Health Assmt Exam 2 Questions

Nothing. It is a normal finding until 7 years of age

As you are assessing a 4 year old child, you observe respirations in the abdominal area. What is a priority action?

8-10

What is the average age of puberty in girls?

9 ½ to 13 1/2

What is the average age range of puberty in boys?

1

A 22-year-old white male comes to the emergency department with a concern about a mass in his testicle. In addition to his age and race, which fact is a known risk factor for testicular cancer? 1. He had an undescended testicle at birth. 2. His mother had breast cancer. 3. He was treated for gonorrhea 18 months ago. 4. He had a hydrocele during infancy.

2

A 50-year-old patient asks how he can reduce his risk of colon cancer. What is the most appropriate response by the nurse? 1. "A diet high in animal protein reduces the risk." 2. "Regular exercise to reduce body fat helps prevent colon cancer." 3. "Taking antacids for heartburn can help prevent colon cancer." 4. "Taking vitamin C daily helps reduce the risk."

ACE

A charge nurse is teaching a newly licensed nurse how to recognize a pleural friction rub. Which of the following descriptions should the nurse use to describe it? (select all that apply) A. Coarse grating tone B. Intermittent popping or bubbling sound C. Heard on inspiration and expiration D. Snoring sound on expiration E. Pain w/ breathing

C

A charge nurse is teaching a newly licensed nurse how to recognize manifestations of decreased oxygenation in a client. Which of the following statements by the newly licensed nurse indicates an understanding? A. "A client using thoracic breathing is experiencing a lack of oxygen" B. "A pulse ox reading of less than 95% indicates respiratory distress" C. "Clubbing of the fingers indicates a chronic state of impaired perfusion" D. "A pinkish hue on the cheeks of a client who is light-skinned indicates they are struggling to breathe."

A

A nurse had completed a cardiovascular assmt on a client. Which of the following findings should the nurse report to the provider? A. Capillary refill of 3 seconds B. +2 radial pulse C. Fingernail with 160 degree curvature D. O2 is 98%

B

A nurse is assessing a client's jugular veins and carotid arteries. The nurse should assist the client into which of the following positions? A. Place the client in high-fowler's position. B. Have the client lay supine with the head of the bed at a 45 degree angle. C. Have the client seated with their chin touching their chest D. Place the client in a left lateral position

D

A nurse is assessing the anterior chest of a client. Which of the following findings should the nurse report to the provider? A. The PMI is located at the 5th ICS B. Symmetrical chest movements during inhalation and expiration C. Absent visible pulsations in the area of the PMI D. A forceful chest movement at the midclavicular line in the 4th ICS

A

A nurse is auscultating heart sounds in a group of clients. Which of the following should the nurse identify as an expected variation? A. An adolescent who has an S3 heart sound B. An older adult who has a heart rate of 48/min C. A young adult who has an irregular apical pulse D. A middle adult who has a murmur

C

A nurse is caring for a client who has a foot ulcer. Which of the following findings should the nurse identify as consistent w/ peripheral venous disease? A. Loss of hair on the lower leg B. Cool skin temp in the lower leg C. Palpable dorsalis pedal pulse D. Regular, even wound border

B

A nurse is caring for a client who is dying and is having periods of deep breathing alternating w/ periods of apnea. The nurse should identify this as which of the following types of breathing? A. Thoracic breathing B. Cheyne-stokes breathing C. Bradypnea D. Kussmaul's breathing

ACE

A nurse is caring for a client who is experiencing episodes of hyperventilation. Which of the following manifestations should the nurse expect? (select all that apply) A. Numbness and tingling of extremities B. Decreased chest wall expansion C. Lightheadedness D. Periods of apnea E. Chest pain

CDE

A nurse is caring for an older adult client who has an enlarged prostate and reports difficulty voiding. Which of the following actions should the nurse take? (Select all that apply) A. Perform a bladder scan within 60 min of voiding B. ensure that the client's intake is significantly greater than the output C. Inspect the client's suprapubic area for distention D. notify the provider if the bladder scan residual volume is greater than 100 ml E. ask the client if they are experiencing pain or a burning sensation when voiding

BCE

A nurse is inspecting and palpating the neck vessels of a client. Which of the following findings should the nurse report to the provider? (select all that apply) A. Visible pulsations observed in the carotid area on both sides of the neck. B. Full bounding pulse noted bilaterally in the carotid arteries upon palpation C. Distention of the jugular vein on one side of the neck. D. Flattening of the jugular veins when the client sits upright. E. The left carotid artery pulse is weak.

AB

A nurse is preparing to assess a client for the presence of a hernia. Which of the following areas should the nurse plan to inspect? (Select all that apply) A. Femoral area B. Inguinal area C. Rectal area D. Length of the shaft E. The circumference of the glans

ABCE

A nurse is preparing to conduct a cardiovascular assessment on a client. Which of the following actions should the nurse take? (select all that apply) A. Auscultate the apical pulse B. Ask the client if they experience shortness of breath C. Check the color of the client's skin D. Auscultate bowel motility E. Inspect the extremities for edema

A

A nurse is preparing to inspect a patient's abdomen with liver disease. Which of the following findings should the nurse expect? A. dilated veins B. stretch marks C. purple striae D. rash

D

A nurse is preparing to palpate a patient's abdomen. Which of the following findings should be expected? A. involuntary rigidity B. voluntary guarding C. boardlike D. nontender

3

A nurse performing an abdominal examination on a 37-year-old woman would document which finding as abnormal? 1. No aortic pulsations to light or deep palpation 2. Bowel sounds every 15 seconds in the lower quadrants 3. Bulges observed when coughing 4. Silver-white striae and a faint vascular network

2

A patient complains of pain in the calf when walking. Which question should the nurse ask for further data? 1. "Does your calf also swell when this pain occurs?" 2. "Does the pain go away when you stop walking?" 3. "Do you become short of breath when you're walking?" 4. "Do you feel dizzy when the pain occurs?"

1

A patient has a herpes lesion on her vulva. While examining her, the nurse should take which measures 1. Wear examination gloves while in contact with the genitalia. 2. Place the patient in an isolation room. 3. Wash the genitalia with alcohol or povidone-iodine (Betadine) before the examination. 4. Inspect the genitalia only; reschedule the patient for a full examination after the lesion has healed.

3

A patient reports a gnawing, burning pain in the midepigastric area that is aggravated by bending over or lying down. Which additional question does the nurse ask for the symptom analysis? 1. "Do you have a family history of this type of pain?" 2. "How long ago did you eat?" 3. "Do you have any symptoms such as nausea with this pain?" 4. "Have you noticed any yellow coloring in your eyes or on your skin?"

3

A patient reports having abdominal distention and having vomited several times yesterday and today. What question is appropriate for the nurse to ask in response to this information? 1. "Has there been a change in the amount of the distention?" 2. "Did you have heartburn before the vomiting?" 3. "What did the vomitus look like?" 4. "Have you noticed a change in the color of your urine or stools?"

2

A patient tells the nurse that her stools have bright red blood in them. The nurse suspects which problem? 1. Gallbladder disease 2. Hemorrhoids 3. Rectal polyps 4. Upper intestinal bleeding

barrel chest

COPD

1

Cervix softening is which sign 1. Goodell 2. Chadwick 3. Kernig 4. Hegar

3

During an examination the nurse palpates the Skene's glands. Which technique best describes this process? 1. Exerting pressure over the clitoris, slide the finger downward (posteriorly) toward the vaginal opening. 2. Palpate the fourchette and slide the finger forward (anteriorly) toward the vaginal opening. 3. Exert pressure on the anterior vaginal wall and slide the finger outward toward the vaginal opening. 4. Grasp the labia majora between the index finger and thumb and milk the labia outward.

1

Each patient has had consistent blood pressure readings during the last three clinic visits. Which patient has a blood pressure consistent with expected findings? 1. Mr. P, whose blood pressure has been 110/78. 2. Ms. J, whose blood pressure has been 140/90. 3. Mr. Q, whose blood pressure has been 130/76. 4. Ms. Y, whose blood pressure has been 120/80

Pyloric stenosis

Forceful projectile vomiting in a newborn is caused by

3

How does a nurse determine jugular vein pulsations? 1. Elevates the head of the bed about 90 degrees and looks for the jugular vein pulsation parallel to the sternocleidomastoid muscle as the head of the bed is slowly lowered 2. Looks for jugular vein pulsations at the jaw line as the patient turns from supine to a side-lying position 3. Elevates the head of the bed until the external jugular vein pulsation is seen above the clavicle 4. Positions the patient supine and asks him or her to cough; looks for jugular vein pulsations during the cough

apex of the heart

Identify the location where the apical pulse is auscultated

3

On auscultation of the heart, the nurse recognizes which expected finding? 1. A low-pitched blowing sound is heard over the abdominal aorta. 2. A high-pitched vibration is heard over the base of the heart. 3. The S1 heart sound is louder at the apex of the heart. 4. The S3 heart sound sounds like "Ken-tuck-y."

4

The nurse is interviewing a patient with a history of flank pain, fever, chills, and pain radiating to the groin. Which examination technique is most appropriate for this patient? 1. Percussion of the costovertebral angle 2. Deep palpation of the lower abdomen 3. Inspection of a urine specimen 4. Auscultation of the lower quadrants of the abdomen

4

The nurse is listening to the patient's heart at the left sternal border (LSB) at the second intraclavicular space (ICS). Which area is being auscultated? 1. Erb's point 2. Mitral area 3. Aortic area 4. Pulmonic area

1

The nurse palpates the abdomen to gather data about which organs located in the right upper quadrant? 1. Liver and gallbladder 2. Stomach and spleen 3. Uterus, if enlarged, and right ovary 4. Right ureter and ascending colon

3

The nurse recognizes which symptom as commonly associated with prostate enlargement? 1. Constipation 2. Rectal bleeding 3 Weak urinary stream 4. Penile discharge

3

To inspect the glans penis of the uncircumcised male, the nurse retracts the foreskin. After inspection she is unable to replace the foreskin over the glans. The nurse recognizes that this situation could potentially lead to which complication? 1. Decreased sperm production 2. Urinary tract infection 3. Tissue necrosis of the penis 4. Testicular cancer

First injection, 2 months, 6 months

What is the frequency of the Gardisil vaccine?

4

What is the most accurate technique for detecting a venous thrombosis at the bedside? 1. Dorsiflex the calf and note if the patient complains of pain. 2. Elevate one leg above the level of the heart to determine if the veins empty. 3. Palpate the pulses distal to the areas of the suspected thrombosis. 4. Measure the thigh circumference to detect an increase from the baseline.

1

What question does a nurse ask a patient with a history of pancreatitis who is complaining of abdominal pain? 1. "Which foods aggravate the pain?" 2. "Have you recently traveled outside the United States?" 3. "Have you noticed a change in your bowel habits?" 4. "How severe is the pain on a scale of 0 to 10?

2

When a patient complains of chest pain, which question is pertinent to ask to gain additional data? 1. "What were you doing when the pain first occurred?" 2. "What does the pain feel like?" 3. "Do you have episodes of shortness of breath?" 4. "Has anyone in your family ever had a similar pain?"

2

When assessing a patient's abdomen, the nurse uses assessment techniques in which order? 1. Inspection, palpation, and auscultation 2. Inspection, auscultation, and palpation 3. Auscultation, inspection, and palpation 4. Palpation, auscultation, and inspection

2

Where does a nurse palpate to assess the posterior tibial pulse? 1. Behind the knee in the popliteal fossa 2. The inner aspect of the ankle below and slightly behind the medial malleolus 3. Over the dorsum of the foot between the extension tendons of the first and second toes 4. The outer side of the ankle below and slightly behind the lateral malleolus

trachea and larynx

Which area of the chest can you hear bronchial crackles with pneumonia?

4

Which data collected from the history of a 32-year-old female patient should be followed with a symptom analysis? 1. Has never had a mammogram. 2. Experiences light to moderate bleeding during menstrual cycle. 3. Periods began at age 12; has never been pregnant. 4. Has pelvic pain and vaginal discharge.

2

Which finding does the nurse recognize as abnormal when examining a male patient? 1. Testes that are palpable and firm within the scrotal sac bilaterally 2. Discharge from the penis when the glans is compressed 3. Foreskin that lies loosely over the penis 4. Glans a lighter skin tone than the rest of the penis

1

Which finding is expected during a rectal exam? 1. The rectal wall is smooth. 2. Severe pain is reported when the finger is introduced through the anus. 3. Hard stool is present in the rectum. 4. The anus is surrounded by white flat lesions.

3

Which is an expected finding of an abdominal examination of an adult? 1. Abdomen has a rounded contour 2. Venus hum over the epigastrium 3. High-pitched gurgles every 5 to 15 seconds 4. Swishing sounds over the abdominal aorta

D

Which of the following findings is an indication of a pneumothorax? A. The client's ribs slope downward at a 45 degree angle B. The client is making a high-pitched crowing sound that can be heard in the neck area C. The diameter of the client's chest appears barrel-like w/ horizontal ribs D. The client is experiencing unequal movement of the posterior chest

D

Which of the following findings is an indication of a pneumothorax? A. the client's ribs slope downwards at a 45 degree angle B. the patient is making a high pitched crowing sound that can be heard in the neck area C. the diameter of the client's chest appears barrel like with horizontal ribs D. the client is experiencing unequal movement of the posterior chest

D

Which of the following findings should the nurse expect for hypoactive bowel sounds? A. bowel sounds absent after 5 mins B. bowel sounds auscultated every 5-30 seconds C. bowel sounds auscultated every 3 seconds D. bowel sounds heard after 2 mins

3

Which patient has the greatest risk for hypertension? 1. An Asian man who is 5 ft 5 in (165 cm) tall, weighs 125 lbs (56.7 kg), and complains of a headache over his forehead and eyes 2. A Cheyenne Indian woman who complains of a gnawing, burning epigastric pain radiating to her neck and jaw 3. An African American man who has type 2 diabetes mellitus, exercises once a month, and drinks two-to-three alcoholic drinks a night with dinner 4. A Caucasian woman who has a family history of heart disease and complains of pain in her chest when she takes a deep breath

4

Which technique does the nurse use to palpate a patient's abdomen? 1. Asks the patient to breath slowly though the mouth 2. Uses the heel of the hand to perform deep palpation 3. Uses the left hand to lift the rib cage away from the abdominal organs 4. Depresses the abdomen 1 cm for light palpation

3

While inspecting the legs of a male patient, the nurse notes that the skin is shiny and taut with little hair growth. Which additional data would the nurse find to indicate that this patient has peripheral arterial disease? 1. Pitting edema of one or both feet or legs 2. Increased circumference in the thighs bilaterally 3. Pale, cool legs with diminished-to-absent dorsalis pulses 4. Pain when legs are dependent that is relieved when legs are elevated

2

While taking the health history of a 23-year-old female patient, the nurse considers risk factors for STD. Which data from the patient suggest a need for patient education? 1. She has been in a monogamous sexual relationship for 2 years; she uses a condom to prevent pregnancy. 2. She has been sexually involved with one man for the last 2 weeks; she uses spermicidal gel to prevent pregnancy. 3. She has a Pap test each year and the results have been negative. 4. She uses oral contraceptives to prevent pregnancy.