Chapter 15 Health Assessment quiz, Chapter 14, Ch. 13 - Head, Face, and Neck, Including Regional Lymphatics, Chapter 5: Mental Status (Jarvis), Chapter 12: Skin, Hair, and Nails Jarvis: Physical Examination & Health Assessment, 7th Edition, Pain, Jar...

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What is the pulse pressure for a patient whose blood pressure is 158/96 mm Hg and whose pulse rate is 72 beats per minute?

62 (158-96 = 62)

A 75-year-old woman is at the office for a preoperative interview. The nurse is aware that the interview may take longer than interviews with younger persons. What is the reason for this? a. An aged person has a longer story to tell. b. An aged person is usually lonely and likes to have someone with whom to talk. c. Aged persons lose much of their mental abilities and require longer time to complete an interview. d. As a person ages, he or she is unable to hear; thus the interviewer usually needs to repeat much of what is said

During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question? a. "How do you feel today?" b. "Would you please repeat the following words?" c. "Have these medications had any effect on your pain?" d. "Has this pain affected your ability to get dressed by yourself?"

The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations? a. Palpation b. Inspection c. Percussion d. Auscultation

Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient? a. Palpation b. Inspection c. Percussion d. Auscultation

Which technique is correct when the nurse is assessing the radial pulse of a patient? The pulse is counted for: a. 1 minute, if the rhythm is irregular. b. 15 seconds and then multiplied by 4, if the rhythm is regular. c. 2 full minutes to detect any variation in amplitude. d. 10 seconds and then multiplied by 6, if the patient has no history of cardiac abnormalities.

meningeal inflammation

A 19-year-old college student is brought to the emergency department with a severe headache he describes as "Like nothing I've ever had before." His temperature is 104° F, and he has a stiff neck. The nurse looks for other signs and symptoms of which problem?

normal and should disappear within 3 to 4 months of age

A mother brings in her newborn infant for an assessment and tells the nurse that she has noticed that whenever her newborn's head is turned to the right side, she straightens out the arm and leg on the same side and flexes the opposite arm and leg. After finding this on examination, the nurse would tell her that this is:

damage to the trigeminal nerve

A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects

A patient repeats, "I feel hot. Hot, cot, rot, tot, got. I'm a spot." The nurse documents this as an illustration of: a. Blocking b. Clanging c. Echolalia d. Neologism

The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation? a. No sensation b. Firm pressure c. Pain during palpation d. Pain sensation behind eyes

ANS: B The person should feel firm pressure but no pain. Sinus areas are tender to palpation in persons with chronic allergies or an acute infection (sinusitis).

A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find: a. Pallor b. Coolness c. Distended veins d. Prolonged capillary filling time

ANS: C Keeping the feet in a dependent position causes venous pooling, resulting in redness, warmth, and distended veins. Prolonged elevation would cause pallor and coolness. Immobilization or prolonged inactivity would cause prolonged capillary filling time (see Table 12-1).

When examining the nares of a 45-year-old patient who has complaints of rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notices the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these conditions is most likely the cause? a. Nasal polyps b. Acute sinusitis c. Allergic rhinitis d. Acute rhinitis

ANS: C Rhinorrhea, itching of the nose and eyes, and sneezing are present with allergic rhinitis. On physical examination, serous edema is noted, and the turbinates usually appear pale with a smooth, glistening surface. (See Table 16-1 for descriptions of the other conditions.)

During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notices the presence of blood in the anterior chamber of the eye. This finding indicates the presence of:

ANS: hyphema. Hyphema is the term for blood in anterior chamber is a serious result of blunt trauma (a fist or a baseball) or spontaneous hemorrhage and may indicate scleral rupture or major intraocular trauma. See Table 14-7 for descriptions of the other terms.

In a patient who has anisocoria, the nurse would expect to observe:

ANS: pupils of unequal size. Unequal pupil size is termed anisocoria. It exists normally in 5% of the population but may also be indicative of central nervous system disease.

The nurse is providing care for a 68-year-old woman who is complaining of constipation. What concern exists regarding her nutritional status?

Absorption of nutrients may be impaired.

C has a slower response time response time is slower in an aging adult; it may take longer for the brain to process information and react. Timed intelligence testing may be lower for an aging adult; intelligence has not declined, but it may take longer to respond to questions. Recent memory requires processing and may decrease with aging. Remote memory is not affected by the aging process. Aging does not usually have an impact on mental status

An older adult: a. experiences a 10-point decrease in intelligence b. has diminished recent and remote memory recall c. has a slower response time d. has difficulty with problem solving

When measuring a patients weight, the nurse is aware of which of these guidelines?

Attempts should be made to weigh the patient at approximately the same time of day, if a sequence of weights is necessary

A 1-month-old infant has a head measurement of 34 cm and has a chest circumference of 32 cm. Based on the interpretation of these findings, the nurse would: a. Refer the infant to a physician for further evaluation. b. Consider these findings normal for a 1-month-old infant. c. Expect the chest circumference to be greater than the head circumference. d. Ask the parent to return in 2 weeks to re-evaluate the head and chest circumferences.

The pulse is counted for:

1 minute, if the rhythm is irregular.

A patients weekly blood pressure readings for 2 months have ranged between 124/84 mm Hg and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this blood pressure falls within which blood pressure category? a. Normal blood pressure b. Prehypertension c. Stage 1 hypertension d. Stage 2 hypertension

During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This behavior is an example of: a. Social phobia b. Compulsive disorder c. Generalized anxiety disorder d. Posttraumatic stress disorder

The nurse is nearing the end of an interview. Which statement is appropriate at this time? a. Did we forget something? b. Is there anything else you would like to mention? c. I need to go on to the next patient. Ill be back. d. While Im here, lets talk about your upcoming surgery.

When assessing an older adult, which vital sign changes occur with aging? a. Increase in pulse rate b. Widened pulse pressure c. Increase in body temperature d. Decrease in diastolic blood pressure

With which of these patients would it be most appropriate for the nurse to use games during the assessment, such as having the patient blow out the light on the penlight? a. Infant b. Preschool child c. School-age child d. Adolescent

The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask? a. "Do you wear glasses?" b. "Are you able to dress yourself?" c. "Do you have any thyroid problems?" d. "How many times a day do you have a bowel movement?"

B Functional assessment measures how a person manages day-to-day activities. For the older person, the meaning of health becomes those activities that they can or cannot do. The other responses do not relate to functional assessment.

When assessing a patients pulse, the nurse should also notice which of these characteristics?

Force

In teaching a patient how to determine total body fat at home, the nurse includes instructions to obtain measurements of:

Height and weight.

When considering a nutritional assessment, the nurse is aware that the most common anthropometric measurements include:

Height and weight.

If an American Indian woman has come to the clinic to seek help with regulating her diabetes, then the nurse can expect that she: a. Will comply with the treatment prescribed. b. Has obviously given up her belief in naturalistic causes of disease. c. May also be seeking the assistance of a shaman or medicine man. d. Will need extra help in dealing with her illness and may be experiencing a crisis of faith.

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

Is a reflection of the hearts stroke volume

The nurse is assessing a 30-year-old unemployed immigrant from an underdeveloped country who has been in the United States for 1 month. Which of these problems related to his nutritional status might the nurse expect to find

Osteomalacia (softening of the bones)

While measuring a patients blood pressure, the nurse recalls that certain factors, such as __________, help determine blood pressure.

Peripheral vascular resistance

Which of the following changes in aging adults affect nutritional status? (Select all that apply.)

Poor dentition decreased visual acuity slow GI motility

The nurse knows that one advantage of the tympanic membrane thermometer (TMT) is that:

Rapid measurement is useful for uncooperative younger children

A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings?

The change in blood pressure readings is called orthostatic hypotension.

The nurse is assessing children in a pediatric clinic. Which statement is true regarding the measurement of blood pressure in children?

The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children.

The nurse is conducting a heritage assessment. Which question is most appropriate for this assessment? a. What is your religion? b. Do you mostly participate in the religious traditions of your family? c. Do you smoke? d. Do you have a history of heart disease?

The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore during the interview? a. "I sleep like a baby." b. "I have no health problems." c. "I never did too good in school." d. "I am not currently taking any medications."

The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status? a. Mental status assessment diagnoses specific psychiatric disorders. b. Mental disorders occur in response to everyday life stressors. c. Mental status functioning is inferred through the assessment of an individual's behaviors. d. Mental status can be directly assessed, similar to other systems of the body (e.g., heart sounds, breath sounds).

allergies

The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. These findings are characteristic of:

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

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

In order for a weight-loss program to be effective, what fat intake would be considered a low-fat diet?

Between 20% and 25% of the total calorie intake

A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate his blood pressure?

Blood pressure and pulse should be recorded in the supine, sitting, and standing positions.

A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of suicide attempts. She describes difficulty sleeping at night and has lost 10 pounds in the past month. Which of these statements or questions is the nurse's best response in this situation? a. "Do you have a weapon?" b. "How do other people treat you?" c. "Are you feeling so hopeless that you feel like hurting yourself now?" d. "People often feel hopeless, but the feelings resolve within a few weeks."

A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. For the mental status examination, the nurse should first assess the patient's: a. Affect and mood b. Memory and affect c. Language abilities d. Level of consciousness and cognitive abilities

During the interview portion of data collection, the nurse collects __________ data. a. Physical b. Historical c. Objective d. Subjective

Which of these individuals would the nurse consider at highest risk for a suicide attempt? a. Man who jokes about death b. Woman who, during a past episode of major depression, attempted suicide c. Adolescent who just broke up with her boyfriend and states that she would like to kill herself d. Older adult man who tells the nurse that he is going to "join his wife in heaven" tomorrow and plans to use a gun

The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response? a. "Maybe she is just teething." b. "I will check her ear for an ear infection." c. "Are you sure she is really having pain?" d. "Describe what she is doing to indicate she is having pain."

D Rationale: With a very young child, the parent is asked, "How do you know the child is in pain?" A young child pulling at his or her ears should alert parents to the child's ear pain. Statements about teething and questioning whether the child is really having pain do not explore the symptoms, which should be done before a physical examination.

trapezius muscle

move the shoulders and extend and turn the head

While measuring a patients blood pressure, the nurse uses the proper technique to obtain an accurate reading. Which of these situations will result in a falsely high blood pressure reading? Select all that apply.

- The person supports his or her own arm during the blood pressure reading. -The blood pressure cuff is too narrow for the extremity - The cuff is loosely wrapped around the arm. - The person is sitting with his or her legs crossed.

. A 30-year-old woman has recently moved to the United States with her husband. They are living with the womans sister until they can get a home of their own. When company arrives to visit with the womans sister, the woman feels suddenly shy and retreats to the back bedroom to hide until the company leaves. She explains that her reaction to guests is simply because she does not know how to speak perfect English. This woman could be experiencing: a. Culture shock. b. Cultural taboos. c. Cultural unfamiliarity. d. Culture disorientation.

. A woman who has lived in the United States for a year after moving from Europe has learned to speak English and is almost finished with her college studies. She now dresses like her peers and says that her family in Europe would hardly recognize her. This nurse recognizes that this situation illustrates which concept? a. Assimilation b. Heritage consistency c. Biculturalism d. Acculturation

. During a class on cultural practices, the nurse hears the term cultural taboo. Which statement illustrates the concept of a cultural taboo? a. Believing that illness is a punishment of sin b. Trying prayer before seeking medical help c. Refusing to accept blood products as part of treatment d. Stating that a childs birth defect is the result of the parents sins

. When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American-Indian patient? a. Are you of the Christian faith? b. Do you want to see a medicine man? c. How often do you seek help from medical providers? d. What cultural or spiritual beliefs are important to you?

When auscultating the blood pressure of a 25-year-old patient, the nurse notices the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patients blood pressure?

200/92

The nurse is evaluating patients for obesity-related diseases by calculating the waist-to-hip ratios. Which one of these patients would be at increased risk?

29-year-old woman whose waist measures 33 inches and hips measure 36 inches

trunk growth

during infancy what period of growth predominates?

head growth

during the fetal period what growth predominates?

The nurse has collected the following information on a patient: palpated blood pressure180 mm Hg; auscultated blood pressure170/100 mm Hg; apical pulse60 beats per minute; radial pulse70 beats per minute. What is the patients pulse pressure?

. During a follow-up visit, the nurse discovers that a patient has not been taking his insulin on a regular basis. The nurse asks, Why havent you taken your insulin? Which statement is an appropriate evaluation of this question? a. This question may place the patient on the defensive. b. This question is an innocent search for information. c. Discussing his behavior with his wife would have been better. d. A direct question is the best way to discover the reasons for his behavior.

A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination? a. Auscultate the lungs and heart while the infant is still sleeping. b. Examine the infants hips, because this procedure is uncomfortable. c. Begin with the assessment of the eye, and continue with the remainder of the examination in a head-to-toe approach. d. Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems

A female nurse is interviewing a man who has recently immigrated. During the course of the interview, he leans forward and then finally moves his chair close enough that his knees are nearly touching the nurses knees. The nurse begins to feel uncomfortable with his proximity. Which statement most closely reflects what the nurse should do next? a. The nurse should try to relax; these behaviors are culturally appropriate for this person. b. The nurse should discreetly move his or her chair back until the distance is more comfortable, and then continue with the interview. c. These behaviors are indicative of sexual aggression, and the nurse should confront this person about his behaviors. d. The nurse should laugh but tell him that he or she is uncomfortable with his proximity and ask him to move away.

A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice? a. Trained interpreter b. Male family member c. Female family member d. Volunteer college student from the foreign language studies department

A man is at the clinic for a physical examination. He states that he is very anxious about the physical examination. What steps can the nurse take to make him more comfortable? a. Appear unhurried and confident when examining him. b. Stay in the room when he undresses in case he needs assistance. c. Ask him to change into an examining gown and to take off his undergarments. d. Defer measuring vital signs until the end of the examination, which allows him time to become comfortable.

A patient describes feeling an unreasonable, irrational fear of snakes. His fear is so persistent that he can no longer comfortably look at even pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. The nurse recognizes that he: a. Has a snake phobia. b. Is a hypochondriac; snakes are usually harmless. c. Has an obsession with snakes. d. Has a delusion that snakes are harmful, which must stem from an early traumatic incident involving snakes.

A patient drifts off to sleep when she is not being stimulated. The nurse can easily arouse her by calling her name, but the patient remains drowsy during the conversation. The best description of this patient's level of consciousness would be: a. Lethargic b. Obtunded c. Stuporous d. Semialert

A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and is lethargic. The nurse's best approach regarding this examination is to: a. Plan to defer the rest of the mental status examination. b. Skip the language portion of the examination, and proceed onto assessing mood and affect. c. Conduct an in-depth speech evaluation, and defer the mental status examination to another time. d. Proceed with the examination, and assess the patient for suicidal thoughts because dysarthria is often accompanied by severe depression.

A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse's best response? a. "Can you point to where it hurts?" b. "We'll talk more about that later in the interview." c. "What have you had to eat in the last 24 hours?" d. "Have you ever had any surgeries on your abdomen?"

A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse's best course of action? a. Perform a complete mental status examination. b. Refer him to a psychometrician. c. Plan to integrate the mental status examination into the history and physical examination. d. Reassure his wife that memory loss after a physical shock is normal and will soon subside.

As the nurse enters a patients room, the nurse finds her crying. The patient states that she has just found out that the lump in her breast is cancer and says, Im so afraid of, um, you know. The nurses most therapeutic response would be to say in a gentle manner: a. Youre afraid you might lose your breast? b. No, Im not sure what you are talking about. c. Ill wait here until you get yourself under control, and then we can talk. d. I can see that you are very upset. Perhaps we should discuss this later.

During morning rounds, the nurse asks a patient, "How are you today?" The patient responds, "You today, you today, you today!" and mumbles the words. This speech pattern is an example of: a. Echolalia b. Clanging c. Word salad d. Perseveration

During reporting, the nurse hears that a patient is experiencing hallucinations. Which is an example of a hallucination? a. Man believes that his dead wife is talking to him. b. Woman hears the doorbell ring and goes to answer it, but no one is there. c. Child sees a man standing in his closet. When the lights are turned on, it is only a dry cleaning bag. d. Man believes that the dog has curled up on the bed, but when he gets closer he sees that it is a blanket.

In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking? a. Note-taking may impede the nurses observation of the patients nonverbal behaviors. b. Note-taking allows the patient to continue at his or her own pace as the nurse records what is said. c. Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level. d. Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort.

The nurse discovers speech problems in a patient during an assessment. The patient has spontaneous speech, but it is mostly absent or is reduced to a few stereotypical words or sounds. This finding reflects which type of aphasia? a. Global b. Broca's c. Dysphonic d. Wernicke's

The nurse is administering a Mini-Cog test to an older adult woman. When asked to draw a clock showing the time of 10:45, the patient drew a clock with the numbers out of order and with an incorrect time. This result indicates which finding? a. Cognitive impairment b. Amnesia c. Delirium d. Attention-deficit disorder

The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this childs respirations? a. Respirations should be counted for 1 full minute, noticing rate and rhythm. b. Childs pulse and respirations should be simultaneously checked for 30 seconds. c. Childs respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern. d. Patients respirations should be counted for 15 seconds and then multiplied by 4 to obtain the number of respirations per minute.

The nurse is interviewing a male patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient? a. Determine the communication method he prefers. b. Avoid using facial and hand gestures because most hearing-impaired people find this degrading. c. Request a sign language interpreter before meeting with him to help facilitate the communication. d. Speak loudly and with exaggerated facial movement when talking with him because doing so will help him lip read.

The nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient? a. "Do you perform testicular self-examinations?" b. "Have you ever noticed any pain in your testicles?" c. "Have you had any problems with passing urine?" d. "Do you have any history of sexually transmitted diseases?"

The nurse is performing a general survey. Which action is a component of the general survey? a. Observing the patients body stature and nutritional status b. Interpreting the subjective information the patient has reported c. Measuring the patients temperature, pulse, respirations, and blood pressure d. Observing specific body systems while performing the physical assessment

The nurse is performing a health interview on a patient who has a language barrier, and no interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation? a. Do you take medicine? b. Do you sterilize the bottles? c. Do you have nausea and vomiting? d. You have been taking your medicine, havent you?

The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: a. Is used to listen for high-pitched sounds. b. Is used to listen for low-pitched sounds. c. Should be lightly held against the persons skin to block out low-pitched sounds. d. Should be lightly held against the persons skin to listen for extra heart sounds and murmurs.

The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by the new nurse, indicates that more review is needed? a. Percussing once over each area b. Quickly lifting the striking finger after each stroke c. Striking with the fingertip, not the finger pad d. Using the wrist to make the strikes, not the arm

The nurse is reviewing the principles of nociception. During which phase of nociception does the conscious awareness of a painful sensation occur? a. Perception b. Modulation c. Transduction d. Transmission

The nurse knows that one advantage of the tympanic membrane thermometer (TMT) is that: a. Rapid measurement is useful for uncooperative younger children. b. Using the TMT is the most accurate method for measuring body temperature in newborn infants. c. Measuring temperature using the TMT is inexpensive. d. Studies strongly support the use of the TMT in children under the age 6 years.

The nurse makes which adjustment in the physical environment to promote the success of an interview? a. Reduces noise by turning off televisions and radios b. Reduces the distance between the interviewer and the patient to 2 feet or less c. Provides a dim light that makes the room cozy and helps the patient relax d. Arranges seating across a desk or table to allow the patient some personal space

To assess a rectal temperature accurately in an adult, the nurse would: a. Use a lubricated blunt tip thermometer. b. Insert the thermometer 2 to 3 inches into the rectum. c. Leave the thermometer in place up to 8 minutes if the patient is febrile. d. Wait 2 to 3 minutes if the patient has recently smoked a cigarette.

When assessing a patients pulse, the nurse should also notice which of these characteristics? a. Force b. Pallor c. Capillary refill time d. Timing in the cardiac cycle

When evaluating the temperature of older adults, the nurse should remember which aspect about an older adults body temperature? a. The body temperature of the older adult is lower than that of a younger adult. b. An older adults body temperature is approximately the same as that of a young child. c. Body temperature depends on the type of thermometer used. d. In the older adult, the body temperature varies widely because of less effective heat control mechanisms.

When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should: a. Consider this a normal finding. b. Palpate this area for an underlying mass. c. Reposition the hands, and attempt to percuss in this area again. d. Consider this finding as abnormal, and refer the patient for additional treatment.

When preparing to perform a physical examination on an infant, the nurse should: a. Have the parent remove all clothing except the diaper on a boy. b. Instruct the parent to feed the infant immediately before the examination. c. Encourage the infant to suck on a pacifier during the abdominal examination. d. Ask the parent to leave the room briefly when assessing the infants vital signs.

When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurses best response to this behavior? a. Be silent, and allow him to continue when he is ready. b. Smile at him and say, Dont worry about all of this. Im sure we can find out why youre having these pains. c. Lean back in the chair and ask, You are looking at me kind of funny; there isnt anything wrong, is there? d. Stand up and say, I can see that this interview is uncomfortable for you. We can continue it another time.

The nurse is asking a patient for his reason for seeking care and asks about the signs and symptoms he is experiencing. Which of these is an example of a symptom? a. Chest pain b. Clammy skin c. Serum potassium level at 4.2 mEq/L d. Body temperature of 100° F

A A symptom is a subjective sensation (e.g., chest pain) that a person feels from a disorder. A sign is an objective abnormality that the examiner can detect on physical examination or in laboratory reports, as illustrated by the other responses.

A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes that: a. She probably does not have any problems. b. She is only trying to shock people and that her dress should be ignored. c. She has a manic syndrome because of her abnormal dress and grooming. d. More information should be gathered to decide whether her dress is appropriate.

A 23-year-old patient in the clinic appears anxious. Her speech is rapid, and she is fidgety and in constant motion. Which of these questions or statements would be most appropriate for the nurse to use in this situation to assess attention span? a. "How do you usually feel? Is this normal behavior for you?" b. "I am going to say four words. In a few minutes, I will ask you to recall them." c. "Describe the meaning of the phrase, 'Looking through rose-colored glasses.'" d. "Pick up the pencil in your left hand, move it to your right hand, and place it on the table."

A 26-year-old woman was robbed and beaten a month ago. She is returning to the clinic today for a follow-up assessment. The nurse will want to ask her which one of these questions? a. "How are things going with the trial?" b. "How are things going with your job?" c. "Tell me about your recent engagement!" d. "Are you having any disturbing dreams?"

A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not ____ four unrelated words ____. a. Invent; within 5 minutes b. Invent; within 30 seconds c. Recall; after a 30-minute delay d. Recall; after a 60-minute delay

A 63-year-old Chinese-American man enters the hospital with complaints of chest pain, shortness of breath, and palpitations. Which statement most accurately reflects the nurses best course of action? a. The nurse should focus on performing a full cardiac assessment. b. The nurse should focus on psychosomatic complaints because the patient has just learned that his wife has cancer. c. This patient is not in any danger at present; therefore, the nurse should send him home with instructions to contact his physician. d. It is unclear what is happening with this patient; consequently, the nurse should perform an assessment in both the physical and the psychosocial realms.

A Has a change in behavior and the family is concerned

A full mental status examination should be completed if the patient: a. has a change in behavior and the family is concerned b. develops dysphagia c. has a new diagnosis of type 2 diabetes mellitus d. complains of insomnia

A Impaired short-term and long-term memory Dementia is the presence of cognitive deficits; the deficits include memory impairment. Hallucinations are a form of delirium. Delirium is a disturbance that develops over a short period of time. Delirium may be substance-induced

A major characteristic of dementia is: a. impaired short-term and long-term memory b. hallucinations c. sudden onset of symptoms d. cognitive deficits that are substance-induced

parotid gland

A male patient with a history of AIDS has come in for an examination and he states, "I think that I have the mumps." The nurse would begin by examining the:

"That 'soft spot' is normal, and actually allows for growth of the brain during the first year of your baby's life."

A mother brings her 2-month-old daughter in for an examination and says, "My daughter rolled over against the wall and now I have noticed that she has this spot that is soft on the top of her head. Is there something terribly wrong?" The nurse's best response would be:

Head circumference should be greater than chest circumference at birth.

A mother brings her newborn in for an assessment and asks, "Is there something wrong with my baby? His head seems so big." The nurse recognizes that which statement is true regarding the relative proportions of the head and trunk of the newborn?

XI; asking the patient to shrug her shoulders against resistance

A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to cranial nerve (CN) _____ and proceeds with the examination by _____.

migraine headaches

A patient complains that while studying for an examination he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. The nurse suspects that he may be suffering from:

A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the content. This behavior is a display of: a. Confusion b. Ambivalence c. Depersonalization d. Inappropriate affect

A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. During the tests of cognitive function, the nurse would expect that he: a. May display some disruption in thought content. b. Will state, "I am so relieved to be out of intensive care." c. Will be oriented to place and person, but the patient may not be certain of the date. d. May show evidence of some clouding of his level of consciousness.

parotid gland

A patient has come in for an examination and states, "I have this spot in front of my ear lobe here on my cheek that seems to be getting bigger and is tender. What do you think it is?" The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his:

A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, "I buy obie get spirding and take my train." What is the best description of this patient's problem? a. Global aphasia b. Broca's aphasia c. Echolalia d. Wernicke's aphasia

B Judgement To assess judgement in the interview, the nurse should notice what the person says about job plans, social or family obligations, and plans for the future. Job and future plans should be realistic and should take into account the person's health situation. Thought processes should be consistent, coherent, relevant, and logical. Perceptions should be congruent; the person should be consistently aware of reality. Intellectual functioning is measured by problem-solving and reasoning abilities.

A patient in whom a seizure disorder was recently diagnosed plans to continue a career as a pilot. At this time in the interview, the nurse begins to questions the patient's: a. thought process b. judgement c. perception d. intellect

cluster headaches

A patient presents with excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that lasts about 1/2 to 2 hours, occurring once or twice each day. The nurse should suspect:

A patient repeatedly seems to have difficulty coming up with a word. He says, "I was on my way to work, and when I got there, the thing that you step into that goes up in the air was so full that I decided to take the stairs." The nurse will note on his chart that he is using or experiencing: a. Blocking b. Neologism c. Circumlocution d. Circumstantiality

is mobile and not hard

A patient says that she has recently noticed a lump in the front of her neck below her "Adam's apple" that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule):

A patient states, "I feel so sad all of the time. I can't feel happy even doing things I used to like to do." He also states that he is tired, sleeps poorly, and has no energy. To differentiate between a dysthymic disorder and a major depressive disorder, the nurse should ask which question? a. "Have you had any weight changes?" b. "Are you having any thoughts of suicide?" c. "How long have you been feeling this way?" d. "Are you having feelings of worthlessness?"

had a cerebrovascular accident (stroke)

A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he has:

thyroid

A patient's laboratory data reveal an elevated thyroxine level. The nurse would proceed with an examination of the _____ gland.

soft, whooshing, pulsatile sound best heard with the bell

A patient's thyroid is enlarged, and the nurse is preparing to auscultate the thyroid for the presence of a bruit. A bruit is a __________ of the stethoscope

It is probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin.

A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give to her?

at the level of the C7 vertebra.

A physician tells the nurse that a patient's vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is the area:

the front with the nurse's thumbs placed on either side of his trachea and his head tilted forward.

A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. He would probably be most comfortable with the nurse examining his thyroid from:

myxedema

A woman comes to the clinic and states, "I've been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry." The nurse will assess for other signs and symptoms of:

The nurse is assessing a patient who is admitted with possible delirium. Which of these are manifestations of delirium? Select all that apply. a. Develops over a short period. b. Person is experiencing apraxia. c. Person is exhibiting memory impairment or deficits. d. Occurs as a result of a medical condition, such as systemic infection. e. Person is experiencing agnosia.

A, C, D

The nurse is assessing a patient's headache pain. Which questions reflect one or more of the critical characteristics of symptoms that should be assessed? Select all that apply. a. "Where is the headache pain?" b. "Did you have these headaches as a child?" c. "On a scale of 1 to 10, how bad is the pain?" d. "How often do the headaches occur?" e. "What makes the headaches feel better?" f. "Do you have any family history of headaches?"

A, C, D, E The mnemonic PQRSTU may help the nurse remember to address the critical characteristics that need to be assessed: (1) P: provocative or palliative; (2) Q: quality or quantity; (3) R: region or radiation; (4) S: severity scale; (5) T: timing; and (6) U: understand the patient's perception. Asking, "Where is the pain?" reflects "region." Asking the patient to rate the pain on a 1 to 10 scale reflects "severity." Asking "How often..." reflects "timing." Asking what makes the pain better reflects "provocative." The other options reflect health history and family history.

A mother asks when her newborn infant's eyesight will be developed. The nurse should reply:

ANS: "By about 3 months, infants develop more coordinated eye movements and can fixate on an object." Eye movements may be poorly coordinated at birth, but by 3 to 4 months of age, the infant should establish binocularity and should be able to fixate on a single image with both eyes simultaneously

When taking the history on a patient with a seizure disorder, the nurse assesses whether the patient has an *aura*. Which of these would be the best question for obtaining this information? a. "Does your muscle tone seem tense or limp?" b. "After the seizure, do you spend a lot of time sleeping?" c. "Do you have any warning sign before your seizure starts?" d. "Do you experience any color change or incontinence during the seizure?"

ANS: "Do you have any warning sign before your seizure starts?" Aura is a subjective sensation that precedes a seizure; it could be auditory, visual, or motor. The other questions are not correct regarding asking about an aura.

In obtaining a history on a 74-year-old patient the nurse notes that he *drinks alcohol daily and that he has noticed a tremor in his hands* that affects his ability to hold things. With this information, what should the nurse's response be? a. "Does your family know you are drinking every day?" b. "Does the tremor change when you drink alcohol?" c. "We'll do some tests to see what is causing the tremor." d. "You really shouldn't drink so much alcohol; it may be causing your tremor."

ANS: "Does the tremor change when you drink the alcohol?" Senile tremor is relieved by alcohol, although this is not a recommended treatment. The nurse should assess whether the person is abusing alcohol in an effort to relieve the tremor.

While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a great deal of aspirin while she was pregnant. What question would the nurse want to include in the history?

ANS: "Does your baby seem to startle with loud noise?" Children at risk for hearing deficit include those exposed in utero to a variety of conditions, such as maternal rubella, or to maternal ototoxic drugs.

The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation?

ANS: "Was there any relationship between the ear pain and the discharge you mentioned?" Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then drainage occurs

A 70-year-old woman tells the nurse that every time she gets up *in the morning or after she's been sitting she gets "really dizzy"* and feels like she is going to fall over. The nurse's best response would be: a. "Have you been extremely tired lately?" b. "You probably just need to drink more liquids." c. "I'll refer you for a complete neurologic examination." d. "You need to get up slowly when you've been lying down or sitting."

ANS: "You need to get up slowly when you've been lying or sitting." Aging is accompanied by a progressive decrease in cerebral blood flow. In some people this causes dizziness and a loss of balance with position change. These people need to be taught to get up slowly. The other responses are incorrect.

The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse?

ANS: "Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily." The infant's eustachian tube is relatively shorter and wider, and its position is more horizontal than the adult's, so it is easier for pathogens from the nasopharynx to migrate through to the middle ear. The other responses are not appropriate.

The nurse is reviewing a patient's medical record and notes that he is in a coma. Using the *Glasgow Coma Scale, which number indicates that the patient* is in a coma? a. 6 b. 12 c. 15 d. 24

ANS: 6 A fully alert, normal person has a score of 15, whereas a score of 7 or less reflects coma on the Glasgow Coma Scale. See Figure 23-59.

A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because: a. The woman could be at increased risk for infection and lesions because of her chronic disease. b. With her diabetes, she has increased circulation to her foot, and it could cause severe bleeding. c. She is 75 years old and is unable to see; consequently, she places herself at greater risk for self-injury with the scissors. d. With her peripheral vascular disease, her range of motion is limited and she may not be able to reach the corn safely.

ANS: A A personal history of diabetes and peripheral vascular disease increases a person's risk for skin lesions in the feet or ankles. The patient needs to seek a professional for assistance with corn removal.

A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding? a. Color variation b. Border regularity c. Symmetry of lesions d. Diameter of less than 6 mm

ANS: A Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.

While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in color. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition? a. Heart failure b. Venous thrombosis c. Local inflammation d. Blockage of lymphatic drainage

ANS: A Bilateral edema or edema that is generalized over the entire body is caused by a central problem such as heart failure or kidney failure. Unilateral edema usually has a local or peripheral cause.

The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find: a. Lesions that run together. b. Annular lesions that have grown together. c. Lesions arranged in a line along a nerve route. d. Lesions that are grouped or clustered together.

ANS: A Confluent lesions (as with urticaria [hives]) run together. Grouped lesions are clustered together. Annular lesions are circular in nature. Zosteriform lesions are arranged along a nerve route.

During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of: a. Dehydration. b. Irritation by gastric juices. c. A normal oral assessment. d. Side effects from nausea medication.

ANS: A Dry mouth occurs with dehydration or fever. The tongue has deep vertical fissures.

The nurse is performing an oral assessment on a 40-year-old Black patient and notices the presence of a 1 cm, nontender, grayish-white lesion on the left buccal mucosa. Which one of these statements is true? This lesion is: a. Leukoedema and is common in dark-pigmented persons. b. The result of hyperpigmentation and is normal. c. Torus palatinus and would normally be found only in smokers. d. Indicative of cancer and should be immediately tested.

ANS: A Leukoedema, a grayish-white benign lesion occurring on the buccal mucosa, is most often observed in Blacks.

The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of: a. Acquired immunodeficiency syndrome (AIDS). b. Measles. c. Leukemia. d. Carcinoma.

ANS: A Oral Kaposi's sarcoma is a bruiselike, dark red or violet, confluent macule that usually occurs on the hard palate. It may appear on the soft palate or gingival margin. Oral lesions may be among the earliest lesions to develop with AIDS.

When assessing the tongue of an adult, the nurse knows that an abnormal finding would be: a. Smooth glossy dorsal surface. b. Thin white coating over the tongue. c. Raised papillae on the dorsal surface. d. Visible venous patterns on the ventral surface.

ANS: A The dorsal surface of the tongue is normally roughened from papillae. A thin white coating may be present. The ventral surface may show veins. Smooth, glossy areas may indicate atrophic glossitis (see Table 16-5).

The nurse is examining a patient who tells the nurse, "I sure sweat a lot, especially on my face and feet but it doesn't have an odor." The nurse knows that this condition could be related to: a. Eccrine glands. b. Apocrine glands. c. Disorder of the stratum corneum. d. Disorder of the stratum germinativum.

ANS: A The eccrine glands are coiled tubules that directly open onto the skin surface and produce a dilute saline solution called sweat. Apocrine glands are primarily located in the axillae, anogenital area, nipples, and naval area and mix with bacterial flora to produce the characteristic musky body odor. The patient's statement is not related to disorders of the stratum corneum or the stratum germinativum.

The salivary gland that is the largest and located in the cheek in front of the ear is the _________ gland. a. Parotid b. Stensen's c. Sublingual d. Submandibular

ANS: A The mouth contains three pairs of salivary glands. The largest, the parotid gland, lies within the cheeks in front of the ear extending from the zygomatic arch down to the angle of the jaw. The Stensen's duct (not gland) drains the parotid gland onto the buccal mucosa opposite the second molar. The sublingual gland is located within the floor of the mouth under the tongue. The submandibular gland lies beneath the mandible at the angle of the jaw.

A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. His hair seems to be breaking off in patches, and he notices some scaling on his head. The nurse begins the examination suspecting: a. Tinea capitis. b. Folliculitis. c. Toxic alopecia. d. Seborrheic dermatitis.

ANS: A Tinea capitis is rounded patchy hair loss on the scalp, leaving broken-off hairs, pustules, and scales on the skin, and is caused by a fungal infection. Lesions are fluorescent under a Wood light and are usually observed in children and farmers; tinea capitis is highly contagious. (See Table 12-12, Abnormal Conditions of Hair, for descriptions of the other terms.)

The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient? a. "Are you aware of having any allergies?" b. "Do you have an elevated temperature?" c. "Have you had any symptoms of a cold?" d. "Have you been having frequent nosebleeds?"

ANS: A With chronic allergies, the mucosa looks swollen, boggy, pale, and gray. Elevated body temperature, colds, and nosebleeds do not cause these mucosal changes.

During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is: a. Xerosis. b. Pruritus. c. Alopecia. d. Seborrhea.

ANS: A Xerosis is the term used to describe skin that is excessively dry. Pruritus refers to itching, alopecia refers to hair loss, and seborrhea refers to oily skin.

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

ANS: A dark retinal background There is an ethnically based variability in the color of the iris and in retinal pigmentation, with darker irides having darker retinas behind them.

The nurse is performing an ear examination of an 80-year-old patient. Which of these would be considered a normal finding?

ANS: A high-tone frequency loss A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging. The pinna loses elasticity, causing earlobes to be pendulous. The eardrum may be whiter in color and more opaque and duller than in the young adult.

A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion?

ANS: A shattered look to the light rays reflecting off the cornea A corneal abrasion causes irregular ridges in reflected light, which produce a shattered look to light rays. There should be no opacities in the cornea. The other responses are not correct.

The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct? Select all that apply. a. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color b. Bulla: Elevated, circumscribed lesion filled with turbid fluid (pus) c. Papule: Hypertrophic scar d. Vesicle: Known as a friction blister e. Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm

ANS: A, D, E A pustule is an elevated, circumscribed lesion filled with turbid fluid (pus). A hypertrophic scar is a keloid. A bulla is larger than 1 cm and contains clear fluid. A papule is solid and elevated but measures less than 1 cm.

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

ANS: Acute alcohol intoxication During the finger-to-finger test, if the person has clumsy movement with overshooting the mark, either a cerebellar disorder or acute alcohol intoxication should be suspected. The person's movements should be smooth and accurate. The other options are not correct.

The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure?

ANS: Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber Intraocular pressure is determined by a balance between the amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber. The other responses are incorrect.

The nurse is examining a patient's retina with an ophthalmoscope. Which finding is considered normal?

ANS: An optic disc that is a yellow-orange color The optic disc is located on the nasal side of the retina. It is a creamy yellow-orange to pink color, and the edges are distinct and sharply demarcated, not blurred. A pigmented crescent is black, and it is due to the accumulation of pigment in the choroid.

An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. Additional information the nurse would need to know includes which of these?

ANS: Any prolonged exposure to extreme cold Frostbite causes reddish-blue discoloration and swelling of the auricle after exposure to extreme cold. Vesicles or bullae may develop, and the person feels pain and tenderness.

To test for *gross motor skill and coordination of a 6-year-old child*, which of these techniques would be appropriate? a. Hop on one foot. b. Stand on his head. c. Touch his finger to his nose. d. Make "funny" faces at the nurse.

ANS: Ask child to hop on one foot. Normally a child can hop on one foot and can balance on one foot for about 5 seconds by 4 years of age, and can balance on one foot for 8 to 10 seconds at 5 years of age. Children enjoy performing these tests. Failure to hop after 5 years of age indicates incoordination of gross motor skill. Touching the finger to the nose checks fine motor coordination. Having the child make "funny" faces tests cranial nerve VII. It is not appropriate to ask a child to stand on his or her head.

During an assessment the nurse notices that an elderly patient has tears rolling down his face from his left eye. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling "dry and itchy." Which action by the nurse is correct?

ANS: Assess for other signs of ectropion. The condition described is known as ectropion, and it occurs in aging due to atrophy of elastic and fibrous tissues. The lower lid does not approximate to the eyeball, and, as a result, the puncta cannot siphon tears effectively, and excessive tearing results. Ptosis is drooping of the upper eyelid. These are not signs of a foreign body in the eye or basal cell carcinoma.

The nurse *places a key in the hand of a patient and he identifies it as a penny*. What term would the nurse use to describe this finding? a. Extinction b. Astereognosis c. Graphesthesia d. Tactile discrimination

ANS: Astereognosis Stereognosis is the person's ability to recognize objects by feeling their forms, sizes, and weights. Astereognosis is an inability to identify objects correctly, and it occurs in sensory cortex lesions. Tactile discrimination tests fine touch. Extinction tests the person's ability to feel sensations on both sides of the body at the same point.

A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. The nurse suspects that this coloring is due to: a. Polycythemia. b. Carbon monoxide poisoning. c. Carotenemia. d. Uremia.

ANS: B A bright cherry-red coloring in the face, upper torso, nail beds, lips, and oral mucosa appears in cases of carbon monoxide poisoning.

A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition? a. Acne b. Basal cell carcinoma c. Melanoma d. Squamous cell carcinoma

ANS: B Basal cell carcinoma usually starts as a skin-colored papule that develops rounded, pearly borders with a central red ulcer. It is the most common form of skin cancer and grows slowly. This description does not fit acne lesions. (See Table 12-11 for descriptions of melanoma and squamous cell carcinoma.)

During an oral examination of a 4-year-old Native-American child, the nurse notices that her uvula is partially split. Which of these statements is accurate? a. This condition is a cleft palate and is common in Native Americans. b. A bifid uvula may occur in some Native-American groups. c. This condition is due to an injury and should be reported to the authorities. d. A bifid uvula is palatinus, which frequently occurs in Native Americans.

ANS: B Bifid uvula, a condition in which the uvula is split either completely or partially, occurs in some Native-American groups.

A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds areas of buccal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is: a. Aphthous ulcers. b. Candidiasis. c. Leukoplakia. d. Koplik spots.

ANS: B Candidiasis is a white, cheesy, curdlike patch on the buccal mucosa and tongue. It scrapes off, leaving a raw, red surface that easily bleeds. It also occurs after the use of antibiotics or corticosteroids and in persons who are immunosuppressed. (See Table 16-4 for descriptions of the other lesions.)

A 22-year-old woman comes to the clinic because of severe sunburn and states, "I was out in the sun for just a couple of minutes." The nurse begins a medication review with her, paying special attention to which medication class? a. Nonsteroidal antiinflammatory drugs for pain b. Tetracyclines for acne c. Proton pump inhibitors for heartburn d. Thyroid replacement hormone for hypothyroidism

ANS: B Drugs that may increase sunlight sensitivity and give a burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.

A mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects: a. Eczema. b. Impetigo. c. Herpes zoster. d. Diaper dermatitis.

ANS: B Impetigo is moist, thin-roofed vesicles with a thin erythematous base and is a contagious bacterial infection of the skin and most common in infants and children. Eczema is characterized by erythematous papules and vesicles with weeping, oozing, and crusts. Herpes zoster (i.e., chickenpox or varicella) is characterized by small, tight vesicles that are shiny with an erythematous base. Diaper dermatitis is characterized by red, moist maculopapular patches with poorly defined borders.

When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process? a. Teeth appearing shorter b. Tongue that looks smoother in appearance c. Buccal mucosa that is beefy red in appearance d. Small, painless lump on the dorsum of the tongue

ANS: B In the aging adult, the tongue looks smoother because of papillary atrophy. The teeth are slightly yellowed and appear longer because of the recession of gingival margins.

During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patient's scleras are not yellow. From this finding, the nurse could probably rule out: a. Pallor b. Jaundice c. Cyanosis d. Iron deficiency

ANS: B Jaundice is exhibited by a yellow color, which indicates rising levels of bilirubin in the blood. Jaundice is first noticed in the junction of the hard and soft palate in the mouth and in the scleras.

The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS) and notices multiple patchlike lesions on the temple and beard area that are faint pink in color. The nurse recognizes these lesions as: a. Measles (rubeola). b. Kaposi's sarcoma. c. Angiomas. d. Herpes zoster.

ANS: B Kaposi's sarcoma is a vascular tumor that, in the early stages, appears as multiple, patchlike, faint pink lesions over the patient's temple and beard areas. Measles is characterized by a red-purple maculopapular blotchy rash that appears on the third or fourth day of illness. The rash is first observed behind the ears, spreads over the face, and then spreads over the neck, trunk, arms, and legs. Cherry (senile) angiomas are small (1 to 5 mm), smooth, slightly raised bright red dots that commonly appear on the trunk in all adults over 30 years old. Herpes zoster causes vesicles up to 1 cm in size that are elevated with a cavity containing clear fluid.

A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull's eye pattern across his midriff and behind his knees. The nurse suspects: a. Rubeola. b. Lyme disease. c. Allergy to mosquito bites. d. Rocky Mountain spotted fever.

ANS: B Lyme disease occurs in people who spend time outdoors in May through September. The first disease state exhibits the distinctive bull's eye and a red macular or papular rash that radiates from the site of the tick bite with some central clearing. The rash spreads 5 cm or larger, and is usually in the axilla, midriff, inguinal, or behind the knee, with regional lymphadenopathy.

A woman who is in the second trimester of pregnancy mentions that she has had "more nosebleeds than ever" since she became pregnant. The nurse recognizes that this is a result of: a. A problem with the patient's coagulation system. b. Increased vascularity in the upper respiratory tract as a result of the pregnancy. c. Increased susceptibility to colds and nasal irritation. d. Inappropriate use of nasal sprays.

ANS: B Nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity in the upper respiratory tract.

A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would: a. Tell the patient to watch the lesion and report back in 2 months. b. Refer the patient because of the suggestion of melanoma on the basis of her symptoms. c. Ask additional questions regarding environmental irritants that may have caused this condition. d. Tell the patient that these signs suggest a compound nevus, which is very common in young to middle-aged adults.

ANS: B The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, the development of itching, burning, and bleeding, or a new-pigmented lesion. Any one of these signs raises the suggestion of melanoma and warrants immediate referral.

The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct? a. Inserting the speculum at least 3 cm into the vestibule b. Avoiding touching the nasal septum with the speculum c. Gently displacing the nose to the side that is being examined d. Keeping the speculum tip medial to avoid touching the floor of the nares

ANS: B The correct technique for using an otoscope is to insert the apparatus into the nasal vestibule, avoiding pressure on the sensitive nasal septum. The tip of the nose should be lifted up before inserting the speculum.

The primary purpose of the ciliated mucous membrane in the nose is to: a. Warm the inhaled air. b. Filter out dust and bacteria. c. Filter coarse particles from inhaled air. d. Facilitate the movement of air through the nares.

ANS: B The nasal hairs filter the coarsest matter from inhaled air, whereas the mucous blanket filters out dust and bacteria. The rich blood supply of the nasal mucosa warms the inhaled air.

The nurse keeps in mind that a thorough skin assessment is extremely important because the skin holds information about a person's: a. Support systems. b. Circulatory status. c. Socioeconomic status. d. Psychological wellness.

ANS: B The skin holds information about the body's circulation, nutritional status, and signs of systemic diseases, as well as topical data on the integumentary system itself.

In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is correct response to these findings? a. Refer the patient to a throat specialist. b. No response is needed; this appearance is normal for the tonsils. c. Continue with the assessment, looking for any other abnormal findings. d. Obtain a throat culture on the patient for possible streptococcal (strep) infection.

ANS: B The tonsils are the same color as the surrounding mucous membrane, although they look more granular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood until puberty and then involutes.

The nurse is assessing a patient who has liver disease for jaundice. Which of these assessment findings is indicative of true jaundice? a. Yellow patches in the outer sclera b. Yellow color of the sclera that extends up to the iris c. Skin that appears yellow when examined under low light d. Yellow deposits on the palms and soles of the feet where jaundice first appears

ANS: B The yellow sclera of jaundice extends up to the edge of the iris. Calluses on the palms and soles of the feet often appear yellow but are not classified as jaundice. Scleral jaundice should not be confused with the normal yellow subconjunctival fatty deposits that are common in the outer sclera of dark-skinned persons.

While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response? a. "While sitting up, place a cold compress over your nose." b. "Sit up with your head tilted forward and pinch your nose." c. "Just allow the bleeding to stop on its own, but don't blow your nose." d. "Lie on your back with your head tilted back and pinch your nose."

ANS: B With a nosebleed, the person should sit up with the head tilted forward and pinch the nose between the thumb and forefinger for 5 to 15 minutes.

While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess? a. Nutritional status b. When the patient first noticed the lesion c. Whether the patient has had a recent cold d. Whether the patient has had any recent exposure to sick animals

ANS: B With carcinoma, the initial lesion is round and indurated, but then it becomes crusted and ulcerated with an elevated border. Most cancers occur between the outer and middle thirds of the lip. Any lesion that is still unhealed after 2 weeks should be referred.

An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination? a. Smooth mucous membranes and lips b. Dry mucous membranes and cracked lips c. Pale mucous membranes d. White patches on the mucous membranes

ANS: B With dehydration, mucous membranes appear dry and the lips look parched and cracked. The other responses are not found in dehydration.

During an assessment, a patient mentions that "I just can't smell like I used to. I can barely smell the roses in my garden. Why is that?" For which possible causes of changes in the sense of smell will the nurse assess? Select all that apply. a. Chronic alcohol use b. Cigarette smoking c. Frequent episodes of strep throat d. Chronic allergies e. Aging f. Herpes simplex virus I

ANS: B, D, E The sense of smell diminishes with cigarette smoking, chronic allergies, and aging. Chronic alcohol use, a history of strep throat, and herpes simplex virus I are not associated with changes in the sense of smell.

The nurse is teaching a health class to high-school boys. When discussing the topic of using smokeless tobacco (SLT), which of these statements are accurate? Select all that apply. a. One pinch of SLT in the mouth for 30 minutes delivers the equivalent of one cigarette. b. Using SLT has been associated with a greater risk of oral cancer than smoking. c. Pain is an early sign of oral cancer. d. Pain is rarely an early sign of oral cancer. e. Tooth decay is another risk of SLT because of the use of sugar as a sweetener. f. SLT is considered a healthy alternative to smoking.

ANS: B, D, E One pinch of SLT in the mouth for 30 minutes delivers the equivalent of three cigarettes. Pain is rarely an early sign of oral cancer. Many brands of SLT are sweetened with sugars, which promotes tooth decay. SLT is not considered a healthy alternative to smoking, and the use of SLT has been associated with a greater risk of oral cancer than smoking.

A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer. Which of these findings are characteristic of a stage II pressure ulcer? Select all that apply. a. Intact skin appears red but is not broken. b. Partial thickness skin erosion is observed with a loss of epidermis or dermis. c. Ulcer extends into the subcutaneous tissue. d. Localized redness in light skin will blanch with fingertip pressure. e. Open blister areas have a red-pink wound bed. f. Patches of eschar cover parts of the wound.

ANS: B, E Stage I pressure ulcers have intact skin that appears red but is not broken, and localized redness in intact skin will blanche with fingertip pressure. Stage II pressure ulcers have partial thickness skin erosion with a loss of epidermis or also the dermis; open blisters have a red-pink wound bed. Stage III pressure ulcers are full thickness, extending into the subcutaneous tissue; subcutaneous fat may be seen but not muscle, bone, or tendon. Stage IV pressure ulcers involve all skin layers and extend into supporting tissue, exposing muscle, bone, and tendon. Slough (stringy matter attached to the wound bed) or eschar (black or brown necrotic tissue) may be present.

During the history of a 78-year-old man, his wife states that he occasionally has *problems with short-term memory loss and confusion: "He can't even remember how to button his shirt*." In doing the assessment of his sensory system, which action by the nurse is most appropriate? a. The nurse would not test the sensory system as part of the examination because the results would not be valid. b. The nurse would perform the tests, knowing that mental status does not affect sensory ability. c. The nurse would proceed with an explanation of each test, making certain that the wife understands. d. Before testing, the nurse would assess the patient's mental status and ability to follow directions.

ANS: Before testing, the nurse would assess the patient's mental status and ability to follow directions at this time. The nurse should ensure validity of the sensory system testing by making sure the patient is alert, cooperative, comfortable, and has an adequate attention span. Otherwise, the nurse may obtain misleading and invalid results.

During an otoscopic examination, the nurse notices an area of black and white dots on the tympanic membrane and ear canal wall. What does this finding suggest?

ANS: Blood in the middle ear A colony of black or white dots on the drum or canal wall suggests a yeast or fungal infection (otomycosis).

The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal?

ANS: Bloody or clear watery drainage can indicate a basal skull fracture. Frank blood or clear watery drainage (cerebrospinal leak) after trauma suggests a basal skull fracture and warrants immediate referral. Purulent drainage indicates otitis externa or otitis media.

The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? a. "We will need to get a biopsy to determine the cause." b. "This is an overgrowth of hair and will go away in a few days." c. "Black, hairy tongue is a fungal infection caused by all the antibiotics you have received." d. "This is probably caused by the same bacteria you had in your lungs."

ANS: C A black, hairy tongue is not really hair but the elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue. It occurs after the use of antibiotics, which inhibit normal bacteria and allow a proliferation of fungus.

A patient comes in for a physical examination and complains of "freezing to death" while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to: a. Venous pooling. b. Peripheral vasodilation. c. Peripheral vasoconstriction. d. Decreased arterial perfusion.

ANS: C A chilly or air-conditioned environment causes vasoconstriction, which results in false pallor and coolness (see Table 12-1).

A 13-year-old girl is interested in obtaining information about the cause of her acne. The nurse should share with her that acne: a. Is contagious. b. Has no known cause. c. Is caused by increased sebum production. d. Has been found to be related to poor hygiene.

ANS: C Approximately 90% of males and 80% of females will develop acne; causes are increased sebum production and epithelial cells that do not desquamate normally.

The nurse is assessing for inflammation in a dark-skinned person. Which technique is the best? a. Assessing the skin for cyanosis and swelling b. Assessing the oral mucosa for generalized erythema c. Palpating the skin for edema and increased warmth d. Palpating for tenderness and local areas of ecchymosis

ANS: C Because inflammation cannot be seen in dark-skinned persons, palpating the skin for increased warmth, for taut or tightly pulled surfaces that may be indicative of edema, and for a hardening of deep tissues or blood vessels is often necessary.

A 42-year-old woman complains that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse expects that the spots are probably: a. Anasarca. b. Scleroderma. c. Senile angiomas. d. Latent myeloma.

ANS: C Cherry (senile) angiomas are small, smooth, slightly raised bright red dots that commonly appear on the trunk of adults over 30 years old.

The nurse is assessing a 3 year old for "drainage from the nose." On assessment, a purulent drainage that has a very foul odor is noted from the left naris and no drainage is observed from the right naris. The child is afebrile with no other symptoms. What should the nurse do next? a. Refer to the physician for an antibiotic order. b. Have the mother bring the child back in 1 week. c. Perform an otoscopic examination of the left nares. d. Tell the mother that this drainage is normal for a child of this age.

ANS: C Children are prone to put an object up the nose, producing unilateral purulent drainage with a foul odor. Because some risk for aspiration exists, removal should be prompt.

During an assessment of a 26 year old at the clinic for "a spot on my lip I think is cancer," the nurse notices a group of clear vesicles with an erythematous base around them located at the lip-skin border. The patient mentions that she just returned from Hawaii. What would be the most appropriate response by the nurse? a. Tell the patient she needs to see a skin specialist. b. Discuss the benefits of having a biopsy performed on any unusual lesion. c. Tell the patient that these vesicles are indicative of herpes simplex I or cold sores and that they will heal in 4 to 10 days. d. Tell the patient that these vesicles are most likely the result of a riboflavin deficiency and discuss nutrition.

ANS: C Cold sores are groups of clear vesicles with a surrounding erythematous base. These evolve into pustules or crusts and heal in 4 to 10 days. The most likely site is the lip-skin junction. Infection often recurs in the same site. Recurrent herpes infections may be precipitated by sunlight, fever, colds, or allergy.

The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition? a. Severe obesity b. Childhood growth spurts c. Severe dehydration d. Connective tissue disorders such as scleroderma

ANS: C Decreased skin turgor is associated with severe dehydration or extreme weight loss.

Immediately after birth, the nurse is unable to suction the nares of a newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next? a. Attempt to suction again with a bulb syringe. b. Wait a few minutes, and try again once the infant stops crying. c. Recognize that this situation requires immediate intervention. d. Contact the physician to schedule an appointment for the infant at his or her next hospital visit.

ANS: C Determining the patency of the nares in the immediate newborn period is essential because most newborns are obligate nose breathers. Nares blocked with amniotic fluid are gently suctioned with a bulb syringe. If obstruction is suspected, then a small lumen (5 to 10 Fr) catheter is passed down each naris to confirm patency. The inability to pass a catheter through the nasal cavity indicates choanal atresia, which requires immediate intervention.

A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings? a. Epistaxis b. Rhinorrhea c. Dysphagia d. Xerostomia

ANS: C Dysphagia is difficulty with swallowing and may occur with a variety of disorders, including stroke and other neurologic diseases. Rhinorrhea is a runny nose, epistaxis is a bloody nose, and xerostomia is a dry mouth.

A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During the assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment aware that another finding may be: a. Keratoses. b. Xerosis. c. Chloasma. d. Acrochordons.

ANS: C In pregnancy, skin changes can include striae, linea nigra (a brownish-black line down the midline), chloasma (brown patches of hyperpigmentation), and vascular spiders. Keratoses are raised, thickened areas of pigmentation that look crusted, scaly, and warty. Xerosis is dry skin. Acrochordons, or skin tags, occur more often in the aging adult.

A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, "What causes these liver spots?" The nurse tells her, "They are: a. "Signs of decreased hematocrit related to anemia." b. "Due to the destruction of melanin in your skin from exposure to the sun." c. "Clusters of melanocytes that appear after extensive sun exposure." d. "Areas of hyperpigmentation related to decreased perfusion and vasoconstriction."

ANS: C Liver spots, or senile lentigines, are clusters of melanocytes that appear on the forearms and dorsa of the hands after extensive sun exposure. The other responses are not correct.

A black patient is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patient's skin? a. Ruddy blue. b. Generalized pallor. c. Ashen, gray, or dull. d. Patchy areas of pallor.

ANS: C Pallor attributable to shock, with decreased perfusion and vasoconstriction, in black-skinned people will cause the skin to appear ashen, gray, or dull (see Table 12-2).

A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say, "The physician is referring to the: a. "Blue dilation of blood vessels in a star-shaped linear pattern on the legs." b. "Fiery red, star-shaped marking on the cheek that has a solid circular center." c. "Confluent and extensive patch of petechiae and ecchymoses on the feet." d. "Tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color."

ANS: C Purpura is a confluent and extensive patch of petechiae and ecchymoses and a flat macular hemorrhage observed in generalized disorders such as thrombocytopenia and scurvy. The blue dilation of blood vessels in a star-shaped linear pattern on the legs describes a venous lake. The fiery red, star-shaped marking on the cheek that has a solid circular center describes a spider or star angioma. The tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color describes petechiae.

A patient has been admitted for severe psoriasis. The nurse expects to see what finding in the patient's fingernails? a. Splinter hemorrhages b. Paronychia c. Pitting d. Beau lines

ANS: C Sharply defined pitting and crumbling of the nails, each with distal detachment characterize pitting nails and are associated with psoriasis. (See Table 12-13 for descriptions of the other terms.)

A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has: a. Posterior epistaxis. b. Frontal sinusitis. c. Maxillary sinusitis. d. Nasal polyps.

ANS: C Signs of maxillary sinusitis include facial pain after upper respiratory infection, red swollen nasal mucosa, swollen turbinates, and purulent discharge. The person also has fever, chills, and malaise. With maxillary sinusitis, dull throbbing pain occurs in the cheeks and teeth on the same side, and pain with palpation is present. With frontal sinusitis, pain is above the supraorbital ridge.

During an oral assessment of a 30-year-old Black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding? a. Check the patient's hemoglobin for anemia. b. Assess for other signs of insufficient oxygen supply. c. Proceed with the assessment, knowing that this appearance is a normal finding. d. Ask if he has been exposed to an excessive amount of carbon monoxide.

ANS: C Some Blacks may have bluish lips and a dark line on the gingival margin; this appearance is a normal finding.

A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. The nurse's best response would be: a. "How many teeth did you have at this age?" b. "All 20 deciduous teeth are expected to erupt by age 4 years." c. "This is a normal number of teeth for an 18 month old." d. "Normally, by age 2 years, 16 deciduous teeth are expected."

ANS: C The guidelines for the number of teeth for children younger than 2 years old are as follows: the child's age in months minus the number 6 should be equal to the expected number of deciduous teeth. Normally, all 20 teeth are in by 2 years old. In this instance, the child is 18 months old, minus 6, equals 12 deciduous teeth expected.

The projections in the nasal cavity that increase the surface area are called the: a. Meatus. b. Septum. c. Turbinates. d. Kiesselbach plexus.

ANS: C The lateral walls of each nasal cavity contain three parallel bony projections: the superior, middle, and inferior turbinates. These increase the surface area, making more blood vessels and mucous membrane available to warm, humidify, and filter the inhaled air.

A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors? a. Subcutaneous fat deposits are high in the newborn. b. Sebaceous glands are overproductive in the newborn. c. The newborn's skin is more permeable than that of the adult. d. The amount of vernix caseosa dramatically rises in the newborn.

ANS: C The newborn's skin is thin, smooth, and elastic and is relatively more permeable than that of the adult; consequently, the infant is at greater risk for fluid loss. The subcutaneous layer in the infant is inefficient, not thick, and the sebaceous glands are present but decrease in size and production. Vernix caseosa is not produced after birth.

The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. During an inspection of his mouth, the nurse should look for: a. Swollen, red tonsils. b. Ulcerations on the hard palate. c. Bruising on the buccal mucosa or gums. d. Small yellow papules along the hard palate.

ANS: C The nurse should notice any bruising or laceration on the buccal mucosa or gums of an infant or young child. Trauma may indicate child abuse from a forced feeding of a bottle or spoon.

The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient? a. Hypertrophy of the gums b. Increased production of saliva c.Decreased ability to identify odors d. Finer and less prominent nasal hair

ANS: C The sense of smell may be reduced because of a decrease in the number of olfactory nerve fibers. Nasal hairs grow coarser and stiffer with aging. The gums may recede with aging, not hypertrophy, and saliva production decreases.

A patient has been diagnosed with strep throat. The nurse is aware that without treatment, which complication may occur? a. Rubella b. Leukoplakia c. Rheumatic fever d. Scarlet fever

ANS: C Untreated strep throat may lead to rheumatic fever. When performing a health history, the patient should be asked whether his or her sore throat has been documented as streptococcal.

A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is: a. Caused by an excess of melanin pigment b. Caused by an excess of apocrine glands in her feet c. Caused by the complete absence of melanin pigment d. Related to impetigo and can be treated with an ointment

ANS: C Vitiligo is the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orifices—otherwise, the depigmented skin is normal.

A 10 year old is at the clinic for "a sore throat that has lasted 6 days." Which of these findings would be consistent with an acute infection? a. Tonsils 1+/1-4+ and pink; the same color as the oral mucosa b. Tonsils 2+/1-4+ with small plugs of white debris c. Tonsils 3+/1-4+ with large white spots d. Tonsils 3+/1-4+ with pale coloring

ANS: C With an acute infection, tonsils are bright red and swollen and may have exudate or large white spots. Tonsils are enlarged to 2+, 3+, or 4+ with an acute infection.

The nurse is reviewing the function of the cranial nerves. Which of the cranial nerves is responsible for conducting nerve impulses to the brain from the organ of Corti?

ANS: CN VIII The nerve impulses are conducted by the auditory portion of CN VIII to the brain.

A 30-year-old woman tells the nurse that she has been very *unsteady and has had difficulty in maintaining her balance*. Which area of the brain would the nurse be concerned about with these findings? a. Thalamus b. Brainstem c. Cerebellum d. Extrapyramidal tract

ANS: Cerebellum The cerebellar system coordinates movement, maintains equilibrium, and helps maintain posture. The thalamus is the main relay station where sensory pathways of the spinal cord, cerebellum, and brainstem for synapses on their way to the cerebral cortex. The brainstem consists of the midbrain, pons, and medulla and has various functions, especially concerning autonomic centers. The extrapyramidal tract maintains muscle tone for gross automatic movements, such as walking.

The nurse knows that determining whether a person is *oriented to his or her surroundings will test the functioning* of which of these structures? a. Cerebrum b. Cerebellum c. CNs d. Medulla oblongata

ANS: Cerebrum The cerebral cortex is responsible for thought, memory, reasoning, sensation, and voluntary movement. The other options structures are not responsible for a person's level of consciousness.

The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct?

ANS: Cerumen is necessary for transmitting sound through the auditory canal. The ear is lined with glands that secrete cerumen, which is a yellow waxy material that lubricates and protects the ear.

A 50-year-old woman is in the clinic for *weakness in her left arm and leg that she has noticed for the past week*. The nurse should perform which type of neurologic examination? a. Glasgow Coma Scale b. Neurologic recheck examination c. Screening neurologic examination d. Complete neurologic examination

ANS: Complete neurologic examination The nurse should perform a complete neurologic examination on persons who have neurologic concerns (e.g., headache, weakness, loss of coordination) or who have shown signs of neurologic dysfunction. The Glasgow Coma scale is used to define a person's level of consciousness. The neurologic recheck examination is appropriate for persons with demonstrated neurologic deficits. The screening neurologic examination is performed on seemingly well persons who have no significant subjective findings from the history.

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

ANS: Constriction of both pupils occurs in response to bright light. The pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina. The other responses are not correct.

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

ANS: Convergence of the axes of the eyes The accommodation reaction includes pupillary constriction and convergence of the axes of the eyes. The other responses are not correct.

A mother brings her 4-month-old infant to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since 1 month of age. The infant has no health problems. On physical examination, the nurse notices a 0.5-cm, fleshy, elevated area in the middle of the upper lip. No evidence of inflammation or drainage is observed. What would the nurse tell this mother? a. "This area of irritation is caused from teething and is nothing to worry about." b. "This finding is abnormal and should be evaluated by another health care provider." c. "This area of irritation is the result of chronic drooling and should resolve within the next month or two." d. "This elevated area is a sucking tubercle caused from the friction of breastfeeding or bottle-feeding and is normal."

ANS: D A normal finding in infants is the sucking tubercle, a small pad in the middle of the upper lip from the friction of breastfeeding or bottle-feeding. This condition is not caused by irritation, teething, or excessive drooling, and evaluation by another health care provider is not warranted.

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a: a. Bulla. b. Wheal. c. Nodule. d. Papule.

ANS: D A papule is something one can feel, is solid, elevated, circumscribed, less than 1 cm in diameter, and is due to superficial thickening in the epidermis. A bulla is larger than 1 cm, superficial, and thin walled. A wheal is superficial, raised, transient, erythematous, and irregular in shape attributable to edema. A nodule is solid, elevated, hard or soft, and larger than 1 cm.

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult? a. Increased vascularity of the skin b. Increased numbers of sweat and sebaceous glands c. An increase in elastin and a decrease in subcutaneous fat d. An increased loss of elastin and a decrease in subcutaneous fat

ANS: D An accumulation of factors place the aging person at risk for skin disease and breakdown: the thinning of the skin, a decrease in vascularity and nutrients, the loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, the social changes of aging, a increasingly sedentary lifestyle, and the chance of immobility.

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding? a. Anasarca b. Scleroderma c. Pedal erythema d. Clubbing of the nails

ANS: D Clubbing of the nails occurs with congenital cyanotic heart disease and neoplastic and pulmonary diseases. The other responses are assessment findings not associated with pulmonary diseases.

A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and takes oral hypoglycemic agents. The patient needs to be concerned about which possible effect of her medications? a. Increased possibility of bruising b. Skin sensitivity as a result of exposure to salt water c. Lack of availability of glucose-monitoring supplies d. Importance of sunscreen and avoiding direct sunlight

ANS: D Drugs that may increase sunlight sensitivity and give a burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.

A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition is due to hyperemia and knows that it can be caused by: a. Decreased amounts of bilirubin in the blood b. Excess blood in the underlying blood vessels c. Decreased perfusion to the surrounding tissues d. Excess blood in the dilated superficial capillaries

ANS: D Erythema is an intense redness of the skin caused by excess blood (hyperemia) in the dilated superficial capillaries.

A 32-year-old woman is at the clinic for "little white bumps in my mouth." During the assessment, the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient? a. "These spots i ndicate an infection such as strep throat." b. "These bumps could be indicative of a serious lesion, so I will refer you to a specialist." c. "This condition is called leukoplakia and can be caused by chronic irritation such as with smoking." d. "These bumps are Fordyce granules, which are sebaceous cysts and are not a serious condition."

ANS: D Fordyce granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and are not significant. Chalky, white raised patches would indicate leukoplakia. In strep throat, the examiner would see tonsils that are bright red, swollen, and may have exudates or white spots.

A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started bleeding. What would be an appropriate response by the nurse? a. "Your condition is probably due to a vitamin C deficiency." b. "I'm not sure what causes swollen and bleeding gums, but let me know if it's not better in a few weeks." c. "You need to make an appointment with your dentist as soon as possible to have this checked." d. "Swollen and bleeding gums can be caused by the change in hormonal balance in your system during pregnancy."

ANS: D Gum margins are red and swollen and easily bleed with gingivitis. A changing hormonal balance may cause this condition to occur in pregnancy and puberty.

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

ANS: D In the aging hair matrix, the number of functioning melanocytes decreases; as a result, the hair looks gray or white and feels thin and fine. The other options are not correct.

The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, "I think she is getting her first tooth because she has started drooling a lot." The nurse's best response would be: a. "You're right, drooling is usually a sign of the first tooth." b. "It would be unusual for a 3 month old to be getting her first tooth." c. "This could be the sign of a problem with the salivary glands." d. "She is just starting to salivate and hasn't learned to swallow the saliva."

ANS: D In the infant, salivation starts at 3 months. The baby will drool for a few months before learning to swallow the saliva. This drooling does not herald the eruption of the first tooth, although many parents think it does.

A patient has had a "terrible itch" for several months that he has been continuously scratching. On examination, the nurse might expect to find: a. A keloid. b. A fissure. c. Keratosis. d. Lichenification.

ANS: D Lichenification results from prolonged, intense scratching that eventually thickens the skin and produces tightly packed sets of papules. A keloid is a hypertrophic scar. A fissure is a linear crack with abrupt edges, which extends into the dermis; it can be dry or moist. Keratoses are lesions that are raised, thickened areas of pigmentation that appear crusted, scaly, and warty.

A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration. The nurse should test skin mobility and turgor over the infant's: a. Sternum. b. Forehead. c. Forearms. d. Abdomen.

ANS: D Mobility and turgor are tested over the abdomen in an infant. Poor turgor, or tenting, indicates dehydration or malnutrition. The other sites are not appropriate for checking skin turgor in an infant.

The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which statement is true in relation to a newborn infant? a. Sphenoid sinuses are full size at birth. b. Maxillary sinuses reach full size after puberty. c. Frontal sinuses are fairly well developed at birth. d. Maxillary and ethmoid sinuses are the only sinuses present at birth.

ANS: D Only the maxillary and ethmoid sinuses are present at birth. The sphenoid sinuses are minute at birth and develop after puberty. The frontal sinuses are absent at birth, are fairly well developed at age 7 to 8 years, and reach full size after puberty.

A newborn infant has Down syndrome. During the skin assessment, the nurse notices a transient mottling in the trunk and extremities in response to the cool temperature in the examination room. The infant's mother also notices the mottling and asks what it is. The nurse knows that this mottling is called: a. Café au lait. b. Carotenemia. c. Acrocyanosis. d. Cutis marmorata.

ANS: D Persistent or pronounced cutis marmorata occurs with infants born with Down syndrome or those born prematurely and is a transient mottling in the trunk and extremities in response to cool room temperatures. A café au lait spot is a large round or oval patch of light-brown pigmentation. Carotenemia produces a yellow-orange color in light-skinned persons. Acrocyanosis is a bluish color around the lips, hands and fingernails, and feet and toenails.

While obtaining a health history from the mother of a 1-year-old child, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, "It makes a great pacifier." The best response by the nurse would be: a. "You're right. Bottles make very good pacifiers." b. "Using a bottle as a pacifier is better for the teeth than thumb-sucking." c. "It's okay to use a bottle as long as it contains milk and not juice." d. "Prolonged use of a bottle can increase the risk for tooth decay and ear infections."

ANS: D Prolonged bottle use during the day or when going to sleep places the infant at risk for tooth decay and middle ear infections.

A man has come in to the clinic for a skin assessment because he is worried he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and "stuck on" his skin. Which is the best prediction? a. Senile lentigines, which do not become cancerous b. Actinic keratoses, which are precursors to basal cell carcinoma c. Acrochordons, which are precursors to squamous cell carcinoma d. Seborrheic keratoses, which do not become cancerous

ANS: D Seborrheic keratoses appear like dark, greasy, "stuck-on" lesions that primarily develop on the trunk. These lesions do not become cancerous. Senile lentigines are commonly called liver spots and are not precancerous. Actinic (senile or solar) keratoses are lesions that are red-tan scaly plaques that increase over the years to become raised and roughened. They may have a silvery-white scale adherent to the plaque. They occur on sun-exposed surfaces and are directly related to sun exposure. They are premalignant and may develop into squamous cell carcinoma. Acrochordons are skin tags and are not precancerous.

The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis: a. Contains mostly fat cells. b. Consists mostly of keratin. c. Is replaced every 4 weeks. d. Contains sensory receptors.

ANS: D The dermis consists mostly of collagen, has resilient elastic tissue that allows the skin to stretch, and contains nerves, sensory receptors, blood vessels, and lymphatic vessels. It is not replaced every 4 weeks.

The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is: a. Highly vascular. b. Thick and tough. c. Thin and nonstratified. d. Replaced every 4 weeks.

ANS: D The epidermis is thin yet tough, replaced every 4 weeks, avascular, and stratified into several zones.

The tissue that connects the tongue to the floor of the mouth is the: a. Uvula. b. Palate. c. Papillae. d. Frenulum.

ANS: D The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth. The uvula is the free projection hanging down from the middle of the soft palate. The palate is the arching roof of the mouth. Papillae are the rough, bumpy elevations on the tongue's dorsal surface.

During a checkup, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray because of her allergies. She also states that it does not work as well as it used to when she first started using it. The best response by the nurse would be: a. "You should never use over-the-counter nasal sprays be cause of the risk of addiction." b. "You should try switching to another brand of medication to prevent this problem." c. "Continuing to use this spray is important to keep your allergies under control." d. "Using these nasal medications irritates the lining of the nose and may cause rebound swelling."

ANS: D The misuse of over-the-counter nasal medications irritates the mucosa, causing rebound swelling, which is a common problem.

The nurse is assessing for clubbing of the fingernails and expects to find: a. Nail bases that are firm and slightly tender. b. Curved nails with a convex profile and ridges across the nails. c. Nail bases that feel spongy with an angle of the nail base of 150 degrees. d. Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy.

ANS: D The normal nail is firm at its base and has an angle of 160 degrees. In clubbing, the angle straightens to 180 degrees or greater and the nail base feels spongy.

A mother brings her child into the clinic for an examination of the scalp and hair. She states that the child has developed irregularly shaped patches with broken-off, stublike hair in some places; she is worried that this condition could be some form of premature baldness. The nurse tells her that it is: a. Folliculitis that can be treated with an antibiotic. b. Traumatic alopecia that can be treated with antifungal medications. c. Tinea capitis that is highly contagious and needs immediate attention. d. Trichotillomania; her child probably has a habit of absentmindedly twirling her hair.

ANS: D Trichotillomania, self-induced hair loss, is usually due to habit. It forms irregularly shaped patches with broken-off, stublike hairs of varying lengths. A person is never completely bald. It occurs as a child absentmindedly rubs or twirls the area while falling asleep, reading, or watching television. (See Table 12-12, Abnormal Conditions of Hair, for descriptions of the other terms.)

The nurse is performing an assessment. Which of these findings would cause the greatest concern? a. Painful vesicle inside the cheek for 2 days b. Presence of moist, nontender Stensen's ducts c. Stippled gingival margins that snugly adhere to the teeth d. Ulceration on the side of the tongue with rolled edges

ANS: D Ulceration on the side or base of the tongue or under the tongue raises the suspicion of cancer and must be investigated. The risk of early metastasis is present because of rich lymphatic drainage. The vesicle may be an aphthous ulcer, which is painful but not dangerous. The other responses are normal findings.

The nurse notices that a school-aged child has bluish-white, red-based spots in her mouth that are elevated approximately 1 to 3 mm. What other signs would the nurse expect to find in this patient? a. Pink, papular rash on the face and neck b. Pruritic vesicles over her trunk and neck c. Hyperpigmentation on the chest, abdomen, and back of the arms d. Red-purple, maculopapular, blotchy rash behind the ears and on the face

ANS: D With measles (rubeola), the examiner assesses a red-purple, blotchy rash on the third or fourth day of illness that appears first behind the ears, spreads over the face, and then over the neck, trunk, arms, and legs. The rash appears coppery and does not blanch. The bluish-white, red-based spots in the mouth are known as Koplik spots.

A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in the health history would be: a. "Do you use a fluoride supplement?" b. "Have you had tonsillitis in the last year?" c. "At what age did you get your first tooth?" d. "Have you noticed any dryness in your mouth?"

ANS: D Xerostomia (dry mouth) is a side effect of many drugs taken by older people, including antidepressants, anticholinergics, antispasmodics, antihypertensives, antipsychotics, and bronchodilators.

Which of these tests would the nurse use to check the *motor coordination of an 11-month-old* infant? a. Denver II b. Stereognosis c. Deep tendon reflexes d. Rapid alternating movements

ANS: Denver II To screen gross and fine motor coordination, the nurse should use the Denver II with its age-specific developmental milestones. Stereognosis tests a person's ability to recognize objects by feeling them, and is not appropriate for an 11-month-old infant. Testing of the deep tendon reflexes is not appropriate for checking motor coordination. Testing rapid alternating movements is appropriate for testing coordination in adults.

During an ophthalmoscopic examination of the eye, the nurse notices areas of exudate that look like "cotton wool" or fluffy gray-white cumulus clouds. This finding indicates which possible problem?

ANS: Diabetes Soft exudates or "cotton wool" areas look like fluffy gray-white cumulus clouds, They occur with diabetes, hypertension, subacute bacterial endocarditis, lupus, and papilledema of any cause. These exudates are not found with hyperthyroidism, glaucoma, or hypotension.

A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying "I'm just getting old!" After the nurse completes a thorough neurologic assessment, which findings would be indicative of *Alzheimer's disease*? Select all that apply. a. Occasionally forgetting names or appointments b. Difficulty performing familiar tasks, such as placing a telephone call c. Misplacing items, such as putting dish soap in the refrigerator d. Sometimes having trouble finding the right word e. Rapid mood swings, from calm to tears, for no apparent reason f. Getting lost in one's own neighborhood

ANS: Difficulty performing familiar tasks, such as placing a telephone call Misplacing items, such as putting dish soap in the refrigerator Rapid mood swings, from calm to tears, for no apparent reason Getting lost in one's own neighborhood Difficulty performing familiar tasks, misplacing items, rapid mood swings, and getting lost in one's own neighborhood can be warning signs of Alzheimer's disease. Occasionally forgetting names or appointments, and sometimes having trouble finding the right word are part of normal aging. For other examples see Table 23-2.

The nurse is doing an assessment on a 29-year-old woman who visits the clinic complaining of "always dropping things and falling down." While testing rapid alternating movements, the nurse notices that the woman is *unable to pat both her knees*. Her response is very slow and she misses frequently. What should the nurse suspect? a. Vestibular disease b. Lesion of CN IX c. Dysfunction of the cerebellum d. Inability to understand directions

ANS: Dysfunction of the cerebellum When a person performs rapid, alternating movements, slow, clumsy, and sloppy responses occur with cerebellar disease. The other responses are incorrect.

When examining a patient's eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system:

ANS: Elevates the eyelid and dilates the pupil. Stimulation of the sympathetic branch of the autonomic nervous system dilates the pupil and elevates the eyelid. Parasympathetic nervous system stimulation causes the pupil to constrict. The muscle fibers of the iris contract the pupil in bright light to accommodate for near vision. The ciliary body controls the thickness of the lens.

In an individual with otitis externa, which of these signs would the nurse expect to find on assessment?

ANS: Enlarged superficial cervical nodes The lymphatic drainage of the external ear flows to the parotid, mastoid, and superficial cervical nodes. The signs are severe swelling of the canal, inflammation, and tenderness. Rhinorrhea, periorbital edema, and pain over the maxillary sinuses do not occur with otitis externa.

When the nurse is testing the *triceps reflex*, what is the expected response a. Flexion of the hand b. Pronation of the hand c. Extension of the forearm d. Flexion of the forearmse? not on powerpoint

ANS: Extension of the forearm The normal response of the triceps reflex is extension of the forearm. The normal response of the biceps reflex causes flexion of the forearm. The other responses are incorrect.

A patient's vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient:

ANS: Has poor vision. Normal visual acuity is 20/20 in each eye. The larger the denominator, the poorer the vision.

In assessing a 70-year-old patient who has had a recent *cerebrovascular accident, the nurse notices right-sided weakness*. What might the nurse expect to find when testing his reflexes on the right side? a. Lack of reflexes b. Normal reflexes c. Diminished reflexes d. Hyperactive reflexes

ANS: Hyperactive reflexes Hyperreflexia is the exaggerated reflex seen when the monosynaptic reflex arc is released from the influence of higher cortical levels. This occurs with upper motor neuron lesions (e.g., a cerebrovascular accident). The other responses are incorrect.

In a person with an *upper motor neuron lesion such as a cerebrovascular accident*, which of these physical assessment findings should the nurse expect to see? a. Hyperreflexia b. Fasciculations c. Loss of muscle tone and flaccidity d. Atrophy and wasting of the muscles

ANS: Hyperreflexia Hyperreflexia, diminished or absent superficial reflexes, and increased muscle tone or spasticity can be expected with upper motor neuron lesions. The other options reflect a lesion of lower motor neurons. See Table 23-7.

The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane?

ANS: Hypomobility An early sign of otitis media is hypomobility of the tympanic membrane. As pressure increases, the tympanic membrane begins to bulge.

A 59-year-old patient has a *herniated intervertebral disc*. Which of the following findings should the nurse expect to see on physical assessment of this individual? a. Hyporeflexia b. Increased muscle tone c. Positive Babinski sign d. Presence of pathologic reflexes

ANS: Hyporeflexia With a herniated intervertebral disk or lower motor neuron lesion there is loss of tone, flaccidity, atrophy, fasciculations, and hyporeflexia or areflexia. No Babinski's sign or pathologic reflexes would be seen. The other options reflect a lesion of upper motor neurons. See Table 23-7.

During an assessment of a 22-year-old woman who has a head injury from a car accident 4 hours ago, the nurse notices the following change: *pupils were equal, but now the right pupil is fully dilated and nonreactive, left pupil is 4 mm and reacts to light*. What does finding this suggest? a. Injury to the right eye b. Increased intracranial pressure c. Test inaccurately performed d. Normal response after a head injury

ANS: Increased intracranial pressure In a brain-injured person, a sudden, unilateral, dilated, and nonreactive pupil is ominous. Cranial nerve III runs parallel to the brainstem. When increasing intracranial pressure pushes the brainstem down (uncal herniation), it puts pressure on cranial nerve III, causing pupil dilation. The other responses are incorrect.

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

ANS: Is expected. The palpebral fissure is the elliptical open space between the eyelids, and, when closed, the lid margins approximate completely, which is a normal finding.

The nurse is reviewing the structures of the ear. Which of these statements concerning the eustachian tube is true?

ANS: It helps equalize air pressure on both sides of the tympanic membrane. The eustachian tube allows equalization of air pressure on each side of the tympanic membrane so that the membrane does not rupture (e.g., during altitude changes in an airplane). The tube is normally closed, but it opens with swallowing or yawning.

The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction?

ANS: It is the normal pathway for hearing. The normal pathway of hearing is air conduction, which starts when sound waves produce vibrations on the tympanic membrane. Conductive hearing loss results from a mechanical dysfunction of the external or middle ear.

A 52-year-old patient describes the presence of occasional "floaters" or "spots" moving in front of his eyes. The nurse should:

ANS: Know that floaters are usually not significant and are caused by condensed vitreous fibers. Floaters are a common sensation with myopia or after middle age owing to condensed vitreous fibers. Usually they are not significant, but acute onset of floaters may occur with retinal detachment.

While gathering equipment after an injection, *a nurse accidentally received a prick* from an improperly capped needle. To interpret this sensation, which of these areas must be intact? Not on powerpoint a. Corticospinal tract, medulla, and basal ganglia b. Pyramidal tract, hypothalamus, and sensory cortex c. Lateral spinothalamic tract, thalamus, and sensory cortex d. Anterior spinothalamic tract, basal ganglia, and sensory cortex

ANS: Lateral spinothalamic tract, thalamus, and sensory cortex The spinothalamic tract contains sensory fibers that transmit the sensations of pain, temperature, and crude or light touch. Fibers carrying pain and temperature sensations ascend the lateral spinothalamic tract, whereas those of crude touch form the anterior spinothalamic tract. At the thalamus, the fibers synapse with another sensory neuron, which carries the message to the sensory cortex for full interpretation. The other options are not correct.

The nurse is caring for a patient who has *just had neurosurgery. To assess for increased intracranial pressure*, what would the nurse include in the assessment? a. CNs, motor function, and sensory function b. Deep tendon reflexes, vital signs, and coordinated movements c. Level of consciousness, motor function, pupillary response, and vital signs d. Mental status, deep tendon reflexes, sensory function, and pupillary response

ANS: Level of consciousness, motor function, pupillary response, and vital signs Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process. These people must be monitored closely for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure. The nurse should use an abbreviation of the neurologic examination in the following sequence: level of consciousness, motor function, pupillary response, and vital signs.

The nurse is reviewing for a class in age-related changes in the eye. Which of these physiological changes is responsible for presbyopia?

ANS: Loss of lens elasticity The lens loses elasticity and decreases its ability to change shape to accommodate for near vision. This condition is called presbyopia.

During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to *relax his muscles completely. The nurse then moves each extremity through full range of motion*. Which of these results would the nurse expect to find? a. Firm, rigid resistance to movement b. Mild, even resistance to movement c. Hypotonic muscles as a result of total relaxation d. Slight pain with some directions of movement

ANS: Mild, even resistance to movement Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It shows a mild resistance to passive stretch. Normally, the nurse will notice a mild, even resistance to movement. The other responses are not correct.

During an assessment of the cranial nerves, the nurse finds the following: *asymmetry when the patient smiles or frowns, uneven lifting of eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek*. This would indicate dysfunction of which of these cranial nerves? a. Motor component of CN IV b. Motor component of CN VII c. Motor and sensory components of CN XI d. Motor component of CN X and sensory component of CN VII

ANS: Motor component of VII The findings listed reflect a dysfunction of the motor component of cranial nerve VII, the facial nerve.

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says he "can't always tell where the sound is coming from" and the words often sound "mixed up." What might the nurse suspect as the cause for this change?

ANS: Nerve degeneration in the inner ear Presbycusis is a type of hearing loss that occurs in 60% of those older than 65 years of age, even in people living in a quiet environment. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear. Words sound garbled, and the ability to localize sound is impaired also. This communication dysfunction is accentuated when background noise is present.

A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, "I don't know what the matter is. All of a sudden, I can't hear you out of my left ear!" What should the nurse do next?

ANS: Notify the patient's health care provider. Any sudden loss of hearing in one or both ears, that is not associated with an upper respiratory infection, needs to be reported at once to the patient's health care provider. Hearing loss associated with trauma is often sudden. It is not appropriate to irrigate the ear or remove cerumen at this time.

A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this?

ANS: Observe the distance between the palpebral fissures. Ptosis is drooping of the upper eyelid that would be apparent by observing the distance between the upper and lower eyelids. The confrontation test measures peripheral vision. Measuring near vision or the corneal light test does not check for ptosis.

The nurse is performing the diagnostic positions test. Normal findings would be which of these results?

ANS: Parallel movement of both eyes A normal response for the diagnostic positions test is parallel tracking of the object with both eyes. Eye movement that is not parallel indicates weakness of an extraocular muscle or dysfunction of the cranial nerve innervating it.

The nurse is conducting a child safety class for new mothers. Which of these is a risk factor for ear infections in young children?

ANS: Passive cigarette smoke Exposure to passive and gestational smoke is a risk factor for ear infections in infants and children.

The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the *patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae*. Given this information, what would the nurse suspect? a. Hyperalgesia b. Hyperesthesia c. Peripheral neuropathy d. Lesion of sensory cortex

ANS: Peripheral neuropathy Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism). Peripheral neuropathy is worse at the feet and gradually improves as the examiner moves up the leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome.

The nurse is testing superficial reflexes on an adult patient. When *stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes*. How should the nurse document this finding? not on powerpoint a. Positive Babinski sign b. Plantar reflex abnormal c. Plantar reflex present d. Plantar reflex 2+ on a scale from "0 to 4+"

ANS: Plantar reflex present With the same instrument, the nurse should draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot, like an upside-down "J." The normal response is plantar flexion of the toes and sometimes of the whole foot. A positive Babinski sign is abnormal and occurs with the response of dorsiflexion of the big toe and fanning of all toes. The plantar reflex is not graded on a 0 to 4+ scale.

The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which of these reflects correct procedure?

ANS: Pull the pinna down. For an otoscopic examination, pull the pinna down on an infant and a child under 3 years of age. The other responses are not part of the correct procedure.

The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?

ANS: Pull the pinna up and back before inserting the speculum. Pull the pinna up and back on an adult or older child. This helps straighten the S-shape of the canal. Traction should not be released on the ear until the examination is completed and the otoscope is removed.

The nurse is testing a patient's visual accommodation, which refers to which action?

ANS: Pupillary constriction when looking at a near object The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision, which also results in pupil constriction. The other responses are not correct.

To assess the *head control of a 4-month-old infant, the nurse lifts the infant up in a prone position while supporting his chest*. The nurse looks for what normal response? a. Raises the head, and arches the back. b. Extends the arms, and drops down the head. c. Flexes the knees and elbows with the back straight. d. Holds the head at 45 degrees, and keeps the back straight

ANS: Raises head and arches back At 3 months of age, the infant raises the head and arches the back as if in a swan dive. This is the Landau reflex, which persists until 1 1/2 years of age. The other responses are incorrect. See Figure 23-43.

In the assessment of a 1-month-old infant, the nurse notices a *lack of response to noise or stimulation*. The mother reports that in the last week he has been sleeping all the time, and when he is awake all he does is cry. The nurse hears that the *infant's cries are very high pitched and shrill*. What should be the nurse's appropriate response to these findings? . Refer the infant for further testing. b. Talk with the mother about eating habits. c. Do nothing; these are expected findings for an infant this age. d. Tell the mother to bring the baby back in 1 week for a recheck.

ANS: Refer the infant for further testing. A high-pitched, shrill cry or cat-sounding screech occurs with central nervous system damage. Lethargy, hyporeactivity, hyperirritability, and parent's report of significant change in behavior all warrant referral. The other options are not correct responses.

While obtaining a history of a 3-month-old infant from the mother, the nurse asks about the infant's *ability to suck and grasp the mother's finger*. What is the nurse assessing? a. Reflexes b. Intelligence c. CNs d. Cerebral cortex function

ANS: Reflexes Questions regarding reflexes include such questions as "What have you noticed about the infant's behavior," "Do the infant's sucking and swallowing seem coordinated," and "Does the infant grasp your finger?" The other responses are incorrect.

A 21-year-old patient has a *head injury resulting from trauma* and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes? a. Reflexes will be normal. b. Reflexes cannot be elicited. c. All reflexes will be diminished but present. d. Some reflexes will be present, depending on the area of injury.

ANS: Reflexes will be normal. A reflex is a defense mechanism of the nervous system. It operates below the level of conscious control and permits a quick reaction to potentially painful or damaging situations.

A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these statements is correct regarding the significance of this in relation to the infant's hearing?

ANS: Rubella can damage the infant's organ of Corti, which will impair hearing. If maternal rubella infection occurs during the first trimester, then it can damage the organ of Corti and impair hearing

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

ANS: Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction. To test the pupillary light reflex, the nurse should advance a light in from the side and note the direct and consensual pupillary constriction.

A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next?

ANS: Shorten the distance between the patient and the chart until it is seen and record that distance. If the person is unable to see even the largest letters, then the nurse should shorten the distance to the chart until it is seen and should record that distance (e.g., "10/200"). If visual acuity is even lower, then the nurse should assess whether the person can count fingers when they are spread in front of the eyes or can distinguish light perception from a penlight. If vision is poorer than 20/30, then a referral to an ophthalmologist or optometrist is necessary, but first the nurse must assess the visual acuity.

A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks his *left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step*. What type of gait disturbance is this individual experiencing? a. Scissors gait b. Cerebellar ataxia c. Parkinsonian gait d. Spastic hemiparesis

ANS: Spastic hemiparesis With spastic hemiparesis, the arm is immobile against the body. There is flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder, which does not swing freely. The leg is stiff and extended and circumducts with each step. Causes of this type of gait include cerebrovascular accident. See Table 23-6 for more information and for descriptions of the other abnormal gaits.

During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:

ANS: Stimulated by cranial nerves III, IV, and VI. Movement of the extraocular muscles is stimulated by three cranial nerves: III, IV, and VI.

During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus?

ANS: The absence of drainage from the puncta when pressing against the inner orbital rim There should be no swelling, redness, or drainage from the puncta when it is pressed. Regurgitation of fluid from the puncta, when pressed, indicates duct blockage. The lacrimal glands are not functional at birth.

A patient has a *severed spinal nerve* as a result of trauma. Which of these statements is true in this situation? a. Because there are 31 pairs of spinal nerves, no effect results if only one nerve is severed. b. The dermatome served by this nerve will no longer experience any sensation. c. The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve. d. A severed spinal nerve will only affect motor function of the patient because spinal nerves have no sensory component

ANS: The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve. A dermatome is a circumscribed skin area that is supplied mainly from one spinal cord segment through a particular spinal nerve. The dermatomes overlap, which is a form of biologic insurance. That is, if one nerve is severed, most of the sensations can be transmitted by the spinal nerve above and spinal nerve below.

Which of these statements *concerning areas of the brain* is true? a. The cerebellum is the center for speech and emotions. b. The hypothalamus controls body temperature and regulates sleep. c. The basal ganglia are responsible for controlling voluntary movements. d. Motor pathways of the spinal cord and brainstem synapse in the thalamus.

ANS: The hypothalamus controls temperature and regulates sleep. The hypothalamus is a vital area with many important functions: temperature controller, sleep center, anterior and posterior pituitary gland regulator, and coordinator of autonomic nervous system activity and emotional status. The cerebellum controls motor coordination, equilibrium, and balance. The basal ganglia control autonomic movements of the body. The motor pathways of the spinal cord synapse in various areas of the spinal cord, not the thalamus.

The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true?

ANS: The image formed on the retina is upside down and reversed from its actual appearance in the outside world. The image formed on the retina is upside down and reversed from its actual appearance in the outside world. The light rays are refracted through the transparent media of the eye before striking the retina, and the nerve impulses are conducted through the optic nerve tract to the visual cortex of the occipital lobe of the brain. The left side of the brain interprets vision for the right eye.

The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response?

ANS: The infant turns the head to localize sound. With a loud sudden noise, the nurse should notice the infant turning his or her head to localize sound and responding to his or her own name. A startle reflex and acoustic blink reflex is expected in newborns; at age 3 to 4 months, the infant stops movements and appears to listen.

The nurse is preparing to perform an otoscopic examination of a newborn infant. Which statement is true regarding this examination?

ANS: The normal membrane may appear thick and opaque. During the first few days, the tympanic membrane often looks thickened and opaque. It may look "injected" and have a mild redness from increased vascularity. The other statements are not correct.

The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true?

ANS: The outer layer of the eye is very sensitive to touch. The cornea and the sclera make up the outer layer of the eye. The cornea is very sensitive to touch. The middle layer, the choroid, has dark pigmentation to prevent light from reflecting internally. The trigeminal (CN V) and facial (CN VII) are stimulated when the outer surface of the eye is stimulated. The retina, in the inner layer of the eye, is where light waves are changed into nerve impulses.

A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:

ANS: The patient can read at 20 feet what a person with normal vision can read at 30 feet. The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see.

During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma? Select all that apply.

ANS: The patient experiences tunnel vision in late stages. Vision loss begins with peripheral vision. There are virtually no symptoms. Open-angle glaucoma is the most common type of glaucoma; there are virtually no symptoms. Vision loss begins with the peripheral vision, which often goes unnoticed because individuals learn to compensate intuitively by turning their heads. The other characteristics are those of closed-angle glaucoma.

Which of these statements about the *peripheral nervous system* is correct? a. The CNs enter the brain through the spinal cord. b. Efferent fibers carry sensory input to the central nervous system through the spinal cord. c. The peripheral nerves are inside the central nervous system and carry impulses through their motor fibers. d. The peripheral nerves carry input to the central nervous system by afferent fibers and away by efferent fibers

ANS: The peripheral nerves carry input to the central nervous system by afferent fibers and away by efferent fibers. A nerve is a bundle of fibers outside the central nervous system. The peripheral nerves carry input to the central nervous system by their sensory afferent fibers and deliver output from the central nervous system by the efferent fibers.

During an assessment of the sclera of an African-American patient, the nurse would consider which of these an expected finding?

ANS: The presence of small brown macules on the sclera In dark-skinned people, one normally may see small brown macules in the sclera.

The nurse is testing the hearing of a 78-year-old man and keeps in mind the changes in hearing that occur with aging include which of the following? Select all that apply.

ANS: The progression is slow. The aging person may find it harder to hear consonants than vowels Sounds may be garbled and difficult to localize Presbycusis is a type of hearing loss that occurs with aging and is found in 60% of those older than 65 years. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve, and it slowly progresses after age 50. The person first notices a high-frequency tone loss; it is harder to hear consonants (high-pitched components of speech) than vowels. This makes words sound garbled. The ability to localize sound is impaired also.

The mother of a 2-year-old is concerned about the upcoming placement of tympanostomy tubes in her son's ears. The nurse would include which of these statements in the teaching plan?

ANS: The purpose of the tubes is to decrease the pressure and allow for drainage. Polyethylene tubes are inserted surgically into the eardrum to relieve middle ear pressure and to promote drainage of chronic or recurrent middle ear infections. Tubes extrude spontaneously in 6 months to 1 year.

A patient with *lack of oxygen to his heart will have pain in his chest and possibly the shoulder, arms, or jaw*. The nurse knows that the statement that best explains why this occurs is which of these? a. A problem exists with the sensory cortex and its ability to discriminate the location. b. The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing the pain. c. The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere. d. A lesion has developed in the dorsal root, which is preventing the sensation from being transmitted normally.

ANS: The sensory cortex does not have the ability to localize pain in the heart, so the pain is felt elsewhere. The sensory cortex is arranged in a specific pattern, forming a corresponding "map" of the body. Pain in the right hand is perceived at a specific spot on the map. Some organs are absent from the brain map, such as the heart, liver, and spleen. Pain originating in these organs is referred because no felt image exists in which to have pain. Pain is felt "by proxy" by another body part that does have a felt image. The other responses are not correct explanations.

During the assessment of an 80-year-old patient, the nurse notices that his *hands show tremors when he reaches for something and his head is always nodding*. There is no associated rigidity with movement. Which of these statements is most accurate? Not on powerpoint a. These findings are normal, resulting from aging. b. These findings could be related to hyperthyroidism. c. These findings are the result of Parkinson disease. d. This patient should be evaluated for a cerebellar lesion.

ANS: These are normal findings resulting from aging. Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson disease include rigidity, slowness, and weakness of voluntary movement. The other responses are incorrect.

During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding?

ANS: This is a normal finding and no further follow-up is necessary. Asians and Native Americans are more likely to have dry cerumen, whereas African Americans and Caucasians usually have wet cerumen.

During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient *responds to pain by extending, adducting, and internally rotating his arms. His palms pronate and his lower extremities extend with plantar flexion*. Which of these statements about these findings is accurate? a. Indicates a lesion of the cerebral cortex. b. Indicates a completely nonfunctional brainstem. c. Is normal and will go away in 24 to 48 hours. d. Is a very ominous sign and may indicate brainstem injury.

ANS: This is a very ominous sign and may indicate brainstem injury. These findings are all indicative of decerebrate rigidity, which is a very ominous condition and may indicate a brainstem injury.

The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception the nurse decides to complete the test as quickly as possible. When the nurse *applies the sharp point of the pin on his arm several times*, he is only able to identify these as one "very sharp prick." What would be the most accurate explanation for this? Not on powerpoint a. The patient has hyperesthesia as a result of the aging process. b. This response is most likely the result of the summation effect. c. The nurse was probably not poking hard enough with the pin in the other areas. d. The patient most likely has analgesia in some areas of arm and hyperalgesia in others.

ANS: This is most likely the result of the *summation effect*. Let at least 2 seconds elapse between each stimulus to avoid summation. With summation, frequent consecutive stimuli are perceived as one strong stimulus. The other responses are incorrect.

During an examination, the nurse notices *severe nystagmus in both eyes of a patient*. Which of these conclusions by the nurse is correct? a. Is a normal occurrence. b. May indicate disease of the cerebellum or brainstem. c. Is a sign that the patient is nervous about the examination. d. Indicates a visual problem, and a referral to an ophthalmologist is indicated.

ANS: This may indicate disease of the cerebellum or brainstem. End-point nystagmus at an extreme lateral gaze occurs normally. The nurse should assess any other nystagmus carefully. Severe nystagmus occurs with disease of the vestibular system, cerebellum, or brainstem.

While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: *abduction and flexion of arms and legs; fanning of fingers, and curling of index and thumb in a C position followed by infant bringing in arms and legs to body*. What does the nurse know about this response? Not on powerpoint a. This response could indicate brachial nerve palsy. b. This reaction is an expected startle response at this age. c. This reflex should have disappeared between 1 and 4 months of age. d. This response is normal as long as the movements are bilaterally symmetric.

ANS: This reflex should have disappeared between 1 and 4 months of age. The Moro reflex is present at birth and disappears at 1 to 4 months. Absence of the Moro reflex in the newborn or persistence after 5 months of age indicates severe central nervous system injury. The other responses are incorrect.

A colleague is assessing an 80-year-old patient who has ear pain and asks him to hold his nose and swallow. The nurse knows that which of the following is true concerning this technique?

ANS: This should not be used in an 80-year-old patient. The eardrum is flat, slightly pulled in at the center, and flutters when the person performs the Valsalva maneuver or holds the nose and swallows (insufflation). One may elicit these maneuvers to assess drum mobility. However, these maneuvers should be avoided with an aging person because they may disrupt equilibrium.

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

ANS: Unequal pupillary constriction in response to light Pupils are small in old age, and the pupillary light reflex may be slowed, but pupillary constriction should be symmetric. The assessment findings in the other responses are considered normal in older persons.

The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed?

ANS: Use the Snellen chart positioned 20 feet away from the patient. The Snellen alphabet chart is the most commonly used and most accurate measure of visual acuity. The confrontation test is a gross measure of peripheral vision. The Jaeger card or newspaper tests are used to test near vision.

In performing a voice test to assess hearing, which of these actions would the nurse do? A) Shield the lips so that the sound is muffled.

ANS: Whisper a set of random numbers and letters and ask the patient to repeat them. With your head 30 to 60 cm (1 to 2 ft) from the person's ear, exhale and whisper slowly a set of random numbers and letters, such as "5, B, 6." Normally, the person repeats each number and letter correctly after you say it.

The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a *light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient's toes fan out*, and the big toe shows dorsiflexion. The nurse interprets this result as: a. Negative Babinski sign, which is normal for adults. b. Positive Babinski sign, which is abnormal for adults. c. Clonus, which is a hyperactive response. d. Achilles reflex, which is an expected response.

ANS: a *positive Babinski's sign*, which is abnormal for adults. Dorsiflexion of the big toe and fanning of all toes is a positive Babinski's sign, also called "upgoing toes." This occurs with upper motor neuron disease of the corticospinal (or pyramidal) tract and is an abnormal finding for adults.

While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is not visible. The nurse interprets these findings to indicate:

ANS: acute otitis media. Absent or distorted light reflex and a bright red color of the eardrum are indicative of acute otitis media. See Table 15-5 for descriptions of the other conditions.

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

ANS: ask the patient if he or she has a history of heart failure. Periorbital edema occurs with local infections, crying, and systemic conditions such as heart failure, renal failure, allergy, and hypothyroidism. Periorbital edema is not associated with blepharitis.

The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When *striking the Achilles and quadriceps*, the nurse is unable to elicit a reflex. The nurse's next response should be to: Not on powerpoint a. Ask the patient to lock her fingers and pull. b. Complete the examination, and then test these reflexes again. c. Refer the patient to a specialist for further testing. d. Document these reflexes as 0 on a scale of 0 to 4+.

ANS: ask the patient to lock her fingers and "pull." Sometimes the reflex response fails to appear. It is too soon to document this as "absent" reflexes. Try further encouragement of relaxation, varying the person's position or increasing the strength of the blow. Reinforcement is another technique to relax the muscles and enhance the response. Ask the person to perform an isometric exercise in a muscle group somewhat away from the one being tested. For example, to enhance a patellar reflex, ask the person to lock the fingers together and "pull."

A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to:

ANS: ask the patient what medications he is currently taking. A simple increase in amplitude may not enable the person to understand words. Sensorineural hearing loss may be caused by presbycusis, which is a gradual nerve degeneration that occurs with aging and by ototoxic drugs, which affect the hair cells in the cochlea.

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

ANS: auricle. The external ear is called the auricle or pinna and consists of movable cartilage and skin.

Two parts of the *nervous system* are the: a. Motor and sensory. b. Central and peripheral. c. Peripheral and autonomic. d. Hypothalamus and cerebral.

ANS: central and peripheral. The nervous system can be divided into two parts—central and peripheral. The central nervous system includes the brain and spinal cord. The peripheral nervous system includes the 12 pairs of cranial nerves, the 31 pairs of spinal nerves, and all their branches.

A 32-year-old woman tells the nurse that she has noticed "*very sudden, jerky movements" mainly in her hands and arms. She says, "They seem to come and go, primarily when I am trying to do something. I haven't noticed them when I'm sleeping*." This description suggests: a. Tics. b. Athetosis. c. Myoclonus. d. Chorea.

ANS: chorea. Chorea is characterized by sudden, rapid, jerky, purposeless movements that involve the limbs, trunk, or face. Chorea occurs at irregular intervals, and the movements are all accentuated by voluntary actions. See Table 23-5 for descriptions of athetosis, myoclonus, and tics.

A patient with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the patient that the middle ear functions to:

ANS: conduct vibrations of sounds to the inner ear. Among its other functions, the middle ear conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear. The other responses are not functions of the middle ear.

A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would:

ANS: consider this a normal finding. By 2 to 4 weeks an infant can fixate on an object. By the age of 1 month, the infant should fixate and follow a bright light or toy.

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should:

ANS: consider this a normal finding. Reflection of the light on the corneas should be in exactly the same spot on each eye, or symmetric. If asymmetry is noted, then the nurse should administer the cover test.

In using the ophthalmoscope to assess a patient's eyes, the nurse notices a red glow in the patient's pupils. On the basis of this finding, the nurse would:

ANS: consider this a normal reflection of the ophthalmoscope light off the inner retina. The red glow filling the person's pupil is the red reflex, and it is a normal finding caused by the reflection of the ophthalmoscope light off the inner retina. The other responses are not correct.

The ability that humans have to perform *very skilled movements such as writing* is controlled by the: Not on powerpoint a. Basal ganglia. b. Corticospinal tract. c. Spinothalamic tract. d. Extrapyramidal tract.

ANS: corticospinal tract. Corticospinal fibers mediate voluntary movement, particularly very skilled, discrete, purposeful movements, such as writing. The corticospinal tract (also known as the pyramidal tract) is a newer, "higher" motor system that humans have that permits very skilled and purposeful movements. The other responses are not related to skilled movements.

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

ANS: could be a potential carcinoma and should be referred. An ulcerated crusted nodule with an indurated base that fails to heal is characteristic of a carcinoma. These lesions fail to heal and bleed intermittently. Individuals with such symptoms should be referred for a biopsy. The other responses are not correct. See Table 15-2.

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

ANS: dacryocystitis. A hordeolum, or stye, is a painful, red, and swollen pustule at the lid margin. A chalazion is a nodule protruding on the lid, toward the inside, and is nontender, firm, with discrete swelling. Dacryocystitis is an inflammation of the lacrimal sac. Blepharitis is inflammation of the eyelids. See Table 14-3.

While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, *he tells the nurse that he is on a cruise ship and is 30 years old*. The nurse knows that this finding is indicative of: a. Great sense of humor. b. Uncooperative behavior. c. Inability to understand questions. d. Decreased level of consciousness.

ANS: decreased level of consciousness. A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. The other responses are incorrect.

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

ANS: frontal The frontal lobe has areas concerned with personality, behavior, emotions, and intellectual function. The parietal lobe has areas concerned with sensation; the occipital lobe is responsible for visual reception; and the temporal lobe is concerned with hearing, taste and smell.

An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates:

ANS: increased intracranial pressure. Papilledema, or choked disk, is a serious sign of increased intracranial pressure, which is caused by a space-occupying mass such as a brain tumor or hematoma. This pressure causes venous stasis in the globe, showing redness, congestion, and elevation of the optic disc, blurred margins, hemorrhages, and absent venous pulsations. Papilledema is not associated with the conditions in the other responses.

A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding:

ANS: is a characteristic of recruitment. Recruitment is a marked loss occurring when speech is at low intensity, but sound actually becomes painful when the speaker repeats at a louder volume. The other responses are not correct

The nurse is performing a middle ear assessment on a 15-year-old patient who has a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and landmarks visible. The nurse should:

ANS: know that these are scars caused from frequent ear infections. Dense white patches on the tympanic membrane are sequelae of repeated ear infections. They do not necessarily affect hearing.

The nurse is testing the function of *cranial nerve XI*. Which of these best describes the response the nurse should expect if the nerve is intact? The patient: a. Demonstrates the ability to hear normal conversation. b. Sticks out the tongue midline without tremors or deviation. c. Follows an object with his or her eyes without nystagmus or strabismus. d. Moves the head and shoulders against resistance with equal strength.

ANS: moves the head and shoulders against resistance with equal strength. These are the expected normal findings when testing cranial nerve XI (spinal accessory nerve): The patient's sternomastoid and trapezius muscles are of equal size; the person can rotate the head both ways forcibly against resistance applied to the side of the chin with equal strength; the patient can shrug the shoulders against resistance with equal strength on both sides. Checking the patient's ability to hear normal conversation checks the function of CN VIII. Having the patient stick out the tongue checks the function of CN XII. Testing the eyes for nystagmus or strabismus is done to check CN III, IV, and VI.

A mother of a 1-month-old infant asks the nurse *why it takes so long for infants to learn to roll over*. The nurse knows that the reason for this is that: a. A demyelinating process must be occurring with her infant. b. Myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated. c. The cerebral cortex is not fully developed; therefore, control over motor function gradually occurs. d. The spinal cord is controlling the movement because the cerebellum is not yet fully developed.

ANS: myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated. The infant's sensory and motor development proceeds along with the gradual acquisition of myelin because myelin is needed to conduct most impulses. Very little cortical control exists, and the neurons are not yet myelinated. The other responses are not correct.

During an assessment of an 80-year-old patient, the nurse notices the following: *inability to identify vibrations at the ankle and to identify position of big toe, slower and more deliberate gait, and slightly impaired tactile sensation*. All other neurologic findings are normal. The nurse should interpret that these findings indicate: a. CN dysfunction. b. Lesion in the cerebral cortex. c. Normal changes attributable to aging. d. Demyelination of nerves attributable to a lesion.

ANS: normal changes due to aging. Some aging adults show a slower response to requests, especially for those calling for coordination of movements. The findings listed are normal in the absence of other significant abnormal findings. The other responses are incorrect.

During an examination, the nurse notices that the patient stumbles a bit while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse notices that the patient is experiencing:

ANS: objective vertigo. With objective vertigo, the patient feels like the room spins; with subjective vertigo, the person feels like he or she is spinning. Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders. Dizziness is not the same as true vertigo; the person who is dizzy may feel unsteady and lightheaded

A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume. The most likely cause of his hearing loss is:

ANS: otosclerosis. Otosclerosis is a common cause of conductive hearing loss in young adults between the ages of 20 and 40 years. Presbycusis is a type of hearing loss that occurs with aging. Trauma and frequent ear infections are not a likely cause of his hearing loss.

During an assessment of a 62-year-old man the nurse notices the patient has a *stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements*. These findings would be consistent with: a. Parkinsonism. b. Cerebral palsy. c. Cerebellar ataxia. d. Muscular dystrophy.

ANS: parkinsonism. The stooped posture, shuffling walk, short steps, flat facial expression, and pill-rolling finger movements are all found in parkinsonism. See Table 23-8 for more information and for descriptions of the other options.

When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear:

ANS: pearly gray and slightly concave. The tympanic membrane is a translucent membrane with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The tympanic membrane is oval and slightly concave, pulled in at its center by the malleus, which is one of the middle ear ossicles.

In performing an examination of a 3 year old with a suspected ear infection, the nurse would:

ANS: perform the otoscopic examination at the end of the assessment In addition to its place in the complete examination, eardrum assessment is mandatory for any infant or child requiring care for illness or fever. For the infant or young child, the timing of the otoscopic examination is best toward the end of the complete examination.

The nurse knows that *testing kinesthesia* is a test of a person's: a. Fine touch. b. Position sense. c. Motor coordination. d. Perception of vibration.

ANS: position sense. Kinesthesia, or position sense, is the person's ability to perceive passive movements of the extremities. The other options are incorrect.

When the nurse asks a 68-year-old patient to *stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart*. The nurse would document this finding as a(n): a. Ataxia. b. Lack of coordination. c. Negative Homans sign. d. Positive Romberg sign.

ANS: positive Romberg sign. Abnormal findings for Romberg test include swaying, falling, and widening base of feet to avoid falling. Positive Romberg sign is loss of balance that is increased by closing of the eyes. Ataxia is uncoordinated or unsteady gait. Homans' sign is used to test the legs for deep vein thrombosis.

A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include:

ANS: shadow or diminished vision in one quadrant or one half of the visual field. With retinal detachment, the person has shadows or diminished vision in one quadrant or one half of the visual field. The other responses are not signs of retinal detachment.

A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble with reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that:

ANS: she may have macular degeneration. Macular degeneration is the most common cause of blindness. It is characterized by loss of central vision. Cataracts would show lens opacity. Chronic open-angle glaucoma, the most common type of glaucoma, involves a gradual loss of peripheral vision.

The area of the nervous system that is responsible for *mediating reflexes* is the: a. Medulla. b. Cerebellum. c. Spinal cord. d. Cerebral cortex.

ANS: spinal cord. The spinal cord is the main highway for ascending and descending fiber tracts that connect the brain to the spinal nerves, and it mediates reflexes.

The nurse is assessing color vision of a male child. Which statement is correct? The nurse should:

ANS: test for color vision once between the ages of 4 and 8. Test only boys for color vision once between the ages of 4 and 8 years. It is not tested in females because it is rare in females. Testing is done with the Ishihara test, which is a series of polychromatic cards.

The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has "lazy eye" and should:

ANS: test for strabismus by performing the corneal light reflex test. Testing for strabismus is done by performing the corneal light reflex test as well as the cover test. The Snellen eye chart and confrontation test are not used to test for strabismus.

During an interview, the patient states he has the sensation that "everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is:

ANS: the labyrinth. If the labyrinth ever becomes inflamed, it feeds the wrong information to the brain, creating a staggering gait and a strong, spinning, whirling sensation called vertigo.

A patient is *not able to perform rapid alternating movements such as patting her knees rapidly*. The nurse should document this as: a. Ataxia. b. Astereognosis. c. Presence of dysdiadochokinesia. d. Loss of kinesthesia.

ANS: the presence of dysdiadochokinesia. Slow clumsy movements and the inability to perform rapid alternating movements occur with cerebellar disease. The condition is termed dysdiadochokinesia. Ataxia is uncoordinated or unsteady gait. Astereognosis is the inability to identify an object by feeling it. Kinesthesia is the person's ability to perceive passive movement of the extremities, or the loss of position sense.

When a light is directed across the iris of a patient's eye from the temporal side, the nurse is assessing for:

ANS: the presence of shadows, which may indicate glaucoma. The presence of shadows in the anterior chamber may be a sign of acute angle-closure glaucoma. The normal iris is flat and creates no shadows. This is not the correct method for assessment for dacryocystitis, conjunctivitis, or cataracts.

When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in color and that there are air bubbles behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that:

ANS: this is most likely a serous otitis media. An amber-yellow color to the tympanic membrane suggests serum or pus in the middle ear. Often air or fluid or bubbles behind the tympanic membrane are visible. The patient may have feelings of fullness, transient hearing loss, and a popping sound with swallowing. The other responses are not correct.

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

ANS: tinnitus. Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders.

A 17-year-old student is a swimmer on her high school's swim team. She has had three bouts of otitis externa so far this season and wants to know what to do to prevent it. The nurse instructs her to:

ANS: use rubbing alcohol or 2% acetic acid eardrops after every swim. With otitis externa (swimmer's ear), swimming causes the external canal to become waterlogged and swell; skinfolds are set up for infection. Prevent by using rubbing alcohol or 2% acetic acid eardrops after every swim.

During the history, a patient tells the nurse that *"it feels like the room is spinning around me."* The nurse would document this as: a. Vertigo. b. Syncope. c. Dizziness. d. Seizure activity.

ANS: vertigo. True vertigo is rotational spinning caused by neurologic dysfunction or a problem in the vestibular apparatus or the vestibular nuclei in the brainstem. Dizziness is a lightheaded, swimming sensation. Syncope is a sudden loss of strength or a temporary loss of consciousness. Seizure activity is characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances.

After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of the concept of ethnicity with which statement? a. Ethnicity is dynamic and ever changing. b. Ethnicity is the belief in a higher power. c. Ethnicity pertains to a social group within the social system that claims shared values and traditions. d. Ethnicity is learned from birth through the processes of language acquisition and socialization.

After a symptom is recognized, the first effort at treatment is often self-care. Which of the following statements about self-care is true? Self-care is: a. Not recognized as valuable by most health care providers. b. Usually ineffective and may delay more effective treatment. c. Always less expensive than biomedical alternatives. d. Influenced by the accessibility of over-the-counter medicines.

A student is late for his appointment and has rushed across campus to the health clinic. The nurse should

Allow 5 minutes for him to relax and rest before checking his vital signs

C Appearance, behavior, cognition, and thought processes

Although a full mental status examination may not be required for every patient, the health care provider must address the four main components during a health history and physical examination. The four components are: a. memory, attention, thought content, and perceptions b. language, orientation, attention, and abstract reasoning c. appearance, behavior, cognition, and thought process d. mood, affect, consciousness, and orientation

An Asian-American woman is experiencing diarrhea, which is believed to be cold or yin. The nurse expects that the woman is likely to try to treat it with: a. Foods that are hot or yang. b. Readings and Eastern medicine meditations. c. High doses of medicines believed to be cold. d. No treatment is tried because diarrhea is an expected part of life.

The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults?

An increased respiratory rate and a shallower inspiratory phase are expected findings.

An individual who takes the magicoreligious perspective of illness and disease is likely to believe that his or her illness was caused by: a. Germs and viruses. b. Supernatural forces. c. Eating imbalanced foods. d. An imbalance within his or her spiritual nature.

An older Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally sensitive nurse would: a. Contact the hospital administrator about the best course of action. b. Automatically get a curandero for her, because requesting one herself is not culturally appropriate. c. Further assess the patients cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires. d. Ask the family what they would like to do because Mexican-Americans traditionally give control of decision making to their families.

A A language disturbance in speaking, writing, or understanding

Aphasia is best described as: a. a language disturbance in speaking, writing, or understanding b. the impaired ability to carry out motor activities despite intact motor function c. the impaired ability to recognize or identify objects despite intact sensory function d. a disturbance in executive functioning (planning, organizing, sequencing, abstracting)

The nurse is performing a general survey of a patient. Which finding is considered normal?

Arm span (fingertip to fingertip) equals the patients height

. During a visit to the clinic, a patient states, The doctor just told me he thought I ought to stop smoking. He doesnt understand how hard Ive tried. I just dont know the best way to do it. What should I do? The nurses most appropriate response in this case would be: a. Id quit if I were you. The doctor really knows what he is talking about. b. Would you like some information about the different ways a person can quit smoking? c. Stopping your dependence on cigarettes can be very difficult. I understand how you feel. d. Why are you confused? Didnt the doctor give you the information about the smoking cessation program we offer?

A 16-year-old boy has just been admitted to the unit for overnight observation after being in an automobile accident. What is the nurses best approach to communicating with him? a. Use periods of silence to communicate respect for him. b. Be totally honest with him, even if the information is unpleasant. c. Tell him that everything that is discussed will be kept totally confidential. d. Use slang language when possible to help him open up.

A mother brings her 28-month-old daughter into the clinic for a well-child visit. At the beginning of the visit, the nurse focuses attention away from the toddler, but as the interview progresses, the toddler begins to warm up and is smiling shyly at the nurse. The nurse will be most successful in interacting with the toddler if which is done next? a. Tickle the toddler, and get her to laugh. b. Stoop down to her level, and ask her about the toy she is holding. c. Continue to ignore her until it is time for the physical examination. d. Ask the mother to leave during the examination of the toddler, because toddlers often fuss less if their parent is not in view.

A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient? a. Count the patients respirations. b. Bilaterally percuss the thorax, noting any differences in percussion tones. c. Call for a chest x-ray study, and wait for the results before beginning an assessment. d. Inspect the thorax for any new masses and bleeding associated with respirations.

A patient repeats, "I feel hot. Hot, cot, rot, tot, got. I'm a spot." The nurse documents this as an illustration of: a. Blocking b. Clanging c. Echolalia d. Neologism

A pregnant woman states, I just know labor will be so painful that I wont be able to stand it. I know it sounds awful, but I really dread going into labor. The nurse responds by stating, Oh, dont worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain. Which statement is true regarding this response? The nurses reply was a: a. Therapeutic response. By sharing something personal, the nurse gives hope to this woman. b. Nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the womans fears. c. Therapeutic response. By providing information about the medications available, the nurse is giving information to the woman. d. Nontherapeutic response. The nurse is essentially giving the message to the woman that labor cannot be tolerated without medication.

A woman is discussing the problems she is having with her 2-year-old son. She says, He wont go to sleep at night, and during the day he has several fits. I get so upset when that happens. The nurses best verbal response would be: a. Go on, Im listening. b. Fits? Tell me what you mean by this. c. Yes, it can be upsetting when a child has a fit. d. Dont be upset when he has a fit; every 2 year old has fits.

During a mental status assessment, which question by the nurse would best assess a person's judgment? a. "Do you feel that you are being watched, followed, or controlled?" b. "Tell me what you plan to do once you are discharged from the hospital." c. "What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?" d. "What would you do if you found a stamped, addressed envelope lying on the sidewalk?"

During a prenatal check, a patient begins to cry as the nurse asks her about previous pregnancies. She states that she is remembering her last pregnancy, which ended in miscarriage. The nurses best response to her crying would be: a. Im so sorry for making you cry! b. I can see that you are sad remembering this. It is all right to cry. c. Why dont I step out for a few minutes until youre feeling better? d. I can see that you feel sad about this; why dont we talk about something else?

The nurse has used interpretation regarding a patients statement or actions. After using this technique, it would be best for the nurse to: a. Apologize, because using interpretation can be demeaning for the patient. b. Allow time for the patient to confirm or correct the inference. c. Continue with the interview as though nothing has happened. d. Immediately restate the nurses conclusion on the basis of the patients nonverbal response.

The nurse is assessing a patients skin during an office visit. What part of the hand and technique should be used to best assess the patients skin temperature? a. Fingertips; they are more sensitive to small changes in temperature. b. Dorsal surface of the hand; the skin is thinner on this surface than on the palms. c. Ulnar portion of the hand; increased blood supply in this area enhances temperature sensitivity. d. Palmar surface of the hand; this surface is the most sensitive to temperature variations because of its increased nerve supply in this area.

The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature36 C; pulse48 beats per minute; respirations14 breaths per minute; blood pressure104/68 mm Hg. Which statement is true concerning these results? a. The patient is experiencing tachycardia. b. These are normal vital signs for a healthy, athletic adult. c. The patients pulse rate is not normalhis physician should be notified. d. On the basis of these readings, the patient should return to the clinic in 1 week.

The nurse is conducting an interview with a woman who has recently learned that she is pregnant and who has come to the clinic today to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs loudly. Considering the concept of communication, which statement does the nurse know to be most accurate? The woman is: a. Excited about her pregnancy but nervous about the labor. b. Exhibiting verbal and nonverbal behaviors that do not match. c. Excited about her pregnancy, but her husband is not and this is upsetting to her. d. Not excited about her pregnancy but believes the nurse will negatively respond to her if she states this.

The nurse is examining a patient who is complaining of feeling cold. Which is a mechanism of heat loss in the body? a. Exercise b. Radiation c. Metabolism d. Food digestion

The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination? a. When the infant is sleeping b. At the end of the examination c. Before auscultation of the thorax d. Halfway through the examination

The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination? a. A patient's family is the best resource for information about the patient's coping skills. b. Gathering mental status information during the health history interview is usually sufficient. c. Integrating the mental status examination into the health history interview takes an enormous amount of extra time. d. To get a good idea of the patient's level of functioning, performing a complete mental status examination is usually necessary.

The nurse is preparing to examine a 4-year-old child. Which action is appropriate for this age group? a. Explain the procedures in detail to alleviate the childs anxiety. b. Give the child feedback and reassurance during the examination. c. Do not ask the child to remove his or her clothes because children at this age are usually very private. d. Perform an examination of the ear, nose, and throat first, and then examine the thorax and abdomen

The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase: a. Usually yields little information. b. Takes time and reveals a surprising amount of information. c. May be somewhat uncomfortable for the expert practitioner. d. Requires a quick glance at the patients body systems before proceeding with palpation.

The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? a. Slope of the earpieces should point posteriorly (toward the occiput). b. Although the stethoscope does not magnify sound, it does block out extraneous room noise. c. Fit and quality of the stethoscope are not as important as its ability to magnify sound. d. Ideal tubing length should be 22 inches to dampen the distortion of sound.

The nurse keeps in mind that the most important reason to share information and to offer brief teaching while performing the physical examination is to help the: a. Examiner feel more comfortable and to gain control of the situation. b. Examiner to build rapport and to increase the patients confidence in him or her. c. Patient understand his or her disease process and treatment modalities. d. Patient identify questions about his or her disease and the potential areas of patient education.

The nurse would use bimanual palpation technique in which situation? a. Palpating the thorax of an infant b. Palpating the kidneys and uterus c. Assessing pulsations and vibrations d. Assessing the presence of tenderness and pain

When assessing the intensity of a patients pain, which question by the nurse is appropriate? a. What makes your pain better or worse? b. How much pain do you have now? c. How does pain limit your activities? d. What does your pain feel like?

When assessing the pulse of a 6-year-old boy, the nurse notices that his heart rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. The nurses next action would be to: a. Immediately notify the physician. b. Consider this finding normal in children and young adults. c. Check the childs blood pressure, and note any variation with respiration. d. Document that this child has bradycardia, and continue with the assessment.

When performing a physical assessment, the first technique the nurse will always use is: a. Palpation. b. Inspection. c. Percussion. d. Auscultation.

When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination? a. Washing ones hands after removing gloves is not necessary, as long as the gloves are still intact. b. Hands are washed before and after every physical patient encounter. c. Hands are washed before the examination of each body system to prevent the spread of bacteria from one part of the body to another. d. Gloves are worn throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.

When the nurse is evaluating the reliability of a patient's responses, which of these statements would be correct? The patient: a. Has a history of drug abuse and therefore is not reliable. b. Provided consistent information and therefore is reliable. c. Smiled throughout interview and therefore is assumed reliable. d. Would not answer questions concerning stress and therefore is not reliable.

Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer? a. Wait 30 minutes if the patient has ingested hot or iced liquids. b. Leave the thermometer in place 3 to 4 minutes if the patient is afebrile. c. Place the thermometer in front of the tongue, and ask the patient to close his or her lips. d. Shake the mercury-in-glass thermometer down to below 36.6 C before taking the temperature.

The nurse is assessing a new patient who has recently immigrated to the United States. Which question is appropriate to add to the health history? a. "Why did you come to the United States?" b. "When did you come to the United States and from what country?" c. "What made you leave your native country?" d. "Are you planning to return to your home?"

B Biographic data, such as when the person entered the United States and from what country, are appropriate additions to the health history. The other answers do not reflect appropriate questions.

During an assessment of a patient's family history, the nurse constructs a genogram. Which statement best describes a genogram? a. List of diseases present in a person's near relatives b. Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family members c. Drawing that depicts the patient's family members up to five generations back d. Description of the health of a person's children and grandchildren

B Rationale: A genogram (or pedigree) is a graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations (parents, grandparents, siblings). The other options do not describe a genogram.

In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information? a. This information is necessary to determine the patient's reliability. b. Alcohol can interact with all medications and can make some diseases worse. c. The nurse needs to be able to teach the patient about the dangers of alcohol use. d. This information is not necessary unless a drinking problem is obvious.

B Rationale: Alcohol adversely interacts with all medications and is a factor in many social problems such as child or sexual abuse, automobile accidents, and assaults; alcohol also contributes to many illnesses and disease processes. Therefore, assessing for signs of hazardous alcohol use is important. The other options are not correct.

As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at 15 months of age. What recommendation should the nurse make? a. No further MMR immunizations are needed. b. MMR vaccination needs to be repeated at 4 to 6 years of age. c. MMR immunization needs to be repeated every 4 years until age 21 years. d. A recommendation cannot be made until the physician is consulted.

B Rationale: Because of recent outbreaks of measles across the United States, the American Academy of Pediatrics (2006) recommends two doses of the MMR vaccine, one at 12 to 15 months of age and one at age 4 to 6 years.

The review of systems provides the nurse with: a. Physical findings related to each system. b. Information regarding health promotion practices. c. An opportunity to teach the patient medical terms. d. Information necessary for the nurse to diagnose the patient's medical problem.

B Rationale: The purposes of the review of systems are to: (1) evaluate the past and current health state of each body system, (2) double check facts in case any significant data were omitted in the present illness section, and (3) evaluate health promotion practices.

A female patient tells the nurse that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the nurse record this information? a. P-6, B-4, (S)Ab-2 b. Grav 6, Term 4, (S)Ab-2, Living 4 c. Patient has had four living babies. d. Patient has been pregnant six times.

B Rationale:Obstetric history includes the number of pregnancies (gravidity), number of deliveries in which the fetus reached term (term), number of preterm pregnancies (preterm), number of incomplete pregnancies (abortions), and number of children living (living). This is recorded: Grav _____ Term _____ Preterm _____ Ab _____ Living _____. For any incomplete pregnancies, the duration is recorded and whether the pregnancy resulted in a spontaneous (S) or an induced (I) abortion

The nurse is incorporating a person's spiritual values into the health history. Which of these questions illustrates the "community" portion of the FICA (faith and belief, importance and influence, community, and addressing or applying in care) questions? a. "Do you believe in God?" b. "Are you a part of any religious or spiritual congregation?" c. "Do you consider yourself to be a religious or spiritual person?" d. "How does your religious faith influence the way you think about your health?"

B The "community" is assessed when the nurse asks whether a person is part of a religious or spiritual community or congregation. The other areas assessed are faith, influence, and addressing any religious or spiritual issues or concerns.

The nurse is conducting a developmental history on a 5-year-old child. Which questions are appropriate to ask the parents for this part of the assessment? Select all that apply. a. "How much junk food does your child eat?" b. "How many teeth has he lost, and when did he lose them?" c. "Is he able to tie his shoelaces?" d. "Does he take a children's vitamin?" e. "Can he tell time?" f. "Does he have any food allergies?"

B, C, E Questions about tooth loss, ability to tell time, and ability to tie shoelaces are appropriate questions for a developmental assessment. Questions about junk food intake and vitamins are part of a nutritional history. Questions about food allergies are not part of a developmental history.

. The nurse makes this comment to a patient, I know it may be hard, but you should do what the doctor ordered because she is the expert in this field. Which statement is correct about the nurses comment? a. This comment is inappropriate because it shows the nurses bias. b. This comment is appropriate because members of the health care team are experts in their area of patient care. c. This type of comment promotes dependency and inferiority on the part of the patient and is best avoided in an interview situation. d. Using authority statements when dealing with patients, especially when they are undecided about an issue, is necessary at times.

A 17-year-old single mother is describing how difficult it is to raise a 3-year-old child by herself. During the course of the interview she states, I cant believe my boyfriend left me to do this by myself! What a terrible thing to do to me! Which of these responses by the nurse uses empathy? a. You feel alone. b. You cant believe he left you alone? c. It must be so hard to face this all alone. d. I would be angry, too; raising a child alone is no picnic.

A 2-year-old child has been brought to the clinic for a well-child checkup. The best way for the nurse to begin the assessment is to: a. Ask the parent to place the child on the examining table. b. Have the parent remove all of the childs clothing before the examination. c. Allow the child to keep a security object such as a toy or blanket during the examination. d. Initially focus the interactions on the child, essentially ignoring the parent until the childs trust has been obtained.

A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He is seen today in the clinic for an unexplained weight loss of 10 pounds over the last 6 weeks. The nurse knows that: a. Weight loss is probably the result of unhealthy eating habits. b. Chronic diseases such as hypertension cause weight loss. c. Unexplained weight loss often accompanies short-term illnesses. d. Weight loss is probably the result of a mental health dysfunction.

A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, You dont smoke, drink, or take drugs, do you? This question is an example of: a. Talking too much. b. Using confrontation. c. Using biased or leading questions. d. Using blunt language to deal with distasteful topics.

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? a. Confusion b. Hyperventilation c. Increased blood pressure and pulse d. Depression

A patients blood pressure is 118/82 mm Hg. He asks the nurse, What do the numbers mean? The nurses best reply is: a. The numbers are within the normal range and are nothing to worry about. b. The bottom number is the diastolic pressure and reflects the stroke volume of the heart. c. The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts. d. The concept of blood pressure is difficult to understand. The primary thing to be concerned about is the top number, or the systolic blood pressure.

During an examination, the nurse can assess mental status by which activity? a. Examining the patient's electroencephalogram b. Observing the patient as he or she performs an intelligence quotient (IQ) test c. Observing the patient and inferring health or dysfunction d. Examining the patient's response to a specific set of questions

During an examination, the nurse notes that a patient is exhibiting flight of ideas. Which statement by the patient is an example of flight of ideas? a. "My stomach hurts. Hurts, spurts, burts." b. "Kiss, wood, reading, ducks, onto, maybe." c. "Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby's bottom." d. "I wash my hands, wash them, wash them. I usually go to the sink and wash my hands."

During an interview, a woman says, I have decided that I can no longer allow my children to live with their fathers violence, but I just cant seem to leave him. Using interpretation, the nurses best response would be: a. You are going to leave him? b. If you are afraid for your children, then why cant you leave? c. It sounds as if you might be afraid of how your husband will respond. d. It sounds as though you have made your decision. I think it is a good one.

During an interview, the nurse would expect that most of the interview will take place at what distance? a. Intimate zone b. Personal distance c. Social distance d. Public distance

During the examination, offering some brief teaching about the patients body or the examiners findings is often appropriate. Which one of these statements by the nurse is most appropriate? a. Your atrial dysrhythmias are under control. b. You have pitting edema and mild varicosities. c. Your pulse is 80 beats per minute, which is within the normal range. d. Im using my stethoscope to listen for any crackles, wheezes, or rubs.

In response to a question about stress, a 39-year-old woman tells the nurse that her husband and mother both died in the past year. Which response by the nurse is most appropriate? a. "This has been a difficult year for you." b. "I don't know how anyone could handle that much stress in 1 year!" c. "What did you do to cope with the loss of both your husband and mother?" d. "That is a lot of stress; now let's go on to the next section of your history."

Receiving is a part of the communication process. Which receiver is most likely to misinterpret a message sent by a health care professional? a. Well-adjusted adolescent who came in for a sports physical b. Recovering alcoholic who came in for a basic physical examination c. Man whose wife has just been diagnosed with lung cancer d. Man with a hearing impairment who uses sign language to communicate and who has an interpreter with him

The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient: a. Will have no decrease in any of his abilities, including response time. b. Will have difficulty on tests of remote memory because this ability typically decreases with age. c. May take a little longer to respond, but his general knowledge and abilities should not have declined. d. Will exhibit had a decrease in his response time because of the loss of language and a decrease in general knowledge.

The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal? a. Increase in body weight from his younger years b. Additional deposits of fat on the thighs and lower legs c. Presence of kyphosis and flexion in the knees and hips d. Change in overall body proportion, including a longer trunk and shorter extremities

The nurse is examining a patients lower leg and notices a draining ulceration. Which of these actions is most appropriate in this situation? a. Washing hands, and contacting the physician b. Continuing to examine the ulceration, and then washing hands c. Washing hands, putting on gloves, and continuing with the examination of the ulceration d. Washing hands, proceeding with rest of the physical examination, and then continuing with the examination of the leg ulceration

The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident (stroke) and has aphasia. Which of these questions is most important to use when assessing mental status in this patient? a. "Please count backward from 100 by seven." b. "I will name three items and ask you to repeat them in a few minutes." c. "Please point to articles in the room and parts of the body as I name them." d. "What would you do if you found a stamped, addressed envelope on the sidewalk?"

The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to: a. Administer the FACT test. b. Ask him to describe his first job. c. Give him the Four Unrelated Words Test. d. Ask him to describe what television show he was watching before coming to the clinic.

The nurse is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct? a. Measuring the infants length by using a tape measure b. Weighing the infant by placing him or her on an electronic standing scale c. Measuring the chest circumference at the nipple line with a tape measure d. Measuring the head circumference by wrapping the tape measure over the nose and cheekbones

The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the __________ of the underlying tissue. a. Turgor b. Texture c. Density d. Consistency

The nurse is providing instructions to newly hired graduates for the mini-mental state examination (MMSE). Which statement best describes this examination? a. Scores below 30 indicate cognitive impairment. b. The MMSE is a good tool to evaluate mood and thought processes. c. This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness. d. The MMSE is useful tool for an initial evaluation of mental status. Additional tools are needed to evaluate cognition changes over time.

The nurse is taking temperatures in a clinic with a TMT. Which statement is true regarding use of the TMT? a. A tympanic temperature is more time consuming than a rectal temperature. b. The tympanic method is more invasive and uncomfortable than the oral method. c. The risk of cross-contamination is reduced, compared with the rectal route. d. The tympanic membrane most accurately reflects the temperature in the ophthalmic artery.

The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next? a. Ask the patient to take deep breaths to relax the abdominal musculature. b. Consider this finding as normal, and proceed with the abdominal assessment. c. Increase the amount of strength used when attempting to percuss over the abdomen. d. Decrease the amount of strength used when attempting to percuss over the abdomen.

The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: a. Auscultate over the area with a fetoscope. b. Use a goniometer to measure the pulsations. c. Use a Doppler device to check for pulsations over the area. d. Check for the presence of pulsations with a stethoscope.

The nurse knows that which statement is true regarding the pain experienced by infants? a. Pain in infants can only be assessed by physiologic changes, such as an increased heart rate. b. The FPS-R can be used to assess pain in infants. c. A procedure that induces pain in adults will also induce pain in the infant. d. Infants feel pain less than do adults.

The nurse should measure rectal temperatures in which of these patients? a. School-age child b. Older adult c. Comatose adult d. Patient receiving oxygen by nasal cannula

When assessing a patients pain, the nurse knows that an example of visceral pain would be: a. Hip fracture. b. Cholecystitis. c. Second-degree burns. d. Pain after a leg amputation.

When assessing the force, or strength, of a pulse, the nurse recalls that the pulse: a. Is usually recorded on a 0- to 2-point scale. b. Demonstrates elasticity of the vessel wall. c. Is a reflection of the hearts stroke volume. d. Reflects the blood volume in the arteries during diastole.

When evaluating a patients pain, the nurse knows that an example of acute pain would be: a. Arthritic pain. b. Fibromyalgia. c. Kidney stones. d. Low back pain.

When measuring a patients body temperature, the nurse keeps in mind that body temperature is influenced by: a. Constipation. b. Patients emotional state. c. Diurnal cycle. d. Nocturnal cycle.

Which of these statements represents subjective data the nurse obtained from the patient regarding the patient's skin? a. Skin appears dry. b. No lesions are obvious. c. Patient denies any color change. d. Lesion is noted on the lateral aspect of the right arm.

Which statement indicates that the nurse understands the pain experienced by an older adult? a. Older adults must learn to tolerate pain. b. Pain is a normal process of aging and is to be expected. c. Pain indicates a pathologic condition or an injury and is not a normal process of aging. d. Older individuals perceive pain to a lesser degree than do younger individuals.

When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of the assessment is being performed? a. Family history b. Review of systems c. Functional assessment d. Reason for seeking care

C Functional assessment includes interpersonal relationships and home environment. Family history includes illnesses in family members; a review of systems includes questions about the various body systems; and the reason for seeking care is the rationale for requesting health care.

The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include: a. Emphysema. b. Head trauma. c. Mental illness. d. Fractured bones.

C Rationale: Questions concerning any family history of heart disease, high blood pressure, stroke, diabetes, obesity, blood disorders, breast and ovarian cancers, colon cancer, sickle cell anemia, arthritis, allergies, alcohol or drug addiction, mental illness, suicide, seizure disorder, kidney disease, and tuberculosis should be asked.

The nurse is performing a review of systems on a 76-year-old patient. Which of these statements is correct for this situation? a. The questions asked are identical for all ages. b. The interviewer will start incorporating different questions for patients 70 years of age and older. c. Questions that are reflective of the normal effects of aging are added. d. At this age, a review of systems is not necessary—the focus should be on current problems..

C The health history includes the same format as that described for the younger adult, as well as some additional questions. These additional questions address ways in which the activities of daily living may have been affected by the normal aging processes or by the effects of chronic illness or disability

During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking?

Certain drugs can affect the metabolism of nutrients

The nurse should measure rectal temperatures in which of these patients?

Comatose adult

Consider this finding normal in children and young adults.

The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed?

Cuff should be inflated 30 mm Hg above the point at which the palpated pulse disappears

During an examination, the nurse notices that a female patient has a round moon face, central trunk obesity, and a cervical hump. Her skin is fragile with bruises. The nurse determines that the patient has which condition?

Cushing syndrome Cushing syndrome is characterized by weight gain and edema with central trunk and cervical obesity (buffalo hump) and round plethoric face (moon face). Excessive catabolism causes muscle wasting; weakness; thin arms and legs; reduced height; and thin, fragile skin with purple abdominal striae, bruising, and acne.

A 29-year-old woman tells the nurse that she has "excruciating pain" in her back. Which would be the nurse's appropriate response to the woman's statement? a. "How does your family react to your pain?" b. "The pain must be terrible. You probably pinched a nerve." c. "I've had back pain myself, and it can be excruciating." d. "How would you say the pain affects your ability to do your daily activities?"

A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, It hurts so bad. Which pain assessment tool would be the best choice when assessing this childs pain? a. Descriptor Scale b. Numeric rating scale c. Brief Pain Inventory d. Faces Pain ScaleRevised (FPS-R)

A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having "black stools" for the last 24 hours. How would the nurse best document his reason for seeking care? a. J.M. is a 59-year-old man seeking treatment for ulcerative colitis. b. J.M. came into the clinic complaining of having black stools for the past 24 hours. c. J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it checked. d. J.M. is a 59-year-old man who states that he has been having "black stools" for the past 24 hours.

A 60-year-old woman has developed reflexive sympathetic dystrophy after arthroscopic repair of her shoulder. A key feature of this condition is that the: a. Affected extremity will eventually regain its function. b. Pain is felt at one site but originates from another location. c. Patients pain will be associated with nausea, pallor, and diaphoresis. d. Slightest touch, such as a sleeve brushing against her arm, causes severe and intense pain.

A female American Indian has come to the clinic for follow-up diabetic teaching. During the interview, the nurse notices that she never makes eye contact and speaks mostly to the floor. Which statement is true regarding this situation? a. The woman is nervous and embarrassed. b. She has something to hide and is ashamed. c. The woman is showing inconsistent verbal and nonverbal behaviors. d. She is showing that she is carefully listening to what the nurse is saying.

A female nurse is interviewing a male patient who is near the same age as the nurse. During the interview, the patient makes an overtly sexual comment. The nurses best reaction would be: a. Stop that immediately! b. Oh, you are too funny. Lets keep going with the interview. c. Do you really think I would be interested? d. It makes me uncomfortable when you talk that way. Please stop.

A man arrives at the clinic for his annual wellness physical. He is experiencing no acute health problems. Which question or statement by the nurse is most appropriate when beginning the interview? a. How is your family? b. How is your job? c. Tell me about your hypertension. d. How has your health been since your last visit?

A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, I quit smoking after my wife died 7 years ago. However, the nurse notices an open pack of cigarettes in his shirt pocket. Using confrontation, the nurse could say: a. Mr. K., I know that you are lying. b. Mr. K., come on, tell me how much you smoke. c. Mr. K., I didnt realize your wife had died. It must be difficult for you at this time. Please tell me more about that. d. Mr. K., you have said that you dont smoke, but I see that you have an open pack of cigarettes in your pocket.

A patient has been admitted to the hospital with vertebral fractures related to osteoporosis. She is in extreme pain. This type of pain would be classified as: a. Referred. b. Cutaneous. c. Visceral. d. Deep somatic.

A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data? a. Mr. Y., at your age, surely you have been hospitalized before! b. Mr. Y., I just need permission to get your medical records from County Medical. c. Mr. Y., you mentioned that you have been hospitalized on several occasions. Would you tell me more about that? d. Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?

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 does the nurse suspect? The patient: a. Is addicted to her pain medications and cannot obtain pain relief. b. Does not want to trouble the nursing staff with her complaints. c. Is not in pain but rates it high to receive pain medication. d. Has experienced chronic pain for years and has adapted to it.

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? a. Completing the physical examination first and then giving the pain medication b. Telling the patient that the pain medication must wait until after the x-ray images are completed c. Evaluating the full range of motion of the knee and then medicating for pain d. Administering pain medication and then proceeding with the assessment

A patient tells the nurse that he is allergic to penicillin. What would be the nurse's best response to this information? a. "Are you allergic to any other drugs?" b. "How often have you received penicillin?" c. "I'll write your allergy on your chart so you won't receive any penicillin." d. "Describe what happens to you when you take penicillin."

A woman has just entered the emergency department after being battered by her husband. The nurse needs to get some information from her to begin treatment. What is the best choice for an opening phase of the interview with this patient? a. Hello, Nancy, my name is Mrs. C. b. Hello, Mrs. H., my name is Mrs. C. It sure is cold today! c. Mrs. H., my name is Mrs. C. How are you? d. Mrs. H., my name is Mrs. C. Ill need to ask you a few questions about what happened.

An examiner is using an ophthalmoscope to examine a patients eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being correctly performed? a. Using the large full circle of light when assessing pupils that are not dilated b. Rotating the lens selector dial to the black numbers to compensate for astigmatism c. Using the grid on the lens aperture dial to visualize the external structures of the eye d. Rotating the lens selector dial to bring the object into focus

Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should: a. Warm the endpiece of the stethoscope by placing it in warm water. b. Leave the gown on the patient to ensure that he or she does not get chilled during the examination. c. Ensure that the bell side of the stethoscope is turned to the on position. d. Check the temperature of the room, and offer blankets to the patient if he or she feels cold.

During an examination of a 3-year-old child, the nurse will need to take her blood pressure. What might the nurse do to try to gain the childs full cooperation? a. Tell the child that the blood pressure cuff is going to give her arm a big hug. b. Tell the child that the blood pressure cuff is asleep and cannot wake up. c. Give the blood pressure cuff a name and refer to it by this name during the assessment. d. Tell the child that by using the blood pressure cuff, we can see how strong her muscles are.

During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his sons treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This changed posture would suggest that the parent is: a. Simply changing positions. b. More comfortable in this position. c. Tired and needs a break from the interview. d. Uncomfortable talking about his sons treatment.

During an interview, the nurse states, You mentioned having shortness of breath. Tell me more about that. Which verbal skill is used with this statement? a. Reflection b. Facilitation c. Direct question d. Open-ended question

In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate? a. Patient denies usual childhood illnesses. b. Patient states he was a "very healthy" child. c. Patient states his sister had measles, but he didn't. d. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.

In using verbal responses to assist the patients narrative, some responses focus on the patients frame of reference and some focus on the health care providers perspective. An example of a verbal response that focuses on the health care providers perspective would be: a. Empathy. b. Reflection. c. Facilitation. d. Confrontation.

The nurse asks, I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here. This question is found at the __________ phase of the interview process. a. Summary b. Closing c. Body d. Opening or introduction

The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child. The nurse should: a. Palpate over the area for increased pain and tenderness. b. Ask the child to take shallow breaths, and percuss over the area again. c. Immediately refer the child because of an increased amount of air in the lungs. d. Consider this finding as normal for a child this age, and proceed with the examination.

The nurse is assessing a patients pain. The nurse knows that the most reliable indicator of pain would be the: a. Patients vital signs. b. Physical examination. c. Results of a computerized axial tomographic scan. d. Subjective report.

The nurse is assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented? a. "I know my name is John. I couldn't tell you where I am. I think it is 2010, though." b. "I know my name is John, but to tell you the truth, I get kind of confused about the date." c. "I know my name is John; I guess I'm at the hospital in Spokane. No, I don't know the date." d. "I know my name is John. I am at the hospital in Spokane. I couldn't tell you what date it is, but I know that it is February of a new year—2010."

The nurse is examining a 2-year-old child and asks, May I listen to your heart now? Which critique of the nurses technique is most accurate? a. Asking questions enhances the childs autonomy b. Asking the child for permission helps develop a sense of trust c. This question is an appropriate statement because children at this age like to have choices d. Children at this age like to say, No. The examiner should not offer a choice when no choice is available

The nurse is preparing to assess a patients abdomen by palpation. How should the nurse proceed? a. Palpation of reportedly tender areas are avoided because palpation in these areas may cause pain. b. Palpating a tender area is quickly performed to avoid any discomfort that the patient may experience. c. The assessment begins with deep palpation, while encouraging the patient to relax and to take deep breaths. d. The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched.

The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history? a. To provide an opportunity for interaction between the patient and the nurse b. To provide a form for obtaining the patient's biographic information c. To document the normal and abnormal findings of a physical assessment d. To provide a database of subjective information about the patient's past and current health

The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? The nurse: a. Performs the examination from the left side of the bed. b. Examines tender or painful areas first to help relieve the patients anxiety. c. Follows the same examination sequence, regardless of the patients age or condition. d. Organizes the assessment to ensure that the patient does not change positions too often.

The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope: a. Is often used to direct light onto the sinuses. b. Uses a short, broad speculum to help visualize the ear. c. Is used to examine the structures of the internal ear. d. Directs light into the ear canal and onto the tympanic membrane.

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? a. Visceral b. Referred c. Cutaneous d. Neuropathic

When assessing a 75-year-old patient who has asthma, the nurse notes that he assumes a tripod position, leaning forward with arms braced on the chair. On the basis of this observation, the nurse should: a. Assume that the patient is eager and interested in participating in the interview. b. Evaluate the patient for abdominal pain, which may be exacerbated in the sitting position. c. Assume that the patient is having difficulty breathing and assist him to a supine position. d. Recognize that a tripod position is often used when a patient is having respiratory difficulties.

When assessing aging adults, the nurse knows that one of the first things that should be assessed before making judgments about their mental status is: a. Presence of phobias b. General intelligence c. Presence of irrational thinking patterns d. Sensory-perceptive abilities

When assessing the quality of a patients pain, the nurse should ask which question? a. When did the pain start? b. Is the pain a stabbing pain? c. Is it a sharp pain or dull pain? d. What does your pain feel like?

When examining a 16-year-old male teenager, the nurse should: a. Discuss health teaching with the parent because the teen is unlikely to be interested in promoting wellness. b. Ask his parent to stay in the room during the history and physical examination to answer any questions and to alleviate his anxiety. c. Talk to him the same manner as one would talk to a younger child because a teens level of understanding may not match his or her speech. d. Provide feedback that his body is developing normally, and discuss the wide variation among teenagers on the rate of growth and development.

When measuring a patients weight, the nurse is aware of which of these guidelines? a. The patient is always weighed wearing only his or her undergarments. b. The type of scale does not matter, as long as the weights are similar from day to day. c. The patient may leave on his or her jacket and shoes as long as these are documented next to the weight. d. Attempts should be made to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.

When observing a patients verbal and nonverbal communication, the nurse notices a discrepancy. Which statement is true regarding this situation? The nurse should: a. Ask someone who knows the patient well to help interpret this discrepancy. b. Focus on the patients verbal message, and try to ignore the nonverbal behaviors. c. Try to integrate the verbal and nonverbal messages and then interpret them as an average. d. Focus on the patients nonverbal behaviors, because these are often more reflective of a patients true feelings.

While measuring a patients blood pressure, the nurse recalls that certain factors, such as __________, help determine blood pressure. a. Pulse rate b. Pulse pressure c. Vascular output d. Peripheral vascular resistance

The nurse is obtaining a health history on an 87-year-old woman. Which of the following areas of questioning would be most useful at this time? a. Obstetric history b. Childhood illnesses c. General health for the past 20 years d. Current health promotion activities

D It is important for the nurse to recognize positive health measures, such as what the person has been doing to help him or herself stay well and to live to an older age. The other responses are not pertinent to a patient of this age.

Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast? a. "I broke my right leg in a car accident 2 weeks ago." b. "The pain is decreasing, but I still need to take acetaminophen." c. "I check the color of my toes every evening just like I was taught." d. "I'm able to transfer myself from the wheelchair to the bed without help."

D Rationale: Functional assessment measures a person's self-care ability in the areas of general physical health or absence of illness. The other statements concern health or illness issues.

A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure? a. Child's birth weight b. Age at which he crawled c. Whether the child has had the measles d. Child's reactions to previous hospitalizations

D Rationale: How the child reacted to previous hospitalizations and any complications should be assessed. If the child reacted poorly, then he or she may be afraid now and will need special preparation for the examination that is to follow. The other items are not significant for the procedure.

During an assessment, the nurse uses the CAGE test. The patient answers "yes" to two of the questions. What could this be indicating? a. The patient is an alcoholic. b. The patient is annoyed at the questions. c. The patient should be thoroughly examined for possible alcohol withdrawal symptoms. d. The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment.

D The CAGE test is known as the "cut down, annoyed, guilty, and eye-opener" test. If a person answers "yes" to two or more of the four CAGE questions, then the nurse should suspect alcohol abuse and continue with a more complete substance abuse assessment.

The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? a. The functional assessment assesses how the individual is coping with life at home. b. It determines how children are meeting developmental milestones. c. The functional assessment can identify any problems with memory the individual may be experiencing. d. It helps determine how a person is managing day-to-day activities.

D The functional assessment measures how a person manages day-to-day activities. The other answers do not reflect the purpose of a functional assessment.

The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins? a. "Please stay during the interview; you can answer for her if she does not know the answer." b. "It would help to interview the three of you together." c. "While I interview your daughter, will you please stay in the room and complete these family health history questionnaires?" d. "While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?"

D The girl should be interviewed alone. The parents can wait outside and fill out the family health history questionnaires.

A 90-year-old patient tells the nurse that he cannot remember the names of the medications he is taking or for what reason he is taking them. An appropriate response from the nurse would be: a. "Can you tell me what they look like?" b. "Don't worry about it. You are only taking two medications." c. "How long have you been taking each of the pills?" d. "Would you have a family member bring in your medications?" .

D The person may not know the drug name or purpose. When this occurs, ask the person or a family member to bring in the drug to be identified. The other responses would not help to identify the medications

A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms? a. "It is a sharp, burning pain in my stomach." b. "I also have the sweats and nausea when I feel this pain." c. "I think this pain is telling me that something bad is wrong with me." d. "This pain happens every time I sit down to use the computer."

D The setting describes where the person is or what the person is doing when the symptom starts. Describing the pain as "sharp and burning" reflects the character or quality of the pain; stating that the pain is "telling" the patient that something bad is wrong with him reflects the patient's perception of the pain; and describing the "sweats and nausea" reflects associated factors that occur with the pain.

In obtaining a review of systems on a "healthy" 7-year-old girl, the health care provider knows that it would be important to include the: a. Last glaucoma examination. b. Frequency of breast self-examinations. c. Date of her last electrocardiogram. d. Limitations related to her involvement in sports activities.

D When reviewing the cardiovascular system, the health care provider should ask whether any activity is limited or whether the child can keep up with her peers. The other items are not appropriate for a child this age.

A 21-year-old woman has been on a low-protein liquid diet for the past 2 months. She has had adequate intake of calories and appears well nourished. After further assessment, what would the nurse expect to find?

Decreased serum albumin

Which of these interventions is most appropriate when the nurse is planning nutritional interventions for a healthy, active 74-year-old woman?

Decreasing the number of calories she is eating because of the decrease in energy requirements from the loss of lean body mass

The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to:

Detect the presence of an auscultatory gap.

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

Diurnal cycle

The nurse is preparing to measure fat and lean body mass and bone mineral density. Which tool is appropriate?

Dual-energy x-ray absorptiometry (DEXA)

During a class on religion and spirituality, the nurse is asked to define spirituality. Which answer is correct? Spirituality: a. Is a personal search to discover a supreme being. b. Is an organized system of beliefs concerning the cause, nature, and purpose of the universe. c. Is a belief that each person exists forever in some form, such as a belief in reincarnation or the afterlife. d. Arises out of each persons unique life experience and his or her personal effort to find purpose in life.

During a class on the aspects of culture, the nurse shares that culture has four basic characteristics. Which statement correctly reflects one of these characteristics? a. Cultures are static and unchanging, despite changes around them. b. Cultures are never specific, which makes them hard to identify. c. Culture is most clearly reflected in a persons language and behavior. d. Culture adapts to specific environmental factors and available natural resources.

During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating the specific and distinct knowledge, beliefs, skills, and customs acquired by members of a society reflects which term? a. Mores b. Norms c. Culture d. Social learning

hydrocephalus

During a well-baby check, the nurse notices that a 1-week-old infant's face looks small compared with his cranium, which seems enlarged. On further examination, the nurse also notices dilated scalp veins and downcast, or "setting sun," eyes. The nurse suspects which condition?

"Head control is usually achieved by 4 months of age"

During a well-baby checkup, a mother is concerned because her 2-month-old infant cannot hold her head up when she is pulled to a sitting position. Which response by the nurse is appropriate?

coarse facial features

During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for:

dehydration

During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition?

During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate? a. Ask the patient about the item and its significance. b. Ask the patient to lock the item with other valuables in the hospitals safe. c. Tell the patient that a family member should take valuables home. d. No action is necessary.

continue the examination because this is a normal finding for this age.

During an examination of a 3-year-old child, the nurse notices a bruit over the left temporal area. The nurse should:

firm but freely movable

During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be:

this is a normal finding during pregnancy

During an examination of a patient in her third trimester of pregnancy, the nurse notices that the patient's thyroid gland is slightly enlarged. No enlargement had been noticed previously. The nurse suspects that:

temporal arteritis

During an examination, the nurse finds that a patient's left temporal artery is tortuous and feels hardened and tender compared with the right temporal artery. The nurse suspects which condition?

Headache, vertigo, tinnitus, and deafness

During an examination, the nurse knows that Paget's disease would be indicated by which of these assessment findings?

Using gentle pressure, palpate with both hands to compare the two sides.

During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement?

A patient is asked to indicate on a form how many times he eats a specific food. This method describes which of these tools for obtaining dietary information?

Food-frequency questionnaire

During an examination of a child, the nurse considers that physical growth is the best index of a childs:

General health

Which of these specific measurements is the best index of a childs general health

Height and weight

A patient is seen in the clinic for complaints of fainting episodes that started last week. How should the nurse proceed with the examination?

His blood pressure is recorded in the lying, sitting, and standing positions.

How should the nurse perform a triceps skinfold assessment?

The nurse is assessing an 8-year-old child whose growth rate measures below the third percentile for a child his age. He appears significantly younger than his stated age and is chubby with infantile facial features. Which condition does this child have?

Hypopituitary dwarfism Hypopituitary dwarfism is caused by a deficiency in growth hormone in childhood and results in a retardation of growth below the third percentile, delayed puberty, and other problems. The childs appearance fits this description. Achondroplastic dwarfism is a genetic disorder resulting in characteristic deformities; Marfan syndrome is an inherited connective tissue disorder characterized by a tall, thin stature and other features. Acromegaly is the result of excessive secretion of growth hormone in adulthood

The nurse is helping another nurse to take a blood pressure reading on a patients thigh. Which action is correct regarding thigh pressure?

If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure. When blood pressure measured at the arm is excessively high, particularly in adolescents and young adults, it is compared with thigh pressure to check for coarctation of the aorta. The popliteal artery is auscultated for the reading. Generally, thigh pressure is higher than that of the arm; however, if coarctation of the artery is present, then arm pressures are higher than thigh pressures.

Illness is considered part of lifes rhythmic course and is an outward sign of disharmony within. This statement most accurately reflects the views about illness from which theory? a. Naturalistic b. Biomedical c. Reductionist d. Magicoreligious

In the hot/cold theory, illnesses are believed to be caused by hot or cold entering the body. Which of these patient conditions is most consistent with a cold condition? a. Patient with diabetes and renal failure b. Teenager with an abscessed tooth c. Child with symptoms of itching and a rash d. Older man with gastrointestinal discomfort

In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this difference is true, probably because Mexican-Americans: a. Have less efficient immune systems and are often ill. b. Consider these symptoms part of normal living, not symptoms of ill health. c. Come from Mexico, and coughing is normal and healthy there. d. Are usually in a lower socioeconomic group and are more likely to be sick

In performing an assessment on a 49-year-old woman who has imbalanced nutrition as a result of dysphagia, which data would the nurse expect to find?

Inadequate nutrient food intake

Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer?

Leave the thermometer in place 3 to 4 minutes if the patient is afebrile The thermometer should be left in place 3 to 4 minutes if the person is afebrile and up to 8 minutes if the person is febrile. The nurse should wait 15 minutes if the person has just ingested hot or iced liquids and 2 minutes if he or she has just smoked

The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of these factors will most likely affect the nutritional status of an older adult?

Living alone on a fixed income

When considering the concepts related to blood pressure, the nurse knows that the concept of mean arterial pressure (MAP) is best described by which statement?

MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle

Many Asians believe in the yin/yang theory, which is rooted in the ancient Chinese philosophy of Tao. Which statement most accurately reflects health in an Asian with this belief? a. A person is able to work and produce. b. A person is happy, stable, and feels good. c. All aspects of the person are in perfect balance. d. A person is able to care for others and function socially.

Which of these conditions is due to an inadequate intake of both protein and calories?

Marasmus

For the first time, the nurse is seeing a patient who has no history of nutrition-related problems. The initial nutritional screening should include which activity?

Measurement of weight and weight history

The nurse is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct?

Measuring the chest circumference at the nipple line with a tape measure

A Emotional and cognitive functioning

Mental status assessment documents: a. emotional and cognitive functioning b. intelligence and educational level c. artistic or writing ability in the mentally ill person d. schizophrenia and other mental health disorders

If a 29-year-old woman weighs 156 pounds, and the nurse determines her ideal body weight to be 120 pounds, then how would the nurse classify the womans weight?

Obese

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

Observing the patients body stature and nutritional status

In a patient with acromegaly, the nurse will expect to discover which assessment findings?

Overgrowth of bone in the face, head, hands, and feet

Prehypertension According to the Seventh Report of the Joint National Committee (JNC 7) guidelines, prehypertension blood pressure readings are systolic readings of 120 to 139 mm Hg or diastolic readings of 50 to 89 mm Hg

The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal?

Presence of kyphosis and flexion in the knees and hips

When assessing a patients nutritional status, the nurse recalls that the best definition of optimal nutritional status is sufficient nutrients that:

Provide for daily body requirements and support increased metabolic demands

A 50-year-old woman with elevated total cholesterol and triglyceride levels is visiting the clinic to find out about her laboratory results. What would be important for the nurse to include in patient teaching in relation to Test Bank - Physical Examination and Health Assessment 8e (by Jarvis) 148 these tests?

Provide information regarding a diet low in saturated fat.

The nurse is examining a patient who is complaining of feeling cold. Which is a mechanism of heat loss in the body?

Radiation

Which of the following is the reason for increased caloric and protein requirements during adolescence?

Rapid physical growth and increasing muscle mass

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

The nurse is preparing to measure the vital signs of a 6-month-old infant. Which action by the nurse is correct?

Respirations are measured; then pulse and temperature.

The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this childs respirations?

Respirations should be counted for 1 full minute, noticing rate and rhythm.

During an assessment of a patient who has been homeless for several years, the nurse notices that his tongue is magenta in color, which is an indication of a deficiency in what mineral and/or vitamin?

Riboflavin

The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiologic changes can directly affect the nutritional status of the older adult and include:

Slowed gastrointestinal motility.

Symptoms, such as pain, are often influenced by a persons cultural heritage. Which of the following is a true statement regarding pain? a. Nurses attitudes toward their patients pain are unrelated to their own experiences with pain. b. Nurses need to recognize that many cultures practice silent suffering as a response to pain. c. A nurses area of clinical practice will most likely determine his or her assessment of a patients pain. d. A nurses years of clinical experience and current position are strong indicators of his or her response to patient pain.

What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap?

Systolic blood pressure may be falsely low

A nurse is helping at a health fair at a local mall. When taking blood pressures on a variety of people, the nurse keeps in mind that:

The blood pressure of a Black adult is usually higher than that of a White adult of the same age.

When evaluating the temperature of older adults, the nurse should remember which aspect about an older adults body temperature?

The body temperature of the older adult is lower than that of a younger adult

D Assesses mental health strengths and coping skills and screens for any dysfunction The purpose of the mental status examination is to assess mental health strengths and coping skills and to screen for any dysfunction. The mental status assessment usually can be completed during the context of the entire health history interview. If basic functions (e.g. language) are abnormal, other assessments may be erroneous. A mental status examination can be performed on all patients.

The mental status examination: a. should be completed at the end of the physical examination b. will not be affected if the patient has a language impairment c. is usually not assessed in children younger than 2 years of age d. assesses mental health strengths and coping skills and screens for any dysfunction

not palpable

The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally:

Head circumference greater than chest circumference, Fontanels firm and slightly concave, and Cervical lymph nodes not palpable

The nurse is assessing a 1-month-old infant at his well-baby check up. Which assessment findings are appropriate for this age?

A, C, D

head and neck, arms, inguinal area, and axillae.

The nurse is aware that the four areas in the body where lymph nodes are accessible are the:

The nurse is comparing the concepts of religion and spirituality. Which of the following is an appropriate component of ones spirituality? a. Belief in and the worship of God or gods b. Attendance at a specific church or place of worship c. Personal effort made to find purpose and meaning in life d. Being closely tied to ones ethnic background

The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain? a. All patients will behave the same way when in pain. b. Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain. c. Cultural norms have very little to do with pain tolerance, because pain tolerance is always biologically determined. d. A patients expression of pain is largely dependent on the amount of tissue injury associated with the pain.

The nurse is reviewing the development of culture. Which statement is correct regarding the development of ones culture? Culture is: a. Genetically determined on the basis of racial background. b. Learned through language acquisition and socialization. c. A nonspecific phenomenon and is adaptive but unnecessary. d. Biologically determined on the basis of physical characteristics.

The nurse is reviewing the hot/cold theory of health and illness. Which statement best describes the basic tenets of this theory? a. The causation of illness is based on supernatural forces that influence the humors of the body. b. Herbs and medicines are classified on their physical characteristics of hot and cold and the humors of the body. c. The four humors of the body consist of blood, yellow bile, spiritual connectedness, and social aspects of the individual. d. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors of the body.

The nurse is reviewing theories of illness. The germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions, is a basic belief of which theory of illness? a. Holistic b. Biomedical c. Naturalistic d. Magicoreligious

The nurse manager is explaining culturally competent care during a staff meeting. Which statement accurately describes the concept of culturally competent care? The caregiver: a. Is able to speak the patients native language. b. Possesses some basic knowledge of the patients cultural background. c. Applies the proper background knowledge of a patients cultural background to provide the best possible health care. d. Understands and attends to the total context of the patients situation.

tragus

The nurse needs to palpate the temporomandibular joint for crepitation. This joint is located just below the temporal artery and anterior to the:

VII

The nurse notices that a patient's palpebral fissures are not symmetrical. On examination, the nurse may find that there has been damage to cranial nerve:

area proximal to the enlarged node

The nurse notices that a patient's submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the patient's:

cephalhematoma

The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is very concerned. She tells the nurse that she noticed the lump about 8 hours after her baby's birth, and that it seems to be getting bigger. One possible explanation for this is:

The nurse recognizes that an example of a person who is heritage consistent would be a: a. Woman who has adapted her clothing to the clothing style of her new country. b. Woman who follows the traditions that her mother followed regarding meals. c. Man who is not sure of his ancestors country of origin. d. Child who is not able to speak his parents native language.

The nurse recognizes that categories such as ethnicity, gender, and religion illustrate the concept of: a. Family. b. Cultures. c. Spirituality. d. Subcultures.

The nurse recognizes that working with children with a different cultural perspective may be especially difficult because: a. Children have spiritual needs that are influenced by their stages of development. b. Children have spiritual needs that are direct reflections of what is occurring in their homes. c. Religious beliefs rarely affect the parents perceptions of the illness. d. Parents are often the decision makers, and they have no knowledge of their childrens spiritual needs.

A 4-month-old child is at the clinic for a well-baby check-up and immunizations. Which of these actions is most appropriate when the nurse is assessing an infants vital signs?

The nurse should auscultate an apical rate for 1 minute and then assess for any normal irregularities, such as sinus arrhythmia. The nurse palpates or auscultates an apical rate with infants and toddlers. The pulse should be counted for 1 full minute to account for normal irregularities, such as sinus arrhythmia. Children younger than 3 years of age have such small arm vessels; consequently, hearing Korotkoff sounds with a stethoscope is difficult. The nurse should use either an electronic blood pressure device that uses oscillometry or a Doppler ultrasound device to amplify the sounds.

tachycardia

The nurse suspects that a patient has hyperthyroidism and laboratory data indicate that the patient's thyroxine and tri-iodothyronine hormone levels are elevated. Which of these findings would the nurse most likely find on examination?

pushed to the unaffected side

The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is aware that this means that the patient's trachea is:

A patients blood pressure is 118/82 mm Hg. He asks the nurse, What do the numbers mean? The nurses best reply is:

The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts

When checking for proper blood pressure cuff size, which guideline is correct?

The width of the rubber bladder should equal 40% of the arm circumference.

These are normal vital signs for a healthy, athletic adult.

A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He is seen today in the clinic for an unexplained weight loss of 10 pounds over the last 6 weeks. The nurse knows that:

Unexplained weight loss often accompanies short-term illnesses.

To assess a rectal temperature accurately in an adult, the nurse would

Use a lubricated blunt tip thermometer.

An older adult patient in a nursing home has been receiving tube feedings for several months. During an oral examination, the nurse notes that patients gums are swollen, ulcerated, and bleeding in some areas. The nurse suspects that the patient has what condition?

Vitamin C deficiency

A 50-year-old patient has been brought to the emergency department after a housemate found that the patient could not get out of bed alone. He has lived in a group home for years but for several months has not participated in the activities and has stayed in his room. The nurse assesses for signs of undernutrition, and an x-ray study reveals that he has osteomalacia, which is a deficiency of:

Vitamin D and calcium.

When discussing the use of the term subculture, the nurse recognizes that it is best described as: a. Fitting as many people into the majority culture as possible. b. Defining small groups of people who do not want to be identified with the larger culture. c. Singling out groups of people who suffer differential and unequal treatment as a result of cultural variations. d. Identifying fairly large groups of people with shared characteristics that are not common to all members of a culture.

sternomastoid and trapezius

When examining a patient's cranial nerve (CN) function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the:

ear dysplasia

When examining children affected with Down syndrome (trisomy 21), the nurse looks for the possible presence of:

parotid and submandibular

When examining the face, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the _____ glands.

C Abnormal findings are usually related to not achieving an expected developmental milestone. Abnormalities in mental status in children are often problems of omission; the child does not achieve a milestone that is expected. The validity of the Denver II screening test is based on more than 2000 children in Colorado; the sample represented spectrum of children and was representative of the U.S. population with only minor demographic differences. The behavioral checklist is useful as a mental status assessment for school-age children. A child's psychosocial development and mental status assessment is mostly based on information obtained from the parent.

Which of the following statements about mental status testing of children is correct? a. the results of the Denver II screening test are valid for white, middle-class children only b. the behavioral checklist is useful to assess children who are 3 to 5 years old c. abnormal findings are usually related to not achieving an expected developmental milestone d. input from parents and caretakers is discouraged when assessing psychosocial developement

is a normal finding for a well child of this age

While performing a well-child assessment on a 5 year old, the nurse notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5 cm in size, round, mobile, and nontender. The nurse suspects that this:

The nurse notices a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. The nurse should expect the reading to:

Yield a falsely high blood pressure.

Obesity in adults is defined as:

a body mass index of 30 or greater

presyncope

a lightheaded, swimming sensation or feeling of fainting or falling caused by decreased blood flow to brain or heart irregularity causing decreased cardiac output; "I feel like I'm going to faint"

A comprehensive nutritional assessment always includes

anthropometric measures

A 1-month-old infant has a head measurement of 34 cm and has a chest circumference of 32 cm. Based on the interpretation of these findings, the nurse would:

b. Consider these findings normal for a 1-month-old infant

The nurse is assessing a patient who is obese for signs of metabolic syndrome. This condition is diagnosed when three or more certain risk factors are present. Which of these assessment findings are risk factors for metabolic syndrome? Select all that apply. a. Fasting plasma glucose level less than 100 mg/dL b. Fasting plasma glucose level greater than or equal to 110 mg/dL c. Blood pressure reading of 140/90 mm Hg d. Blood pressure reading of 110/80 mm Hg e. Triglyceride level of 120 mg/dL

b. Fasting plasma glucose level greater than or equal to 110 mg/dL c. Blood pressure reading of 110/80 mm Hg

The nurse is counting an infants respirations. Which technique is correct?

Watching the abdomen for movement

A patient tells the nurse that his food simply does not have any taste anymore. The nurses best response would be:

When did you first notice this change?

When reviewing the demographics of ethnic groups in the United States, the nurse recalls that the largest and fastest growing population is: a. Hispanic. b. Black. c. Asian. d. American Indian.

B Blocking Thought process is defined as the way a person thinks or as the logical train of thought. Lability is an abnormality of mood and affect; the person has a rapid shift of emotions. A compulsion is an abnormality of thought content; the person displays unwanted repetitive, purposeful acts. Aphasia is a speech abnormality; the person is unable to comprehend language, produce language or both.

Which of the following best illustrates an abnormality of thought process? a. lability b. blocking c. compulsion d. aphasia

When assessing an older adult, which vital sign changes occur with aging

Widened pulse pressure With aging, the nurse keeps in mind that the systolic blood pressure increases, leading to widened pulse pressure. With many older people, both the systolic and diastolic pressures increase. The pulse rate and temperature do not increase.

sternomastoid muscle

accomplishes head rotation and flexion

V, the trigeminal nerve

facial sensations of pain or touch are mediated by the 3 sensory branches of what cranial nerve?

For optimum health, infants and children up to 2 years of age should receive whole milk. What component of whole milk is essential for neurologic development?

fat

Which of the following is the most accurate and easy to implement nutritional assessment method?

food diary

migraine headache

genetically transmitted vascular origin; headache plus prodrome, aura, and other symptoms; commonly one-sided; throbbing, pulsating

4 lymph nodes that are accessible to exam

head and neck, arms, axillae, and inguinal region

tension headache

headache of musculoskeletal origin; may be mild-to-moderate, less disabling form of migraine; bandlike tightness, viselike, nonthrobbing, nonpulsatile; usually both sides

graves disease (hyperthyroidism)

increased production of thyroid hormones causes an increased metabolic rate; symptoms include nervousness, fatigue, weight loss, muscle cramps, and heat intolerance; signs include forceful tachycardia, shortness of breath, excessive sweating, fine muscle tremor, thin silky hair, warm and moist skin, infrequent blinking, and a staring appearance

cluster headache

intermittent excruciating, unilateral, with autonomic signs; always one-sided; continuous, burning, piercing, excrutiating

Which of the following signs and symptoms would indicate malnutrition? (Select all that apply.)

lips cracked and pale pink, tongue beefy red. Hair dull and dry Bleeding gums

A dietary practice to restrict meat on certain days such as Ash Wednesday and Fridays during Lent is an example of what type of nutritional influence?

religious

Nutritional status is best determined by

serum albumin

fontanels

spaces where sutures intersect; "soft spots" all for growth of the brain during the 1st year; they gradually ossify

XI, the spinal accessory

the major neck muscles are the sternomastoid and the trapezius are innervated by what cranial nerve?

subjective vertigo

the person feels like the he or she is spinning

objective vertigo

the person feels like the room is spinning

vertigo

true rotational spinning often from labyrinthine-vestibular disorder in inner ear; "I feel like I'm spinning"

parotid and submandibular glands

what two pairs of salivary glands are accessible to exam on the face?

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