Health Assessment EXAM 2

The nurse asks a patient to stand with her feet together, her arms placed at her sides, and her eyes closed. The nurse then observes the patient moving her foot to maintain balance and opening her eyes. Based on this finding, which additional assessment does the nurse perform to confirm an abnormality with balance? A. Ask the patient to walk in tandem, putting the heel of one foot directly against the toes of the other foot. B. Ask the patient to sit down and alternatively tap the thighs with your hands using rapid supination and pronation movements. C. Place a vibrating tuning fork in the patient's ankle and ask when she no longer detects the vibration. D. With the patient in a seated position, support one lower leg while sharply dorsiflexing the foot and maintain it in flexion.

A

What are the characteristics of lymph nodes in patients who have an acute infection? A. They are enlarged and tender. B. They are round, rubbery, and mobile. C. They are hard, fixed, and painless. D. They are soft, mobile, and painless.

A

Which breath sounds are expected over the posterior chest of an adult? A. Vesicular B. Bronchovesicular C. Bronchial D. Bronchoalveolar

A

Which question gives the nurse additional information about a patient's report of his hands shaking for the last 2 months? A. "Does the shaking occur when your hands are at rest or when you are picking up an item?" B. "Do you experience any abnormal sensations, such as tingling or coldness, at the same time?" C. "What actions do you take to relieve the shaking when it occurs?" D. "Have you ever experienced this shaking before?"

A

A nurse in a provider's office is preparing to auscultate and percuss a client's abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Tympany B. High-Pitched clicks C. Borborygmi D. Friction rubs E. Bruits

A, B

A nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications the client currently takes should alert the nurse to a further risk for ototoxicity? (Select all that apply.) A. Furosemide B. Ibuprofen C. Cimetidine D. Simvastatin E. Amiodarone

A, B

A nurse is performing a neurologic examination for a client. Which of the following assessments should the nurse perform to test the client's balance? (Select all that apply.) A. Romberg test B. Heel-to-toe walk C. Snellen test D. Spinal accessory function E. Rosenbaum test.

A, B

A 19-year-old college student comes to the student health center because she discovered a small, nontender, firm, rubbery lump in her right breast. What is the most common cause of breast lumps in women her age? A. Breast cancer B. Fibradenoma C. Ductal ectasia D. Breast abscess

B

A 24-year-old female patient has a 2-day history of clear nasal drainage. Based on these data, which question is the most logical for the nurse to ask? A. "Is there a foul odor coming from your nose?" B. "Have you recently had nosebleeds?" C. "Do you snore when sleeping?" D. "Do you have allergies?"

D

What is the earliest and most sensitive indication of altered cerebral function? A. Memory impairment B. Loss of deep tendon reflexes C. Inability to communicate D. Change in level of consciousness

D

A man seeks treatment for "recent breast enlargement." On examination the nurse notes bilateral enlargement of the breasts. Which question asked by the nurse is most appropriate based on this finding? A. "What medication are you currently taking?" B. "Have you recently been lifting weights?" C. "Did your mother have large breasts?" D. "Have you ever had cancer?"

A

A nurse is caring for a client who asks what their Snellen eye test results mean. The client's visual acuity is 20/30. Which of the following responses should the nurse make? A. "Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet." B. "Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet." C. "Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet." D. "Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet."

A

A nurse is obtaining a health history from a 52-year-old male patient with a red lesion at the base of the tongue. What additional data does the nurse specifically collect about this patient? A. Alcohol and tobacco use B. Date of his last dental examination C. Use of dentures D. A history of pyorrhea

A

A patient describes a recent onset of frequent and severe unilateral headaches that last about 1 hour. Based on these symptoms, the nurse suspects which type of headache? A. Cluster headache B. Migraine headache C. Tension headache D. Sinus headache

A

During a physical examination, the nurse is unable to feel the patient's thyroid gland with palpation from an anterior approach. What is the appropriate action of the nurse at this time? A. Recognize that this is an expected finding. B. Auscultate the thyroid area. C. Palpate the thyroid using a posterior approach. D. Refer the patient for follow-up with an endocrinologist.

A

Narrowing of the bronchi creates which adventitious sound? A. Wheeze B. Crackles C. Rhonchi D. Pleural friction rub

A

On auscultation of a patient's lungs, the nurse hears a low-pitched, coarse, loud, and low snoring sound. Which term does the nurse use to document this findings? A. Rhonchi B. Wheeze C. Crackles D. Pleural friction rub

A

A nurse is collecting data from an older adult client as part of a neurologic examination. Which of the following findings should the nurse expect as changes associated with aging? (Select al that apply.) A. Slower light touch sensation B. Some vision and hearing decline C. Slower fine finger movement D. Some short-term memory decline E. Decreased risk of depression.

A, B, C, D

A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (select all that apply.) A. Weber test showing lateralization to the right ear B. Light reflex at 10 o'clock in the left ear C. Indications of obstruction in the left ear canal D. Rinne test showing less time for air and bone conduction E. Rinne test showing air conduction less than bone conduction in the left ear

A, D

A nurse in a provider's office is preparing to perform a breast examination for an older adult client who is postmenopausal. Which of the following findings should the nurse expect? (Select all that apply.) A. Smaller nipples B. Less adipose tissue C. Nipple discharge D. More pendulous E. Nipple inversion

A, D, E

A nurse is assessing a client's thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Palpating the thyroid in the lower half of the neck B. Visualizing the thyroid on inspection of the neck C. Hearing a bruit when auscultating the thyroid D. Feeling the thyroid ascend as the client swallows E. Findings symmetric extension off the trachea on both sides of the midline.

A, D, E

A 32-year-old woman has a 4-day history of sore throat and difficulty swallowing. The nurse observes tonsils covered with yellow patches. The tonsils are so large that they fill the entire oropharynx and appear to be touching. How does the nurse document these findings? A. "Tonsils yellow and edematous." B. "Enlarged tonsils 4+ with yellow exudate." C. "Strep infection to tonsils with 3+ swelling." D. "1+ edema of tonsils with pus."

B

A nurse is auscultating the lungs of a healthy female patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding? A. Make sure the bell of the stethoscope is used rather than the diaphragm. B. Ask the patient to cough then repeat the auscultation. C. Ask the patient not to talk while the nurse is listening to the lungs. D. Change the patient's position.

B

A nurse suspects a viral infection or upper respiratory allergies when the patient describes the sputum as being which color? A. Green B. Clear C. Yellow D. Pink tinged

B

During a health history, a patient reports having difficulty swallowing. Based on this report, which assessment technique does the nurse use to collect more data about the patient's ability to swallow? A. Ask the patient to puff out her cheeks, purse her lips, and blow out.. B. Observe the soft palate when the patient says "ahh." C. Observe the patient while she swallows water from a paper cup. D. Wearing gloves, grasp the patient's tongue and palpate all sides.

B

The nurse examines a patient's auditory canal and tympanic membrane with an otoscope. Which findings is considered abnormal? A. Presence of cerumen B. Yellow color to the tympanic membrane C. Presence of a cone of light C. Shiny, translucent tympanic membrane

B

What is the expected patient response when assessing the function of CN XI (spinal accessory)? A. Demonstrates full, active range of motion of the neck B. Moves shoulders against resistance equally C. Follows an object with eyes without nystagmus D. Sticks out tongue without tremor or deviation

B

You had to yell his name to get him to open his eyes; he could not tell you his name or location, and he could raise his hands when asked. Using the Glasgow Coma Scale (see Fig. 15.23), what score would you give to this patient? A. 12 B. 13 C. 14 D. 15

B

During a cardiovascular examination, a nurse in a provider's office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following data is the nurse attempting to auscultate? (Select all that apply.) A. Ventricular gallop B. Closure of the mitral valve C. Closure of the pulmonic valve D. Apical heart rate E. Murmur

B, D

A nurse is assessing an adult client's internal ear canals with an otoscope as part of a head and neck examination. Which of the following actions should the nurse take? (Select all that apply.) A. Pull the auricle down and back. B. Insert the speculum slightly down and forward. C. Insert the speculum 2 to 2.5 cm (0.8 to 1 in). D. Make sure the speculum does not touch the ear canal. E. Use the light to visualize the tympanic membrane in a cone shape.

B, D, E

A nurse is caring for a client who had a stroke and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? (Select all that apply.) A. Speak at a higher volume to the client. B. Make sure only one person speaks at a time. C. Avoid discouraging the client by indicating that they cannot be understood. D. Allow plenty of time for the client to respond. E. Use brief sentences with simple words.

B, D, E

A nurse finds the patient's AP diameter of the chest to be the same as the lateral diameter. Based on this finding, what additional data would the nurse anticipate? A. Bronchial breath sounds in the posterior thorax B. Decrease in respiratory rate C. Decreased breath sounds on auscultation D. Complaint of sharp chest pain on inspiration

C

A nurse is caring for a client who had an amphetamine toxicity and has sensory overload. Which of the following interventions should the nurse implement? A. Immediately complete a through assessment? B. Encourage visitors to distract the client. C. Provide a private room, and limit stimulation. D. Speak at a higher volume to the client.

C

A nurse is caring for a client who reports pain with internal rotation of the right shoulder. This discomfort can affect the client's ability to perform which of the following activities? A. Exercising the deltoid muscle when using hand weights B. Brushing the hair on the back of the head C. Fastening or zipping closures on the back while dressing D. Reaching into a cabinet above the sink

C

A patient has an infection of the terminal bronchioles and alveoli that involves the right lower lobe of the lung. Which abnormal findings are expected? A. Dyspnea with diminished breath sounds bilaterally B. Asymmetric chest expansion and rhonchi on the right side C. Fever and tachypnea with crackles over the right lower lobe D. Prolonged expiration with an occasional wheeze in the right lower lobe

C

During a symptom analysis, the patient reports a pain that radiates from the right lateral thigh, over the knee, and around to the right medial ankle. The nurse refers to the dermatome map (see Fig. 15.8) to determine that the patient's description of pain is consistent with dysfunction of which spinal nerve? A. Second lumbar (L2) B. Third lumbar (L3) C. Fourth lumbar (L4) D. Fifth lumbar (L5)

C

During an abdominal examination, a nurse in a provider's office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect? A. Fat B. Fluid C. Flatus D. Hernias

C

How does the nurse asses a patient's consensual reaction? A. By touching the cornea with a small piece of sterile cotton and observing the change in the pupil size B. By observing the patient's pupil size when the patient looks at an object 2 to 3 feet away and then looks at an object 6 to 8 inches away. C. By shining a light into the patient's right eye and observing the pupillary reaction of the left eye. D. By covering one eye with a card and observing the pupillary reaction when the card is removed.

C

What is the reason for palpation axillary lymph nodes during a clinical breast examination? A. Axillary nodes fluctuate during the month in response to the menstrual cycle. B. Axillary node tenderness is the most common initial symptom of breast cancer. C. The lymph network in the breast primarily drains towards the axillary lymph nodes. D. This is a matter of convenience because of the close proximity of the axillae to the breasts.

C

Which data from the health history of a 42-year-old man should be evaluated further as a possible risk for hearing loss? A. "I watch TV in the evenings with my wife and children." B. "When I was younger, I wore an earring." C. "My primary hobby is carpentry work." D. "I have been an accountant for 16 years for an insurance agency."

C

Which findings is considered abnormal when conduction a breast examination on a 68-year-old woman? A. Dark pink areola B. Pendulous breasts C. Serous nipple drainage D. Granular texture

C

Which patient behavior indicates to the nurse that the patient's facial cranial nerve (CN VII) is intact? A. The patient's eyes move to the left, right, up, down, and obliquely. B. The patient moistens the lips with the tongue. C. The sides of the mouth are symmetric when the patient smiles. D. The patient's eyelids blink periodically.

C

A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should the nurse expect? (Select all that apply.) A. Reddened gums B. Lowered vocal pitch C. Tooth loss D. Glare intolerance E. Thickened eardrums

C, D, E

A nurse in a provider's office is preparing to assess a young adult client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Concave thoracic spine posteriorly B. Exaggerated lumbar curvature C. Concave lumbar spine posteriorly D. Exaggerated thoracic curvature E. Muscles slightly larger on the dominant side

C, E

A nurse in a provider's office is preparing to test a client's cranial nerve function. Which of the following directions should the nurse include when testing cranial nerve V? (Select all that apply.) A. "Close your eyes." B. "Tell me what you can taste." C. "Clench your teeth." D. "Raise your eyebrows." E. "Tell me when you feel a touch."

C, E

A nurse is a provider's office is preparing to auscultate and percuss a client's thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Rhonchi B. Crackles C. Resonance D. Tactile fremitus E. Bronchovesicular sounds.

C, E

A 51-year-old woman has found a small lump in her breast. Which data from her history are risk factors for breast cancer? A. Her husband's mother died from breaks cancer at age 43. B. She drinks a glass of wine each night with dinner. C. Menarche occurred at age 14; menopause occurred at age 46. D. She underwent radiation treatment for Hodgkin disease at age 17.

D

A nurse in the emergency department is assessing a patient with a moderate left pneumothorax. What does this nurse expect to find during the respiratory examination? A. Increased fremitus over the left chest B. Tracheal deviation to the left side C. Crepitus on the left chest during palpation D. Distant to absent breath sounds over the left chest

D

A nurse is reviewing instruction with a client who has a hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I use a damp cloth to clean the outside part of my hearing aids." B. "I clean the ear molds of my hearing aids with rubbing alcohol." C. "I keep the volume of my hearing aids turned up so I can hear better." D. "I take the batteries out of my hearing aids when I take them off at night."

D

A nurse, who is assessing a client's neurologic system, should ask the client to close their eyes and identify which of the following items? A. A word the nurse whispers 30 cm from the ear B. A number the nurse traces on the palm of the hand C. The vibration of a tuning fork the nurse places on the foot D. A familiar object the nurse places in the hand.

D

As a patient is walking into the exam room, the nurse notices his unsteady gait. Which findings does the nurse anticipate during the neurologic exam? A. When the patient stands with his feet together and eyes closed, his upright posture is maintained. B. The nurse notices no patient responses after striking the right patellar tendon with a reflex hammer. C. The patient is able to move the heel of one foot down the shin of the other leg while lying supine. D. A tremor is observed in his hands while he touches his fingers to his thumb on the same hand.

D

During an eye examination, how does a nurse recognize normal accommodation? A. The patient has peripheral vision of 90 degrees left and right. B. The patient's eyes move up and down, side to side, and obliquely. C. The right pupil constricts when a light is shown in the left pupil. D. The patient's pupils dilate when looking toward a distant object.

D

During inspection of the respiratory system the nurse documents which finding as abnormal? A. Skin color consistent with patient's race B. 1:2 ratio of anteroposterior to lateral diameter C. Respiratory rate of 20 breaths per minute D. Patient leaning forward with arms braced on the knees

D

How does the nurse palpate the chest for tenderness, bulges, and symmetry? A. Uses the fist of the dominant hand to gently tap the anterior, lateral, and posterior chest, comparing one side with another B. Uses the ulnar surface of one hand to palpate the anterior, posterior, and lateral chest, comparing one side with another C. Use the tips of the fingers to palpate the skin over the chest and the alignment of vertebrae D. Uses the palmar surface of fingers of both hands to feel the texture of the skin over the chest and the alignment of vertebrae

D

Which technique does the nurse use to assess the triceps reflex? A. Holds the patient's relaxed arm with the elbow extended while striking the appropriate tendon with a reflex hammer. B. Holds the patient's relaxed forearm with the hand slightly pronated while striking the appropriate tendon with a reflex hammer. C. Holds the patient's relaxed arm with elbow flexed at a 90-degree angle, places a thumb over the appropriate tendon, and strikes the thumb with the reflex hammer. D. Holds the patient's relaxed arm with elbow flexed at a 90-degree angle in one hand and strikes the appropriate tendon just above the elbow with a reflex hammer.

D

Which technique is used for palpating lymph nodes? A. Apply firm pressure over the nodes with the pads of the fingers. B. Apply gentle pressure over the nodes with the tips of the fingers. C. Apply firm pressure anterior to the nodes with the tips of the fingers. D. Apply gentle pressure over the nodes with the pads of the fingers.

D

While talking with a patient, the nurse suspects that he has hearing loss. Which examination technique is most accurate for assessing hearing loss? A. Whispered voice test B. Rinne test C. Weber test D. Test using audioscope

D