N3320/Assessemtn: Exam 1 review

A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to enhance the sounds of the heart tones? Select all that apply. a) Eliminate distracting noises from the environment b) Readjust the ear pieces to ensure a snug fit c) Place the diaphragm against the client's clothing d) Tell the client to hold their breathe e) Angle the binurals towards the nose

• Eliminate distracting noises from the environment • Readjust the ear pieces to ensure a snug fit • Angle the binurals towards the nose

nursing assessment of a client with dementia is most likely to reveal what findings? (Select all that apply.) a) Attention preserved b) Clouding of consciousness c) Thoughts impoverished d) Sad affect or mood e) Global impairment of intellect

• Global impairment of intellect • Attention preserved • Thoughts impoverished

Choice Multiple question - Select all answer choices that apply. The nurse is preparing to conduct a mental status examination with a patient. Which areas will the nurse include when assessing the patient's APPEARANCE & BEAVIOR?(Select all that apply.) a) Facial expressions b) Posture c) Orientation d) Articulation of words e) Level of consciousness

• Level of consciousness • Posture • Facial expressions

Choice Multiple question - Select all answer choices that apply. Which is an example of percussion? Select all that apply. a) The nurse notes dullness over the patient's liver. b) The nurse notes rustling over the patient's thorax. c) The nurse notes gurgling throughout the patient's abdomen. d) The nurse notes resonance over the patient's thorax. e) The nurse notes tympany over the patient's lower abdomen.

• The nurse notes resonance over the patient's thorax. • The nurse notes tympany over the patient's lower abdomen. • The nurse notes dullness over the patient's liver.

Geriatric Depression Scale

-depression often mimics signs and symptoms of dementia -used if depression is suspected in the older client. Read the questions to the client if the client cannot read.

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV.

1. intact, firm skin with redness 2. ulceration involving the dermis 3. full-thickness skin loss 4. necrosis with damage to underlying muscle

client is unresponsive even to painful stimuli

Coma

If the client opens eyes, answers the question, and falls back to sleep

Lethargic

Opens eyes to a loud voice and answers with confusion

Obtunded

client awakens to a vigorous shake or painful stimuli

Stupor

When inspecting structures such as the jugular venous pulse, what would be the best lighting to use? a) Diffuse lighting b) Tangential lighting (optimal for inspecting structures such as the jugular venous pulse, the thyroid gland, and the apical impulse of the heart.) c) Back lighting d) Direct lighting

Tangential lighting

Which of the following statements most accurately provides the underlying rationale for the use of auscultation and percussion as assessment techniques? a) Pitch and duration of sound depend on each other and allow for conclusions regarding client health. b) Percussion and auscultation findings are more objective than inspection and palpation findings. c) High-intensity sounds indicate compromised tissue integrity, lack of tissue density, or both. d) The nature and elasticity of tissue and body structures influence sound.

The nature and elasticity of tissue and body structures influence sound.

A nurse is taking a rectal (97.4-100.3 F) temperature on an unconscious patient. What reading would reflect temperature within the normal range? a) 99°F b) 100°F c) 98°F d) 97°F

a) 99 F

A 23-year-old ticket agent is brought in by her husband because he is concerned about her recent behavior. He states that for the last 2 weeks she has been completely out of control. She hasn't showered in days, stays awake most of the night cleaning their apartment, and has run up more than $5,000 on their credit cards. While he is talking the client interrupts him frequently, declares this is all untrue, and says she has never been so happy and fulfilled in her whole life. She speaks very quickly, changing the subject often. After a longer than normal interview, the nurse learns that the client has had no recent illnesses or injuries. Her past medical history is unremarkable. Both her parents are healthy, but the husband has heard rumours about an aunt with similar symptoms. The client and her husband have no children. She smokes one pack of cigarettes a day (although she has been chain smoking in the last 2 weeks), drinks four to six times a week, and smokes marijuana occasionally. She is very loud and outspoken. Physical examination findings are unremarkable. Which mood disorder does she most likely have? a) Manic episode b) Dysthymic disorder c) Schizophrenia d) Major depressive episode

a) Manic episode -consists of a persistently elevated mood for at least 1 week with symptoms such as inflated self-esteem, decreased need for sleep, pressured speech, racing thoughts, and involvement in high-risk activities (e.g., drug use, spending sprees, indiscriminate sexual activity)

The nurse is providing care for an 83-year-old woman with a history of hypotension who has been admitted to hospital following a fall. The nurse recognizes the need to assess for orthostatic hypotension. How should the nurse perform this assessment? a) Measure the client's heart rate and blood pressure while supine then within 3 minutes of standing. b) Estimate systolic blood pressure by palpation while the client is lying, then measure blood pressure when the client is standing. c) Measure the client's blood pressure and heart rate while she is standing then after 10 minutes of lying supine. d) Alternate the scheduled blood pressure measurements between the standing and lying positions.

a) Measure the client's HR & BP while SUPINE then w/i 3 mins. of STANDING

A client has a 7-mm lesion with IRREGULAR borders and color VARIATION that has grown over the last several weeks. The nurse knows that this lesion could possibly be what type of cancer? a) Melanoma b) Nevus ( another word for a mole) c) Angioma ( tumor consisting of blood vessels) d) Dermatoma (circumscribed thickening of the skin)

a) Melanoma

Choice Multiple question - Select all answer choices that apply. What factors contribute to the patient's individual makeup? (Select all that apply.) a) Nutrition b) Genetic composition c) Cultural norms d) Geographic location e) Ethnicity of patient

a) Nutrition b) Genetic composition c) Cultural norms d) Geographic location e) Ethnicity of patient

A young man comes to the clinic with an extremely pruritic rash over his knees and elbows, which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. Examination reveals scabbing and crusting with some silvery scales. The nurse also notices small "pits" in the nails. What would account for these findings? a) Psoriasis b) Tinea infection c) Pityriasis rosea d) Eczema

a) Psoriasis

A nurse assesses a client for past history of NAILS PROBLEMS. The nurse should ask questions about which of these conditions? a) Psoriasis, fungal infections, trauma b) Alopecia, dermatitis, chemotherapy c) Vitiligo, hirsutism, vitamin deficiency d) Eczema, melanoma, herpes zoster

a) Psoriasis, fungal infections, trauma

The nurse is providing discharge teaching to a client who underwent a hip fracture repair. The nurse should instruct the client to report which findings that indicate surgical site infection? (Select all that apply.) a) Redness over hip area b) Pain at incision site c) Tenderness at incision site d) Diffuse hives over body e) Surgical site warm to touch

a) Redness over hip area b) Pain at incision site c) Tenderness @ incision site e) Surgical site warm to touch

Upon examination of a client, the nurse finds a circumscribed elevated, palpable mass containing serous fluid. How should the nurse properly document this finding? a) Vesicle ( containing serous fluid) b) Wheal (with transient borders and no fluid cavity) c) Cyst (encapsulated fluid-filled or semisolid mass located in the subcutaneous tissue or dermis) d) Papule (elevated, palpable, solid mass with a circumscribed border)

a) Vesicle

An adult client visits a clinic and tells the nurse that she suspects she has urinary tract infection. To detect tenderness over the client's kidneys, the nurse should instruct the client that he or she will be performing a) blunt percussion. (detect tenderness over organs (e.g., KIDNEYS) by placing one hand flat on the body surface and using the fist of the other hand to strike the back of the hand flat on the body surface) b) moderate palpation. (Depress the skin surface 1 to 2 cm. with your dominant hand, and use a circular motion to feel for easily palpable body organs and masses) c) indirect percussion. (most commonly used method of percussion d) deep palpation. (allows you to feel very deep organs or structures that are covered by thick muscle)

a) blunt percussion. -.

A patient with a ZOSTERIFORM RASH has a rash that a) is distributed along a dermatome b) has lesions distributed over a large body area c) appears with a single lesion in close proximity to a larger lesion, as if "orbiting" the larger lesion d) is distributed equally on both sides of the body

a) is distributed along a dermatome

The nurse is gathering equipment to perform a skin assessment on an elderly client. What type of equipment will be needed? Select all that apply. a) Magnifying glass b) Adequate light source c) Tape measure d) Shoe covers e) Examination gown f) Eye protection

a) magnifying glass b) Adequate light source c) Tape measure e) Examination gown

In interviewing a client about his heart rate, the nurse asks whether he has noticed any ALTERATION TO HIS HEARTBEAT. The client responds that he sometimes FELLS HIS HEART RACE even when he has not been exerting himself physically. This alteration is known as which of the following? a) Palpitation (FELT by the client) b) Dyspnea c) Pulse pressure d) Apical beats

a) palpitation

A mother brings her 4-year-old daughter to the clinic and reports that the child has developed a rash that she is constantly scratching on her abdomen. On examination, the nurse finds that the rash is SERPIGINOUS. The nurse would know that the rash is most probably caused by a) scabies b) allergies c) lice d) ticks

a) scabies

The nurse is admitting a patient to the mental health unit with a diagnosis of attempted suicide. Which is the best question for the nurse to ask first? a) Do you have any thoughts of wanting to harm or kill yourself? b) On a sense of 0 to 10, with 10 being most intense, how suicidal do you feel now? c) Do you have a sense of hope for the future? d) Do you hear voices that tell you what to do?

a). Do you have any thoughts of wanting to harm or kill yourself?

A nurse assesses the pulse rate of an athletic client during a routine checkup. The nurse should anticipate the pulse rate to be in what range of beats per minute? a) 85-100 b) 45-60 c) 65-80 d) 105-120

b) 45-60

A female client is admitted to the health care facility due to reports of decreased appetite, LOSS OF SLEEP, FEELINGS of being UNSAFE in her own home, and INABILITY TO CONCENTRATE. She appears pale; her hair is disheveled, she is not wearing makeup, and she will not make eye contact (POOR EYE CONTACT). Based on this data, which nursing diagnosis can the nurse confirm? a) Risk for self-directed violence b) Anxiety c) Impaired verbal communication d) Imbalanced nutrition: less than body requirements

b) Anxiety

A nurse observes the presence of hirsuitism (facial hair) on a female client (due to an imbalance of adrenal hormones). The nurse should perform further assessment on this client for findings associated with which disease process? a) Basal cell carcinoma (causes lesions but not facial hairs) b) Cushing's disease c) Iron deficiency anemia (may cause loss of hair but not excessive hair) d) Lupus erythematosus (causes patchy skin loss but does not cause excessive facial hair)

b) Cushing's disease

The apocrine glands are stimulated by what? a) Temperature b) Emotional stress c) Physical stress d) Overhydration

b) Emotional stress

When observing a patient diagnosed with mania, the nurse observes his mood to be elated. Another term for this type of mood includes which of the following? a) Labile (changible) b) Euphoric (elated) c) Dysphoric (depressed, disquieted, restless) d) Euthymic (normal)

b) Euphoric

The nurse documents findings from the client's Mini-Mental State Examination. The following information will be documented as a result of this test. a) Mood, feelings, expressions, and perceptions. b) Orientation, memory, and cognitive function. c) Appropriateness of dress, grooming, and eye contact. d) Energy level, satisfaction, and social participation.

b) Orientation, memory, and cognitive function.

Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the nurse practitioner notes the area to be a REDDISH-PINK lesion covered with SILVERY SCALES. What would the nurse practitioner chart? a) Contact dermatitis ( inflammatory response to an antigen) b) Psoriasis c) Seborrhea (an inflammatory skin disorder) d) Eczema (atopic dermatitis, pink macular or papular lesions, can occur anywhere on the body)

b) Psoriasis

A nurse in a dermatology clinic cares for an adolescent patient with multiple purulent, FLUID-FILLED lesion on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this patient? a) Cystic acne b) Pustular acne c) Bullous impetigo d) Chickenpox

b) Pustular acne

When assessing level of consciousness, what should a nurse do if a client does not respond appropriately to a verbal stimulus? a) Gently shake the client and observe the response b) Repeat the command louder and in a lower tone of voice c) Vigorously shake the client and speak loudly d) Apply a painful stimulus and observe the client movements

b) Repeat the command louder and in a lower tone of voice

For which assessment would the nurse plan to use direct percussion? a) Liver (indirect percussion) b) Sinuses (by tapping the fingers directly on the patient's skin) c) Gallbladder (indirect percussion) d) Kidneys (indirect percussion)

b) Sinuses

The nurse is conducting a skin assessment on a client who suffered a burn injury. The client's wound exhibits rapid capillary refill, is moist, red, and painful. What depth of burn should the nurse document? a) Full thickness b) Superficial c) Superficial-dermal d) Dermal

b) Superficial exhibits brisk bleeding, is painful, has rapid capillary refill, and is moist and red.

While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had a) steroid therapy. b) a recent illness. c) chemotherapy. d) radiation.

b) a recent illness.

When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.) a) pink color b) asymmetry c) diameter great than 6 cm d) notched border

b) asymetry c) diameter greater than 6cm d) notched border

The nurse needs to assess the visual, perceptual, and constructional ability of a client. Which of the following assessments should the nurse use? a) Ask the client today's date b) Have the client draw the face of a clock c) Ask the client to pick up a pencil with the left hand, move it to the right, and then hand it to her (concentration) d) Perform the SLUMS exam (used for cognitive function)

b) have the client draw the face of a clock -way to assess visual, perceptual, and constructional ability

Choice Multiple question - Select all answer choices that apply. A nurse is assessing a client's pain level while taking his blood pressure. Which of the following are signs of pain that the nurse should look for in the assessment? Select all that apply. a) Lack of position shifting b) Holding a shoulder c) Shallow, rapid breathing d) Relaxed posture e) Alert facial expression f) Grimacing

b) holding a shoulder c) shallow, rapid breathing c) grimacing

When assessing the client's ability to make sound judgments, what question should the nurse ask? a) "How many dimes are in one dollar?" b) "Can you keep track of your finances on an ongoing basis?" c) "How do you plan to pay rent if you lose your job?" d) "Do you eat breakfast?"

c) "How do you plan to pay rent if you lose your job?"

Which piece of equipment should a nurse use to perform a test for stereognosis (ability to recognize objects by touch) a) Tuning fork b) Tongue depressor c) Coin or key d) Reflex hammer?

c) Coin or key

A school age child is brought to the pediatric clinic by her mother, who tells the nurse practitioner that the child has a sore on her leg that "just keeps getting bigger." On examination, the nurse practitioner notes an area of vesicles and bulla, some of which have ruptured and are oozing serous fluid. A honey-colored crust covers the area. What would the nurse practitioner tell the mother the lesion is? a) Rubella b) Varicella c) Impetigo d) Scabies

c) Impetigo -highly contagious superficial skin infection commonly caused by Staphylococcus aureus or Group A beta-hemolytic streptococci. -characterized by vesicles or bullae that eventually rupture and ooze serous fluid that forms the classic honey-colored crust

Which of the following statements is true of the role of inspection in the physical examination? a) It should be performed after auscultation but before palpation and percussion. b) To maximize findings, local inspection should be conducted prior to general inspection. c) It is often the source of the most physical signs. d) The acuity of the client will determine whether general or local inspection should be implemented in the examination.

c) It is often the source of the most physical signs.

A 4-year-old child presents to the health care clinic with CIRCULAR LESION. Which of the following conditions should the nurse most suspect in this client, based on the configuration of the lesions? a) Tinea versicolor ( confluent configuration, smaller lesions run together to form a larger lesion) b) Multiple nevi (discrete configuration, the lesions are individual and distinct) c) Tinea corporis (annular configuration, CIRCULAR LESIONS) d) Herpes simplex ( a clustered configuration, lesions are grouped together)

c) Tinea corporis

Choice Multiple question - Select all answer choices that apply. The nurse is having difficulty auscultating Korotkoff sounds. The nurse should (Select all that apply.) a) keep the cuff inflated for 30 seconds before auscultating b) request an ECG c) consider shock d) be certain there is full skin contact with the bell e) reposition the stethoscope

c) consider shock d) be certain there is full skin contact with the bell e) reposition the stethoscope

The nurse is caring for an adult client who tells the nurse "For weeks now, I've been so tired. I just can't get to sleep at night because of all the noise in my neighborhood." An actual nursing diagnosis for this client is a) sleep deprivation related to noisy neighborhood and inability to sleep. b) chronic fatigue syndrome related to excessive levels of noise in neighborhood. c) fatigue related to excessive noise levels as manifested by the client's statements of chronic fatigue. d) readiness for enhanced sleep related to control of noise level in the home.

c) fatigue related to excessive noise levels as manifested by the client's statements of chronic fatigue.

During the health-history interview, which of the following components of cognitive function can the nurse QUICKLY ASSESS? a) Abstract thinking and perceptions b) Calculation and language c) Memory and attention d) Judgment and behaviour

c) memory & attention

The nurse aide reports to the nurse that an older adult client has abnormal vital signs. What is important to remember in this type of situation? a) At client's age, abnormal vital signs are an indication of something serious b) Normal readings get higher with advanced age c) Normal readings vary according to age d) Normal readings get lower with advanced age

c) normal readings vary according to age

The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that a) African Americans are the least susceptible to skin cancers. b) melanoma skin cancers are the most common type of cancers. c) squamous cell carcinomas are most common on body sites with heavy sun exposure. d) usually there are precursor lesions for basal cell carcinomas.

c) squamous cell carcinomas are most common on body sites with heavy sun exposure.

A teenage client with a spinal cord injury from a diving accident is being discharged home with a caregiver. The nurse is providing discharge teaching to the client, family members, and caregiver. The nurse would include what risk factors for SOCIAL ISOLATION? a) Being unable to independently perform ADLs b) Losing appetite c) Sleeping too much d) Losing interest in sex

c). Sleeping too much

Wernicke's aphasia

client can speak effortlessly and fluently, but his words often make no sense. Words can be malformed or completely invented

An elderly client is admitted with new onset of left-sided weakness, slurred speech, and hypotension. The client's husband states that she has stopped taking her blood pressure medications for the past week because they were making her feel dizzy and lacking in energy. Which nursing diagnosis can be confirmed from this data? a) Hypertension b) Risk for activity intolerance c) Acute confusion d) Dressing self-care deficit

d) Dressing self-care deficit

When counting the patient's pulse, what beats may be difficult to detect peripherally? a) Split beats b) Late beats c) Irregular beats d) Early beats

d) Early beats

A nurse has been asked to complete a mental status examination of a psychiatric-mental health client. Which of the following is included in this assessment? a) Questions regarding past behaviors b) Evaluation of medication compliance c) A review of systems d) Evaluation of insight and judgment

d) Evaluation of insight and judgment

A mother brings her child to the health care clinic and reports that her son has a four-day history of intense itching to his legs. On inspection of the child's legs, the nurse notes a honey-colored exudate coming from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition? a) Psoriasis (does not produce exudate & is not a vesicular rash) b) Viral Exanthum (a macular or papular rash that is present along with a viral infection) c) Herpes zoster (can produce exudate but it is usually confined to one area of the body) d) Impetigo (Honey colored exudate in a vesicular rash)

d) Impetigo

Hair follicles, sebaceous glands, and sweat glands originate from the a) eccrine glands. b) keratinized tissue. c) epidermis. d) dermis.

d) dermis -the origin of sebaceous glands, sweat glands, and hair follicles -well-vascularized, connective tissue layer containing collagen and elastic fibers, nerve endings, and lymph vessels

The nurse documents findings from the client's Mini-Mental State Examination. The following information will be documented as a result of this test. -Cognitive abilities include orientation, concentration, recent and remote memory, abstract reasoning, judgment, visual perception, and constructional ability. a) Energy level, satisfaction, and social participation. b) Mood, feelings, expressions, and perceptions. c) Appropriateness of dress, grooming, and eye contact. d) Orientation, memory, and cognitive function.

d) orientation, memory, and cognitive function

The patient states, "I don't know why God as abandoned me; I am a good person." The nurse suspects the patient is at risk for: a) Psychosis (occurs when the patient has difficulty distinguishing reality from internal perceptions) b) Confabulation ( refers to making up answer to cover for not knowing) c) Delusions (false beliefs the person holds despite lack of supportive evidence) d) Suicide (patient who does not experience a sense of hope for the future may be at risk)

d) suicide

To assess an adult client's SKIN TUGOR, the nurse should a) use the dorsal surfaces of the hands on the client's arms. b) press down on the skin of the feet. c) use the fingerpads to palpate the skin at the sternum. d) use two fingers to pinch the skin under the clavicle.

d) use two fingers to pinch the skin under the clavicle.