Ch 31 Study Guide

A nurse is teaching a child's parent about precautions to follow in providing effective care to the child who has frequent nosebleeds. Which of the parent's statements indicates a need for further teaching? 1. "I should instruct my child to breathe slowly through the nose." 2. "I should apply pressure to the anterior nose with my thumb." 3. "I should apply ice to the nose bridge if the bleeding continues after pressure has been applied." 4. "I should make my child sit up and lean forward when a nosebleed occurs."

1. "I should instruct my child to breathe slowly through the nose.

While assessing the skin of a patient, the nurse suspects hypoxia. Which skin discoloration led the nurse to this conclusion? 1. Bluish 2. Reddish 3. Tan-brown 4. Yellowish orange

1. Bluish

A nurse is examining a patient's skin using palpation. Which action made by the nurse needs correction? 1. Checking the patient's skin turgor and elasticity by using the dorsum of the hand 2. Checking the patient's skin texture using the palmar surface of the hand 3. Checking the patient's skin thickness with the palmar surface of the hand 4. Checking the patient's temperature using the dorsum of the hand or fingers

1. Checking the patient's skin turgor and elasticity by using the dorsum of the hand

The healthcare provider is testing pupillary reflexes in an adult patient. When the healthcare provider shines a penlight into the patient's right eye, the nurse observes constriction of the left pupil but no constriction of the right pupil. When a distant object is brought closer to the patient, the left eye converges and its pupil constricts, but the right eye fails to constrict. What do these findings indicate? Select all that apply. 1. Consensual light reflex of the left eye is positive. 2. Direct light reflex of the right eye is negative. 3. Direct light reflex of the right eye is positive. 4. Accommodation is present in the right eye. 5. Accommodation is present in the left eye.

1. Consensual light reflex of the left eye is positive. 2. Direct light reflex of the right eye is negative. 5. Accommodation is present in the left eye.

A patient is admitted to the hospital with an intestinal obstruction. The surgical nurse records the vitals and starts to examine the patient's abdomen. In which order should the nurse conduct the examination? Arrange the activities in the correct order. 1. Consent from the patient 2. Inspection of abdomen 3. Palpation of abdomen 4. Auscultation of abdomen

1. Consent from the patient 2. Inspection of abdomen 4. Auscultation of abdomen 3. Palpation of abdomen

The nurse is assessing a patient who has been admitted to the hospital. For which symptoms should the nurse contact the provider, knowing the patient requires ophthalmology follow up? Select all that apply. 1. Eye floaters 2. Headache 3. Toothache 4. Diplopia 5. Halos around lights

1. Eye floaters 4. Diplopia 5. Halos around lights

The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship? 1. Inspecting appearance and behavior 2. Taking measurement of vital signs 3. Observing specific body systems 4. Conducting a detailed health history

1. Inspecting appearance and behavior

A patient comes to a clinic for a regular checkup. The nurse is performing a physical examination of the patient. Which interventions should the nurse follow during inspection to get the best results? Select all that apply. 1. Make sure that adequate lighting is available. 2. Use a penlight or lamp to inspect body cavities. 3. Inspect each area for size, shape, color, symmetry, position, and abnormality. 4. Expose the patient completely for an easy inspection. 5. Check for side-to-side symmetry.

1. Make sure that adequate lighting is available. 2. Use a penlight or lamp to inspect body cavities. 3. Inspect each area for size, shape, color, symmetry, position, and abnormality. 5. Check for side-to-side symmetry.

A patient has received an eye examination in the emergency room. After an initial assessment, the nurse finds that the patient can clearly see close objects but cannot see distant objects. Which condition does the patient have? 1. Myopia 2. Hyperopia 3. Presbyopia 4. Retinopathy

1. Myopia

Which physical examination technique is used to measure lymph swelling? 1. Palpation of the lymph nodes using the pads of the fingers 2. Inspection of the lymph nodes for any change in size 3. Percussion of the lymph nodes using fingertips 4. Auscultation of the lymph nodes using a stethoscope

1. Palpation of the lymph nodes using the pads of the fingers

Using light pressure with the index and middle fingers, the nurse cannot palpate any of the patient's superficial lymph nodes. What should the nurse do next? 1. Record this finding as normal. 2. Reassess the lymph nodes using deeper pressure. 3. Ask the patient about any history of radiation therapy. 4. Notify the health care provider that x-rays of the nodes will be necessary.

1. Record this finding as normal.

Which is not a function of the lymph nodes? 1. Secrete hormones 2. Protect the body from foreign antigens 3. Remove damaged cells from circulation 4. Provide a partial barrier to malignant cell growth

1. Secrete hormones

A patient's nose is bleeding. What should the nurse assess to help determine the cause of the bleeding? 1. The mucosa 2. Symmetry of the nose 3. The septum for deviation 4. The septum for perforation

1. The mucosa

Turgor is related to the elasticity of the skin. What is the effect on the skin when a patient has poor turgor? 1. The skin stays pinched. 2. The skin has an edematous area. 3. The skin has ruby red papules. 4. The skin falls immediately back to its original position.

1. The skin stays pinched.

During a skin assessment, the nurse observes that the patient's skin lifts easily and falls immediately back to its resting position. What should the nurse interpret from this assessment? 1. This is a normal skin finding. 2. This indicates dehydration. 3. This indicates pitting edema. 4. This indicates lost skin vascularity.

1. This is a normal skin finding.

When examining a patient from behind, which anatomic chest wall landmark extends down from the center of the neck? 1. Vertebral line 2. Midaxillary line 3. Midsternal line 4. Midclavicular line

1. Vertebral line

Which lesion is the result of a mosquito bite? 1. Wheal 2. Papule 3. Macule 4. Pustule

1. Wheal

A patient is exhibiting pallor of the face, conjunctivae, nail beds, and palms of the hands. What condition might this patient be experiencing? 1. Vitiligo 2. Anemia 3. Jaundice 4. Shock

2. Anemia

What is an early indication that a patient may be developing caries? 1. Brown teeth 2. Chalky white teeth 3. Stained yellow teeth 4. White and shiny teeth

2. Chalky white teeth

Which abnormality may be due to neuromuscular injury? 1. Bulging eyes 2. Crossed eyes 3. Inflamed eyes 4. Protruding eyes

2. Crossed eyes

What is the reason for clubbing in a patient with a congenital heart disease? 1. It is a disorder of the nail. 2. It is due to insufficient oxygenation at the periphery. 3. It is a condition that runs in families. 4. It is secondary to neurological damage due to heart disease

2. It is due to insufficient oxygenation at the periphery.

A nurse is preparing to examine a patient's rectum. Which position should the nurse ask the patient to assume? 1. Prone 2. Knee-chest 3. Dorsal recumbent 4. Lateral recumbent

2. Knee-chest

Which nursing action is most appropriate when preparing to perform a physical examination on a patient? 1. Filling out the consent form before physical examination 2. Maintaining the appropriate room temperature 3. Performing the physical examination in the radiology unit 4. Asking the patient's family members to sit beside the patient

2. Maintaining the appropriate room temperature

What characteristic of the hair is due to androgen hormone stimulation? 1. Dull 2. Oily 3. Brittle 4. Thinning

2. Oily

Which statement regarding hearing acuity in older adults is true? 1. Older adults hear high-frequency sounds best. 2. Older adults are at risk of hearing loss caused by auditory nerve injury. 3. Older adults may lose the ability to hear vowel sounds. 4. Swelling of the auditory canal can cause older adults to gradually lose hearing acuity.

2. Older adults are at risk of hearing loss caused by auditory nerve injury.

Which portion of the hand is used to assess the thickness of skin? 1. Finger pads 2. Palmar surface 3. Dorsum 4. Fingertips

2. Palmar surface

A patient is scheduled for angiography. The nurse observes that the patient is anxious and unwilling to sit through the procedure. What would be the most appropriate nursing action? 1. Suggest the patient change positions and resume the angiography. 2. Reschedule the angiography and provide more information about the procedure. 3. Force the patient to cooperate as per the schedule. 4. Ask a family member to calm the patient down before starting the procedure.

2. Reschedule the angiography and provide more information about the procedure.

Jaundice produces a yellow-orange discoloration of body tissues. Which body part is the best site for the nurse to inspect for jaundice? 1. Lips 2. Sclera 3. Mouth 4. Tongue

2. Sclera

Which is the best site to inspect for jaundice? 1. Lips 2. Sclera 3. Nail beds 4. Arms

2. Sclera

Which position provides easy access to a patient's pulse sites during a physical examination? 1. Prone 2. Supine 3. Lithotomy 4. Dorsal recumbent

2. Supine

Which statement regarding the nasolacrimal gland is true? 1. Tenderness is commonly felt on palpation. 2. The nasolacrimal duct sometimes blocks the flow of tears. 3. Tears flow from the gland across the outer canthus of the eye. 4. It is located in the upper outer wall of the posterior part of the orbit.

2. The nasolacrimal duct sometimes blocks the flow of tears.

The nurse inspects a patient's nails and finds that the nails have concave curves. What could the nurse infer from this observation? 1. The patient's nails are normal. 2. The patient has anemia. 3. The patient has a nail injury. 4. The patient has a local infection.

2. The patient has anemia.

Which condition of the exam room is not ideal for a skin assessment? 1. The room has lots of sunlight. 2. The room is chilly. 3. The room has fluorescent lighting. 4. The room's temperature is comfortable.

2. The room is chilly.

The nurse has to position a patient in the lithotomy position. Which statement about the lithotomy position is true? Select all that apply. 1. This position helps in detecting murmurs. 2. This position facilitates insertion of vaginal speculum. 3. This position is adopted for examination of female genitalia. 4. The patient is laid down laterally with flexion of hip and knee. 5. The patient is laid down supine, the legs are raised, and knees flexed.

2. This position facilitates insertion of vaginal speculum. 3. This position is adopted for examination of female genitalia. 5. The patient is laid down supine, the legs are raised, and knees flexed.

Which lesion is an example of a nodule? 1. Hive 2. Wart 3. Acne 4. Freckle

2. Wart

During an assessment, the nurse suspects impairment of cranial nerve VII. Which symptom may have led the nurse to this suspicion? 1.Eye protrusion 2.Inability to move the eyebrows 3.Abnormal drooping of the lid over the pupil 4. Presence of a yellow lump on the follicles of eyelash

2.Inability to move the eyebrows

A registered nurse is teaching a nursing student about head assessment. Which of the nursing student's statements indicates a need for further teaching? 1. "Slight asymmetry is normal." 2. "I should assist in holding the patient's head upright and midline to the trunk for inspection." 3. "Jerking of the patient is indicative of unilateral hearing loss." 4. "Tilting of the head to one side is indicative of muscle weakness."

3. "Jerking of the patient is indicative of unilateral hearing loss."

The nurse is measuring the body temperature of a patient. How can the nurse check a patient's body temperature using a palpation technique? 1. By using deep palpation 2. By using only the pads of the fingers 3. By using the dorsal surface of the hand 4. By using the palmar surface of the hand

3. By using the dorsal surface of the hand

While examining a patient's skin, the nurse finds a circumscribed elevated solid mass that is deep and firm. The lesion is 1 to 2 cm in diameter. What is this mass called? 1. Papule 2. Vesicle 3. Nodule 4. Pustule

3. Nodule

A nurse taps a patient's skin with the fingertips to vibrate underlying tissues and organs. Which physical assessment technique is the nurse using? 1. Palpation 2. Inspection 3. Percussion 4. Auscultation

3. Percussion

The nurse is teaching a young mother to palpate her 8-year-old child to quickly evaluate whether the child has a fever. Which information is important for the nurse to include? 1. Place the palm of the hand on the child's back. 2. Lightly touch the child's forehead with the fingertips. 3. Place the back of your hand against the child's forehead 4. Use the pads of your fingers and press against the child's neck and over the thorax.

3. Place the back of your hand against the child's forehead

Which scale is used to weigh infants? 1. Bed scale 2. Chair scale 3. Platform scale 4. Standing scale

3. Platform scale

The nurse assesses a patient who presents with a cough. Which position should the nurse instruct the patient to assume for a proper examination? 1. Sims' 2. Prone 3. Sitting 4. Supine

3. Sitting

A nurse is preparing to assess a patient's abdomen, genitalia, and rectum. Which nursing intervention is the most appropriate in this situation? 1. Asking the patient to assume prone position 2. Changing latex gloves to vinyl or nitrile gloves 3. Asking the patient to assume lateral recumbent position 4. Asking the patient if he or she needs to use the restroom

4. Asking the patient if he or she needs to use the restroom

A nurse uses the bell of a stethoscope to hear a patient's heart sounds. Which physical examination technique of is the nurse using? 1. Palpation 2. Inspection 3. Percussion 4. Auscultation

4. Auscultation

During the physical examination of a patient, the nurse listens to the heart sounds to detect variations from normal. Which physical examination technique is the nurse performing? 1. Palpation 2. Inspection 3. Percussion 4. Auscultation

4. Auscultation

Which color of the lips indicates carbon monoxide poisoning? 1. Bluish 2. Very pale pink to white 3. Pink to plum 4. Bright red

4. Bright red

A patient is suspected to have dehydration. How should the nurse assess the elasticity of the skin? 1. By using a light palpation method anywhere on the body 2. By inspecting edematous areas on the skin 3. By inspecting reddened, pink, or pale areas on the skin 4. By folding the skin of the forearm with the fingertips and releasing it

4. By folding the skin of the forearm with the fingertips and releasing it

A nurse instructs a patient to assume the lithotomy position. For what does the nurse plan to assess? 1. Heart 2. Rectum and vagina 3. Musculoskeletal system 4. Genitalia and genital tract

4. Genitalia and genital tract

What is the color of a normal tympanic membrane? 1. Red 2. Pink 3. White 4. Gray

4. Gray

While assessing the eyelids of a patient, the nurse suspects the patient has nystagmus. Which finding may have led the nurse to this suspicion? 1. Lid margins that are turned out 2. Redness in the conjunctivae 3. Abnormal drooping of the lid over the pupil 4. Involuntary and rhythmical oscillations of the eyes

4. Involuntary and rhythmical oscillations of the eyes

The nurse finds lesions on the outer layers of sun-exposed skin. Upon further assessment, the lesions were found to be cancerous and had spread to lymph nodes. What type of cancer does the patient have? 1. Melanoma 2. Cherry angioma 3. Basal cell carcinoma 4. Squamous cell carcinoma

4. Squamous cell carcinoma

Which assessment helps in early identification of a pressure ulcer? 1. Turgor 2. Texture 3. Moisture 4. Temperature

4. Temperature

Which characteristic of the skin is measured using the dorsum of the hand? 1. Texture 2. Moisture 3. Tenderness 4. Temperature

4. Temperature

Which characteristics of the hair are associated with diabetes and thyroiditis? 1. Dry and brittle 2. Fine and brittle 3. Stringy and dull 4. Thinning

4. Thinning

Upon assessment, why might a nurse ask a patient if his or her nose has experienced recent trauma? 1. To determine the nature of nasal discharge 2. To determine the presence of infection or allergy 3. To determine causes of physical change in the mucosa. 4. To determine causes of septal deviation and asymmetry of the external nose.

4. To determine causes of septal deviation and asymmetry of the external nose.

A patient comes to the clinic for a regular checkup. The nurse is performing a physical examination on the patient. Which intervention should the nurse perform during palpation? 1. Palpate the tender areas first. 2. Ask the patient to take shallow breaths. 3. Instruct the patient to keep both hands on the abdomen. 4. Warm the hands and use a gentle approach.

4. Warm the hands and use a gentle approach.