Health Assessment Final

What response should the nurse make to best support a client who states, "I'm ready to accept my impeding death?"

"Is there anyone you'd like to talk with about your feelings?"

How much does the nurse expect to spend on the Mini-Cog examination with which patient?

3 minutes with an 86-year-old Alzheimer's patient on a med-surg unit

The nurse assesses brisk reflexes in a client. The nurse would document this finding as what?

3+

The area known as Erb's point is the third site for auscultation on the precordium. Where is it located?

3rd left rib space

When analyzing the nursing history recently taken on a client, which factor would most strongly alert the nurse to a significantly increased risk for chronic arterial insufficiency?

A 14-year history of smoking a pack a day

A nurse is receiving report from the night shift about four clients. Which client would the nurse see first?

A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min.

Theophylline is

A long-acting maintenance inhaler

A patient is diagnosed with pericarditis. The nurse would expect to hear what with auscultation?

A pericardial friction rub

Albuterol is:

A short acting bronchodilator

The nursing instructor is discussing assessment of the heart with students. A student states that he has a client with a rushing vibration in the precordium that the student could feel and that it was in the area of the pulmonic valve. What should the instructor explain that the student is feeling?

A thrill

Which CN is intact when the patient can look to each side while keeping their head in place?

Abducens

A woman and her teenager have come to the clinic. The teenager has acne lesions that are not well controlled. The mother asks the nurse what causes acne. What would be the nurse's best response?

Acne is caused by the impedance of sebum secretion onto the skins surface

A school nurse working is preparing a presentation to parents regarding school age assessments. At which developmental stage should the nurse add scoliosis screening?

Adolescent/pre-adolescent

All of the following are part of the lymphatic system except:

Adrenal gland

A nursing instructor is discussing mental health assessment with a class of nursing students. While reviewing risk factors for mental illness, what would the instructor be sure to identify as a factor that cannot be changed?

Age

A medication used to reduce ocular pressure is:

An anti-glaucoma medication

The nurse caring for a patient diagnosed with a 2nd rib fracture should know the location of the sternal angle also called what?

Angle of Louis

Effient is a type of

Anti-platelet medication

A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test cranial nerve I. What would the nurse do?

Ask the client to identify scents

A nurse is preparing a client for ambulation. Which of the following action should the nurse take to determine the client's level of strength?

Ask the client to push her feet against the nurse's palms.

A client in the emergency department is short of breath. While collecting the history, what is the nurse's best action?

Ask the client's relatives about the client's history.

The nurse is assessing a client who presents with shoulder pain. No signs of inflammation are present. What is the nurse's priority action?

Assess for shortness of breath

A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client?

Assess the client regarding characteristics of the pain

An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse?

Assess the client's respiratory rate and pattern

A woman newly immigrated to the united states is admitted to the obstetric unit. While doing a transcultural assessment, how would the nurse individualize questions for this client?

Assessing if the client speaks and understands English

The student nurse knows elderly patients are at an increased risk of developing which of the following:

Atrial fibrillation

Acute shortness of breath is a medical emergency. Immediate assessments are necessary. What is the priority assessment the nurse would make with a patient who has acute shortness of breath?

Auscultate the lungs

A nurse is attending to a patient who suddenly loses consciousness. After a careful neurology assessment, the nurse notes that the toes fan and great toe dorsiflexes when the instrument is run down the foot. The nurse knows this is a positive

Babinski's sign.

A nurse is preparing to assess a client's cerebellar function. What would the nurse expect to test?

Balance

At what level does a spinal cord injury cause paraplegia?

Below T1

For a nursing exam, students must label a diagram using the correct medical terminology. Where would the students label the metacarpophalangeal joint?

Between the hand and the finger

A client has a nursing diagnosis of ineffective airway clearance related to fatigue and inability to cough effectively as evidenced by respiratory rate and dyspnea. What outcome would be appropriate for this client?

Breath sounds return to baseline within 1 week

The nurse practitioner auscultated both lobes of a clients enlarged thyroid gland. Identification of what sound would tend to confirm a diagnosis of a toxic goiter.

Bruit

The nurse is admitting a client to the hospital following a motor vehicle collision in which alcohol may have been a contributing factor. What tool might the nurse use to assess whether alcohol is a problem in this client's life?

CAGE

A patient asks the nurse, "Which cranial nerve allows me to smell?" The nurse's best response is:

CN 1

A patient with pneumonia is coughing up thick, yellow sputum. The patient states, "This stuff is making me sick coming up. It gags me to the point of almost throwing up." That statement lets the nurse know which CN is intact?

CN 10

A patient with hypertension states that two members of his immediate family have suffered strokes in the past. Upon assessment, you notice both symmetrical eyes and mouth, yet the patient cannot look to left or right well. Which CN could be affected?

CN 11

When assessing the tongue, the nurse notices the patient's tongue has full range of motion. This means which CN is intact?

CN 12

When performing a Snellen chart examination, the nurse is assessing which CN?

CN 2

A patient complains of waking up jaw and dental pain on the right side. The nurse knows an assessment of which CN needs to be performed?

CN 5

An elderly patient presents to the ER with a large bruise on the right side of her jaw. When asked what happened, the patient seems confused to what the nurse is talking about. She then presses on the bruised area and asks, "Where is the bruise?" The nurse knows there is an obvious deficit in which CN?

CN 7

The nurse knows that Bell's Palsy and stroke may show a deficit in this cranial nerve with a baseline visual assessment?

CN 7

A patient says, "I don't know why, but I keep getting dizzy for no reason." The nurse knows to assess which CN?

CN 8

The Whisper Test assesses which CN?

CN 8

A new stroke patient has asked you for a drink of water. Which CN's will need to be assessed prior to giving any po fluids?

CN 9 & 10

A nurse is assessing a patient in the ER after head trauma. During the neurological assessment, the patient is unable to look up and down without moving his head. The nurse documents which cranial nerve is impaired.

CN III

When assessing eyesight, the nurse knows which three CN's are related to eye movement and visual responsiveness?

CN's 3, 4, 6

An obese adult client is undergoing a preoperative examination prior to having bariatric surgery. The client tells the nurse that he has a red sore in the groin area that appears to be spreading. The nurse assesses the lesion and finds a macular erythematous lesion with satellite pustules. What would the nurse expect?

Candida

Nystatin is a medication used for:

Candida infection

Assessment of a client's lower extremities reveals unilateral edema of the right foot and ankle. What would the nurse do next?

Compare measurements of both extremities

When determining a client's strength, it is necessary to implement what assessment?

Comparing one side to the other

Betamethasone is a tropical steroid which is used for:

Contact dermatitis

Which cranial nerve is being assessed when eye abduction occurs?

Cranial Nerve VI: Abducens

A 69 year female is noting problem with hearing and maintaining balance. Which cranial nerve should the nurse assess first?

Cranial Nerve VIII: Vestibulocochlear

Which Cranial Nerve is being assessed when the nurse elicits a gag reflex?

Cranial Nerve X: Vagus

A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II?

Cranial nerve II controls central and peripheral vision. The Snellen chart is used to assess visual acuity and dysfunction of cranial nerve II (optic).

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Cranial nerve III is the oculomotor nerve and is responsible, along with cranial nerves IV (trochlear) and VI (abducens), for eye movement and pupillary response to light. If the cranial nerve is functioning properly, the expected reaction is pupil constriction in response to light.

A client comes to the clinic and reports a sore knee. The nurse notes popping and cracking noises when the client attempts to bend the knee. The client exhibits signs of pain by facial expression. The nurse knows that the popping and cracking noises should be charted as what?

Crepitus

A shared, learned, and symbolic system of values, beliefs, and attitudes that shape and influence how people see and behave in the world is a definition of what?

Culture

What characteristic nail color should the nurse recognize as an indication of hypoxia?

Cyanotic

A new graduate nurse, attending a hospital orientation, is asked to explain what the goals of a cultural assessment include. What would be the graduate nurses best answer?

Developing and implementing a culturally congruent plan of care

The nurse performs a neurological assessment and determines the Glasgow Coma Scale (GCS) score is 15. What is the nurse's best action?

Document the findings

The nurse is caring for a client with venous ulcers on both legs. The client is complaining of pain. What is the nurse's best action?

Elevate the legs on pillows

This thin layer of the heart lines interiors of both chambers and valves:

Endocardium

The nurse should encourage the patient to use the incentive spirometer how often?

Every 2 hours

A nurse is caring for an 82-year-old male patient who has been hospitalized after a fall. A family member asks how often should the patient bathe. What is the nurses best response?

Every two to three days

A nursing student is preparing a community education presentation on stroke. Which of the following is an acronym used to help responsiveness to stroke patients?

F.A.S.T.

True or False: "Fight or Flight" reactions are a product of the Parasympathetic Nervous System (PNS).

False

True or False: The tricuspid valve is a semilunar valve

False

True or False: the manual compression test evaluates the saphenous vein valves and retrograde filling of the superficial veins.

False

Parkinsons disease is often diagnosed by the patient's

Gait

Which of the following tools would a nurse practitioner be more likely than a registered nurse to use during the performance of a musculoskeletal assessment on a client to measure maximum flexion of a joint?

Goniometer

The nurse is assessing a 69-year-old woman's risks for lung disease. The woman states, "It shouldn't be a problem for me. My husband smokes quite heavily but I've been a lifelong nonsmoker." The nurse should recognize the need to teach the client about what topic?

Health risks of second-hand smoke

A student is learning to compute the cardiac output of his or her patients. What is the formula for computing cardiac output?

Heart rate x stroke volume

Which of the following is often seen after a stroke?

Hemiplegia

Acyclovir is an antiviral used to treat:

Herpes simplex

During a health screening event, the nurse is assessing a client's risk factors for lung cancer. When addressing the most significant risk factor for lung cancer, the nurse should question the client about which of the following?

History of tobacco use

How can a nurse best prepare to provide clients with effective, culturally competent care?

Identify personal biases that create barriers to an effective nurse-client relation

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

Impetigo

When caring for a client from a culturally different background, what is the goal for incorporating the client's health beliefs and practices into the nursing plan of care?

Improvement of the client's health outcomes

A nursing student is preparing a community education presentation on stroke risk. Which of the following is considered an emergent symptom related to stroke?

Inability to make or interpret sensible language.

Which of the following is not a lifespan consideration regarding the effects of aging on respiration:

Increased flexibility in rib cartilage

The nurse is assessing an older adult. The client states that she feels a constant, sharp pain only when walking. The nurse suspects the client is experiencing what?

Intermittent claudication

Which is an example of a hinge joint?

Knees

A nurse is assessing an older adult client who has experienced some loss of bone density. The nurse observes a "hunchback" curvature of the client's spine. The nurse should expect the provider to document which of the following disorders?

Kyphosis

The nurse is preparing to auscultate the client's thorax. What action is the priority during this component of assessment?

Listen at each site for at least one complete respiratory cycle

Which of the following anticoagulants is a low molecular weight heparin?

Lovenox

A client is coughing copious amounts of purulent mucous. What disease condition is related to this finding?

Lung abscess

The lymphatic system functions to? (Mark all that apply.)

Maintain protein balance Fight infection Maintain fluid balance

A group of students is reviewing the structures of the heart, noting that the thickest layer of the heart is made up of contractile muscle cells. How would the students identify this layer?

Myocardium

An older adult presents at the clinic with reports of a painful neck. On palpation, the nurse notes a hard, non-movable mass, approximately 20 mm, that is painful to touch. The area seems to have several nodes matted together. How would the nurse chart this finding?

Nodes are delimited on palpation

Madeline Leininger formulated a theory that highlights what?

Nursing behaviors necessary to carry out an effective cultural assessment

A patient asks the nurse what cranial nerve number three is. The nurse's best response is:

Oculomotor

A nurse in a clinic is caring for a client who reports pain, crepitus and a popping sound in his temporomandibular joint. The nurse confirms this by

Palpating bilaterally beneath and in front of the ears while opening and closing the jaw.

A patient's wife tells the nurse, "He has to sleep in the recliner because when he lays down in the bed, he usually only sleeps an hour or two before he wakes up short of breath." When asked if there is any difficulty with the patient's sleep pattern in the recliner, the patient's wife states, "No, he does fine as long as he's sitting up." A good diagnosis for this patient would be:

Paroxysmal nocturnal dyspnea

A triage nurse is working in the emergency department of a busy hospital. Four clients have recently been admitted. Patient A has an arrhythmia diagnosed as atrial fibrillation; Patient B is in chronic congestive heart failure; Patient C is assessed and found to have a probable pulmonary embolism; Patient D complains of chest pain relieved by nitroglycerin and rest. Which client would be the nurse's highest priority?

Patient C

A pediatric nurse is doing the initial shift assessments on assigned clients. One of the clients is an older adult with pneumonia. How would the nurse assess this client's skin turgor?

Pinch a fold of skin on the client's sternum

The inability to regulate core body temperature is known as what?

Poikilothermia

What pulse is located in the groove between the medial malleolus and the Achilles tendon?

Posterior tibial

A nurse is caring for a client with impairment of cranial nerves IX and X due to a right-sided acoustic neuroma. Which of the following is an appropriate intervention?

Provide suction at the client's bedside

Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the nurse practitioner notes the area to be a reddish pink lesion covered with silvery scales. What would the nurse practitioner chart?

Psoriasis

Which of the following is a non-modifiable risk factor for stroke?

Race

A nurse enters a client's room to find the client is short of breath. The oxygen saturation is 87%. Which of the following actions is a priority?

Raise the head of the bed

A hospice nurse is admitting a new client who states, "I'm not religious but consider myself spiritual." What change in attitude has been noted when illness stresses such a client's beliefs and values?

Religious activities may take a central position in life

The nurse is assessing the various lobes of the client's lungs. To gather accurate data, the nurse must assess which lobe anteriorly?

Right middle lobe

An occupational nurse is reviewing a client case who is complaining of wrist pain. Which of the following occupations are at risk for carpal tunnel syndrome?

Secretary

Matters of the human soul are referred to as what?

Spirituality

When learning about peripheral vascular disease, the nursing student would learn that signs and symptoms of a DVT require which immediate intervention?

Start of anticoagulants

A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what?

Stridor

When a nurse asks a patient "Do you have any thoughts of wanting to harm or kill yourself?" for what is the nurse assessing?

Suicide ideation

The nurse suspects substance abuse in an adult client who has been admitted to the ED following a motor vehicle collision. What is the reason the nurse would administer the CAGE tool to this client?

The CAGE tool addresses the client's denial.

While assessing a patient the nurse asks the patient to stand with eyes open and closed. This test for balance is called

The Romberg Test

What is known as the pacemaker of the heart?

The SA node

The nurse is caring for a client with a nursing diagnosis of impaired skin integrity related to a stage III pressure ulcer. What would be the most important outcome for this client?

The client exhibits no signs or symptoms of infection.

A nurse is caring for a client who scores a 3 on the Glasgow Coma Scale. The nurse anticipates this client is

The client is in a deep coma and needs total care.

A nurse is assessing a new patient. The family reports they suspect the patient has Alzheimers disease. The nurse would expect the practitioner's assessment to include

The clock test

The popliteal joint is located in

The leg

A nurse is educating a family about a loved one's new diagnosis of myasthenia gravis. Which of the following should the nurse include in the teaching?

The patient will develop muscle weakness involving swallowing and breathing.

What are the blood vessels that transfer freshly oxygenated blood from the lungs to the left atria of the heart?

The pulmonary veins

The nurse has the bell of the stethoscope to the left of the sternal border in the second intercostal space. As a student nurse, you know that what can be heard here?

The pulmonic valve

A client has sustained a brainstem injury. Which of the following would the nurse need to keep in mind about this client's respiratory effort?

There is loss of involuntary respiratory control

What information should the nurse provide the client when preparing to administer the mini-cog assessment tool?

This will take about 3 minutes to administer

A nurse witnesses a client having a seizure with sudden brief jerking motions of muscles with arms turning inward toward the body. The nurse knows this to be

Tonic clonic movement.

What would be the students most appropriate response when asked by the preceptor what is the most important assessment when considering the overall health care provided a multiethnic population?

Transcultural

A patient asks the nurse, "What is the fourth cranial nerve?" The nurse's best response is:

Trochlear

True or False: Antibiotic drops used for infections in the eyes can also be utilized in the ears.

True

What nurse focused characteristic cited by Purnell's model of transcultural health care is fundamental to the ability to provide culturally competent care?

Understanding different cultures first requires understanding oneself

A caregiver brings a handicapped client to the ED reporting the presence of an altered level of consciousness and the client's refusal to eat. When the client is found to be severely dehydrated, the nurse suspects neglect and asks the caregiver several questions regarding the client's activities, diet, and care. The caregiver states, "I didn't know it could hurt him if he didn't drink anything." This is an example of what kind of abuse?

Unintentional

Madeline Leininger identified attributes and behaviors that a nurse practicing effective care across cultures must have. What statement is reflective of Leininger's theory?

Use of active listening by the nurse is fundamental to effective care

A client has a brownish discoloration of the skin of both lower legs. What should the nurse suspect is occurring with this client?

Venous insufficiency

A nurse is educating a group of menopausal women about osteoporosis. What activity would the nurse educate them to do to reduce their risk?

Walking regularly

Which open-ended question might be helpful when assessing abuse with a client demonstrating discomfort discussing the issue?

What would you like me to know?

A nurse is caring for a patient who has a spinal cord injury. The patient has become despondent and resistant to therapy. What intervention would be appropriate to engage the patient?

Work with the patient to develop a care plan with short, realistic goals that show some reward.

A nurse is conducting a neurological assessment on 83 year male. The nurse instructs the patient to shrug his shoulders, which cranial nerve is the nurse assessing?

XI - Spinal Accessory

Please match the medication type with its method of action.

a. Inotropes - help the heart squeeze stronger to deliver more blood. b. Beta-Blockers - slow the heart rate, lessen cardiac demand and lower BP. c. ACE inhibitors - block angiotensin-converting enzyme which lowers BP. d. Calcium channel blockers - reduce contractility to lower BP. e. ARB's - lessen the effects of hormones on BP preventing damage to heart and kidneys. f. Anti-arrythmias - slow the electrical conduction in the heart.