Health Assess 1

While auscultating a patient's heart rate and rhythm, you note it sounds irregular. What additional assessments would help you determine the cause? Select all that apply. a. Note if there is any pattern to the irregularity. b. Note if the rate varies with inspiration and expiration. c. Carefully listen to the bilateral carotid arteries. d. Auscultate the apical beat while palpating the radial pulse, and note any difference in rate.

a,b,d

You are examining a 10-year-old girl for a sports physical. What is the first physical change associated with puberty in girls? Select all that apply. a. Breasts enlarge and areolae enlarge over breasts. b. A small mound of breast tissue develops under the nipple. c. Height spurt. d. Pubic hair development.

b,d

1. A 30-year-old woman reports having persistent, intense pain in her right arm related to trauma sustained from a car accident 5 months ago. She states that the slightest touch or clothing can exacerbate the pain. This report is suggestive of: a. Referred pain. b. Psychogenic pain. c. Complex regional pain I. d. Cutaneous pain.

c

Atrial systole occurs: a. During ventricular systole. b. During ventricular diastole. c. Concurrently with ventricular systole. d. Independently of ventricular function.

B

Select the best description of the tricuspid valve. a. Left semilunar valve. b. Right atrioventricular valve. c. Left atrioventricular valve. d. Right semilunar valve.

B

When assessing the carotid artery, you will palpate: a. Bilaterally at the same time while standing behind the patient. b. Medial to the sternomastoid muscle, one side at a time. c. For a bruit while asking the patient to hold their breath briefly. d. For unilateral distention while turning the patient's head to one side.

B

Which assessment finding is most likely to be immediately life-threatening? a. Bronchial breath sounds over a peripheral lung field. b. Stridor. c. Absent breath sounds over one lung lobe. d. Soft high-pitched expiratory wheezing with forced expiration.

B

You are examining a hospitalized woman who is on bedrest and has difficulty turning. Which is your best approach to completing the inspection, palpation, and auscultation of the thorax? a. Inspect, palpate, and auscultate the anterior and lateral thorax only, omitting the posterior thorax to optimize patient comfort. b. Find an assistant to help you turn the woman side to side, and perform the complete assessment while comparing bilaterally as much as possible. c. Have the woman turn as best as she can, omitting assessment of areas of the thorax that are not accessible. d. Omit inspection of the posterior thorax and push down the mattress to move your hand and stethoscope endpiece under the woman while palpating and auscultating.

B

A murmur is heard after S1 and before S2. This murmur would be classified as: a. Diastolic (possibly benign). b. Diastolic (always pathologic). c. Systolic (possibly benign). d. Systolic (always pathologic).

C

The function of the pulmonic valve is to: a. Divide the left atrium and left ventricle. b. Guard the opening between the right atrium and right ventricle. c. Protect the orifice between the right ventricle and pulmonary artery. d. Guard the entrance to the aorta from the left ventricle.

C

The major factor contributing to the need for cultural care nursing is: a. An increasing birth rate. b. Limited access to health care services. c. Demographic change. d. A decreasing rate of immigration.

C

You are the triage nurse in the emergency department and perform the initial intake assessment on a patient who does not speak English. Based on your understanding of linguistic competence, which action would present as a barrier to effective communication? a. Maintaining a professional, respectful demeanor b. Allowing for additional time to complete the process c. Providing the patient with a paper and pencil so answers can be written d. Obtaining interpreter services so the family does not need to translate

C

The second heart sound is the result of: a. Opening of the mitral and tricuspid valves. b. Closing of the mitral and tricuspid valves. c. Opening of the aortic and pulmonic valves. d. Closing of the aortic and pulmonic valves.

D

Which statement best describes religion? a. An organized system of beliefs concerning the cause, nature, and purpose of the universe b. Belief in a divine or superhuman spirit to be obeyed and worshiped c. Affiliation with one of the 1200 recognized religions in the United States d. The following of established rituals, especially in conjunction with health-seeking behaviors

a

You are preparing to assess a patient who reports changes in skin pigmentation. The best option for lighting is: a. Natural daylight b. Overhead lighting c. Tangential lighting d. Sun lamp

a

What questions should be included in a cultural assessment? Select all that apply. a. Are there any foods that you are unable to eat due to cultural beliefs? b. Are you using any complementary or alternative treatments currently? c. Could pregnancy be the reason for your irregular periods and illness? d. What is your favorite food to eat? e. How are you doing in your classes? Have you been able to make friends?

a,b

You visit the home of a 35-year-old mother with her first baby. She is 4 days postpartum. She has a tender thickening in one breast with the overlying skin reddened and tender. She has fatigue but no fever. What teaching would you give? Select all that apply. a. "Nurse the baby on the affected side first at each nursing." b. "Nurse the baby frequently to keep the breast as empty as possible." c. "This condition is common when you and the baby are both learning to nurse." d. "I will request an antibiotic for you that will not harm the baby."

a,b,c

When caring for a patient with advanced dementia, which of the following categories are included in the PAINAD Scale? Select all that apply. a. Breathing independent of vocalization b. Yelling c. Body language d. Consolability e. Activity f. Negative vocalization g. Positive vocalization h. Facial expression i. Face j. Vital signs

a,b,c,d,f,h

1. You are caring for a 36-year-old male who presents to the emergency department with acute right lower quadrant abdominal pain rated at 10/10 on the numeric pain rating scale. The patient is tachycardic, tachypneic, grimacing, and curled in the fetal position. During the workup, the provider refuses to order any pain medication. You should: a. Advocate for the patient to receive pain medication. It will be easier to complete the workup if the patient is comfortable. b. Let the patient know that no pain medication can be given until the workup is complete, as the medication may mask symptoms. c. Recognize that the provider understands the need for the patient to feel the pain so he can adequately describe it. d. Call your supervisor to intervene. The patient should have pain medication ordered immediately.

a

A 13-year-old girl presents to your clinic for a school physical examination. She asks you why her breasts "don't match" in size. What is your best response? a. "One breast may temporarily grow faster than the other during development." b. "In these cases, I usually ask another examiner to come in and double check." c. "It is a sign that you will have small cystic lumps in one side; these are common." d. "This may show a temporary hormonal imbalance. We will check again in 6 months."

a

M.J., age 85, has been diagnosed with terminal lung cancer. During report you were told that the family does not want her to know the diagnosis. M.J. asks you, "Am I going to die?" Which of the following is the best therapeutic response from you, the nurse? a. "Tell me what prompted that question." b. "I will ask your physician to discuss this matter with you." c. "Let's take each day as it comes." d. "I think you should discuss that with your family."

a

Select the finding that most accurately describes appearance of a patient. a. Tense posture and restless activity. Clothing clean but not appropriate for season. b. Oriented × 3. Affect appropriate for circumstances. c. Alert and responds to verbal stimuli. Tearful when diagnosis discussed. d. Laughing inappropriately, oriented × 3.

a

The nurse is assessing a patient's skin for swelling during an office visit. What is the best technique to use to assess the patient's skin for lumps and swelling? Use the: a. fingertips because they have better tactile discrimination than the rest of the hand. b. dorsal surface of the hand because the skin is thinner than on the palms of the hand. c. ulnar portion of the hand because there is increased blood supply that enhances temperature sensitivity. d. palmar surface of the hand because it is most sensitive to temperature variations.

a

The practitioner, entering the examining room to meet a patient for the first time, states: "Hello, I'm M.M., and I'm here to gather some information from you and to perform your examination. This will take about 30 minutes. D.D. is a student working with me. If it's all right with you, she will remain during the examination." Which of the following must be added to cover all aspects of the interview contract? a. A statement regarding confidentiality, patient costs, and the expectations of each person b. The purpose of the interview and the role of the interviewer c. Time and place of the interview and a confidentiality statement d. An explicit purpose of the interview and a description of the physical examination, including diagnostic studies

a

When auscultating the heart, your first step is to: a. Identify S1 and S2. b. Listen for S3 and S4. c. Listen for murmurs. d. Identify all four sounds on the first round.

a

Which of the following assessments best confirms symmetric chest expansion? a. Place hands on the posterolateral chest wall with thumbs at the level of T9 or T10. b. Inspect the shape and configuration of the chest wall. c. Compare bilateral auscultatory points for the presence of any adventitious sounds. d. Percuss the posterior chest.

a

You have examined the following women during one shift. Which ones should you refer for further evaluation? Select all that apply. a. A 28-year-old with multiple distinct nodules palpated in each breast. b. A 48-year-old who has a 6-month history of reddened and sore left nipple and areolar area. c. A 22-year-old with asymmetric breasts and inversion of nipples since adolescence. d. A 64-year-old with an ulcerated area at the tip of the right nipple; no masses, tenderness, or enlarged lymph nodes present.

a,b,d

Mu-opioid receptors are located in the: Select all that apply. a. Small intestine b. Amygdala c. Hypothalamus d. Thalamus e. Insula f. Prefrontal cortex g. Spinal cord ventral horn h. Brainstem i. Spinal cord dorsal horn

a,b,d,,e,h,i

Palpation can be used for which of the following? Select all that apply. a. Position of an organ b. Size of a mass c. Density of an organ d. Deep tendon reflex e. Pulsation f. Vibration

a,b,e,f

A 74-year-old woman has a history of coronary artery disease. Which 3 signs and symptoms lead you to suspect the woman may have heart failure? Select all that apply. a. Reports 2-month history of orthopnea, sleeping on 3 pillows because "it is easier to breathe" b. Reports burning epigastric pain after eating c. 2+ bilateral pretibial edema d. S3 gallop e. Clear, adventitious breath sounds f. Warm, flushed skin

a,c,d,

You are preparing to enter the room of a patient with suspected pertussis. To protect yourself and others you will: Select all that apply. a. use standard precautions b. use contact precautions c. use droplet precautions d. use airborne precautions e. use hand sanitizer f. wash your hands with soap and water if visibly soiled g. always wash your hands instead of using hand sanitizer

a,c,e,f

Factors important during an interview include: Select all that apply. a. Equal status seating b. Leading questions c. Active listening d. Distancing e. Social responses f. Avoidance language g. Providing privacy h. Professional jargon

a,c,g,

You are teaching a 34-year-old woman who is 2 months pregnant what common breast changes to expect. You would include: Select all that apply. a. The areolae become darker brown. b. Nipple retraction. c. Able to express breast milk after 2 months. d. Blue vascular pattern over both breasts.

a,d

A 57-year-old woman presents to your clinic for a health checkup, having deferred any health care visits for 1.5 years. During a breast examination, you palpate a 2-cm firm mass with irregular edges. What is your next best action? a. Request a breast biopsy. b. Request a mammogram. c. Review her medication list for drugs that cause breast lumps. d. Proceed with the examination; this is a common finding in a menopausal woman.

b

During an interview with a patient diagnosed with a seizure disorder, the patient states, "I plan to be an airline pilot." If the patient continues to have this as a career goal after teaching regarding seizure disorders has been provided, you might question the patient's: a. Thought processes. b. Judgment. c. Attention span. d. Recent memory.

b

During the examination of a 30-year-old woman, she asks about "the large mole" below her left breast. After inspecting a 1-cm circular brown area with a central bump, what is your best response? a. "I think you should be examined by a dermatologist." b. "This is a common finding of an extra, undeveloped nipple." c. "These are Montgomery glands, which are common." d. "Is there a possibility that you are pregnant?"

b

Extra heart sounds and murmurs are described as low-pitched sounds. Given your knowledge of the stethoscope, you know that low-pitched sounds are best heard with the: a. bell end piece held firmly to the skin b. bell end piece held lightly against the skin c. diaphragm end piece held firmly to the skin d. diaphragm end piece held lightly to the skin

b

Which statement best reflects the biomedical causation of illness? a. Each being is only a part of a larger structure in the world of nature as it relates to health and illness. b. Causal relationship exists, leading to expression of illness. c. Belief in the struggle between good and evil is reflected in the regulation of health and illness. d. Illness occurs as a result of disturbances between hot and cold reactions.

b

You are assessing the pain in a patient in the neonatal intensive care unit. J.K. is a female infant born at 34 weeks gestation who underwent surgery to correct esophageal atresia. When you admit the patient postoperatively, she is not actively crying, does not require oxygen to maintain an oxygen saturation above 98%, her HR and BP are increased from baseline though not significantly, she grimaces frequently, and she wakes frequently. Using the CRIES instrument on page 174 of the textbook, how would you rate the infant's pain? a. 2 b. 3 c. 6 d. 1 e. 4

b

You are auscultating heart sounds and hear a click early in systole at the 2nd right interspace and the apex. There is also a systolic murmur. Which question to the patient demonstrates you understand the significance of your auscultation findings? a. "Have you been told you have a mitral valve replacement?" b. "Have you been told you have aortic stenosis?" c. "Have you been told you have mitral valve prolapse?" d. "Have you been told you have heart failure?"

b

You are presenting the internal anatomy of the breast for a community health care clinic. Which of the following are accurate points to include? Select all that apply. a. The bulk of the breast is mainly pectoralis muscle tissue. b. The fibrous connective tissue extends from inside the breast skin surface toward the chest wall muscles. c. The breast tissue slopes upward into the axilla. d. Most lymphatic drainage of the breast flows inward to deeper chest lymph ducts.

b,c

For a patient experiencing orthopnea, which physical assessment findings would be most relevant? Select all that apply. a. Right-sided carotid bruit. b. Elevated jugular venous pressure. c. Presence of a split S2 toward the end of every expiration. d. Presence of an S3 heart sounds in both supine and sitting positions.

b,d

After positioning a patient at 45 degrees and shining a light across the neck from the right side, you note an undulating pulsation that moves down the neck when the person takes a deep breath. In addition, the pulsation disappears entirely when the patient sits up to 90 degrees. Which interpretation of this finding is correct? a. This is the carotid pulse, and the finding is normal. b. This is the carotid pulse, and the finding may suggest carotid stenosis. c. This is the jugular venous pulse, and the finding is normal. d. This is the jugular venous pulse, and the finding may suggest hypovolemia.

c

During the examination of a 70-year-old man, you note gynecomastia. You next best action is to: a. Request a breast biopsy. b. Request a mammogram. c. Review the medications for drugs that have gynecomastia as a side effect. d. Proceed with the examination; this is a normal part of the aging process.

c

The bimanual technique is your preferred approach for a woman: a. Who is pregnant. b. Who is having the first breast examination by a health care provider. c. With large pendulous breasts. d. Who has felt a change in the breast during self-examination.

c

The precordium is: a. A synonym for mediastinum. b. The area on the chest where the apical impulse is felt. c. The area on the anterior chest overlying the heart and great vessels. d. A synonym for the area where the superior and inferior venae cavae return unoxygenated venous blood to the right side of the heart.

c

When teaching the breast self-examination, you would inform the woman that the best time to conduct breast self-examination is: a. At the onset of the menstrual period. b. On the 14th day of the menstrual cycle. c. On the 4th to 7th days of the cycle. d. Just before the menstrual period.

c

You are assessing a 75-year-old man. What is an expected finding? a. He will have no decrease in any of his abilities, including response time. b. He will have difficulty on tests of remote memory because this typically decreases with age. c. It may take him a little longer to respond, but his general knowledge and abilities should not have declined. d. He will have had a decrease in his response time due to language loss and a decrease in general knowledge.

c

You are completing a mental status examination on a patient who had a stroke 3 days ago. He is alert and oriented × 3. During the exam, you note agraphia and agrammatic speech. Upon talking to his partner, you learn he is well educated and had no speech difficulty prior to his stroke. Given this information, you know the stroke likely impacted: a. Broca area. b. Wernicke area. c. Posterior language area. d. Frontal language area.

c

You are examining a patient and count a respiratory rate of 30 breaths per minute. There are no adventitious sounds, but you do note that the breath sounds are decreased and the patient's breathing seems shallow. Which term best describes this breathing pattern? a. Hyperventilation. b. Hypoventilation. c. Tachypnea. d. Cheyne-Stokes respirations.

c

You are preparing to assess a 1-month-old who is awake and fussy. Given what you know of development, you begin the assessment by: a. moving in a head-to-toe fashion so you do not forget anything. b. listening to the heart and lungs first while the infant is being held. c. personalizing the assessment based on the infant's temperament. d. avoiding eye contact because the infant has stranger anxiety.

c

You are providing health promotion for a 50-year-old woman. What is the current recommendation for women aged 45 to 54 years of age for screening mammography? a. Opportunity to begin mammograms at age 55. b. Mammogram now and every 2 years. c. Annual mammogram. d. Only baseline examination needed unless the woman has symptoms.

c

. After examining a patient, you note: fever, increased respiratory rate, chest expansion decreased on the left side, dull to percussion over the left lower lobe, and breath sounds louder with fine crackles over the left lower lobe. These findings are consistent with: a. Acute bronchitis. b. Asthma. c. Pleural effusion. d. Lobar pneumonia.

d

A 62-year-old man complains of chest pain. You ask him to describe the chest pain. Which statement would cause you to consider an ischemic cardiovascular cause? a. "The pain is much worse when I take a deep breath, and I keep coughing too." b. "It feels sharp and stabbing, but it's a bit better when I lean forward." c. "This pain is burning; I notice it more after I eat and my mouth tastes terrible." d. "My chest feels tight and heavy, but it does go away when I rest for a few minutes."

d

A patient has osteoarthritis in her hips and knees. She can move around in her room this morning and has offered no complaints. When asked, she states that her pain is "bad this morning" and rates the pain at an 8 on a 0 to 10-point scale. The nurse suspects the patient: a. Is addicted to her pain medication and cannot obtain relief from small doses. b. Does not want to trouble anyone with her complaints. c. Is not in severe pain but would like pain medication. d. Has experienced pain for years and adapted to the chronic pain.

d

A patient reports dry cough, shortness of breath with activity, and orthopnea. You auscultate fine inspiratory crackles over the bilateral posterior lung bases. What is your next best action? a. Request pulmonary function studies to check for emphysema. b. Request an x-ray image to check for lobar pneumonia. c. Auscultate for absent breath sounds to check for pneumothorax. d. Report to provider; these findings are consistent with heart failure.

d

On auscultating a patient, you note a coarse, low-pitched sound during both inspiration and expiration. This patient reports pain with breathing. These findings are consistent with: a. Fine crackles. b. Wheezes. c. Atelectatic crackles. d. Pleural friction rub.

d

The first step to cultural competency by a nurse is to: a. Identify the meaning of health to the patient. b. Understand how a health care delivery system works. c. Develop a frame of reference to traditional health care practices. d. Understand their heritage and its basis in cultural values.

d

When teaching a client how to effectively manage their new medication regimen, the nurse recognizes that the best method of communicating therapeutically with the client is to: a. Talk to the client in the visitors' lounge b. Talk to the client within his personal space c. Communicate with the client using touch d. Face the client while leaning slightly forward

d

You are auscultating breath sounds on a 70-year-old man who states he feels dizzy. Which is your next best action? a. Quickly move through the remaining auscultatory points. b. Stop the exam and record that the patient could not tolerate auscultation portion. c. Ask the patient to hold his breath for 10 seconds, then continue with auscultation. d. Allow the patient to take a break, then resume auscultation while monitoring for any worsening dizziness.

d

You are examining a patient with respiratory distress. Which of the following assessments would best determine if that patient has acute hypoxemia? a. Inspect the nailbeds for presence of clubbing. b. Palpate for areas of decreased tactile fremitus. c. Auscultate for presence of any adventitious breath sounds. d. Inspect the nailbeds and mucous membranes for presence of cyanosis.

d

You are interviewing a 14-year-old adolescent who has just started playing soccer and has been complaining of cramping leg pain during practice. The teen is very concerned that something is wrong. What should be your next action? a. Tell the teen it's probably dehydration, and encourage intake of more fluids and electrolytes. b. Talk to the attending provider about obtaining further tests to assess for any atherosclerotic disease in the legs. c. Tell the teen that growing pains are normal, and that you will follow up for improvement at the next visit. d. Assess arm versus leg blood pressures, bilateral femoral pulse amplitude, and for presence of any murmurs.

d

You are taking a health history on a 44-year-old man who reports use of cigarettes. You calculate a 24-pack year history of smoking, and learn that he has never attempted to quit before. What is your best statement to facilitate a discussion of quitting smoking? a. "Smoking is deadly; you really need to stop as soon as possible." b. "Do you have any family members who have died because of smoking-related illnesses?" c. "Here is a list of resources for when you are ready to quit smoking." d. "Are you interested in exploring options to help you quit smoking?"

d

"Life's Simple 7"

not smoking, healthy weight, adequate physical activity and balanced healthy diet, as well as achieving target values for cholesterol, blood pressure and blood glucose.

List eight items of information that should be communicated to the client concerning the terms or expectations of the interview.

· Time and place of the interview and succeeding physical examination. • Introduction of yourself and a brief explanation of your role. • The purpose of the interview. • How long it will take. • Expectation of participation for each person. • Presence of any other people (e.g., family, other health professionals, students). • Confidentiality and to what extent it may be limited. • Any costs to the client.