Health Assessment Final

The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the ____ artery

Brachial

The review of systems provides the nurse with:

Information regarding health promotion practices.

The nurse knows that normal splitting of the S2 is associated with

Inspiration.

During the history of a 78-year-old man, his wife states that he occasionally has problems with short term memory loss and confusion: "He can't even remember how to button his shirt." In doing the assessment of his sensory system, which action by the nurse is most appropriate?

Before testing, the nurse would assess the patient's mental status and ability to follow directions.

In assessing for an S4 heart sound with the stethoscope, the nurse would listen with the:

Bell of the stethoscope at the apex with the patient in the left lateral position.

The nurse is preparing for a class on risk factors for HTN and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world?

Blacks

The nurse is auscultating the chest in an adult. Which technique is correct?

Firmly holding the diaphragm of the stethoscope against the chest.

The nurse is assessing for clubbing of the fingernails and expects to find:

Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy.

While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse's response?

No further response is needed because sinus arrhythmia can occur normally.

While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and umbilicus. The nurse would suspect that these are:

Normal abdominal aortic pulsations.

After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be:

Objective

The nurse is preforming a general survey. Which action is a component of the general survey?

Observing the patient's body stature and nutritional status.

The articulation of the mandible and the temporal bone is known as the:

Temporomandibular joints

A patient who has a severed spinal nerve as a result of trauma. Which statement is true in this situation?

The adjacent spinal nerves will continue to carry sensations for the dermatome severed by the severed nerve.

During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. No associated rigidity is observed with movement. Which of these statements is most accurate?

These findings are normal, resulting from aging.

The nurse is taking temperatures in a clinic with a TMT. Which statement is true regarding use of the TMT?

The risk of cross-contamination is reduced, compared with the rectal route.

The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history?

To provide a database of subjective information about the patient's past and current health.

When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process?

Tongue that looks smoother in appearance.

The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include:

Tympany, hyperresonance, and dullness

The nurse is performing an assessment. Which of these findings would cause the greatest concern?

Ulceration on the side of the tongue with rolled edges.

The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal?

Unequal pupillary constriction in response to light.

A nurse is taking complete health histories on all of the patient attending a wellness workshop. On the history form, one of the written questions asks, "You don't smoke, drink, or take drugs, do you?" This question is an example of:

Using biased or leading questions

During the taking of the health history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this finding as:

Vertigo.

During the cardiac auscultation, the nurse hears a sound immediately occurring after the S2 at the second left intercostal space. To further assess this sound, what should the nurse do?

Watch the patient's respirations while listening for the effect on the sound.

During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?

When part of the lung is obstructed or collapsed.

During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?

When the bronchial tree is obstructed.

Which statement is true regarding the arterial system?

Which statement is true regarding the arterial system?

A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate?

"A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles"

A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say:

"Confluent and extensive patch of petechiae and ecchymoses on the feet."

When taking the health history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of these would be the best question for obtaining this information?

"Do you have any warning sign before your seizure starts?"

During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse's most appropriate response to this would be:

"I would like some more information about the pain in your left breast."

Which technique is correct when the nurse is assessing the radial pulse of a patient? The pulse is counted for:

1 minute, if the rhythm is irregular.

An imaginary line connecting the highest point on each iliac crest would cross the ____ vertebra.

4th lumbar

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as silent bowel sounds, the nurse should listen for at least

5 minutes.

The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm?

A pulsating mass is usually present.

A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination because he said he fell and hit his head. During the examination, the nurse asks him to use his index finger to touch the nurse's finger, then his own nose, then the nurse's finger again (which has been moved to a different location). The patient is clumsy, unable to follow the instructions, and overshoots the mark, missing the finger. The nurse should suspect which of the following?

Acute alcohol intoxication

A patient is being assessed for range-of-joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called

Adduction.

During a routine office visit, a patient takes off his shoes and shows the nurse "this awful sore that won't heal." On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well-defined edges, and no drainage. The nurse should assess for other signs and symptoms of:

An arterial ischemic ulcer

A 22-year-old man comes to the clinic for an examination after falling of his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding the assessment of the spleen in this situation?

An enlarged spleen should not be palpated because it can easily rupture.

The nurse is bathing an 80-year-old man and noticed that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult?

An increased loss of elastin and a decrease in subcutaneous fat.

When listening to heart sounds, the nurse know the valve closures that can be heard best at the base of the heart are:

Aortic and pulmonic.

During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate?

Ask the patient about the item and its significance.

The nurse notices that presence of perioribital edema when performing an eye assessment on a 70-year-old patient. The nurse should:

Ask the patient if he or she has a history of heart failure.

The nurse is attempting to assess the femoral pulse in an obese patient. Which of the following actions would be most appropriate?

Ask the patient to bend his or her knees to the side in a froglike position.

What step of the nursing process includes data collection by health history, physical examination, and interview?

Assessment

The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are:

Atelectatic crackles that do not have a pathologic cause.

The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the:

Auricle/Pinna

A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse's best response?

Can you point to where it hurts?

A patient has a normal pupillary reflex. The nurse recognizes that this reflex indicates that:

Constriction of both pupils occurs in response to bright light.

The two parts of the nervous system are the:

Central and peripheral

In performing an assessment of a woman's axillary lymph system, the nurse should assess which of these nodes?

Central, lateral, pectoral, and subscapular.

The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structures?

Cerebrum

A patient has been admitted to the ED with a possible medical Dx of pulmonary embolism. The nurse expects to see which assessment finding related to this condition?

Chest pain that is worse on deep inspiration and dyspnea.

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding?

Clubbing of the nails.

When listening to heart sounds, the nurse knows that the S1:

Coincides with the carotid artery pulse.

A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding?

Color variation.

A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurological examination?

Complete neurological examination.

The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a ___ profile.

Concave

When assessing a patient's lungs, the nurse recalls that the left lung:

Consists of two lobes.

The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding?

Convergence of the axes of the eyes.

The nurse is performing an assessment on a 65-year-old man. He reports a crusty nodule behind the pinna. It intermittently bleeds and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this:

Could be a potential carcinoma, and the patient should be referred for a biopsy.

During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects:

Crepitus.

The primary muscles of respiration include the:

Diaphragm and intercostals.

Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient?

Dark retinal background.

The nurse is assessing an 80-year-old patient. Which of these finding would be expected for this patient?

Decreased ability to identify odors.

The nurse is aware that one change that may occur in the GI system of an aging adult:

Decreased gastric acid secretion.

While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of a:

Decreased level of consciousness.

The nurse knows that a normal finding when assessing the respiratory system of an elderly adult is:

Decreased mobility of the thorax

When measuring a patient's body temperature, the nurse keeps in mind that body temperature is influenced by:

Diurnal cycle.

The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear?

Dullness

Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites?

Dullness across the abdomen.

A patient is having difficulty swallowing medications and food. The nurse would document that this patient has:

Dysphagia.

The nurse is reviewing information about EBP. Which statement best reflects EBP?

EBP emphasizes the use of best evidence techniques for the treatment of patients.

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates:

Elevated pressure related to heart failure.

During reporting, the student nurse hears that a patient has hepatomegaly and recognizes that this term refers to:

Enlarged liver

The nurse knows that during an abdominal assessment, deep palpation is used to determine:

Enlarged organs.

The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment?

Examine the tender area last.

Which statement about the apices of the lungs is true? The apices of the lungs:

Extend 3 to 4 cm above the inner third of the clavicles.

The primary purpose of the ciliated mucous membrane in the nose is to:

Filter our dust and bacteria.

The nurse is assessing a patient's ischial tuberosity. To palpate the ischial tuberosity, the nurse knows that it is best of have the patient:

Flexing the hip

A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform which movement?

Flexion

The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of which movement(s)?

Flexion and extension

A nurse notices that a patient has ascites, which indicates the presence of:

Fluid

The tissue that connects the tongue to the floor of the mouth is the:

Frenulum

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries and becomes angry very easily.The nurse recalls that the cerebral lobe responsible for these behaviors is the _____ lobe.

Frontal

During a cardiac assessment on a 38-year old patient in the hospital for "chest pain," the nurse finds the following: jugular vein pulsations 4 cm above the sternal angle when the patient is elevated at 45 degrees. blood pressure 98/60 mm Hg, heart rate 130 BPM, ankle edema, difficulty breathing when supine, and an S3 on auscultation. Which of these conditions best explains the cause of these findings?

Heart failure

A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is a:

Hordeolum (stye)

In a person with an upper motor neuron lesion such as a CVA, which of these physical assessment findings should the nurse expect?

Hyperreflexia.

A patient has been admitted to the ED for a suspected drug overdose. His respirations are shallow, which an irregular pattern, which a rate of 12 per minute. The nurse interprets this respiration pattern as which of the following?

Hypoventilation.

In assessing a 70-year-old man, the nurse finds the following: BP 140/100 mm Hg, heart rate 104 BPM and slightly irregular, and the split S2 heart sound. WHich of these findings can be explained by expected hemodynamic changes related to age?

Increase in systolic BP.

A patient states that the pain medication is "not working" and rates his pain at a 10 on a scale of 1-10. Which of these findings indicates an acute pain response to poorly controlled pain?

Increased BP and pulse.

The nurse is explaining to a patient that there are shock absorbers in his back to cushion the spine and to help it move. The nurse is referring to his:

Intervertebral disks.

The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanisms(s) by which venous blood returns to the heart?

Intraluminal valves ensure unidirectional flow toward the heart.

When assessing the force, or strength, of a pulse, the nurse recalls that the pulse:

Is a reflection of the heart's stroke volume.

When examining the eye, the nurse notices that the patient's eyelid margins approximate completely. The nurse recognizes that this assessment finding:

Is expected.

During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patient's scleras are not yellow. From this find, the nurse could probably rule out:

Jaundice.

The functional units of the musculoskeletal system are the:

Joints

A patient is complaining of a sharp pain along the costovertebral angles. The nurse is aware that this symptom is most often indicative of:

Kidney inflammation

When evaluating a patient's pain, the nurse knows that an example of acute pain would be:

Kidney stones.

The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation?

Lateral to the extensor tendon of the great toe.

The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find:

Lesions that run together

A patient has had a "terrible itch" for several months that he has been continuously scratching. On examination, the nurse might expect to find:

Lichinification.

Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called:

Ligaments

The nurse is preparing to auscultate for heart sounds. Which technique is correct?

Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex.

During auscultation of breath sounds, the nurse should use the stethoscope correctly, in which of the following ways?

Listening to at least one full respiration in each location.

The nurse is assessing the lungs of an older adult. Which of these changes are normal in the respiratory system of the older adult?

Lungs are less elastic and distensible, which decreases their ability to collapse and recoil.

During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning:

Melanocytes

The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include:

Mental illness.

During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find?

Mild, even resistance to movement

During an assessment of the CNS, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and ascape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which CN?

Motor component of CN VII.

The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient:

Moves the head and shoulders against resistance with equal strength.

A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer. Which of these findings are characteristic of a stage II pressure ulcer?

Open blister areas have a red-pink wound bed. Partial thickness skin erosion is observed with a loss of epidermis or dermis.

During an interview, the nurse states, "You mentioned having SOB. Tell me more about that." Which verbal skills is used with this statement?

Open-ended questions.

The nurse asks, "I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here." This question is found at the ______ phase of the interview process.

Opening or introduction.

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse would report this as a:

Papule

Which of these statements represents subjective data the nurse obtained from the patient regarding the patient's skin?

Patient denies any color change.

During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process?

Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure

The nurse is comparing the concepts of religion and spirituality. Which of the following is an appropriate component of one's spirituality?

Personal effort made to find purpose and meaning in life.

The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct (select all that apply)

Petechiae, Vesicle, Nodule

When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:

Positive Romberg Sign.

A patients weekly BP readings for 2 months has an average of 126/86 mmHg. The nurse knows that this BP falls within with BP category?

Pre-hypertension

A patient is not able to perform rapid alternating movements such as patting her knees rapidly. The nurse should document this as:

Presence of dysdiadochokinesia

During an assessment of the sclera of a black patient, the nurse would consider which of these an expected finding?

Presence of small brown macules on the sclera.

A patient complains of leg pain that wakes him up at night. He states that he "has been having problems" with his legs. He develops pain in his legs when they are elevated, which disappears when he dangles them. He recently noticed "a sore" on the inner aspect of the right ankle. Based on this history information, the patient is most likely experiencing:

Problems related to arterial insufficiency.

During an oral assessment of a 30-year-old African-American patient, the nurse notices bluish lips and a dark line along the gingival margin. What would the nurse do in response to this finding?

Proceed with the assessment, knowing that this appearance is a normal finding.

The nurse is testing the hearing of a 78-year-old man and is reminded of the changes in hearing that occur with aging that include which of the following?

Progression of hearing loss is slow, sounds may be garbled and difficult to localize, the aging person may find it harder to hear consonants than vowels.

A patient's abdomen is bulging and stretched in appearance. The nurse should describe this finding as:

Protuberant

When assessing a 75-year-old patient who has asthma, the nurse notes that he assumes a tripod position, leaning forward with his arms braced on the chair. On the basis of this observation, the nurse should:

Recognize that a tripod position is often used when a patient is having respiratory issues.

The nurse makes which adjustment in the physical environment to promote the success of an interview?

Reduces noise by turning off TV and radios.

A 40-year-old woman reports a change in mole size, accompanies by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would:

Refer the patient because of the suggestion of melanoma on the basis of her symptoms.

The direction of blood flow through the heart is best described by which of these?

Right atrium to right ventricle to pulmonary artery to lungs to pulmonary vein to left atrium to left ventricle

The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition?

Severe dehydration.

When inspecting the anterior chest of an adult, the nurse should include which assessment?

Shape and configuration of the chest wall.

When assessing the pupillary light reflex, the nurse should use which technique?

Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction.

A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient?

Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema.

The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is ____ comparison.

Side-to-side

Which structure is located in the left lower quadrant of the abdomen?

Sigmoid colon.

In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history?

Smoking, HTN, obesity, diabetes, and high cholesterol.

When assessing the tongue of an adult, the nurse knows that an abnormal finding would be:

Smooth glossy dorsal surface.

The area of the nervous system that is responsible for mediating reflexes is the:

Spinal cord.

When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved?

Spleen

A patient tells the nurse that he is very nervous, is nauseated, and "feels hot." These types of data would be:

Subjective

The nurse is assessing a patient's pain. The nurse knows that the most reliable indicator of pain would be the:

Subjective report.

The nurse is reviewing the anatomy and physiologic functioning of the heart. Which statement best describes what is meant by an atrial kick?

The atria contract toward the end of diastole and push the remaining blood into the ventricles.

Which statement concerning the areas of the brain is true?

The hypothalamus controls body temperatures and regulates sleep.

In performing a breast examination, the nurse knows that it is especially important to examine the upper outer quadrant of the breast. The reason for this is that the upper outer quadrant is:

The location of most breast tumors

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?

A patient with lack of oxygen to his heart will have pain in his chest and possibly the shoulder, arms, or jaw. The nurse knows that the statement that best explains why this occurs is which of these?

The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere.

During an examination, the patient states he is hearing a buzzing sound and says that it is "Driving me crazy!" The nurse recognizes that his symptom indicates:

Tinnitus

The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds?

Wheezes.

During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is:

Xerosis.

When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. The nurse should next:

consider this a normal finding and proceed with the peripheral vascular evaluation.