307 Final Review

The interview is essentially a contract formed between the nurse and the patient. Which statement is descriptive of this contract?

The contract consists of spoken and unspoken rules for behavior. During the interview, a contract is formed between the nurse and the patient. The contract consists of spoken and unspoken rules for behavior. The contract sets the tone for future interactions with the patient as an active, not passive, partner with the mutual goal of optimal health. The contract does not specify the nature of future interactions between the patient and the health care system.

When does the general survey begin?

The moment you see the patient

A patient has had arthritic pain in her hips for several years since a hip fracture. She is able to move around in her room and has not offered any complaints so far this morning. However, when asked, she states that her pain is "bad this morning" and rates it at an 8 on a 1-to-10 scale. What is the likely reason for this?

The patient has experienced chronic pain for years and has adapted to it.

What is the priority information to obtain when interviewing a patient admitted to the emergency department under the influence of illicit drugs?

Time, name, and amount of drug last taken The top priority when interviewing a patient under the influence of illicit drugs is to find out the time, the name, and the amount of each drug that was taken. This information helps to assess any withdrawal patterns.

Why do you include a review of systems as a part of an individual's health history? (Select all that apply.)

To evaluate the past and present health state of each body system To provide another opportunity to gather data related to the presenting problem To evaluate health promotion practices

For which purpose would you develop a genogram as part of your documentation on a new patient?

To provide a concise display of family history

In assessing a patient, you use body mass index (BMI) as a practical indicator of obesity or undernutrition in your patient. Which formula is used to calculate this value?

Weight in pounds divided by height in inches squared times 703

When is a complete database obtained?

When a baseline measure of overall health status is needed. The complete database is obtained when a baseline measure of overall health status is needed. It includes a complete history and a full physical examination. The complete database is often collected in primary care settings and is an opportunity to build and strengthen your relationship with the patient.

When testing the deep tendon reflexes (DTRs) of a 74-year-old male, you find hyperreflexia. What does this finding tell you about the underlying problem? a. An upper motor neuron lesion exists. b. Sensory afferents are interrupted. c. Motor efferents are destroyed. d. Anterior horn cells are impaired.

a. An upper motor neuron lesion exists. Hyperreflexia is the exaggerated reflex seen when the monosynaptic reflex arc is released from the usually inhibiting influence of higher cortical levels. This occurs with upper motor neuron lesions. Sensory afferents, motor efferents, and anterior horn cells are part of the lower motor neuron.

Mr. Sanchez is a 62-year-old patient who presents for a complete neurologic examination. How will you test for the transmission of pain sensation in the spinothalamic tract? a. Ask him to identify when the skin is being touched with the sharp or dull end of a pin/broken tongue blade. b. Ask him to rate the degree of pain when the skin is pinched. c. Ask him to differentiate between being touched with the sharp end of a pin and the sharp end of a broken tongue blade. d. Touch the skin with gradually decreasing pressure and have him identify when the skin is no longer being touched by the pin.

a. Ask him to identify when the skin is being touched with the sharp or dull end of a pin/broken tongue blade. The spinothalamic tract transmits the sensations of pain, temperature, and crude or light touch. To test for the transmission of pain in the spinothalamic tract, the patient is asked to identify when the skin is being touched with the sharp or dull end of a pin/broken tongue blade.

Ms. Parsons is a 43-year-old patient with multiple sclerosis. On examination, which findings would you classify as clinical manifestations of the disease? (Select all that apply.) a. Babinski sign b. Flaccidity c. Athetosis d. Diplopia e. Impaired balance f. Weakness

a. Babinski sign d. Diplopia e. Impaired balance f. Weakness

Your patient can understand language and knows what he or she wants to say, but can produce only a garbled sound. Which area of the brain do you conclude is damaged? a. Broca's area b. Wernicke's area c. Basal ganglion d. Postcentral gyrus

a. Broca's area Broca's area in the frontal lobe is responsible for mediating motor speech. When it is damaged, the patient can understand language, knows what he or she wants to say, but can produce only garbled sound. Wernicke's area in the temporal lobe is associated with language comprehension. The basal ganglia are additional bands of gray matter buried deep within the two cerebral hemispheres that form the subcortical associated motor system (the extrapyramidal system). They control automatic associated movements of the body (e.g., the arm swing alternating with the legs during walking). The postcentral gyrus of the parietal lobe is the primary center for sensation.

A mother reports her 18-month-old child had a seizure. What are some of the questions you should ask? (Select all that apply.) a. Did the child lose consciousness? b. Has the child had a recent middle ear infection? c. Were there any noticeable warning signs before the seizure began? d. Did the child have a high fever? e. Has the child had any problems with balance? f. What did the child do after the seizure?

a. Did the child lose consciousness? c. Were there any noticeable warning signs before the seizure began? d. Did the child have a high fever? f. What did the child do after the seizure?

When you ask your patient to "open wide and stick out your tongue," you note that her tongue deviates to the right. A lesion of which cranial nerve would cause this finding? a. Hypoglossal b. Abducens c. Glossopharyngeal d. Trigeminal

a. Hypoglossal The tongue deviates to one side as a result of lesions of the hypoglossal nerve. When this occurs, deviation is toward the paralyzed side. The abducens nerve is responsible for lateral movement of the eye. The motor component of the glossopharyngeal nerve mediates phonation and swallowing. The motor component of the trigeminal nerve innervates the muscles of mastication.

Which are characteristics of lower motor neuron lesions? (Select all that apply.) a. Loss of muscle tone b. Muscle atrophy c. Hyperreflexia d. Fasciculations e. Positive Babinski sign f. Weakened hand grips

a. Loss of muscle tone b. Muscle atrophy d. Fasciculations

How do you test a patient's position sense? a. Move the patient's finger or big toe up or down and ask the patient which way it is moved. b. Touch the patient's skin quickly and ask the patient to touch the same location. c. Strike a tuning fork and place it on the patient's great toe; ask the patient to say when the vibration starts and stops. d. Apply two points of an opened paper clip to the patient's skin at decreasing distances apart; ask the patient to say when only one point is felt.

a. Move the patient's finger or big toe up or down and ask the patient which way it is moved. Position sense is the ability to perceive passive movements of the extremities. It is tested by moving a patient's finger or big toe up and down and asking the patient to tell you which way it moved without looking. When performing this test, hold the digit to be moved by its sides and vary the way you move it. Normally movement of a few millimeters can be detected.

Which signs are suggestive of a hemorrhagic stroke? (Select all that apply.) a. Nausea and vomiting b. Arm drift c. Focal seizures d. Loss of balance e. Sudden severe headache f. Unilateral facial droop

a. Nausea and vomiting c. Focal seizures e. Sudden severe headache Nausea and vomiting, focal seizures, and sudden, severe headache are signs of hemorrhagic stroke, as is sudden loss of consciousness. Arm drift, loss of balance, and unilateral facial droop along with weakness or paralysis on one side of the body, difficulty with speech, confusion, and clouding of vision are signs of ischemic stroke.

Which pathways in the spinal cord carry sensory impulses to the brain? a. Spinothalamic tract and posterior columns b. Corticospinal and cerebellar tracts c. Pyramidal and extrapyramidal tracts d. Anterior and posterior columns

a. Spinothalamic tract and posterior columns The spinothalamic (anterolateral) tract and posterior (dorsal) columns of the spinal cord carry sensory impulses to the brain. Sensation begins at the sensory receptors found throughout the body, which monitor conscious sensation, internal organ functions, body position, and reflexes. It then travels in the afferent fibers in a peripheral nerve, through the posterior (dorsal) root, and into the spinal cord, where it travels in either the spinothalamic (anterolateral) tract or the posterior (dorsal) columns.

The presence of normal strength on both sides of the temporal and masseter muscles during teeth clenching with inability of the examiner to separate the jaws by pushing down on the chin allows the examiner to infer proper functioning of which cranial nerve? a. V b. VII c. IX d. X

a. V The presence of normal strength on both sides of the temporal and masseter muscles during teeth clenching with inability of the examiner to separate the jaws by pushing down on the chin allows proper function of cranial nerve V to be inferred. function of cranial nerve VII is indicated by facial movements. Proper function of cranial nerves IX and X is inferred by the presence of swallowing, the gag reflex, and coordinated sucking and swallowing.

When assessing a deep tendon reflex on a 21-year-old man, you obtain the expected response. What score should you document? a. 1+ b. 2+ c. 3+ d. 4+

b. 2+ The score that should be documented for the expected deep tendon reflex response of a 21-year-old man is 2+. A 3+ is brisker than average, which may indicate disease. A 4+ indicates very brisk, hyperactive with clonus, indicative of disease. A 1+ indicates diminished, low normal.

A patient presents with a history that suggests he or she may have meningitis. For which reflexes would you check? (Select all that apply.) a. Snout b. Brudzinski c. Gordon d. Kernig e. Oppenheim

b. Brudzinski d. Kernig Brudzinski and Kernig reflexes indicate meningeal irritation. The Brudzinski reflex consists of flexion of the hips and knees when the neck is flexed. The Kernig reflex consists of pain in the lower back and resistance to straightening the leg when it is flexed at the knee or, alternatively, resistance to raising the leg straight when lying flat in the supine position with the thigh flexed on the abdomen. The snout reflex is a sign of frontal release. The Gordon and Oppenheim reflexes occur with corticospinal disease such as trauma or stroke.

You are examining an unconscious patient who sustained head trauma in a motor vehicle accident. The patient's elbow, wrist, and fingers are flexed and the arm is tight against the thorax. The lower extremities are extended and internally rotated and the feet are in plantar flexion. How do you describe this posture in your documentation? a. Opisthotonos b. Decorticate rigidity c. Flaccid quadriplegia d. Decerebrate rigidity

b. Decorticate rigidity decorticate rigidity is the posture in which the elbow, wrist, and fingers are flexed and the arm is tight against the thorax, with the lower extremities extended and internally rotated and the feet in plantar flexion.

Which is a common cause of glove-and-stocking anesthesia? a. Meningioma b. Diabetes mellitus c. Multiple sclerosis d. Vascular occlusion

b. Diabetes mellitus Diabetes mellitus is a common cause of glove-and-stocking anesthesia, which is a loss of all types of sensation in the extremities in a glove-and-stocking pattern (i.e., the loss is most severe distally, in the hands and feet, and gradually improves as the stimulus moves proximally). With meningioma and multiple sclerosis, there is a loss of pain and temperature sensation on the contralateral side starting one to two segments below the level of the lesion as well as loss of vibration and position discrimination on the ipsilateral side below the level of the lesion. Vascular occlusion results in a loss of all sensation in the distribution of the involved nerve.

A patient has a recent history of injury to Broca's area in the frontal lobe. Which problem would you likely find on examination? a. Receptive aphasia b. Expressive aphasia c. Primary aphasia d. Secondary aphasia

b. Expressive aphasia An individual who sustains an injury to Broca's area in the frontal lobe will experience expressive aphasia. Broca's area mediates motor speech; when it is injured, the person cannot talk. The person can understand language and knows what he or she wants to say, but can produce only a garbled sound. Receptive aphasia is a condition that results after sustaining an injury to Wernicke's area. The patient may hear sound, but is unable to make any meaning out of it. Aphasia is not rated as primary or secondary, but rather receptive or expressive.

Mr. McKnight is a 37-year-old patient who presents to your office with a complaint of an unsteady gait. When you are testing the quadriceps reflex, what is the expected response? a. Flexion of the knee b. Extension of the lower leg c. Plantar flexion of the foot d. Relaxation of the quadriceps

b. Extension of the lower leg Extension of the lower leg is an expected response when you are testing the quadriceps reflex. The knee is flexed prior to testing, and the stimulus causes the lower leg and knee to extend. The foot plantar flexes as a result of testing the Achilles tendon. Contraction, not relaxation, of the quadriceps occurs when testing the quadriceps reflex.

Which is a manifestation of dysfunction of cranial nerve III? a. Unilateral loss of smell b. Eyelid ptosis c. Asymmetric jaw movement d. Decreased visual field

b. Eyelid ptosis Cranial nerve III is the oculomotor nerve, the motor portion of which is responsible for most extraocular muscle (EOM) movement and opening of the eyelids. Thus ptosis of the eyelid is a sign of cranial nerve III impairment. Unilateral loss of smell, or neurogenic anosmia, occurs with impairment of cranial nerve I. Asymmetric jaw movement occurs with impairment of cranial nerve V and decreased visual field with impairment of cranial nerve II.

Mr. Shea is a 50-year-old patient with chronic obstructive pulmonary disease and a history of smoking two packs per day. On examination, which alteration related to cranial nerve function should you expect? a. Unilateral anosmia b. Loss of smell bilaterally c. Decreased sensation of touch bilaterally d. No pupillary consensual response bilaterally

b. Loss of smell bilaterally On examination, you would expect to find a loss of smell. Anosmia, which is the technical term, occurs with tobacco smoking, allergic rhinitis, and cocaine use.

Which is a test of the motor function of the trigeminal nerve? a. Press the patient's puffed cheeks in and observe for equal escape of air from both sides. b. Palpate the temporal and masseter muscles as the patient clenches the teeth. c. Ask the patient to frown and then smile. d. Have the patient keep the eyes closed tightly while you try to open them.

b. Palpate the temporal and masseter muscles as the patient clenches the teeth. To assess the motor function of the trigeminal nerve (cranial nerve V), the temporal and masseter muscles are palpated bilaterally while the patient clenches the teeth. The muscles should feel equally strong on both sides. Next, the examiner should try to separate the jaws by pushing down on the chin; normally the jaws cannot be opened. All other actions test the motor component of the facial nerve.

Mr. Walker is a 45-year-old diabetic patient. During his health history, he reports experiencing some numbness and tingling in the extremities. Which term should you use in documenting this information? a. Paresis b. Paresthesia c. Paramnesia d. Paraphasia

b. Paresthesia Numbness and tingling in the extremities would be documented as paresthesia.

What type of testing is specifically associated with the assessment of cerebellar function? a. Stereognosis b. Rapid alternating movements c. Two-point discrimination d. Superficial pain and touch

b. Rapid alternating movements Rapid, alternating movements is a procedure that is specifically associated with testing cerebellar function. Normally the person can pat the knees with both hands, turn the hands over, and pat the knees with the backs of the hands in a quick, rhythmic pace. Lack of coordination is demonstrated by a slow, clumsy, sloppy performance and occurs with cerebellar disease. Stereognosis and two-point discrimination are tests of the dorsal column tract, and testing of superficial pain and touch assesses the spinothalamic tract.

Ms. Wilson is a 46-year-old patient who presents for a neurologic examination. During the examination, you note clonus when testing deep tendon reflexes. What did you see? a. Involuntary contraction of opposing muscle groups b. Set of short, jerking contractions of the same muscle c. Slow, twisting, writhing, continuous movement d. Contraction of a muscle only after the tendon is hit a second time

b. Set of short, jerking contractions of the same muscle Clonus is characterized by a set of short, jerking contractions of the same muscle. Tremor is an involuntary contraction of opposing muscle groups, which results in rhythmic, back-and-forth movement of one or more joints, and may occur at rest or with voluntary movement. All tremors disappear while sleeping. Tremors may be slow (3 to 6 per second) or rapid (10 to 20 per second). Athetosis is a slow, twisting, writhing, continuous movement, resembling a snake or worm. It involves the distal part of the limb more than the proximal part, occurs with cerebral palsy, disappears with sleep, and is characterized by "athetoid" hand—some fingers are flexed and some are extended. Contraction of the muscle appears after hitting the tendon the first time, not the second time, as each strike is a single blow.

Use of the Glasgow Coma Scale (GCS) provides the health care provider with which type of information? a. The site of brain trauma b. The level of consciousness c. The degree of neurologic dysfunction d. The differentiation between upper and lower motor neuron dysfunction

b. The level of consciousness Use of the Glasgow Coma Scale (GCS) provides the health care provider with a measure of the level of consciousness. The GCS assesses the functional state of the brain as a whole, not the function of any part in particular. It does not identify the site of brain trauma or the degree of neurologic dysfunction, nor does it differentiate between upper motor neuron dysfunction and lower motor neuron dysfunction.

For what purpose might you use the NIH Stroke Scale with a patient? a. To grade a transient ischemic attack. b. To predict a stroke patient's outcome. c. To calculate a patient's stroke risk. d. To distinguish hemorrhagic from ischemic stroke.

b. To predict a stroke patient's outcome. The National Institutes of Health (NIH) Stroke Scale provides a quantitative measure of stroke-related neurologic deficit. It is widely used as a clinical assessment tool to evaluate acuity and predict patient outcome.

What is meant by using reinforcement when testing a patient's deep tendon reflexes (DTRs)? a. Stimulating the tendon a second time to reinforce the initial stimulus. b. Striking the tendon twice in 1 second so that the second stimulus reinforces the first. c. Having the individual perform an isometric exercise in a muscle group a distance from the one being tested to reinforce the response. d. Testing the same muscle groups in the right and left extremities consecutively so the initial stimulus is reinforced in the spinal cord.

c. Having the individual perform an isometric exercise in a muscle group a distance from the one being tested to reinforce the response. The concept of reinforcement refers to the fact that, if you are unable to initiate a DTR, having the individual perform an isometric exercise in a muscle group away from the one being tested will enhance the response. When testing the DTRs, you do not stimulate the tendon a second time; rather, you strike a brief, well-aimed blow on the muscle's insertion tendon, and bounce up promptly, not letting the hammer rest on the tendon.

Which are characteristics of upper motor neuron lesions? (Select all that apply.) a. Loss of muscle tone b. Muscle atrophy c. Hyperreflexia d. Fasciculations e. Positive Babinski sign

c. Hyperreflexia e. Positive Babinski sign With upper motor neuron lesions, muscle tone is increased; muscle bulk is basically normal, and there are no abnormal movements. Deep tendon reflexes (DTRs) are hyperreflexive and there is a positive Babinski sign. With lower motor neuron lesions, muscle tone is lost, resulting in flaccidity. Muscle bulk is reduced as a result of atrophy. Fasciculations occur and reflexes are diminished or absent.

In which way does the vagus nerve differ from the other cranial nerves? a. It is the only motor cranial nerve. b. It is the only mixed cranial nerve. c. It innervates organs outside the head and neck. d. It has a spinal nerve component to its origin and structure.

c. It innervates organs outside the head and neck. The vagus cranial nerve differs from the other cranial nerves in that it innervates organs outside the head and neck. The vagus nerve (Lat. vagus, or wanderer, as in "vagabond") travels to the heart, respiratory muscles, stomach, and gallbladder, and it does not have a spinal nerve component to its origin and structure. Cranial nerves III to VII and IX to XII each have a motor component to them. Cranial nerves V, VII, IX, and X all have both sensory and motor components.

What three structures comprise the brainstem? a. Thalamus, hypothalamus, and basal ganglia b. Thalamus, midbrain, and medulla c. Midbrain, pons, and medulla d. Hypothalamus, pons, and cerebellum

c. Midbrain, pons, and medulla The three structures that comprise the brainstem are the midbrain, pons, and medulla. The midbrain, which contains many motor neurons and tracts, is the most anterior part of the brainstem and still has the tubular structure of the spinal cord. The pons contains ascending sensory and descending motor tracts as well as the pneumotaxic and apneustic respiratory centers, which coordinate with the main respiratory center in the medulla. The medulla is the continuation of the spinal cord in the brain that contains all ascending and descending fiber tracts, the vital autonomic centers for respiration, heart, and gastrointestinal function, as well as the nuclei for cranial nerves VIII through XII. The medulla is where pyramidal decussation occurs.

A patient complains of a sensation of burning and tingling in his or her right arm. Which term is appropriate in describing this complaint? a. Kinesthesia b. Paresis c. Paresthesia d. Dysmetria

c. Paresthesia An abnormal sensation of burning and/or tingling is termed paresthesia. Kinesthesia refers to position sense. Paresis is a partial or incomplete paralysis. Dysmetria is the inability to control range of motion of muscles.

The examiner obtains specific information regarding the intactness of which component of a patient's nervous system when the deep tendon reflexes are tested? a. Corticospinal tract b. Medulla c. Reflex arc at specific levels in the spinal cord d. Upper motor and lower motor neuron synaptic junction

c. Reflex arc at specific levels in the spinal cord Testing the deep tendon reflexes gives the examiner specific information regarding the intactness of the reflex arc at specific levels in the spinal cord. Testing the deep tendon reflexes would give the examiner information regarding the intactness of the lower motor neurons, but not the upper motor neurons. The corticospinal tract is an example of an upper motor neuron, which cannot be tested by a deep tendon reflex. The medulla is the continuation of the spinal cord in the brain that contains all ascending and descending fiber tracts connecting the brain and spinal cord; however, testing of the deep tendon reflexes provides more specific information on the intactness of the reflex arcs.

In which part of the brain is the extrapyramidal system located? a. The hypothalamus b. The cerebellum c. The basal ganglia d. The medulla

c. The basal ganglia The extrapyramidal system is located in the basal ganglia. The basal ganglia are large bands of gray matter buried deep within the two cerebral hemispheres that form the subcortical associated motor system. They help to initiate and coordinate movement and control automatic associated movements of the body.

Which sensations are transmitted by the posterior (dorsal) columns? a. Pain, temperature, and crude touch b. Position, vibration, and superficial pain c. Vibration, position, and fine touch d. Crude touch, deep pain, and position

c. Vibration, position, and fine touch The posterior (dorsal) columns are responsible for transmitting the sensations of vibration, position, and fine touch. The spinothalamic tract is responsible for transmitting the sensations of crude touch, pain, and temperature.

Which direction would you give a patient when performing a Romberg test? a. "Walk heel to toe in a straight line." b. "Touch the thumb to each finger on the same hand; repeat in opposite direction." c. "Tell me each time you feel something sharp." d. "Stand with your feet together, arms at sides; close your eyes."

d. "Stand with your feet together, arms at sides; close your eyes." The Romberg test is a test of balance in which a person is asked to stand with feet together and arms at sides. Once stable in this position, the person is asked to close the eyes and hold the position. Normally the person can do this, sometimes with slight swaying for the test period of 20 seconds. If the person sways significantly, falls, or widens the base of the feet to avoid falling, it is a positive Romberg sign. This occurs with cerebellar ataxia, loss of proprioception, and loss of vestibular function.

What percent of the global stroke burden has been found to be due to modifiable risk factors? a. 40% b. 50% c. 80% d. 90%

d. 90% Evidence from 188 countries across the globe over 23 years of data collection shows that 90% of the stroke burden was due to modifiable risk factors; including behavioral risk factors (smoking, poor diet, low physical activity); metabolic risk factors (high systolic BP, high BMI, high fasting glucose, high total cholesterol), and environmental factors (air pollution, lead exposure).

On examining a new patient, you note the presence of a resting tremor, bradykinesia, loss of balance, and cogwheel rigidity. Which problem do you suspect? a. Multiple sclerosis b. Cerebral palsy c. Muscular dystrophy d. Parkinson's disease

d. Parkinson's disease Resting tremor, bradykinesia, loss of balance, and cogwheel rigidity are classic symptoms of parkinsonism. Other symptoms of Parkinson's disease are cognitive decline, depression, urinary incontinence, flat facial expression, excessive salivation, reduced eye blinking, and stooped posture.

In reviewing a patient's record, you note that under mobility a problem with propulsion is identified. What would you observe for when you meet this patient?

difficulty stopping when walking

One purpose of the systems review section of the health history is to:

evaluate health promotion practices.

The health care provider uses data from the family history of the patient to:

identify health risks related to familial tendency or environment.

oculomotor nerve 3

motor, constricts pupil

trochlear nerve 4

motor, move the eye down or outwards

abducens nerve 6

motor, move the eye laterally

accessory nerve 11

motor, neck muscles, shrug

hypoglossal nerve 12

motor, tongue

When considering culture as a part of the assessment of a naval officer, the most obvious subculture is:

occupation Within cultures, groups of people share different beliefs, values, and attitudes. Differences occur because of ethnicity, religion, education, occupation, age, and gender. When such groups function within a large culture, they are referred to as subcultural groups. When considering culture as a part of the assessment of a naval officer, the most obvious subculture is occupation because no gender or ethnicity of the naval officer was stated and subcultures are divided by ethnicity, religion, etc., not by health-related characteristics.

On examination you find that your patient hears sound, but is unable to make any meaning out of it. You document this finding as ______ aphasia.

receptive Receptive aphasia is a condition that results after sustaining an injury to Wernicke's area. The patient may hear sound, but is unable to make any meaning out of it.

glossopharyngeal nerve 9

sensory and motor, "ahh"

facial nerve 7

sensory and motor, close the eye tightly, facial expressions

trigeminal nerve 5

sensory and motor, corneal blink reflex, TMJ, light tough

vagus nerve 10

sensory and motor, gag reflex

vestibulocochlear nerve 8

sensory, hearing acuity

olfactory nerve 1

sensory, sense of smell

optic nerve 2

sensory, vision

When giving her history, a patient states that she takes acetaminophen morning and evening for pain in her knees. Which is the priority follow-up question you would ask?

"How many milligrams do you take?"

Which is an example of an open-ended question?

"How may I help you?" "How may I help you?" is an open-ended question because it asks for narrative information. It is unbiased and leaves the patient free to answer in any way. All the other questions are closed-ended or direct in that they ask for specific information and require only a one- or two-word answer.

When assessing the intensity of a patient's pain, which question by the nurse is appropriate?

"How much pain do you have now?"

Which is an example of appropriate documentation of a patient's reason for seeking care?

"I feel tired all the time."

The nurse is teaching a class on pain at a local retirement community. Which statement about the pain experienced by older adults should the nurse include in the instructions?

"Pain indicates a pathologic condition or an injury and is not a normal process of aging."

Which statement made by a patient who has had a bowel resection with a colostomy for colon cancer is an example of distancing?

"The bowel had a cancer in it and now it has a bag." "The bowel had a cancer in it and now it has a bag" is an example of distancing. Distancing is the use of impersonal speech to put space between self and a threat.

When assessing the quality of a patient's pain, the nurse should ask which question?

"What does your pain feel like?"

A patient comes to the clinic and, when asked the reason for the visit, says, "I have bronchitis." How would you respond?

"What makes you think you have bronchitis?"

Mr. Tucker is a 68-year-old patient who is recovering from his right total knee replacement surgery. You overhear the nurse assigned to Mr. Tucker as she assesses him, and realize that this nurse is using leading questions/statements. Which is a leading question/statement that you might have overheard?

"You are upset about the pain in your knee, right?" An example of a leading question/statement is asking the patient, "You are upset about the pain in your knee, right?" because this question tells the patient what answer is expected.

You attend a patient care conference focused on Mr. Sanchez, a 46-year-old Hispanic, and his son who is dying of a chronic illness. The importance of supporting Mr. Sanchez in meeting his spiritual needs is stressed. Which is the best description of what you are going to support?

A personal effort to find meaning and purpose in life. When supporting a person's spiritual needs, you are concerned with spirituality, which is a personal effort to find meaning and purpose in life. This is different from religion, which is an organized system of beliefs concerning the cause, nature, and purpose of the universe, especially belief in or the worship of God or gods.

Which term is used to describe the losses and changes that occur when an immigrant is adjusting to a new system of beliefs, routines, and social roles?

Acculturative stress The losses and changes that occur when adjusting to or integrating a new system of beliefs, routines, and social roles are known as acculturative stress. Acculturation is the process of adopting the culture and behavior of the majority culture. Socialization or enculturation is the process of being raised within a culture and acquiring the norms, values, and behaviors of that group. "Biculturalism" and "integration" refer to ways new immigrants are forging identities between the countries of origin and their host country.

A patient is complaining of severe knee pain after twisting it during a basketball game and is requesting pain medication. Which action by the nurse is appropriate?

Administering pain medication and then proceeding with the assessment

Ms. Benson is a 24-year-old patient who presents to the clinic for a health assessment. Which assessment findings are classified as objective? (Select all that apply.)

Alert and oriented Ankle edema Heart murmur A patient's level of consciousness (alert) and orientation (oriented to person, place, and time) status is determined by inspection. Ankle edema is determined by inspection and palpation. A heart murmur is identified by auscultation. All are objective data findings because objective data are what the health care professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Subjective data are what the patient reports about himself or herself, so dizziness, ear pain, and abdominal tenderness are all examples of subjective data.

Which constitutes a first-level priority problem?

Anaphylaxis First-level priority problems are those that are emergent, life threatening, and immediate, such as establishing an airway or supporting breathing. Thus anaphylaxis constitutes a first-level priority problem. Second-level priority problems are those that require prompt intervention to prevent further deterioration. Examples of these are acute pain, mental status change, and acute urinary elimination problems. Third-level priority problems are those that are important to the patient's health but can be addressed after more urgent problems. Elevated serum cholesterol levels would fall in this category.

How do you interpret a waist-to-hip ratio of 1.2 in a 34-year-old male patient?

Android obesity is present

When assessing a patient's health status, which data do you classify as subjective?

Anything the patient tells you about self as part of the health history When assessing a patient's health status, subjective information is anything that the patient says about himself or herself as part of the health history. What you as the health professional "observe" through inspection, percussion, palpation, or auscultations during the physical examination are objective data.

During an admission assessment of a patient with dementia, the nurse assesses for pain because the patient has recently had several falls. Which of these are appropriate for the nurse to assess in a patient with dementia? (Select all that apply.)

Assess the patient's breathing independent of vocalization. Note whether the patient is calling out, groaning, or crying. Observe the patient's body language for pacing and agitation.

Use of which type of language is an interviewing trap?

Avoidance language Use of avoidance language is an interviewing trap. Other interviewing traps are the use of authoritative language, use of professional jargon, providing false assurance or reassurance, giving unwanted advice, using leading questions, distancing, talking too much, interrupting, and using "why" questions.

Which are dimensions of the total context of an individual's situation to which a culturally competent caregiver attends? (Select all that apply.)

Awareness of immigration status Stress factors Other social factors Cultural similarities and differences Culturally competent implies that the caregivers understand and attend to the total context of the individual's situation, including all of the following: awareness of immigration status, stress factors, other social factors, and cultural similarities and differences.

Which is the best description of a complete health database?

Baseline description of present and past health against which future changes will be measured. A complete or total health database describes current and past health states and forms a baseline against which all future changes can be measured. It includes a complete health history and a full physical examination. It screens for pathology, yields the first diagnosis, and determines the ways patients respond to health problems.

Under which assessment category of the general survey are nutritional status, posture, position while seated, and the presence of a physical handicap or deformity documented?

Body structure

During assessment of a patient's pain, the nurse is aware that certain nonverbal behaviors are associated with chronic pain. Which of these behaviors are associated with chronic pain? (Select all that apply.)

Bracing Rubbing Sleeping

When performing health assessments both objective and subjective data is gathered. Which are examples of subjective data? (Select all that apply.)

Burning on urination Spots floating in front of the eyes Subjective data are what the patient says about himself or herself. Objective data are those collected by the examiner through observing, percussing, palpating, or auscultating. Thus examples of subjective data are burning on urination and spots floating before the eyes. Uneven gait, left ear canal impacted with dry, dark wax, and pedal edema are examples of objective data.

Which are examples of acculturative stress that may affect a patient from a third world country? (Select all that apply.)

Changing gender roles Financial issues Loss of social status Lack of education Legal status There are three major categories of acculturative stress: instrumental/environmental, social/interpersonal, and societal. Specific areas that fall within the dimension of instrumental/environmental are financial, language barriers, lack of access to health care, unemployment, and lack of education. Within the category of social/interpersonal are loss of social networks, loss of social status, family conflict, family separation, intergenerational conflict, and changing gender roles. Within the societal category are the dimensions of discrimination/stigma, level of acculturation, political/historical forces, and legal status.

Which are critical characteristics that help the interviewer conduct and document a thorough symptom analysis? (Select all that apply.)

Character, location, severity Onset and duration, setting Associated symptoms Aggravating or relieving factors Personal meaning of symptomatology

When assessing a patient's pain, the nurse records that the patient has visceral pain. Which condition would the patient have stated in order for the nurse document visceral pain?

Cholecystitis

Mr. Child is a 35-year-old patient who comes to the clinic for a general health visit. When asked about past medical problems and surgeries, his answers are confusing. Which communication technique do you use?

Clarification Clarification is the communication technique useful when a patient's word choice is ambiguous or confusing. When clarifying, you summarize the patient's words, simplify the statement, and ensure you are on the right track.

What type of database is most appropriate to establish for an individual who is admitted to a long-term care facility?

Complete The complete database is an assessment of an individual s total health, which serves as a basis for measuring future changes in health status. It includes a complete health history plus a full physical examination. The complete database is necessary in this case because many individuals who are admitted to long-term care have complex medical histories and complex medication regimens. This database can also provide support for the practitioner to get the patient necessary resources, such as ambulatory aids.

Mr. Fitzgerald is a 62-year-old new patient who presents to the clinic for a routine health assessment. Which type of health database would be established?

Complete The complete health database is an assessment of an individual's total health. This includes a complete health history plus a full physical examination and can be performed in both primary and acute care settings. The focused (or mini) database is utilized mainly for one limited or short-term problem and is used in all care settings. It is smaller in scope and more targeted than a complete database. The emergency database requires a rapid collection of data and is often combined with lifesaving measures. The follow-up database is used in all care settings and focuses on the evaluation of identified short-term or chronic health problems at regular and appropriate intervals.

What is an integral factor in responding adequately to the health care needs of a 41-year-old Hispanic woman?

Cultural competence Cultural competence implies that the caregivers understand and attend to the total context of the individual's situation, including awareness of immigration status, stress factors, other social factors, and cultural similarities and differences. Ethnocentrism is a bias that prevents someone from understanding the beliefs and practices of another, so this would not be an integral part of the overall effort to respond to the patient. Demonstrating political correctness is important, but this does not demonstrate that the caregivers are responding to the patient's health care needs. Awareness of and respect for racial differences and similarities is only one of the areas that need to be considered when responding to the patient's needs.

A patient has been admitted to the hospital with vertebral fractures r/t osteoporosis. She is in extreme pain. How should the nurse document this type of pain?

Deep somatic

Which term refers to the use of impersonal speech to put space between the self and a threat?

Distancing Distancing is the use of impersonal speech to put space between the self and a threat. Interrupting is when you think you know what the person will say, and you interrupt and cut the person off. This does not show that you are clever. Rather, it signals that you are impatient or bored with the interview. Avoidance language is used by persons to evade issues in order to protect themselves. Confrontation is used when the nurse observes a certain action, feeling, or statement and focuses the person's attention on it. The nurse then gives honest feedback about what was seen or felt.

What type of database is often compiled concurrently with lifesaving measures?

Emergency The emergency database requires a rapid collection of data and is often combined with lifesaving measures. A focused (or mini) database concerns mainly one limited or short-term problem and is used in all care settings. It is smaller in scope and more targeted than a complete database. The follow-up database is used in all care settings and is concerned with the evaluation of identified short-term or chronic health problems at regular and appropriate intervals. The complete database is a total health assessment. This includes a complete health history plus a full physical examination and can be performed in both primary and acute care settings.

Mrs. Denier tells you that she is paranoid and that family members are "out to get her." You respond, "Tell me more." This technique is best described as:

Facilitation With facilitation, the nurse uses responses that encourage the patient to say more, and to continue with the story. Clarification is summarizing the person's words, simplifying them to make them clearer, and then asking if you are on the right track. Reflection is repeating part of what the person has just said, which helps the person elaborate on the problem. Validation means checking to see if the person understands by having him or her repeat instructions, demonstrate the procedure, or act out the meaning.

Mr. Garrett is a 43-year-old patient who comes to the office for the first time saying he hasn't been to a doctor in 12 years and thinks it's time to get checked out even though I feel fine. While taking his complete health history, which areas would you explore when assessing the functional assessment category focused on interpersonal relationships/resources? (Select all that apply.)

Family role Social support Time spent alone

You are obtaining a health history on a 46-year-old male patient. When asked what brings him to the clinic, he replies, I woke up yesterday with a fever, dizziness, and nausea. Today I vomited twice and my stomach is bloated. Which of these complaints do you classify as subjective data? (Select all that apply.)

Fever Dizziness Nausea Vomiting Bloating

During the interview, you notice that the patient is grimacing and guarding his or her abdomen with movement. When asked, the patient denies pain. What should you do?

Focus the patient's attention on the discrepancy between his or her verbal responses and nonverbal behavior. When the patient denies pain and the signs and symptoms indicate pain, it is important to focus the patient's attention on the discrepancy between his or her verbal responses and nonverbal behavior. If the patient is in discomfort, this situation needs attention prior to continuing with the interview, so that the patient will be able to attend to the questions. This focusing process is confrontation.

What type of database is established when a nurse is mainly concerned with one problem?

Focused A focused (or mini) database concerns mainly one limited or short-term problem and is used in all care settings. It is smaller in scope and more targeted than a complete database. The follow-up database is also used in all care settings; however, it focuses on the evaluation of identified short-term or chronic health problems at regular and appropriate intervals. The emergency database requires a more rapid collection of data than the focused database, and is often combined with lifesaving measures. The complete database is a total health assessment. This includes a complete health history plus a full physical examination and can be performed in both primary and acute care settings.

Which type of database is most appropriate to establish when an overall healthy person seeks care for a rash at an ambulatory care center?

Focused In this case, a focused (or mini) database is most appropriate since it concerns mainly one limited or short-term problem (the rash). This database is smaller in scope and more targeted than a complete database; it can be used in all care settings. The follow-up database is also used in all care settings; however, it is concerned with the evaluation of identified short-term or chronic health problems at regular and appropriate intervals. Once this rash is identified and treatment has begun, the patient may return to the clinic to complete a follow-up database. The emergency database requires a more rapid collection of data than the focused database, and is often combined with lifesaving measures. The complete database is a total health assessment. This includes a complete health history plus a full physical examination and can be performed in both primary and acute care settings.

What type of database is most appropriate to establish when a patient's chronic illness problems are being evaluated at regular intervals?

Follow-up The follow-up database is used in all care settings. It is concerned with the evaluation of identified short-term or chronic health problems at regular and appropriate intervals. A focused (or mini) database concerns mainly one limited or short-term problem and is used in all care settings. It is smaller in scope and more targeted than a complete database. The emergency database requires a rapid collection of data and is often combined with lifesaving measures. The complete database is a total health assessment. This includes a complete health history plus a full physical examination and can be performed in both primary and acute care settings.

Which factors do you observe when assessing a patient's mobility? (Select all that apply.)

Gait Range of motion.

One step in the diagnostic reasoning process is clustering of data. What is meant by clustering data in this context?

Grouping together signs and symptoms that appear to be causal or associated Assessment data are organized into meaningful clusters; that is, data that appear to be causal or related are grouped together.

Which is a guideline you should follow in working with a non-English-speaking patient and an interpreter?

Have the interpreter meet with the patient before the health interview begins. When working with a non-English-speaking patient and an interpreter, the interpreter should be allowed to meet with the patient ahead of the interview to establish rapport and to determine the patient's age, occupation, educational level, and attitude toward health care. The interviewer speaks directly to the patient, addressing questions to him or her. During the interview, the interpreter should sit next to the patient. The interviewer is in charge and guides the focus and flow of the interview.

Which phrase refers to the concept that the mind, body, and spirit are interdependent and function as a whole within the environment?

Holistic health The view that the mind, body, and spirit are interdependent and function as a whole within the environment is considered holistic health. Consideration of the whole person is the essence of holistic health. In this view, the basis of disease is multifaceted, originating both from within the person and from the external environment.

At a patient care conference focused on a 76-year-old woman with chronic heart, lung, and mobility problems, you, as the patient's primary nurse, are asked about the disease burden. Which type of information would you provide?

Impact of health problems on the patient's daily activities and overall quality of life

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

Increased blood pressure and pulse

The nurse is evaluating a patient's pain. Which is an example of acute pain?

Kidney stones

Which are the four defining characteristics of culture?

Learned, shared, adapted, and dynamic Culture has four basic characteristics in that it is (1) learned from birth through the processes of language acquisition and socialization, (2) shared by all members of the same cultural group, (3) adapted to specific conditions related to environmental and technical factors and to the availability of natural resources, and (4) dynamic and ever changing. Culture is neither innate nor static.

When performing health assessments, both objective and subjective data are gathered. Which are examples of objective data? (Select all that apply.)

Left tympanic membrane is pearly gray with visible light reflex. Crepitation is present in the left knee joint. Objective data are those collected by the examiner through observing, percussing, palpating, or auscultating. Thus examples of objective data are left tympanic membrane pearly gray with visible light reflex and crepitation in the left knee joint. The condition of the tympanic membrane is determined through inspection with an otoscope, and crepitation is an audible and palpable crunching or grating that accompanies movement.

Internal factors that influence communication are particular to the interviewer. Which is an internal factor that should be cultivated because it facilitates communication?

Liking others Internal factors that influence communication are behaviors, skills, and/or attributes particular to the interviewer. An internal factor that should be cultivated because it facilitates communication, is liking others. Other internal factors to be cultivated are empathy, ability to listen, and self-awareness.

Which factor places the aging adult at greatest nutritional risk?

Living alone

Which is a primary purpose for an interviewer choosing to use closed-ended questions?

Lower response burden A primary purpose for an interviewer to choose the use of closed-ended questions is to lower the response burden for acutely ill patients. A hospitalized person with a critical or severe illness is usually too weak, too short of breath, or in too much pain. In the interview, the first concern the patient mentions should be explored and closed-ended, direct questions are asked early to decrease the response burden.

Which guidelines apply when assessing a potentially aggressive patient? (Select all that apply.)

Maintain an unhurried manner. Always face the person. When assessing a potentially aggressive patient, safety is your first concern. Act calm, unhurried, and interested in what the person has to say. Make sure you leave the door to the exam room open and never turn your back to the patient. Position yourself between the person and the door so you can easily leave the room. Avoid being isolated, and know agency policies and resources. Do not raise your voice or try to argue with the patient.

What is the purpose of assessment?

Make a judgment The result of an assessment is the establishment of a database. From the database, a clinical judgment or diagnosis is made about the individual s health state, response to actual or potential health problems, and life processes. Thus, the purpose of assessment is to make a judgment or diagnosis.

When you use the communication technique of interpretation while interviewing Mr. Thacker, a 39-year-old carpenter who comes to the office for a routine examination, what are you doing?

Making associations and possibly implying cause. Interpretation is a type of verbal response where the nurse links events, makes associations, or implies cause and then expresses his or her own thoughts and feelings. Interpretation is not based on direct observation but on inference or conclusion. Your interpretation may not be correct but it will prompt further discussion.

Ms. Carter is admitted to the hospital for malnutrition. Presenting signs and symptoms include significant loss of weight, skeletal muscle, and adipose tissue. Intact serum protein levels also are present. Which type of malnutrition is indicated by this constellation of signs and symptoms?

Marasmus

A follow-up database is used to:

Monitor progress of short-term or chronic health concerns. A follow-up database is used to monitor progress of short-term or chronic health concerns. A focused database is used to manage a limited or short-term problem usually consisting of one problem, one cue complex, or one body system. A medical diagnosis is concerned with the cause of disease. A thorough or comprehensive health history and physical examination is part of a complete database.

A 57-year-old male patient presents with complaints about feelings of depression. While conducting the general survey, you pay particular attention to the behavior assessment. In addition to facial expression, speech, speech pattern, and dress, which factors does this assessment include?

Mood/affect and personal hygiene

The concept of health literacy refers to which basic abilities? (Select all that apply.)

Navigate the health care system. Understand health care instructions. Communicate concerns to the health professional. Literacy is the ability to read and write; health literacy refers to the ability to understand instructions; navigate the health care system, and communicate concerns with the health care provider. Accessing health care data on the Internet and reading and signing an informed consent document are desirable abilities but they are not essential elements of the concept of health literacy.

The nurse is reviewing the principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system?

Neuropathic

A 48-year-old male patient has a BMI of 22.8. How do you interpret this finding?

Normal weight

You assess a patient's gait as he walks from the waiting room to the exam room. In so doing, you keep in mind which fact about the base of support?

Normally it is equal to shoulder width.

Match the cranial nerve with the function in the eye

Optic - visual acuity Oculomotor - dilate or constrict pupils Trochlear - move eye downward or outward Trigeminal - corneal "blink" reflex Abducens - move eye laterally Facial - close eyes tightly

The nurse is reviewing the principles of nociception. During which phase of nociception does the conscious awareness of a painful sensation occur?

Perception

What is the starting point of diagnostic reasoning?

Performing an organized assessment An organized assessment is the starting point of diagnostic reasoning. Diagnostic reasoning is the process of analyzing the health assessment data and drawing conclusions to identify diagnoses. For the novice this involves forming hypotheses and using deductive reasoning.

What are the four distinct, overriding categories of assessment that comprise the general survey?

Physical appearance, body structure, mobility, and behavior

When measuring a patient's waist circumference which procedural guidelines do you follow?

Position the measuring tape at the iliac crest.

Which factor has been shown by research to have the greatest influence on health status?

Poverty Influences on a person's health status are known as Determinants of Health. These include a myriad of personal, social, economic, and environmental factors such as biology, genetics, lifestyle behaviors, occupation status, environmental quality, poverty, health care services, and political action and legislation. Of all these factors, evidence-based research has consistently shown that poverty has the greatest influence on health status.

Which is the best defining characteristic of intuition as it relates to clinical judgment?

Recognizing patterns immediately Using intuition is a part of functioning at the level of expert in clinical judgment. Using intuition is using knowledge received as a whole and is characterized by the immediate recognition of patterns. Expert practitioners attend to a pattern of assessment data and act without consciously labeling it.

Mr. Woods is a 56-year-old patient who comes to the clinic for a health assessment. Which guideline will you follow to appropriately document the review of systems?

Record the presence or absence of common symptoms specific to each system heading.

Which information should you include when documenting a history source?

Reliability of informant

Which term can be described as an organized system of beliefs concerning the cause, nature, and purpose of the universe, especially belief in a divine or superhuman power to be obeyed and worshipped as the creator and ruler of the universe?

Religion Religion refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe, especially belief in or the worship of God or gods. A ritual is a ceremony or sacrament. The act of worship is the process of practicing your beliefs. Spirituality is a pursuit to discover a supreme being or some unifying truth that will render meaning, purpose, and integrity to existence.

A 53-year-old patient comes to the clinic for an initial evaluation. You question the reliability of the history provided by the patient. How do you respond to this situation?

Rephrase the same questions later in the interview.

The reason that Ms. Kingman seeks care is a complaint of debilitating headaches that cause excessive absences from work. On further exploration, the nurse asks, Can you identify what brings the headaches on? Which aspect of Ms. Kingman's pain does this question address?

Setting

Which is an example of an interviewer's positive, nonverbal behavior?

Sitting, leaning slightly toward the interviewee An example of an interviewer's positive, nonverbal behavior is sitting, leaning slightly toward the interviewee. Standing or leaning slightly away from the interviewee are negative behaviors.

A 60-year-old woman has developed reflexive sympathetic dystrophy after arthroscopic repair of her shoulder. Which is a key feature of this condition?

Slightest touch, such as a sleeve brushing against her arm, causes severe and intense pain.

Which guideline is advisable to follow when interviewing a patient?

Spend more time listening than talking. While interviewing, a good rule to follow is listen more often than talk. Asking "why"-type questions puts the person on the defensive. A second of silence between the person's statement and your next question is desirable to be certain the patient has finished his or her response. Interruptions should be avoided because an interruption can destroy in seconds the rapport that you have spent many minutes building up.

Mr. Grayson is a 67-year-old new patient who comes to the office for an examination. Which behaviors suggest to you that he may have a hearing impairment? (Select all that apply.)

Staring intently at your mouth Speaking in an unusually loud voice Not answering questions asked when not looking at you Behavioral cues to hearing loss include staring intently at the speaker's mouth, using an unusually loud voice, not answering unless looking at the speaker, and frequently requesting that questions be repeated.

As part of the general survey, the examiner compares the patient's appearance to which factor?

Stated age

The nurse is assessing a patient's pain. What should the nurse know is the most reliable indicator of pain?

Subjective report

What do you do when ending the patient interview?

Summarize the patient's health concerns. When ending the interview, you summarize the patient's health concerns. Emphasizing the patient's role in maintaining health and advising the patient on ways to maintain health are done during the interview. Your overall findings are reviewed with the patient at the end of the total assessment.