Health Assessment (Old)
A 48-year-old patient comes to the physician's office complaining of diminished near vision, which the nurse confirms with testing. She should document this finding as: a) Myopia b) Diplopia c) Presbyopia d) Mydriasis
ANS: C Diminished near vision in a patient over age 40 or so years is known as presbyopia. Diminished distant vision is known as myopia. Double vision is known as diplopia. Mydriasis or enlarged pupils may be seen with glaucoma.
The nurse notes an S3 heart sound while performing an assessment on a patient admitted with an acute myocardial infarction. The nurse notifies the physician of the finding, which most likely suggests: a) Heart failure b) Coronary artery disease c) Hypertension d) Pulmonic stenosis
ANS: A A third heart sound, commonly referred to as S3, is heard with heart failure or volume overload. S4 heart sound may be auscultated with coronary artery disease, hypertension, and pulmonic stenosis.
A 6-week-old infant is brought to the pediatrician's office for a well-baby checkup. The nurse notes a flattening of the skull. Flattening of the skull in the infant might suggest: a) The baby has been lying in the same position for several hours a day b) A disorder associated with excessive growth hormone c) An accumulation of excessive cerebrospinal fluid d) Temporomandibular joint syndrome
ANS: A Abnormal flattening of the skull in infants may result from placing the baby in the same position for several hours every day. A large head in an adolescent or adult may be associated with acromegaly, a disorder associated with excess growth hormone. In infants and children, a head that is growing disproportionately faster than the body may be a sign of hydrocephalus, which is fluid collection in the cavity within the brain. Irregular jaw movement and cracking of the jaw in adults may indicate temporomandibular joint (TMJ) syndrome.
The left pupil of a patient fails to accommodate. This finding may reflect an abnormality in which cranial nerve? a) CN III b) CN V c) CN VIII d) CN X
ANS: A CN III, the oculomotor nerve, is responsible for accommodation. Failure of a pupil to accommodate reflects an abnormality in this cranial nerve. CN V, the trigeminal nerve, controls the corneal reflex, chewing, and biting. CN VIII, the acoustic nerve, plays a role in hearing and the sense of balance. CN X, the vagus nerve, affects heart rate, peristalsis, swallowing, and the gag reflex.
The nurse is bathing a newborn infant in the nursery and notices scaly white patches over the infant's scalp. What is the most appropriate action by the nurse? a) Wash the scalp and apply gentle scrubbing. b) Notify the primary care provider. c) Obtain a CT (computed tomography) scan of the infant's head. d) Assess for patches on the infant's lower torso.
ANS: A In newborns, cradle cap—scaly white patches over the scalp due to secretion of sebum—is common. It can be removed with washing and gentle scrubbing. It is not necessary to assess for these patches over the torso, as this is common to the scalp. Notification to a primary care provider or a CT scan is not indicated.
The nurse is performing an otoscopic examination on an adult patient. She has the patient tilt his head to the side not being examined and looks into the ear canal to make sure a foreign body is not present. Which step should she perform next? a) Straighten the ear canal by pulling the helix up and back. b) Insert the speculum into the ear canal slowly. c) Test the mobility of the tympanic membrane. d) Straighten the ear canal by pulling the helix down and back.
ANS: A Next, the nurse should straighten the ear canal by pulling the helix up and back. In a preschool child, the nurse should straighten the ear canal by pulling the helix down and back. After straightening the ear canal, the nurse should slowly insert the speculum and observe the ear canal.
The nurse is planning a breast examination class for a group of women at a community health fair. In planning the class, what is most important for the nurse to consider in preparation for her class? a) Patients who perform breast self-examinations should be trained in proper technique to avoid false-negative findings. b) Breast examinations should be performed yearly for all women over the age of 25 years. c) Research indicates that breast examination and mammography are not needed after the age of 70 years. d) A breast examination that includes assessment of the breast and axillae is indicated only if the patient is at high risk for breast cancer.
ANS: A Researchers agree that patients who perform breast self-examinations should be trained in proper technique to avoid false-negative findings. The majority of breast tumors are found in the tail of Spence, in the axillae. A breast exam therefore always includes an exam of the axillae. Breast exams should be done annually for women aged 40 and older, and every 1 to 3 years for women aged 20 to 39. Annual or biennial mammograms most commonly begin after age 40 or at a younger age and more often for those at high risk. Controversy exists about whether women should continue to have mammograms after age 74.
The nurse is working in an outpatient clinic in her community. Late in the afternoon, three clients come in with suspected pediculosis. Which of the following assessments will the nurse perform? a) Integumentary assessment for head lice b) Oral assessment for bad breath and caries c) Musculoskeletal assessment for spine alignment d) Lower extremity assessment for athlete's foot
ANS: A The integumentary system consists of the skin, hair, and nails. When assessing the hair, inspect and palpate for color, texture, and distribution as well as condition of the scalp. In addition, the hair should be free of debris and pediculosis, which are indicative of a head lice infestation. Pediculosis is unrelated to oral, musculoskeletal, or lower extremity assessments.
Which statement best describes the procedure used to assess capillary refill? a) Briefly press the tip of the nail with firm, steady pressure, then release and observe for changes in color. b) Press firmly with your fingertip for 5 seconds over a bony area, release pressure, and observe the skin for the reaction. c) Tap on the skin with short strokes from your fingers. d) Lift a fold of skin, and allow it to return to its normal position.
ANS: A To assess capillary refill, the nurse should briefly press the tip of the nail with firm, steady pressure, then release, and observe for changes in skin color. Tapping the skin describes the procedure for performing percussion. Lifting a fold of skin demonstrates the procedure for assessing for tenting. The nurse should press firmly with her fingertip for 5 seconds over a bony area, then release her finger, and observe the skin for the reaction to grade edema.
The nurse on a medical unit notes a moderate amount of fluid accumulation in the feet and ankles of a 75-year-old patient. The nurse will further assess this patient for indications of which conditions? Select all that apply. a) Kidney disease b) Heart failure c) Thyroid disease d) Common age-related changes
ANS: A, B Edema, or an excessive amount of fluid in the tissues, is an abnormal finding. It is common in patients with congestive heart failure, kidney disease, peripheral vascular disease, or low albumin levels. It is not related to thyroid disease and it is not a normal or common finding in older adults.
The nurse is performing a vision examination. In assessing for color blindness, the nurse applies which knowledge? Select all that apply. a) It may be genetically inherited. b) It is more common in males. c) It may be the result of macular degeneration. d) It may be the result of a lens defect of the eye.
ANS: A, B, C Color vision is the ability to detect color. Color blindness may be genetically inherited, is usually seen in males, or may result from macular degeneration or other disease that affect the cones of the eye. The cones of the eye are part of the retina and are unrelated to the lens of the eye.
Which of the following statements describe the nurse's general survey? Select all that apply. a) Consists of an overall impression of the patient b) Assists in identifying deviations that need further exploration c) Includes obtaining a full set of vital signs d) Includes the comprehensive physical assessment
ANS: A, B, C The general survey is the nurse's overall impression of the patient. It begins at first contact and continues throughout the examination. If a deviation from normal is discovered during the general survey, the nurse can then explore the finding further along during a focused assessment of that body system. The general survey includes obtaining a full set of vital signs. The general survey does not include a comprehensive physical assessment (CPA), as the CPA includes the health history interview and a complete head-to-toe examination of every body system.
Which of the following statements are true of common neurological changes in older adults? Select all that apply. a) Older adults have a slower reaction and a decreased ability for rapid problem-solving. b) With advanced age, the number of functioning neurons decreases. c) Neurological deficits may be attributed to medications or medication interactions. d) With normal aging, long-term memory and the ability to discriminate decrease.
ANS: A, B, C With advanced age, changes commonly observed are slower reaction time, decreased ability for rapid problem-solving, and slower voluntary movement. The number of functioning neurons decreases. However, intelligence, long-term memory, and discrimination do not change with normal aging. Neurological deficits in older adults are usually the result of adverse effects of medication or medication interactions, nutritional deficits, dehydration, cardiovascular changes that alter cerebral blood flow, diabetes, degenerative neurological condition, alcohol or drug use, depression, or abuse.
Which disorder(s) might limit a patient's visual field? Select all that apply. a) Diabetes b) Advanced glaucoma c) Peripheral vascular disease d) Cataracts
ANS: A, B, D Poorly controlled diabetes, cataracts, macular degeneration, and advanced glaucoma may limit the visual field. Peripheral vascular disease may be associated with diabetes, but it occurs in the extremities, not the eyes.
Which of the following statements describe the proper technique for auscultating heart sounds? Select all that apply. a) Auscultate in an orderly fashion starting at the aortic area and proceeding to pulmonic, tricuspid, and mitral areas. b) Listen for S1 first in all landmark areas, then proceed to listening for S2 in all landmark areas. c) Use the diaphragm of the stethoscope for normal sounds the bell of the stethoscope to detect any extra sounds. d) Rotate the starting point of landmarks at each patient assessment to detect any changes.
ANS: A, C Auscultate in an orderly fashion starting in the aortic area and moving gradually through each landmark. The mnemonic of A-P-T-M can be used. The nurse should listen carefully at each site to each component of the heart sound. Additionally, the diaphragm is used to auscultate high-pitched sounds that normally occur in the heart, lungs, and abdomen. The bell is used to auscultate low-pitched sounds such as extra heart sounds, murmurs, or bruits.
The nurse is performing a comprehensive health assessment on several clients in the community clinic. Which clients are most at risk for developing hemorrhoids? Select all that apply. a) A client with a history of constipation b) A client with a history of prostate cancer c) A woman who has had four children d) Clients older than 65 years
ANS: A, C Hemorrhoids may be seen in patients with a history of constipation. Many women develop hemorrhoids with pregnancy and childbirth. Although an enlarged prostate causes urinary problems, there is no indication that this causes hemorrhoids. There is no evidence that older adults are at a higher risk for hemorrhoids.
The nurse has completed an external genitalia examination on several female clients in the women's health clinic. Which of the following clients would require an internal genital examination? Select all that apply. a) Client on hormone therapy b) Client who has had more than three pregnancies c) A client with an abnormal finding on the external examination d) A 22-year-old client who is not sexually active
ANS: A, C Women who are sexually active; who have abnormal findings on external examinations; who have abdominal, pelvic, or genitourinary complaints; or who are on hormone therapy require an internal genital examination.
When performing a skin assessment, the nurse notices a mole on the patient's upper back. What are the appropriate actions by the nurse in further investigation of the mole? Select all that apply. a) Ask the patient about any new moles or changes in moles. b) Do not alarm the patient by asking questions about the mole. c) Measure the mole's diameter and elevation. d) Assess for any exudate on or around the mole.
ANS: A, C, D Evaluate all skin lesions for the possibility of malignancy, especially those located in a site exposed to chronic rubbing or other trauma. Ask the client whether he has any newly developed moles or skin lesions or whether there has been any change in the appearance of existing lesions. The nurse will further assess for asymmetry, border irregularity, color variation, diameter, and elevation above the skin surface, exudate, itching, or pain.
Which of the following principles apply when performing a focused assessment of the abdomen? Select all that apply. a) Ask the patient to empty his bladder prior to the assessment. b) Follow the assessment sequence of inspection, palpation, percussion, and auscultation. c) Position the patient in supine position with knees slightly flexed. d) Begin palpating with light pressure to detect surface characteristics and move to deep palpation.
ANS: A, C, D The nurse should ask the patient to empty his bladder prior to the examination to promote comfort. The patient is also positioned supine with flexed knees, further promoting comfort and relaxing the abdominal muscles. Begin with light pressure to detect surface characteristics. Then move to deep palpation to assess the underlying structures. The skills used in physical examination include inspection, palpation, percussion, auscultation, and sometimes olfaction. These skills are performed in the above order, with one exception: When performing an abdominal assessment, perform auscultation before percussion and palpation to avoid disturbing the abdominal sounds.
The nurse is assessing the level of consciousness of a client who suffered a head injury. She uses the Glasgow Coma Scale and determines that the client's score is 15. Which responses did the nurse assess in this client? Select all that apply. a) Spontaneous eye opening b) Tachypnea, bradycardia, and hypotension c) Unequal pupil size d) Orientation to person, place, and time e) Motor response to pain localized
ANS: A, D, E The Glasgow Coma Scale assesses level of consciousness by testing and scoring three observations: eye opening, motor response, and verbal stimuli response. Clients are scored on their best responses and these scores are totaled. The highest score is 15. The highest responses in these three categories are spontaneous eye opening, obeying motor commands, and orientation to time, place, and person.
An 85-year-old patient is brought to the emergency department with lethargy and hypotension. When the nurse assesses the patient's tongue, she notes that it appears dry and furry. This finding suggests: a) Fungal infection b) Dehydration c) Allergy d) Iron deficiency
ANS: B A dry, furry tongue is associated with dehydration. A black, hairy tongue is characteristic of a fungal infection. Absence of papillae, reddened mucosa, and ulcerations may indicate allergy. Patients who have a deficiency of iron may have a smooth, red tongue.
Abdominal palpation should be avoided in a child who has which disorder? a) Appendicitis b) Wilms' tumor c) Crohn's disease d) Small bowel obstruction
ANS: B Abdominal palpation should be avoided in the child who has Wilms' tumor, large diffuse pulsation, or a history of organ transplant. Abdominal palpation can be performed with appendicitis, Crohn's disease, and small bowel obstruction.
Which abnormal laboratory value is associated with an icteric sclera? a) Bleeding time b) Bilirubin c) Hemoglobin d) Glucose
ANS: B An icteric sclera is associated with elevated bilirubin levels. Low hemoglobin would indicate anemia. High hemoglobin is polycythemia, which is like thick blood. Low glucose is hypoglycemia, and high sugar is hyperglycemia.
The nurse asks the patient to spread his fingers and then bring them together again. Which of the following is the nurse testing when asking him to bring his fingers together? a) Abduction b) Adduction c) Flexion d) Extension
ANS: B Asking the patient to spread his fingers tests abduction; asking him to bring them together assesses adduction. Asking the patient to make a fist tests flexion, whereas asking him to extend the hand tests extension.
Based on developmental stage, how should the nurse modify the comprehensive physical examination of an older adult? a) Work rapidly to finish as quickly as possible. b) Sequence the examination to limit position changes. c) Demonstrate equipment before using it. d) Omit portions of the examination that may be tiring.
ANS: B Because older adults may tire easily and because they may have stiff muscles and arthritic joints, the nurse should arrange the sequence of the examination to limit position changes. The nurse should work efficiently; however, speed is not the goal, and the nurse should observe the patient's energy level and stop for periods of rest as needed. It is appropriate to demonstrate equipment for school-age children but is not usually necessary for older adults, who have probably experienced other physical examinations. Because this is a comprehensive examination, it is not appropriate to omit portions of it because they may be tiring. As discussed, the patient should rest and then the nurse should return to the examination.
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved? a) CN V and CN VII b) CN VII and CN IX c) CN V and CN VIII d) CN VI and CN X
ANS: B Cranial nerves VII and IX supply sensation to the tongue.
The nurse is concerned that an African American client is experiencing cyanosis. Which of the following signs of cyanosis would the nurse look for in this client? a) The presence of excess interstitial fluid with a decreased elasticity or fullness of the skin b) A bluish tinge in the skin, tongue, and mucous membranes that does not blanch when pressure is applied c) A redness and a variety of rashes over the entire body d) An absence of underlying red tones in the skin most readily seen in the buccal mucosa
ANS: B Cyanosis is a bluish tinge most evident in the skin, tongue, and mucous membranes. Bruised areas normally blanch when pressure is applied. Pallor occurs when there is too little circulating blood or hemoglobin and is characterized by the absence of underlying red tones. Erythema is a redness associated with a variety of rashes, and edema is the presence of excess interstitial fluid. It is important to note that pallor, cyanosis, and erythema may appear differently in clients with brown or black skin, and the nurse must take care not to overlook abnormal findings.
Which test should the patient undergo when the Weber test is positive? a) Romberg test b) Rinne test c) Pure tone audiometry d) Tympanometry
ANS: B If the Weber test is positive, the patient should undergo the Rinne test to assess the type of hearing loss. The Romberg test is performed to test equilibrium. Pure tone audiometry uses a machine to hear sounds at different volumes while the patient wears a headset. Tympanometry assesses pressure in the ear; it does not assess hearing.
Which assessment should the nurse perform if she notes a palpable thyroid gland? a) Illuminate the thyroid gland for the presence of fluid. b) Auscultate the thyroid gland for bruits. c) Percuss the thyroid gland for mass size. d) Measure the thyroid gland to assess change.
ANS: B Normally, the thyroid gland is smooth, firm, and nontender. It is often nonpalpable. If the thyroid gland is palpable, the nurse should auscultate it for bruits. It is not necessary to measure or illuminate the thyroid gland. The thyroid gland should not be percussed.
The nurse notes ptosis in a patient who just arrived in the emergency department. The nurse quickly triages the patient because she knows that this finding, along with other symptoms, might suggest: a) Hyperthyroidism b) Stroke c) Glaucoma d) Macular degeneration
ANS: B Ptosis, or drooping of the eyelid, may be seen in a patient who experienced Bell's palsy or a stroke. Exophthalmos is associated with hyperthyroidism. Mydriasis may be seen with glaucoma. Macular degeneration has no outward signs.
While the nurse assesses a newborn of African American descent, the mother points out a blue-black Mongolian spot on the newborn's back and asks, "What's that? Is something wrong with my baby?" Which response by the nurse is best? a) "I'll ask the physician to look at the spot." b) "Those spots are quite common and typically fade with time." c) "You may want a plastic surgeon to look at that." d) "That spot is benign so it's nothing you need to worry about."
ANS: B The best response by the nurse is to explain that Mongolian spots are common in dark-skinned newborns and typically fade over time. The nurse should report the finding in the patient health record, but there is no need to notify the physician immediately. It is inappropriate for the nurse to recommend that the mother take her newborn to a plastic surgeon; Mongolian spots do not require treatment. Although it contains correct information, ". . . nothing you need to worry about" is condescending.
Which portion of the ear is responsible for maintaining equilibrium? a) External ear b) Inner ear c) Middle ear d) Ossicles
ANS: B The inner ear is responsible for hearing and equilibrium. The middle ear, which contains the ossicles (auditory structures), conducts sound waves to the inner ear. The external ear collects and conveys sound waves to the middle ear.
Which of the following is a correct developmental outcome for an infant? The infant's anterior fontanel (soft spot) typically fuses: a) At about 8 weeks b) At about 14 months c) By 6 months of age d) Before 1 year of age
ANS: B The large soft spot on the top of the head, known as the anterior fontanel, typically fuses at about 12 to 18 months. The infant should be able to hold up his head by age 6 months. The posterior fontanel fuses at about 8 weeks of age.
The mother of a 1-month-old infant states to the examining nurse, "There is something wrong with my baby's eyes. She seems to be cross-eyed." What is the most appropriate response by the nurse? a) "I will need to perform a thorough eye examination." b) "This is not uncommon in infants in their first 2 months of life." c) "Please try not to overreact. You are new parents and there is much for you to learn." d) "I will report your concerns to the pediatrician."
ANS: B The most appropriate response by the nurse is to first reassure the parents that this may be normal. Strabismus (crossed-eye) is a condition in which one or both eyes deviate from the object they are looking at. It is normal during the first 1 to 2 months of life. After that, it may be caused by weak intraocular muscles or a lesion on the oculomotor nerve. As this infant is 1 month old, it may be a normal finding. After the nurse offers reassurance, she can then proceed to the eye exam and if any abnormalities are noted, these would be reported to the pediatrician. It is inappropriate to tell new parents not to overreact, as this may make them reluctant to report future findings.
Which assessment question helps assess immediate memory? a) "How did you get to the hospital today?" b) "Can you repeat the numbers 2, 7, 9 for me?" c) "Do you Knowledge the three items I mentioned earlier?" d) "What was your birth date including the year?"
ANS: B The nurse can assess immediate memory by asking the patient to repeat a series of three numbers and gradually increasing the length of the series until the patient cannot repeat the series correctly. The nurse can assess recent memory by asking the patient how he got to the hospital or by asking the patient to repeat three items what the nurse had mentioned earlier in the examination. The nurse can assess remote memory by asking the patient his birth date or the date of a significant historical event.
A mother brings her 6-month-old infant to the clinic for a well-baby checkup. How should the nurse proceed when weighing the patient? a) Have the mother remain outside the room. b) Ask the mother to remove the infant's clothing and diaper. c) Weigh the infant with the diaper only. d) Place the infant supine on the scale with his knees extended.
ANS: B The nurse should ask the mother to remove the infant's clothing and diaper before weighing and measuring the infant. An older child can be examined in his underwear; infants should be undressed. Infants are typically more comfortable with the parent close by so the mother should remain in the room. The infant should be supine with knees extended on the examination table when being measured, not when being weighed.
The nurse applies resistance to the top of the client's foot and asks him to pull his toes toward his knee. The nurse observes active motion against some, but not against full, resistance. How should the nurse document this finding? a) 5: Normal b) 4: Slight weakness c) 3: Weakness d) 2: Poor ROM
ANS: B The nurse should document 4: Slight weakness. The following is the muscle strength rating scale: Rating Criteria Classification 5 Active motion against full resistance Normal 4 Active motion against some resistance Slight weakness 3 Active motion against gravity Weakness 2 Passive ROM Poor ROM 1 Slight flicker of contraction Severe weakness 0 No muscular contraction Paralysis
Assuming that all are accurate, which documentation about a patient's level of consciousness is best? a) Patient is lethargic and slept when undisturbed. b) Patient responds to tactile stimulation; falls back to sleep immediately after tactile and verbal stimulation are stopped. c) Patient slept throughout the day, missing his meals and bath. d) Patient appears to be tired as he slept throughout the day except when bathed.
ANS: B The option that includes the most detailed information provides the most accurate description of the patient's level of consciousness. The other documentation provides little information about the level of consciousness. From those descriptions, the patient might have a decreased level of consciousness or could simply be exhausted.
The nurse is caring for a patient who underwent abdominal surgery 24 hours ago and has a nasogastric tube for intermittent suction. How should the nurse proceed when performing an abdominal assessment on this patient? a) Avoid palpating the patient's abdomen. b) Turn off the suction before auscultating bowel sounds. c) Listen for bowel sounds for 2 minutes in each quadrant. d) Percuss the abdomen before auscultating bowel sounds.
ANS: B The sound of suction attached to a nasogastric tube can be mistaken for bowel sounds; therefore, the nurse should discontinue the suction or clamp off the tube while auscultating bowel sounds. Light palpation can be performed in the postoperative patient. The nurse should listen for bowel sounds for at least 5 minutes before determining that they are absent. Auscultation should be performed before percussion in examining the abdomen.
The nurse obtains vital signs for a 56-year-old patient who underwent surgery yesterday. Which finding(s) require(s) further assessment? Select all that apply. a) Blood pressure 110/64 mm Hg b) Pulse rate 118 beats/min c) Respiratory rate 35 breaths/min d) Oral temperature 98.6°F (37°C)
ANS: B, C The pulse rate of 118 beats/min and the respiratory rate of 35 breaths/min are abnormally elevated and require further assessment. Blood pressure 110/64 mm Hg and oral temperature 98.6°F (37°C) are considered normal and do not require further assessment.
The nursing student is performing an otoscopic examination on her patient. In assessing the tympanic membrane, the student assesses for what normal findings in appearance? Select all that apply. a) Light red b) Pearly gray c) Shiny d) Translucent
ANS: B, C, D Normally, the tympanic membrane is pearly gray, shiny, and translucent. Changes in the appearance arise from abnormalities such as otitis media, which can cause a red, bulging membrane and the presence of pressure equalization tubes in young patients with chronic ear infections.
An older adult's fingernails appear concave and spoon shaped. The nurse associates this observation with: a) Normal finding in older adults b) Chronic lung disease c) An iron deficiency d) Chronic heart disease
ANS: C A change in nail shape may indicate underlying disease. Spoon-shaped nails may result from iron deficiency. In chronic lung disease, clubbing of the nails may be present due to chronic hypoxia. In heart disease, changes occur with delayed capillary refill time. Spoon-shaped nails are not part of a normal aging process and should be evaluated in the older adult.
The nurse notes a small pulsation at the fifth intercostal space midclavicular line. This should be documented as a: a) Thrill b) Murmur c) Normal finding d) Heave
ANS: C A small pulsation at the fifth intercostal space midclavicular line is known as the point of maximal impulse (PMI) and is considered a normal finding. A thrill is a vibration or pulsation palpated in any area except the PMI. A murmur occurs when structural defects in the heart's chambers or valves cause turbulent blood flow. A heave, which is a visible palpation, is associated with an enlarged ventricle.
Bronchovesicular breath sounds are best heard over which area? a) Midline over the trachea just below the larynx b) Fourth intercostal space, in the midclavicular line c) First and second intercostal spaces next to the sternum d) At the base of the lungs near the diaphragm
ANS: C Bronchovesicular breath sounds are best heard over the first and second intercostal spaces adjacent to the sternum on the anterior chest.
The nurse assesses a 4-year-old child's vision as 20/40. This finding is considered: a) Myopia b) Hyperopia c) Normal d) Presbyopia
ANS: C Children typically do not have 20/20 vision until age 6 or 7 years. A finding of 20/60 in a 4-year-old child is considered normal. Myopia is diminished distant vision, which is associated with a Snellen chart reading of 20/100. Hyperopia is diminished near vision and is represented by a large fraction, such as 20/15; when found in people over age 45 it is known as presbyopia.
A father brings his 18-month-old child to the pediatric clinic for a well-baby checkup. The father tells the nurse that he is concerned because his child's legs are bowed. Which response by the nurse is appropriate? a) "Your child will most likely require physical therapy." b) "You should consider having your child seen by an orthopedic surgeon." c) "This is a normal finding in children for 1 year after they begin walking." d) "Your child is walking fine, so you don't need to worry."
ANS: C Genu varum, or bowlegs, is a normal finding in children for 1 year after they begin walking and the bones of the legs become more ossified with development and weight-bearing. However, assessment over time is important to be sure the gait and positioning develop normally. The nurse should allay the father's concerns by providing him with this information. The child shows no signs, in the scenario, that physical therapy is needed. It is not appropriate for the nurse to recommend an orthopedic surgeon; physician referrals are given by the physician or advanced practice nurse when appropriate. "Your child is walking fine . . ." is condescending and does not appropriately address the father's concerns.
A patient's jugular venous pressure measures 5 cm. This finding indicates: a) A normal finding b) Hypovolemia c) Heart failure d) Dehydration
ANS: C Normal jugular venous pressure is less than 3 cm. A jugular venous pressure of 5 cm is elevated and suggests heart failure.
An older adult comes to the clinic complaining of pain in the left foot. While assessing the patient, the nurse notes smooth, shiny skin that contains no hair on the client's lower legs. Which condition does this finding suggest? a) Venous insufficiency b) Hyperthyroidism c) Arterial insufficiency d) Dehydration
ANS: C Peripheral arterial insufficiency is associated with smooth, thin, shiny skin with little or no hair. Venous insufficiency leads to thick, rough skin that is commonly hyperpigmented. Hyperthyroidism is associated with abnormally warm skin. Decreased turgor would be seen in dehydration.
A female patient has excessive facial hair. The nurse should document this finding as: a) Alopecia b) Albinism c) Hirsutism d) Lanugo
ANS: C The nurse should document this finding as hirsutism, excess facial or trunk hair. Hair loss should be documented as alopecia. Albinism is a condition caused by lack of pigment in which the patient has white hair and very pale skin. Lanugo is the fine, downy growth of hair that covers the body of a newborn.
An adult admitted to the hospital after a stroke does not respond to verbal stimuli. What should the nurse do next to try to provoke a response? a) Apply pressure to the mandible at the jaw. b) Rub the patient's sternum. c) Squeeze the trapezius muscle. d) Gently shake the patient's shoulder.
ANS: D If the patient does not respond to verbal stimuli, the nurse should try tactile stimuli by gently shaking the patient's shoulder. If the patient does not respond to tactile stimuli, the nurse should try painful stimuli by squeezing the trapezius muscle, rubbing the sternum, applying pressure on the mandible at the angle of the jaw, or applying pressure over the moon of the nail. But do not start out with painful stimulation before you are sure the patient is not going to react to a less invasive approach.
Which of the following is an abnormal capillary refill finding that the nurse should report? a) 1 second b) 2 seconds c) 3 seconds d) 4 seconds
ANS: D Normal capillary refill is less than 3 seconds; therefore, the nurse should report a capillary refill of 4 seconds.
The admission assessment form indicates that the patient has pedal pulses that are rated 1 in amplitude. This documentation indicates that the patient's pulses are: a) Bounding b) Normal c) Full d) Diminished
ANS: D Pulses documented as 1 are diminished and barely palpable; those documented as 2 are normal; those as 3 are full and increased; and those as 4 are bounding.
Small hemorrhages are noted under the nailbed of a patient with a history of intravenous drug abuse. This finding is associated with: a) Low albumin levels b) Zinc deficiency c) Renal disease d) Bacterial endocarditis
ANS: D Small hemorrhages under the nailbed, known as splinter hemorrhages, are associated with bacterial endocarditis, a complication of IV drug abuse. A distal band of reddish-pink covering 20% to 60% of the nail (half and half nails) is seen in patients with low albumin levels and renal disease. White spots may indicate zinc deficiency.
Which skin assessment finding would cause the nurse to suspect dehydration in a middle-aged patient admitted to the hospital with traveler's diarrhea? a) Edema b) Hyperhidrosis c) Pallor d) Tenting
ANS: D Tenting, skin that takes several seconds to return to normal after lifting up a fold, may be a sign of dehydration. Edema, an excessive amount of fluid in the tissues, may be a sign of heart failure, kidney disease, peripheral vascular disease, or low albumin levels. Hyperhidrosis is a term for excessive sweating, which may be a sign of thyrotoxicosis. Pallor, abnormal loss of skin color, may be a sign of anemia or blood loss.
While palpating the anterior chest, the nurse notes crackling in the skin around the patient's chest tube insertion site. The nurse recognizes this finding is: a) Tactile fremitus b) Egophony c) Bronchophony d) Crepitus
ANS: D The nurse should document this finding as crepitus, crackling skin caused by air leaking into the subcutaneous tissues. Tactile fremitus involves palpating for vibrations as the client says "99," which indicates the presence of fluid in the chest. Bronchophony is present if the words "1, 2, 3" are clearly heard over the lungs as the nurse listens while the patient says those words. Egophony is present if the sound heard is "ay" when the nurse listens over the lung fields as the patient says "eee."
High-pitched breath sounds produced by airway narrowing are known as: a) Rales b) Crackles c) Rhonchi d) Wheezing
ANS: D Wheezing is a high-pitched sound produced by narrowing of an airway. Rales and crackles are crackling sounds that indicate atelectasis, pulmonary edema, or pneumonia. Rhonchi are low-pitched snoring or rumbling sounds that result from mucous secretions in the large airways.
When testing near vision, the nurse should position printed text how many inches away from the patient? a) 20 b) 18 c) 16 d) 14
ANS: D Test near vision by having the client read text from a distance of 14 inches.
