel? a. Selecting appropriate route and device b. Obtaining temperature measurement at ordered frequency c. Being aware of the usual values for the patient d. Assessing changes in body temperature

ANS: D The nurse is responsible for assessing changes in body temperature. The nurse instructs nursing assistive personnel to select the appropriate route and device to measure temperature, to obtain temperature measurement at ordered frequency, and to be aware of the usual values for the patient.

When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. Why is this preferable to methods used for adults? a. It is accurate even when the forehead is covered with hair. b. It is not affected by skin moisture. c. It reflects rapid changes in radiant temperature. d. There is no risk of injury to patient or nurse

ANS: D The temporal artery thermometer is especially beneficial when used in premature infants, newborns, and children because there is no risk of injury to the patient or nurse. However, it is inaccurate with head covering or hair on the forehead and is affected by skin moisture such as diaphoresis or sweating. It provides very rapid measurement and reflects rapid changes in core temperature, not radiant temperature

Assisting patient with oral care

Activity for daily living.

Discussing a patient's options in choosing palliative care

Counseling.

A nurse reviews all possible consequences before helping a patient ambulate such as how the patient ambulated last time; how mobile the patient was before admission to the health care facility; or any current clinical factors affecting the patient's ability to stand, remain balanced, or walk. Which of the following is an example of a nurse's review of this situation?

Critical thinking.

Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient?

Individualizing how to apply the clinical guideline for a patient

A nurse collects equipment needed to administer an enema to a patient. Previously the nurse reviewed the procedure in the policy manual. The nurse raises the patient's bed and adjusts the room lighting to illuminate the work area. A patient care technician comes into the room to assist. Which aspect of organizing resources and care delivery did the nurse omit?

Patient.

The nurse administers a tube feeding via a patient's nasogastric tube. This is an example of which of the following?

Physical care technique

Using safe patient handling during positioning of a patient

Physical care technique.

A male student comes to the college health clinic. He hesitantly describes that his testis has lumps. The nurse recognizes this as a potential sign of which of the following? a. Inguinal hernia b. Sexually transmitted infection c. Testicular cancer d. Diuretic use

c. Testicular cancer Irregular lumps of the testes may indicate testicular cancer. Testicular cancer is cancer that begins in the testicles. Testicular cancer is the most common form of cancer in men between the ages of 15 and 35 years. A hernia presents with bulging in the scrotum. Sexually transmitted infections often present with genital lesions. Use of diuretics, sedatives, or antihypertensives can cause difficulty in achieving erection or ejaculation but does not usually cause lumps.

During an annual gynecological examination, a college student discusses her upcoming college break at a tropical location. After the student receives an oral contraceptive prescription, the nurse identifies the importance of skin cancer prevention education by discussing which evidence-based prevention health topic? a. Applying water-based sunscreen only before swimming b. Using tanning bed daily for 7 days before college break trip c. Applying broad-spectrum sunscreen of SPF 5 d. Taking extra precautions in the sun secondary to the prescription

d. Taking extra precautions in the sun secondary to the prescription Oral contraceptives can make the skin more sensitive to the sun. For this reason, the patient should be educated about the need for sun protection such as wide-brimmed hats, use of broad-spectrum sunscreen of SPF 15 or greater, not tanning during midday, and not using tanning beds. Broad-spectrum sunscreens should be applied 15 minutes before going into the sun and after swimming or perspiring. Tanning parlors, sunlamps, etc., should be avoided. Sunscreens with SPF of 15 or greater should be used.

Objective physical data describe air moving through small airways over the lung's periphery. The expected inspiratory-to-expiratory phase of this normal vesicular breath sound is which of the following? a. The inspiratory phase lasts exactly as long as the expiratory phase. b. The expiration phase is longer than the inspiration phase. c. The expiration phase is two times longer than the inspiration phase. d. The inspiratory phase is three times longer than the expiratory phase.

d. The inspiratory phase is three times longer than the expiratory phase. Vesicular breath sounds are normal breath sounds; the inspiratory phase is three times longer than the expiratory phase. Bronchovesicular breath sounds have an inspiratory phase equal to the expiratory phase. Bronchial breath sounds have an expiration phase longer than the inspiration phase at a 3:2 ratio.

Which measures does a nurse follow when being asked to perform an unfamiliar procedure?

- Checks scientific literature or policy and procedure - Reassesses the patient's condition - Collects all necessary equipment - Considers all possible consequences of the procedure

The incidence of hypertension is greater in which of the following? a. Non-Hispanic Caucasians b. African Americans c. Asian Americans d. Native Americans

ANS: B The incidence of hypertension is greater in diabetic patients, older adults, and African Americans.

A nurse administered an antibiotic 30 minutes ago and returns to the patient's room to determine if the patient is having any unexpected symptoms. This is an example of assessing for a(n) ___________________.

Adverse reaction.

Before consulting with a physician about a female patient's need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exists, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill?

Cognitive

Protecting a violent patient from injury

Lifesaving measure.

What is the importance of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey?

Measures quality of care within hospitals.

In preparation for a rectal examination of a nonambulatory male patient, the patient is informed of the need to be placed in which position? a. Sims' position b. Forward bending with flexed hips c. Knee-chest d. Dorsal recumbent

a. Sims' position Nonambulatory patients are best examined in a side-lying Sims' position. Forward bending would require the patient to be able to stand upright. Knees to chest would be difficult to maintain in a nonambulatory male and is embarrassing and uncomfortable. Dorsal recumbent does not provide adequate access for a rectal examination and is used for abdominal assessment because it promotes relaxation of abdominal muscles.

A patient in the emergency department is complaining of left lower abdominal pain. The comprehensive abdominal examination would include, in proper order, which of the following? a. Inspection, palpation, auscultation b. Percussion, inspection, auscultation c. Inspection, palpation, percussion d. Inspection, auscultation, palpation

d. Inspection, auscultation, palpation The order of an abdominal examination differs slightly from that of other assessments. Begin with inspection and follow with auscultation. By using auscultation before palpation, the chance of altering the frequency and character of bowel sounds is lessened.

A nurse is conferring with another nurse about the care of a patient with a stage II pressure ulcer. The two decide to review the clinical practice guideline of the hospital for pressure ulcer management. The use of a standardized guideline achieves which of the following?

- Makes it quicker and easier for nurses to intervene - Sets a level of clinical excellence for practice - Delivers evidence-based interventions for stage II pressure ulcer

A nurse is visiting a patient in the home and is assessing the patient's adherence to medications. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient's adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this patient?

- Making a judgment of the value of improved adherence for the patient - Determining all consequences associated with the patient missing specific medicines

During the implementation step of the nursing process, a nurse reviews and revises a patient's plan of care. What are the steps?

- Reassess the patient. - Compare assessment findings to validate existing nursing diagnoses. - Decide if the nursing interventions remain appropriate. - Modify care plan as needed.

A nurse is caring for a complicated patient 3 days in a row. The nurse attends an interdisciplinary conference to discuss the patient's plan of care. In which ways can the nurse develop trust with members of the conference team?

- Shows competence in how to monitor patients' clinical status and inform the physician of critical changes - Listens to opinions of members of interdisciplinary team and expresses recommendations for care clearly

The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse's actions?

- The call to the ostomy and wound care specialist is an indirect care measure. - The cleansing of the skin is a direct care measure.

A nurse working on a surgery floor is assigned five patients and has a patient care technician assisting her. Which of the following shows the nurse's understanding and ability to safely delegate to the patient care tech?

- The nurse considers the time available to gather routine vital signs on one patient before checking on a second patient arriving from a diagnostic test. - The nurse chooses to delegate the measurement of a stable patient's vital signs and not the assessment of the patient arriving from a diagnostic test. - The nurse reviews with the NAP, newly hired to the floor, her experience in measuring a blood pressure.

Of the following patients, which one is the best candidate to have his temperature taken orally? a. A 27-year-old postoperative patient with an elevated temperature b. A teenage boy who has just returned from outside "for a smoke" c. An 87-year-old confused male suspected of hypothermia d. A 20-year-old male with a history of epilepsy

ANS: A An elevated temperature needs to be evaluated, and there is no contraindication in this patient. Ingestion of hot/cold fluids or foods, smoking, or receiving oxygen by mask/cannula can require delays in taking oral temperature. Oral temperatures are not taken for patients who have had oral surgery, trauma, history of epilepsy, or shaking chills, nor for infants, small children, or confused patients.

The patient is restless with a temperature of 102.2° F (39° C). One of the first things the nurse should do is a. Place the patient on oxygen. b. Restrict fluid intake. c. Increase patient activity. d. Increase patient's metabolic rate.

ANS: A During a fever, cellular metabolism increases and oxygen consumption rises. Myocardial hypoxia produces angina. Cerebral hypoxia produces confusion. Interventions during a fever include oxygen therapy. Dehydration is a serious problem through increased respiration and diaphoresis. The patient is at risk for fluid volume deficit. Fluids should not be restricted. Increasing activity would increase the metabolic rate further, which would not be advisable

The posterior hypothalamus helps control temperature by a. Causing vasoconstriction. b. Shunting blood to the skin and extremities. c. Increasing sweat production. d. Causing vasodilation

ANS: A If the posterior hypothalamus senses that the body's temperature is lower than the set point, the body initiates heat conservation mechanisms. Vasoconstriction of blood vessels reduces blood flow to the skin and extremities. The anterior hypothalamus controls heat loss by inducing sweating, vasodilation of blood vessels, and inhibition of heat production

When temperature assessment is required, which of the following cannot be delegated to nursing assistive personnel? a. Temperature measurement b. Assessment of changes in body temperature c. Selection of appropriate route and device d. Consideration of factors that falsely raise temperature

ANS: B The skill of temperature measurement can be delegated. The nurse is responsible for assessing changes in body temperature. The nurse instructs nursing assistive personnel to select the appropriate route and device to measure temperature and to consider specific factors that falsely raise or lower temperature.

The nurse needs to obtain a radial pulse from a patient. To obtain the correct measure, what must the nurse do? a. Place the tips of the first two fingers over the groove along the thumb side of the patient's wrist. b. Place the thumb over the groove along the thumb side of the patient's wrist. c. Apply a very light touch so that the pulse is not obliterated. d. Apply very strong pressure to detect the pulse.

ANS: A Place the tips of the first two or middle three fingers of the hand over the groove along the radial or thumb side of the patient's inner wrist. Fingertips are the most sensitive parts of the hand to palpate arterial pulsation. The thumb has a pulsation that interferes with accuracy. The pulse is more accurately assessed with moderate pressure. Too much pressure occludes the pulse and impairs blood flow.

When heat loss mechanisms of the body are unable to keep pace with excess heat production, the result is known as a. Pyrexia. b. The plateau phase. c. The set point. d. Becoming afebrile.

ANS: A Pyrexia, or fever, occurs because heat loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature. The set point is the temperature point determined by the hypothalamus. When pyrogens trigger immune system responses, the hypothalamus reacts to raise the set point, and the body produces and conserves heat. During the plateau phase, chills subside and the person feels warm and dry as heat production and loss equilibrate at the new level. When the fever "breaks," the patient becomes afebrile.

The nurse is caring for a newborn infant in the hospital nursery. She notices that the infant is breathing rapidly but is pink, warm, and dry. The nurse knows that the normal respiratory rate for a newborn is _____ breaths per minute. a. 30 to 60 b. 25 to 32 c. 16 to 19 d. 12 to 20

ANS: A The acceptable respiratory rate range for a newborn is 30 to 60 breaths per minute. An infant (6 months) is expected to have a rate between 30 and 50 breaths per minute. A toddler's respiratory range is 25 to 32 breaths per minute. A child should breathe 20 to 30 times a minute. An adolescent should breathe 16 to 19 times a minute. An adult should breathe 12 to 20 times a minute.

The patient is admitted with shortness of breath and chest discomfort. Which of the following laboratory values could account for the patient's symptoms? a. Hemoglobin level of 8.0 b. Hematocrit level of 45% c. Red blood cell count of 5.0 million/mm3 d. Pulse oximetry of 90%

ANS: A The concentration of hemoglobin reflects the patient's capacity to carry oxygen. Normal hemoglobin levels range from 10 to 18 g/100 mL in males and from 12 to 16 g/100 mL in females. Hemoglobin of 8.0 is low and indicates a decreased ability to deliver oxygen to meet bodily needs. All other values in the selection are considered normal

One benefit of using a stationary automatic blood pressure device is that the cuff a. Fits over clothing. b. Is extremely reliable. c. Is the method of choice for irregular heart rhythms. d. Is more reliable when pressure is less than 90 mm Hg systolic.

ANS: A The cuff fits over clothing. However, the reliability of stationary machines is limited. Electronic blood pressure measurement is not recommended with irregular heart rates or when blood pressure is less than 90 mm Hg systolic

The thickness or viscosity of the blood affects the ease with which blood flows through small vessels. The nurse examines what value, which might help determine the amount of blood viscosity? a. Hematocrit b. Cardiac output c. Arterial size d. Blood volume

ANS: A The hematocrit, or the percentage of red blood cells in the blood, determines blood viscosity. Blood pressure also depends on the cardiac output or volume pumped by the heart, but cardiac output does not affect viscosity. Arterial size helps to modify blood pressure. The smaller lumen of a vessel increases vascular resistance but does not affect viscosity. Blood volume also affects blood pressure, but it does not directly affect viscosity.

When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. The nurse realizes that his rate is a. Normal for an infant. b. The proper rate for a toddler. c. Too slow for an infant. d. The same as that of a normal adult

ANS: A The normal rate for an infant is 120 to 160 beats/min. The rate obtained (145 beats/min) is within the normal range for an infant. The normal rate for a toddler is between 90 and 140 beats/min. The normal rate for an adult is between 60 and 100 beats/min.

When recording the patient's respiratory status, what must be recorded? (Select all that apply.) a. Respiratory rate b. Character of respirations c. Amount of oxygen therapy d. Only normal findings e. Only in the graphic section

ANS: A, B, C Record respiratory rate and character in nurses' notes or on vital sign flow sheet. Indicate type and amount of oxygen therapy if used during assessment. Document respiratory assessment after administration of specific therapies in narrative form in nurses' notes. The nurse should document normal and abnormal findings.

The nurse is assessing the patient and his family for probable familial causes of the patient's hypertension. The nurse begins by analyzing the patient's personal history, as well as family history and current lifestyle situation. Which of the following issues would be considered risk factors? (Select all that apply.) a. Obesity b. Cigarette smoking c. Recent weight loss d. Heavy alcohol consumption e. Low blood cholesterol levels

ANS: A, B, D Obesity, cigarette smoking, heavy alcohol consumption, high blood cholesterol and triglyceride levels, and continued exposure to stress are risk factors linked to hypertension. Weight loss and low blood cholesterol levels are not risk factors for hypertension.

The patient has a temperature of 105.2° F. The nurse is attempting to lower his temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. The nurse is attempting to lower the patient's temperature through the use of a. Radiation. b. Conduction. c. Convection. d. Evaporation

ANS: B Applying an ice pack or bathing a patient with a cool cloth increases conductive heat loss. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas. Convection is the transfer of heat away from the body by air movement.

The patient is being admitted to the emergency department with complaints of shortness of breath. The patient has had chronic lung disease for many years but still smokes. The nurse should a. Administer high levels of oxygen. b. Use oxygen cautiously in this patient. c. Place a paper bag over the patient's face to allow rebreathing of carbon dioxide. d. Administer CO2 via mask

ANS: B Because low levels of arterial O2 provide the stimulus that allows the patient to breathe, administration of high oxygen levels will be fatal for patients with chronic lung disease. Oxygen must be used cautiously in these types of patients. Patients with chronic lung disease have ongoing hypercarbia (elevated CO2 levels) and do not need to have CO2 administered or "rebreathed."

The nurse is working the night shift on a surgical unit and is making 4 AM rounds. She notices that the patient's temperature is 96.8° F (36° C), whereas at 4 PM the preceding day, it was 98.6° F (37° C). What should the nurse do? a. Call the physician immediately to report a possible infection. b. Realize that this is a normal temperature variation. c. Provide another blanket to conserve body temperature. d. Provide medication to lower the temperature further

ANS: B Body temperature normally changes 0.5° C to 1° C (0.9° F to 1.8° F) during a 24-hour period and is usually lowest between 1:00 and 4:00 AM, making this variation normal for the time of day. Unless the patient is complaining of being cold, there is no physiological need for providing an extra blanket or medication to lower the body temperature further. There is also no need to call a physician to report a normal temperature variation.

While the nurse is assessing the patient's respirations, it is important for the patient to a. Be aware of the procedure being done. b. Not know that respirations are being assessed. c. Understand that respirations are estimated to save time. d. Not be touched until the entire process is finished.

ANS: B Do not let a patient know that respirations are being assessed. A patient who is aware of the assessment can alter the rate and depth of breathing. Respirations are the easiest of all vital signs to assess, but they are often the most haphazardly measured. Do not estimate respirations. Accurate measurement requires observation and palpation of chest wall movement.

The nurse is caring for a patient who is being discharged from the hospital after being treated for hypertension. The patient is instructed to take his blood pressure three times a day and to keep a record of the readings. The nurse recommends that the patient purchase a portable electronic blood pressure device. The nurse also instructs the patient that the a. Patient can apply the cuff in any manner he chooses because the machine is designed to be used by nonprofessionals. b. Machine requires frequent calibration to ensure accuracy. c. Cuff can be placed over clothing if necessary. d. Machine is accurate when blood pressures are low.

ANS: B Electronic devices are easier to manipulate but require frequent recalibration—more than once a year. Because of their sensitivity, improper cuff placement or movement of the arm causes electronic devices to give incorrect readings. Stationary blood pressure devices are often found in public places, and the cuff fits over clothing. The same is not true for portable devices. Electronic blood pressure measurement is not recommended when pressure is less than 90 mm Hg systolic.

The nurse is caring for a patient who complains of feeling light-headed and "woozy." The nurse checks the patient's pulse and finds that it is irregular. The patient's blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do? a. Call the physician immediately. b. Perform an apical/radial pulse assessment. c. Apply more pressure to the radial artery to assess the pulse. d. Use his thumb to detect the patient's pulse

ANS: B If the pulse is irregular, do an apical/radial pulse assessment to detect a pulse deficit. If pulse count differs by more than 2, a pulse deficit exists, which sometimes indicates alterations in cardiac output. The nurse needs to gather as much information as possible before calling the physician. The radial pulse is more accurately assessed with moderate pressure. Too much pressure occludes the pulse and impairs blood flow. Fingertips are the most sensitive parts of the hand to palpate arterial pulsations. The thumb has a pulsation of its own that interferes with accuracy.

The patient was found unresponsive in her apartment and is being brought to the emergency department. She has arm, hand, and leg edema, her temperature is 95.6° F, and her hands are cold secondary to her history of peripheral vascular disease. It is reported that she has a latex allergy. To quickly measure the patient's oxygen saturation, what should the nurse do? a. Attach a finger probe to the patient's index finger. b. Place a nonadhesive sensor on the patient's ear lobe. c. Attach a disposable adhesive sensor to the bridge of the patient's nose. d. Place the sensor on the same arm that the electronic blood pressure cuff is on

ANS: B Select ear or bridge of nose if an adult patient has a history of peripheral vascular disease. Do not attach sensor to finger, ear, or bridge of nose if area is edematous or skin integrity is compromised. Do not use disposable adhesive probes if the patient has latex allergy. Do not attach probe to fingers that are hypothermic. Do not place sensor on the same extremity as electronic blood pressure cuff because blood flow to finger will be temporarily interrupted when cuff inflates.

After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. Why is this done? a. Temperatures are the same regardless of the route used. b. Temperatures vary depending on the route used. c. Temperatures are cooler when taken rectally than when taken orally. d. Axillary temperatures are higher than oral temperatures.

ANS: B Temperatures obtained vary depending on the site used. Rectal temperatures are usually 0.5 C (0.9 F) higher than oral temperatures, and axillary temperatures are usually 0 C (0.9 F) lower than oral temperatures.

The nurse is caring for an elderly patient and notes that his temperature is 96.8° F (36° C). She understands that this patient is a. Suffering from hypothermia. b. Expressing a normal temperature. c. Hyperthermic relative to his age. d. Demonstrating the increased metabolism that accompanies aging.

ANS: B The average body temperature of older adults is approximately 96.8° F (36° C). This is not hypothermia or hyperthermia. Older adults have poor vasomotor control, reduced amounts of subcutaneous tissue, and reduced metabolism. The end result is lowered body temperature

The nurse is caring for an infant and is obtaining the patient's vital signs. The best site for the nurse to obtain the infant's pulse would be the _____ artery. a. Radial b. Brachial c. Femoral d. Popliteal

ANS: B The brachial or apical pulse is the best site for assessing an infant's or a young child's pulse because other peripheral pulses such as the radial, femoral, and popliteal arteries are deep and are difficult to palpate accurately.

The patient requires routine temperature assessment but is confused and easily agitated and has a history of seizures. The nurse's best option would be to take his temperature a. Orally. b. Tympanically. c. Rectally. d. By the axillary method.

ANS: B The tympanic route is easily accessible, requires minimal patient repositioning, and often can be used without disturbing the patient. It also has a very rapid measurement time. Oral temperatures require patient cooperation and are not recommended for patients with a history of epilepsy. Rectal temperatures require positioning and may increase patient agitation. Axillary temperatures need long measurement times and continuous positioning by the nurse. The patient's agitation state may not allow for long periods of attention.

The patient is being encouraged to purchase a portable automatic blood pressure device so he can monitor his own blood pressure at home. What are some of the benefits of this? (Select all that apply.) a. Blood pressures can be obtained if pulse rates become irregular. b. Patients can provide information about patterns to health care providers. c. Patients can actively participate in their treatment. d. Self-monitoring helps with compliance and treatment. e. The risk of obtaining an inaccurate reading is decreased

ANS: B, C, D Self-measurement of blood pressure has several benefits. Sometimes elevated blood pressure is detected in persons previously unaware of a problem. Persons with prehypertension provide information about the pattern of blood pressure values to their health care provider. Patients with hypertension benefit from participating actively in their treatment through self-monitoring, which promotes compliance with treatment. Disadvantages of self-measurement include the risk of inaccurate readings. Electronic devices are not recommended if the patient has an irregular heart rate.

The patient has new-onset restlessness and confusion. His pulse rate is elevated, as is his respiratory rate. His oxygen saturation, however, is 94% according to the portable pulse oximeter. The nurse ignores the oximeter reading and calls the physician to obtain an order for an arterial blood gas (ABG). The nurse does this because many things can cause inaccurate pulse oximetry readings, including which of the following? (Select all that apply.) a. O2 saturations (SaO2) >70% b. Carbon monoxide inhalation c. Nail polish d. Hypothermia at the assessment site e. Intravascular dyes

ANS: B, C, D, E Inaccurate pulse oximetry readings can be caused by outside light sources, carbon monoxide (caused by smoke inhalation or poisoning), patient motion, jaundice, intravascular dyes (methylene blue), nail polish, artificial nails, metal studs, or dark skin. Other factors include peripheral vascular disease (atherosclerosis), hypothermia at the assessment site, pharmacological vasoconstrictors (e.g., epinephrine), low cardiac output, hypotension, peripheral edema, and tight probes.

Of the following mechanisms of heat loss by the body, identify the mechanism that transfers heat away by using air movement? a. Radiation b. Conduction c. Convection d. Evaporation

ANS: C Convection is the transfer of heat away from the body by air movement. Conduction is the transfer of heat from one object to another with direct contact. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas.

The nurse is caring for a patient who has a pulse rate of 44. His blood pressure is within normal limits. In trying to determine the cause of the patient's low heart rate, the nurse would suspect a. That the patient would have a fever. b. Possible hemorrhage or bleeding. c. Calcium channel blockers or digitalis medications. d. Chronic obstructive pulmonary disease (COPD).

ANS: C Negative chronotropic drugs such as digitalis, beta-adrenergic agents, and calcium channel blockers can slow down pulse rate. Fever, bleeding, hemorrhage, and COPD all increase the body's need for oxygen, leading to an increased heart rate.

Which statement is true of the ovulation phase? a. Progesterone levels are below normal. b. Body temperature is below baseline levels. c. Body temperature is at previous baseline levels or higher. d. Intense body heat and sweating occur.

ANS: C Progesterone levels rise and fall cyclically during the menstrual cycle. When progesterone levels are low, the body temperature is a few tenths of a degree below the baseline. The lower temperature persists until ovulation occurs. During ovulation, greater amounts of progesterone enter the circulatory system and raise the body temperature to previous baseline levels or higher. These temperature variations help to predict a woman's most fertile time to achieve pregnancy. Women who undergo menopause (cessation of menstruation) often experience periods of intense body heat and sweating lasting from 30 seconds to 5 minutes (hot flashes)

Which artery is the most appropriate for assessing the pulse of a small child? a. Radial b. Femoral c. Brachial d. Ulnar

ANS: C The brachial or apical pulse is the best site for assessing an infant's or a young child's pulse because other peripheral pulses are deep and difficult to palpate accurately.

The patient's blood pressure is 140/60. The nurse realizes that this equates to a pulse pressure of a. 140. b. 60. c. 80. d. 200.

ANS: C The difference between the systolic pressure and the diastolic pressure is the pulse pressure. For a blood pressure of 140/60, the pulse pressure is 80 (140 - 60 = 80). 140 is the systolic pressure. 60 is the diastolic pressure. 200 is the systolic (140) added to the diastolic (60), but this has no clinical significance.

The physician order reads "Lopressor (metoprolol) 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic." The patient's blood pressure is 92/66. The nurse does not give the medication and a. Does not tell the patient what the blood pressure is. b. Documents only what the blood pressure was. c. Documents that the medication was not given owing to low blood pressure. d. Does not need to inform the health care provider that the medication was held.

ANS: C The nurse must document any interventions initiated as a result of vital sign measurement such as holding an antihypertensive drug. The nurse should inform the patient of the blood pressure value and the need for periodic reassessment of the blood pressure. Documenting the blood pressure only is not sufficient. Any intervention must be documented as well. Abnormal findings must be reported to the nurse in charge or to the health care provider.

While attempting to obtain oxygen saturation readings on a toddler, what should the nurse do? a. Place the sensor on the earlobe. b. Place the sensor on the bridge of the nose. c. Determine whether the toddler has a tape allergy. d. Ignore any variation between the oximeter pulse rate and the patient's apical pulse rate.

ANS: C The nurse should determine whether the patient has latex allergy because disposable adhesive probes should not be used on patients with latex allergies. Earlobe and bridge of the nose sensors should not be used on infants and toddlers because of skin fragility. Oximeter pulse rate and the patient's apical pulse rate should be the same. Any difference requires re-evaluation of oximeter sensor probe placement and reassessment of pulse rates

The nursing assistive person is taking vital signs and reports that a patient's blood pressure is abnormally low. The nurse should a. Have the nursing assistive person retake the blood pressure. b. Ignore the report and have it rechecked at the next scheduled time. c. Retake the blood pressure herself and assess the patient's condition. d. Have the nursing assistive person assess the patient's other vital signs.

ANS: C The nursing assistive person should report abnormalities to the nurse, who should further assess the patient. The nursing assistive person should not retake the blood pressure or other vital signs because the nurse needs to assess the patient. The report cannot be ignored. Assessment must be done by the nurse

The patient is being admitted to the emergency department following a motor vehicle accident. His jaw is broken, and he has several broken teeth. He is ashen, and his skin is cool and diaphoretic. To obtain an accurate temperature, the nurse uses which of the following routes? a. Oral b. Axillary c. Rectal d. Temporal

ANS: C The rectal route is argued to be more reliable when oral temperature cannot be obtained. Oral temperatures are not used for patients who have had oral surgery, trauma, history of epilepsy, or shaking chills. Axillary temperature is affected by exposure to the environment, including time to place the thermometer. It also requires a long measurement time. Temporal artery temperature is affected by skin moisture such as diaphoresis or sweating

The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). His last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). The nurse should a. Call the physician and anticipate an order to treat the fever. b. Assume that the patient has an infection and order blood cultures. c. Wait an hour and recheck the patient's temperature. d. Be aware that temperatures this high are harmful and affect patient safety.

ANS: C Waiting an hour and rechecking the patient's temperature would be the most appropriate action in this case. A fever usually is not harmful if it stays below 102.2° F (39° C), and a single temperature reading does not always indicate a fever. In addition to physical signs and symptoms of infection, a fever determination is based on several temperature readings at different times of the day compared with the usual value for that person at that time. Mild temperature elevations enhance the body's immune system by stimulating white blood cell production. Usually, staff nurses do not order blood cultures, and nurses should base actions on knowledge, not on assumptions.

Of the following sites, which are used for obtaining a core temperature? (Select all that apply.) a. Oral b. Rectal c. Tympanic d. Axillary e. Pulmonary artery

ANS: C, E Intensive care units use the core temperatures of the pulmonary artery, esophagus, and urinary bladder. Because the tympanic membrane shares the same arterial blood supply as the hypothalamus, the tympanic temperature is a core temperature. Oral, rectal, axillary, and skin temperature sites rely on effective blood circulation at the measurement site.

When focusing on temperature regulation of newborns and infants, the nurse understands that a. Temperatures are basically the same for infants and older adults. b. Infants have well-developed temperature-regulating mechanisms. c. The normal temperature range gradually increases as the person ages. d. Newborns need to wear a cap to prevent heat loss.

ANS: D A newborn loses up to 30% of body heat through the head and therefore needs to wear a cap to prevent heat loss. Temperature control mechanisms in newborns are immature and respond drastically to changes in the environment. The normal temperature range gradually drops as individuals approach older adulthood.

The nurse is caring for a patient who has an elevated temperature. The nurse understands that a. Fever and hyperthermia are the same thing. b. Hyperthermia occurs when the body cannot reduce heat loss. c. Hyperthermia is an upward shift in the set point. d. Hyperthermia occurs when the body cannot reduce heat production.

ANS: D Fever and hyperthermia are not the same things. An elevated body temperature related to the body's inability to promote heat loss or reduce heat production is hyperthermia. Fever is an upward shift in the set point. Hyperthermia is not a shift in the set point.

The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed? a. Choose the cuff that says "Child" instead of "Infant." b. Obtain the reading before the child has a chance to "settle down." c. Use the diaphragm portion of the stethoscope to detect Korotkoff sounds. d. Explain to the child what the procedure will be.

ANS: D Preparing the child for the blood pressure cuff's unusual sensation increases cooperation. Most children will understand the analogy of a "tight hug on your arm." Different arm sizes require careful and appropriate cuff size selection. Do not choose a cuff based on the name of the cuff. An "Infant" cuff is too small for some infants. Readings are difficult to obtain in restless or anxious infants and children. Allow at least 15 minutes for children to recover from recent activities and become less apprehensive. Korotkoff sounds are difficult to hear in children because of low frequency and amplitude. A pediatric stethoscope bell is often helpful.

A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before she assesses the patient's blood pressure? a. Neither caffeine nor smoking affects blood pressure. b. She needs to insist that the patient stop smoking for at least 3 hours. c. The nurse should have the patient perform mild exercises. d. Caffeine and smoking can cause false BP elevations.

ANS: D Smoking immediately increases BP, and this increase lasts up to 15 minutes. Caffeine increases BP for up to 3 hours. Both affect a patient's blood pressure. The patient should rest at least 5 minutes before BP is measured.

Of the following values, which value would be considered prehypertension? a. 98/50 in a 7-year-old child b. 115/70 in an infant c. 140/90 in an older adult d. 120/80 in a middle-aged adult

An adult's blood pressure tends to rise with advancing age. The optimal blood pressure for a healthy, middle-aged adult is less than 120/80. Values of 120 to 139/80 to 89 mm Hg are considered prehypertension. Blood pressure greater than 140/90 is defined as hypertension. Blood pressure of 98/50 is normal for a child, whereas 115/70 can be normal for an infant

A febrile preschool-aged child presents to the after-hours clinic. Varicella is diagnosed on the basis of the illness history and the presence of small, circumscribed skin lesions filled with serous fluid. The nurse documents the varicellar lesions as which type of skin lesion? a. Vesicle b. Wheal c. Papule d. Pustule

a. Vesicle Vesicles are circumscribed, elevated skin lesions filled with serous fluid that measure less than 1 cm. Wheals are irregularly shaped, elevated areas of superficial localized edema that vary in size. They are common with bug bits and hives. Papules are palpable, circumscribed, solid elevations in the skin that are smaller than 1 cm. Pustules are elevations of skin similar to vesicles, but they are filled with pus.

The best term for breath sounds created by air moving through large lung airways is a. Bronchovesicular. b. Rhonchi. c. Bronchial. d. Vesicular.

a. Bronchovesicular. Bronchovesicular breath sounds are created by air moving through large airways. Vesicular sounds are created by air moving through smaller airways. Bronchial sounds are created by air moving through the trachea close to the chest wall. Rhonchi are abnormal lung sounds that are loud, low-pitched, rumbling coarse sounds heard during inspiration or expiration that sometimes clear by coughing.

During a sexually transmitted illness presentation to high school students, the nurse recommends the HPV vaccine series to prevent a. Cervical cancer. b. Genital lesions. c. Vaginal discharge. d. Swollen perianal tissues.

a. Cervical cancer. Human papillomavirus (HPV) infection increases the person's risk for cervical cancer. HPV vaccine is recommended by the American Cancer Society for females aged 9 to 26 years. Vaginal discharge, painful or swollen perianal tissues, and genital lesions are signs and symptoms that may indicate a sexually transmitted infection.

The patient is a 50-year-old African American male who has come in for his routine annual physical. Which of the following preventive screenings does the nurse recommend? a. Digital rectal examination of the prostate (DRE) annually b. Ca125 blood test once a year c. Complete eye examination every year d. Colonoscopy every 3 years

a. Digital rectal examination of the prostate (DRE) annually Men need to have a digital rectal examination of the prostate every year beginning at 50 years of age. Ca125 blood tests are indicated for women at high risk for ovarian cancer. Because this patient is a man, Ca125 is not needed. Patients over the age of 65 need to have complete eye examinations yearly. Colonoscopy every 10 years is recommended in patients 50 years of age and older.

On admission, a patient weighs 250 pounds. The weight is recorded as 256 pounds on the second inpatient day. The nurse should evaluate the patient for a. Fluid retention. b. Fluid loss. c. Decreased nutritional reserves. d. Anorexia.

a. Fluid retention. This patient has gained 6 pounds in a 24-hour period. A weight gain of 5 pounds (2.3 kg) or more in a day indicates fluid retention problems. A downward trend may indicate a reduction in nutritional reserves that may be caused by decreased intake such as anorexia or by fluid loss.

A parent calls the school nurse with questions regarding the recent school vision screening. Snellen chart examination revealed 20/60 for both eyes. Considering the visual acuity results, the nurse informs the parent that the child a. Should have an optometric examination. b. Is suffering from strabismus. c. May have presbyopia. d. Has vision issues most likely due to cataracts.

a. Should have an optometric examination. Normal vision is 20/20. The larger the denominator, the poorer the patient's visual acuity. For example, a value of 20/60 means that the patient, when standing 20 feet away, can read a line that a person with normal vision can read from 60 feet away. Strabismus is a (congenital) condition in which both eyes do not focus on an object simultaneously: These eyes appear crossed. Acuity may not be affected. Presbyopia is impaired near vision that occurs in middle-aged and older adults and is caused by loss of elasticity of the lens. Cataracts develop slowly and progressively after age 35 or suddenly after trauma.

A nurse suspects an abnormal thyroid shape during the physical examination. The nurse offers the patient a glass of water and observes her drinking to a. Visualize an enlarged thyroid gland. b. Evaluate for exostosis. c. Test the patient's gag reflex. d. Visualize the uvula and soft palate.

a. Visualize an enlarged thyroid gland. This technique is used to visual an abnormally large thyroid gland. Normally, the thyroid cannot be visualized. An exostosis is a bony growth between the two palates that is noted when the oral cavity is examined. The patient's gag reflex is tested by placing a tongue depressor on the posterior tongue. The uvula and soft palate are visualized by using a penlight. Both structures should rise centrally as the patient says, "Ah."

A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for a patient, the new graduate nurse begins to explain to the patient the purpose of completing a physical assessment. Which of the following statements made by the new graduate nurse requires the preceptor to intervene? a. "I will use the information from my assessment to figure out if your antihypertensive medication is working effectively." b. "Nursing assessment data are used only to provide information about the effectiveness of your medical care." c. "Nurses use data from their patient's physical assessment to determine a patient's educational needs." d. "Information gained from physical assessment helps nurses better understand their patients' emotional needs."

b. "Nursing assessment data are used only to provide information about the effectiveness of your medical care." Nursing assessment data are used to evaluate the effectiveness of all aspects of a patient's care, not just the patient's medical care. Assessment data help to evaluate the effectiveness of medications and to determine a patient's health care needs, including the need for patient education. Nurses also use assessment data to identify patients' psychosocial and cultural needs.

A teen female patient reports intermittent abdominal pain for 12 hours. No dysuria is present. When performing an abdominal assessment, the nurse should a. Recommend that the patient take more laxatives. b. Ask the patient about the color of her stools. c. Avoid sexual references such as possible pregnancy. d. Assess first the spots that are most tender.

b. Ask the patient about the color of her stools. Black or tarry stools (melena) indicate gastrointestinal alteration. The nurse should caution patients about the dangers of excessive use of laxatives or enemas. Determine if the patient is pregnant, and note her last menstrual period. Pregnancy causes changes in abdominal shape and contour. Assess painful areas last to minimize discomfort and anxiety.

During a routine physical examination of a 70-year-old patient, a blowing sound is auscultated over the carotid artery. The nurse notifies the medical provider of the unexpected physical finding known as a. Clubbing. b. Bruit. c. Right-sided heart failure. d. Phlebitis.

b. Bruit. A bruit is the sound of turbulence of blood passing through a narrowed blood vessel. A bruit can reflect cardiovascular disease in the carotid artery of middle-aged to older adults'. Clubbing is due to insufficient oxygenation at the periphery resulting from conditions such as chronic emphysema and congenital heart disease; it is noted in the nails. Jugular venous distention, not bruit, is a possible sign of right-sided heart failure. Some patients with heart disease have distended jugular veins when sitting. Phlebitis is an inflammation of a vein that occurs commonly after trauma to the vessel wall, infection, immobilization, and prolonged insertion of IV catheters. It affects predominantly peripheral veins.

While assessing the skin of an 82-year-old male patient, a nurse discovers non-painful ruby red papules on the patient's trunk. What is the nurse's next action? a. Explain that the patient has basal cell carcinoma and should watch for spread. b. Document cherry angiomas as a normal geriatric skin finding. c. Tell the patient that he has a benign squamous cell carcinoma. d. Document the presence of edema.

b. Document cherry angiomas as a normal geriatric skin finding. The skin is normally free of lesions, except for common freckles or age-related changes such as skin tags, senile keratosis (thickening of skin), cherry angiomas (ruby red papules), and atrophic warts. Basal cell carcinoma is most common in sun-exposed areas and frequently occurs in a background of sun-damaged skin; it almost never spreads to other parts of the body. Squamous cell carcinoma is more serious than basal cell and develops on the outer layers of sun-exposed skin; these cells may travel to lymph nodes and throughout the body. Report abnormal lesions to the health care provider for further examination. Edema is an area of skin that becomes swollen or edematous from a buildup of fluid in the tissues. This has nothing to do with cherry angiomas.

During a preschool readiness examination, the nurse prepares to perform visual acuity screenings. Given the children's age, the best equipment to test central vision is which of the following? a. Snellen test b. E chart c. Reading test d. Penlight

b. E chart The E chart is used when an individual is unable to read, as would be the case for a preschool-aged child. A Snellen chart and a reading test are too advanced for a preschooler's education level. A penlight is used to check light perception. Shine a penlight into the eye, and then turn it off. If the patient notes when the light is turned on or off, light perception is intact.

An elderly patient is being seen for a chronic entropion. The nurse realizes that entropion places the patient at risk for which of the following? a. Ectropion b. Infection c. Exophthalmos d. Strabismus

b. Infection The diagnosis of entropion can lead to lashes of the lids irritating the conjunctiva and cornea. Irritation can lead to infection. Ectropion is when the eyelid margins turn out so that the lashes do not irritate the conjunctiva. Exophthalmos is a bulging of the eyes and usually indicates hyperthyroidism. Strabismus, or crossing of the eyes, results from neuromuscular injury or inherited abnormalities.

During a genitourinary examination of a 30-year-old male patient, the nurse identifies a small amount of a white, thick substance on the patient's uncircumcised glans penis. The nurse's next step is to a. Notify his provider about a suspected STI. b. Recognize this as a normal finding. c. Tell the patient to avoid doing self-examinations until symptoms clear. d. Avoid embarrassing questions about sexual activity.

b. Recognize this as a normal finding. A small amount of thick, white smegma sometimes collects under the foreskin in the uncircumcised male. Penile pain or swelling, genital lesions, and urethral discharge are signs and symptoms that may indicate STI. All men 15 years and older need to perform a male-genital self-examination monthly. The nurse needs to assess a patient's sexual history and use of safe sex habits. Sexual history reveals risks for STI and HIV.

The nurse considers several new female patients to receive additional health education on the need for more frequent Pap smears and gynecological examinations. Which of the following assessment findings reveals the patient at highest risk for cervical cancer and thus having the greatest need for patient education? a. Nonsmoker, 13 years old, not sexually active b. Social smoker, 15 years old, celibate c. 22 years old, smokes 1 pack of cigarettes per day, has multiple sexual partners d. 50 years old, stopped smoking 30 years ago, history of hysterectomy

c. 22 years old, smokes 1 pack of cigarettes per day, has multiple sexual partners Females considered to be at higher risk include those who smoke and are over 21 with weak immune systems, multiple sex partners, and a history of sexually transmitted infections. Of all the assessment findings listed, the 22-year-old smoker with multiple sexual partners has the greatest number of risk factors for cervical cancer. The other patients are at lower risk.

The paramedics transport an adult involved in a motor vehicle accident to the emergency department. On physical examination, the patient's level of consciousness is reported as opening eyes to pain and responding with inappropriate words and flexion withdrawal to painful stimuli. The nurse correctly identifies the patient's Glasgow Coma Scale score as a. 5. b. 7. c. 9. d. 11.

c. 9. According to the guidelines of the Glasgow Coma Scale, the patient has a score of 9. Opening eyes to pain is 2 points; inappropriate word use is 3 points; and flexion withdrawal is 4 points. The total for this patient is 2 + 3 + 4 = 9.

Asking an adult what the statement "A stitch in time saves nine" means to him is a mental status examination technique used to assess a. Knowledge. b. Long-term memory. c. Abstract thinking. d. Recent memory.

c. Abstract thinking. For an individual to explain common phrases such as "A stitch in time saves nine" requires a higher level of intellectual function. Knowledge-based assessment is factual. Assess knowledge by asking how much the patient knows about his illness or the reason for seeking health care. To assess past memory, ask the patient to recall the maiden name of the patient's mother, a birthday, or a special date in history. It is best to ask open-ended questions rather than simple yes/no questions. Patients demonstrate immediate recall by repeating a series of numbers in the order in which they are presented or in reverse order.

An advanced practice nurse is preparing to assess the external genitalia of a 25-year-old American woman of Chinese descent. Which of the following nursing actions does the nurse do first? a. Place the patient in the lithotomy position. b. Drape the patient to enhance patient comfort. c. Assess the patient's feelings and explain the purpose of the examination. d. Ask the patient if she would like her mother to be present in the room during the examination.

c. Assess the patient's feelings and explain the purpose of the examination. Patients who are Chinese American often believe that examination of the external genitalia is offensive. Before proceeding with the examination, the nurse first determines how the patient feels about the procedure and explains the procedure to answer any questions and to help the patient feel comfortable with the assessment. Once the patient is ready to have her external genitalia examined, the nurse places the patient in the lithotomy position and drapes the patient appropriately. Typically, nurses ask adolescents if they want a parent present during the examination. The patient in this question is 25 years old, so she is not an adolescent. Asking her if she would like her mother to be present is inappropriate.

The patient is a 54-year-old male with a medium frame. He weighs 148 pounds and is 5 feet 8 inches tall. The nurse realizes that this patient is a. Overweight. b. Underweight. c. At his desired weight. d. Obese.

c. At his desired weight. According to the Metropolitan Life Insurance Company Statistical Bulletin, a male of medium frame who is 5 feet 8 inches tall should weigh between 145 and 157 pounds. This patient is at his desired weight. He is not overweight, underweight, or obese.

The advanced practice nurse is conducting a comprehensive eye examination on an 80-year-old African American woman. Which of the following findings requires the nurse to contact the patient's physician for further examination? a. A thin white ring along the margin of the iris b. A black pupil c. Dilated pupils d. A black fundus of the eye

c. Dilated pupils Dilated pupils result from glaucoma, trauma, neurological disorders, eye medication, or withdrawal from opioids. Shining a beam of light through the pupil and onto the retina stimulates the third cranial nerve and causes the muscles of the iris to constrict. Any abnormality along the nerve pathways from the retina to the iris alters the ability of the pupils to react to light. A thin white ring along the margin of the iris, called an arcus senilis, is common with aging but is abnormal in anyone younger than age 40. The pupils are normally black, round, regular, and equal in size. The fundus of African American patients can be black.

A school nurse recognizes a belt buckle-shaped ecchymosis on a 7-year-old student. When privately asked about how the injury occurred, the student described falling on the playground. Upon suspecting abuse, the school nurse's best next action is which of the following? a. Interviewing the patient in the presence of his/her teacher b. Ignoring the findings because child abuse is a declining problem c. Realizing that abuse victims usually report abusive situations d. Contacting Social Services and reporting suspected abuse

d. Contacting Social Services and reporting suspected abuse Most states mandate a report to a social service center if nurses suspect abuse or neglect. When abuse is suspected, the nurse interviews the patient in private. Abuse of children, women, and older adults is a growing health problem. It is difficult to detect abuse because victims often will not complain or report that they are in an abusive situation.

A teen patient is tearful and reports locating lumps in her breasts. Other history obtained is that she is currently menstruating. Physical examination reveals soft and movable cysts in both breasts that are painful to palpation. The nurse also notes that the patient's nipples are erect, but the areolae are wrinkled. The next nursing step is which of the following? a. Reassure patient that her symptoms are normal. b. Consult a breast surgeon because of the abnormal nipples and areolae. c. Discuss fibrocystic disease as the likely cause. d. Tell the patient that the symptoms may get worse when her period ends.

c. Discuss fibrocystic disease as the likely cause. A common benign condition of the breast is benign (fibrocystic) breast disease. This patient has symptoms of fibrocystic disease, which include bilateral lumpy, painful breasts sometimes accompanied by nipple discharge. Symptoms are more apparent during the menstrual period. When palpated, the cysts (lumps) are soft, well differentiated, and movable. Deep cysts feel hard. Although a common condition, benign breast disease is not normal; therefore, the nurse does not tell the patient that this is a normal finding. During examination of the nipples and areolae, the nipple sometimes becomes erect with wrinkling of the areola. Therefore, consulting a breast surgeon to treat her nipples and areolae is not appropriate.

The nurse is urgently called to the gymnasium regarding an injured student. The student is crying in severe pain with a malformed fractured lower leg. The proper sequence for the nurse's initial assessment is a. Deep palpation, light palpation, inspection. b. Light palpation, deep palpation, inspection. c. Inspection, light palpation. d. Auscultation, deep palpation, light palpation.

c. Inspection, light palpation. Inspection is the use of vision and hearing to distinguish normal from abnormal findings. Light palpation determines areas of tenderness and skin temperature, moisture, and texture. Deep palpation is used to examine the condition of organs, such as those in the abdomen. Caution is the rule with deep palpation. Deep palpation is done after light palpation. Auscultation is used to evaluate sound.

A nurse identifies Pediculosis humananus capitis. Considering the possible complications of treatment, the nurse knows to not use which of the following treatment products? a. Fine-toothed comb b. Pediculicide c. Lindane-based shampoo d. Vinegar hair rinse

c. Lindane-based shampoo Products containing lindane, a toxic ingredient, often cause adverse reactions. Instruct patients who have head lice to shampoo thoroughly with pediculicide (shampoo available at drugstores) in cold water, comb thoroughly with a fine-toothed comb, and discard the comb. A dilute solution of vinegar and water helps loosen nits.

The nurse is caring for a female victim of rape. To perform the proper evaluation, the nurse should place the patient in which of the following positions? a. Sitting b. Dorsal recumbent c. Lithotomy d. Knee-chest

c. Lithotomy Lithotomy is the position for examination of female genitalia. The lithotomy position provides for the maximum exposure of genitalia and allows the insertion of a vaginal speculum. Sitting does not allow adequate access for speculum insertion and is better used to visualize upper body parts. Dorsal recumbent is used to examine the head and neck, anterior thorax and lungs, breasts, axillae, heart, and abdomen. Knee-chest provides maximal exposure of the rectal area but is embarrassing and uncomfortable.

During a school physical examination, the nurse reviews the patient's current medical history. With a positive medical history of asthma, eczema, and allergic rhinitis, the nurse expects which physical finding on nasal examination? a. Polyp b. Yellow discharge c. Pale nasal mucosa d. Puffiness of nasal mucosa

c. Pale nasal mucosa Pale nasal mucosa with clear mucoid discharge indicates allergic rhinitis. Polyps are tumorlike growths. Yellow discharge would be seen with infection. Habitual use of intranasal cocaine and opioids causes puffiness and increased vascularity of the nasal mucosa.

Which is the best examination position for a complete geriatric physical examination on a weak patient with bilateral basilar pneumonia? a. Prone position b. Sims' position c. Supine position d. Lateral recumbent

c. Supine position This is the most normally relaxed position. It will not compromise the patient's breathing because it is likely compromised with pneumonia. If the patient becomes short of breath easily, raise the head of the bed. This position would be easiest for an elderly weak person to get into position for an examination. Lateral recumbent and prone positions cause respiratory difficulty for any patient with respiratory difficulties. Sims' position is used for assessment of the rectum and the vagina.

A head and neck physical examination is completed on a 50-year-old female patient. All physical findings are normal except for fine brittle hair. Based on the physical findings, which of the following laboratory tests would the nurse expect to be ordered? a. Liver function test b. Lead level c. Thyroid-stimulating hormone test d. Complete blood count

c. Thyroid-stimulating hormone test Thyroid disease can make hair thin and brittle. Liver function testing is indicated for a patient who has jaundice. Lead levels and a CBC are not indicated for the presence of brittle hair.

Having misplaced his stethoscope, a nurse borrows a colleague's stethoscope. He next enters the patient's room and identifies himself, washes his hands with soap, and states the purpose of his visit. He performs proper identification of the patient before he auscultates her lungs. Which critical health assessment step was not performed? a. Running warm water over stethoscope for patient comfort b. Cleaning stethoscope with Betadine c. Using alcohol-based hand disinfectant d. Cleaning stethoscope with alcohol

d. Cleaning stethoscope with alcohol Bacteria and viruses can be transferred from patient to patient when a stethoscope that is not clean is used. The stethoscope should be cleaned before use on each patient. Running water over the stethoscope does not kill bacteria. Betadine is an inappropriate cleaning solution and may damage the equipment. Hand sanitizer is not an approved cleaning product.

During a routine pediatric history and physical, the parents report that their child was a premature infant and was so small that he had to stay in the neonatal intensive care unit longer than usual. They state that the infant was yellow when born, and that he developed an infection that required "every antibiotic under the sun" to cure him. Considering the neonatal history, the nurse determines that it is especially important to perform a focused _____ examination. a. Cardiac b. Respiratory c. Ophthalmic d. Hearing acuity

d. Hearing acuity Risk factors for hearing problems include low birth weight, nonbacterial intrauterine infection, and excessively high bilirubin levels. Hearing loss due to ototoxicity (injury to auditory nerves) can result from high maintenance doses of antibiotics. Cardiac, respiratory, and eye examinations are important assessments but are not relevant to this child's condition.

The patient presents to the clinic with dysuria and hematuria. How does the nurse proceed to assess for kidney inflammation? a. Lightly palpates each abdominal quadrant b. Inspects abdomen for abnormal movement or shadows using indirect lighting c. Uses deep palpation posteriorly d. Percusses posteriorly the costovertebral angle at the scapular line

d. Percusses posteriorly the costovertebral angle at the scapular line With the patient sitting or standing erect, use direct or indirect percussion to assess for kidney inflammation. With the ulnar surface of the partially closed fist, percuss posteriorly the costovertebral angle at the scapular line. If the kidneys are inflamed, the patient feels tenderness during percussion. Use a systematic palpation approach for each quadrant of the abdomen to assess for muscular resistance, distention, abdominal tenderness, and superficial organs or masses. Light palpation would not detect kidney tenderness because the kidneys sit deep within the abdominal cavity. Posteriorly, the lower ribs and heavy back muscles protect the kidneys, so they cannot be palpated. Kidney inflammation will not cause abdominal movement. However, to inspect the abdomen for abnormal movement or shadows, the nurse should stand on the patient's right side and inspect from above the abdomen using direct light over the abdomen.