Chapter 27: Security, Jarvis Chapter 27 The Complete Health Assessment, Chapter 27: Complete Health Assessment, Vital signs Chapter 26 questions, Chapter 26 Measuring Vital Sign

What intervention does the nurse perform to test the stereognosis of a patient? Ask the patient to perform the rapid alternating movements test. Ask the patient to run each heel down the shin of the opposite leg. Ask the patient to extend the arms fully and touch the nose with a finger. Ask the patient to identify an object placed in the hand without visual clues.

Ask the patient to identify an object placed in the hand without visual clues.

Which intervention does the nurse follow while assessing cerebellar function in a patient? Ask the patient to move the heel down along the opposite shin. Ask the patient to bend the knee by holding the edge of the bed. Check the spinal position when the patient bends to touch the toes. Ask the patient to walk on the toes and heels alternately for a few steps.

Ask the patient to move the heal down along the opposite shin.

The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation?

Ask to examine the client alone in order to speak to her privately.

The nurse documents normocephalic as an assessment finding. What did the nurse assess in the patient? Cranium Abdomen Optic nerve Mental status

cranium

A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should:

fill out an incident report, with the goal of preventing a similar event in the future.

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning?

Avoid unattended baths for the toddler.

The nurse is conducting a community education program on bike helmet safety. The nurse determines additional information is needed when a participant states:

"I should be able to fit two fingers between my chin and the chin strap."

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response?

"Is your child breathing at this time?"

A nurse is teaching a community group about bicycle safety. Which statement should be included when creating a teaching plan regarding bicycle safety?

"Parents are effective role models for children when they also wear helmets while riding."

The nurse is assessing an adolescent with an annual physical. The parent reports noticing a change in the child's behavior lately, including mood swings, withdrawal from the family, and failing school grades. The parent does not know what to do and asks the nurse for guidance. What is the most appropriate guidance from the nurse?

"These could be signs of substance use. Open communication and seeing a counselor who specializes in substance use would be beneficial."

Which nurse would be at the highest risk of causing a hazardous situation?

A nurse who has worked 32 hours of overtime this week

The nurse should use which location for eliciting deep tendon reflexes? A) Achilles B) Femoral C) Scapular D) Abdominal

ANS: A) Achilles Deep tendon reflexes are elicited in the biceps, triceps, brachioradialis, patella, and Achilles. Pages: 769-770

A patient's uvula rises midline when she says "ahh" and she has a positive gag reflex. The nurse has just tested which cranial nerves? A) IX, X B) IX, XII C) X, XII D) XI, XII

ANS: A) IX, X Cranial nerves IX and X are being tested by having the patient say "ahh," noting the mobility of the uvula, and when assessing the patient's gag reflex. Page: 766

After the health history has been obtained, and before beginning the physical examination, the nurse should ask the patient to first: A) empty the bladder. B) completely disrobe. C) lie on the examination table. D) walk around the room.

ANS: A) empty the bladder Before beginning the examination, the nurse should ask the person to empty the bladder (save the specimen if needed), disrobe except for underpants, put on a gown, and sit with legs dangling off side of the bed or table. Page: 764

The nurse is performing a vision examination. Which of these charts is most widely used for vision examinations? A) Snellen B) Shetllen C) Smoollen D) Schwellon

ANS: A) snellen The Snellen eye chart is most widely used for vision examinations. The other options are not tests for vision examinations. Page: 764

Which of these statements is true regarding the recording of data from the history and physical examination? A) Use long, descriptive sentences to document findings. B) Record the data as soon as possible after the interview and physical examination. C) If the information is not documented, then it can be assumed that it was done as a standard of care. D) The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing rapport with the patient.

ANS: B) Record the data as soon as possible after the interview and physical examination. The data from the history and physical examination should be recorded as soon after the event as possible. From a legal perspective, if it is not documented, it was not done. Brief notes should be taken during the examination. When documenting, the nurse should use short clear phrases and should avoid redundant phrases and descriptions. Page: 781

Which of these statements is true regarding the complete physical assessment? A) The male genitalia should be examined in the supine position. B) The patient should be in the sitting position for examination of the head and neck. C) The vital signs, height, and weight should be obtained at the end of the examination. D) To promote consistency between patients, the examiner should not vary the order of the assessment.

ANS: B) The patient should be in the sitting position for examination of the head and neck. The head and neck should be examined in the sitting position to best palpate the thyroid and lymph nodes. The male patient should stand during examination of the genitalia. Vital signs are measured early in the assessment. The sequence of the assessment may need to vary according to different patient situations. Page: 764

During a complete health assessment, how would the nurse test the patient's hearing? A) By observing how the patient participates in normal conversation B) Using the whispered voice test C) Using the Weber and Rinne tests D) Testing with an audiometer

ANS: B) Using the whispered voice test During the complete health assessment, the nurse should test hearing with the whispered voice test. The other options are not correct. Page: 765

A 5-year old child is in the clinic for a checkup. The nurse would expect him to: A) have to be held on his mother's lap. B) be able to sit on the examination table. C) be able to stand on the floor for the examination. D) be able to remain alone in the examination room

ANS: B) be able to sit on the examination table. At 4 or 5 years old, a child usually feels comfortable on the examination table. Older infants and young children aged 6 months to 2 or 3 years should be positioned in the parent's lap. Pages: 777-778

An 85-year-old man has come in for a physical examination, and the nurse notices that he uses a cane. When documenting general appearance, the nurse should document this information under the section that covers: A) posture. B) mobility. C) mood and affect. D) physical deformity.

ANS: B) mobility Use of assistive devices would be documented under the mobility section. The other responses are all other categories of the general appearance section of the health history. Page: 764

The nurse should wear gloves for which of these examinations? A) Measuring vital signs B) Palpation of the sinuses C) Palpation of the mouth and tongue D) Inspection of the eye with an ophthalmoscope

ANS: C) Palpation of the mouth and tongue Gloves should be worn when the examiner is exposed to the patient's body fluids. Page: 766

A patient is unable to shrug her shoulders against the nurse's resistant hands. What cranial nerve is involved with successful shoulder shrugging? A) VII B) IX C) XI D) XII

ANS: C) XI Cranial nerve XI enables the patient to shrug her shoulders against resistance. Page: 766

Which of these is included in assessment of general appearance? A) Height B) Weight C) Skin color D) Vital signs

ANS: C) skin color General appearance includes items such as level of consciousness, skin color, nutritional status, posture, mobility, facial expression, mood and affect, speech, hearing, and personal hygiene. Height, weight, and vital signs are considered measurements. Page: 764

The nurse has just completed an examination of a patient's extraocular muscles. When documenting the findings, the nurse should document the assessment of which cranial nerves? A) II, III, VI B) II, IV, V C) III, IV, V D) III, IV, VI

ANS: D) III, IV, VI Extraocular muscles are innervated by cranial nerves III, IV, and VI. Page: 765

During an examination, the nurse notices that a patient is unable to stick out his tongue. Which cranial nerve is involved with successful performance of this action? A) I B) V C) XI D) XII

ANS: D) XII Cranial nerve XII enables the person to stick out his or her tongue. Page: 766

During an examination, a patient has just successfully completed the finger-to-nose and the rapid-alternating-movements tests and is able to run each heel down the opposite shin. The nurse will conclude that the patient's ____ function is intact. A) occipital B) cerebral C) temporal D) cerebellar

ANS: D) cerebellar The nurse should test cerebellar function of the upper extremities by using the finger-to-nose test or rapid-alternating-movements test. The nurse should test cerebellar function of the lower extremities by asking the person to run each heel down the opposite shin. Pages: 769-770

A patient states, "Whenever I open my mouth real wide, I feel this popping sensation in front of my ears." To further examine this, the nurse would: A) place the stethoscope over the temporomandibular joint and listen for bruits. B) place the hands over his ears and ask him to open his mouth "really wide." C) place one hand on his forehead and the other on his jaw and ask him to try to open his mouth. D) place a finger on his temporomandibular joint and ask him to open and close his mouth.

ANS: D) place a finger on his temporomandibular joint and ask him to open and close his mouth. The nurse should palpate the temporomandibular joint by placing your fingers over it as the person opens and closes the mouth. Page: 765

When the nurse performs the confrontation test, the nurse has assessed: A) extraocular eye muscles (EOMs). B) pupils (PERRLA). C) near vision. D) visual fields.

ANS: D) visual fields The confrontation test assesses visual fields. The other options are not tested with the confrontation test. Page: 765

While performing a genital examination of a female patient, the nurse concludes that a patient has normal genitalia. Which observation by the nurse supports this conclusion? Presence of negative Romberg sign in the patient Absence of pink vaginal wall and cervix in the patient Presence of small amount of malodorous cervical discharge Absence of acetowhitening on swabbing of the vaginal mucosa with acetic acid

Absence of acetowhitening on swabbing of the vaginal music with acetic acid

The acronym RACE is commonly taught as a means for remembering priorities for action during a fire. The "A" in this acronym stands for which of the following?

Activate the fire alarm and notify the appropriate person.

The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed despite instructions to remain in bed. Which initial intervention is appropriate?

Assess for the need to urinate.

The older client tells the nurse that the client needs to use the restroom. Which safety intervention must the nurse perform first?

Assess the need for assistance with ambulation.

A school-age child is admitted to the emergency room with the diagnosis of a concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the client?

Assessment of vital signs and respiratory status

What is the most important safety concept that a nurse should include in the teaching plan for a family with a newborn infant in the household?

Avoid stuffed animals and blankets in the crib.

The nurse is teaching the caregiver of a school-age child about safety. Which teaching will the nurse include?

Buy protective sporting equipment.

Which item would alert the home care nurse to a safety hazard threatening a young child?

Dangling blind cords

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply.

Client-centered care Teamwork and collaboration Quality improvement (QI)

While testing the extraocular muscles, the nurse notes that the patient has improper eye movements. Which cranial nerve damage does the nurse suspect in the patient? Select all that apply. Cranial nerve III Cranial nerve IV Cranial nerve VI Cranial nerve VII Cranial nerve IX

Cranial nerve III Cranial nerve IV Cranial nerve VI

While assessing a patient, the nurse finds facial asymmetry. For which cranial nerve damage does the nurse screen in the patient? Cranial nerve III Cranial nerve IV Cranial nerve VI Cranial nerve VII

Cranial nerve VII

One of the leading causes of death in the United States is drowning. How can the nurse assist in lowering this statistic?

Implement drowning prevention strategies.

A child is playing soccer and is involved in a head-to-head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? Select all that apply.

Drowsiness Headache Vomiting

When does the nurse document the assessment finding, "anterior-posterior diameter less than lateral diameter"? During an infant's examination During the otoscopic examination During an adult's respiratory examination During a child's musculoskeletal examination

During an adults respiratory examination

A client has been diagnosed with a glioblastoma and the care team has determined that this brain tumor is inoperable. Which aspects of the the client's subsequent care demonstrate adherence to the Quality and Safety Education for Nurses (QSEN) competencies? Select all that apply.

Each member of the care team uses the best available technology to organize and provide care. Nurses proactively identify threats to the client's safety that may occur as treatment is provided. The care team balances the best available evidence about glioblastoma treatment with the client's preferences. The care team meets with the client and family promptly to identify their preferences for treatment.

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order?

Ensure that two fingers can be inserted between the restraint and the client's extremity.

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety?

Obtain a three-prong grounded plug adapter.

What does the nurse palpate while assessing the inguinal area of a patient? Radial pulse Femoral pulse Dorsalis pedis Popliteal pulse

Femoral pulse

Which tests does the nurse perform while assessing the cerebellar function of a patient? Select all that apply. Occult blood test Confrontation test Finger-to-nose test Whispered voice test Rapid-alternating-movements test

Finger-to-nose test Rapid-alternating-movements test

A client has presented to the emergency department after splashing a chemical in the eyes. When managing the injury, what should be included in the plan of care?

Flush the eyes with water for 10 minutes.

When educating families on fire safety in the home, which information is important for the nurse to emphasize?

Have a meeting place outside the home in case of fire.

Which instructions does the nurse give to the patient while assessing the spinal range of motion? Select all that apply. "Hyperextend your neck." "Bend laterally downward." "Walk a few steps backward." "Perform five sit-ups in a row." "Walk a few steps on your heels."

Hyperextend your neck Bend laterally downward

The unlicensed assistive personnel (UAP) tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse?

Initiate use of a bed alarm.

An order for a waist restraint has been obtained for a client who is a threat to her own safety. The nurse should perform which action?

Insert a fist between the restraint and the client to ensure that her breathing is not constricted.

What interventions does the nurse perform during the examination of a male patient's rectum? Select all that apply. Inspect the perianal area. Check for inguinal hernia. Obtain a stool specimen. Palpate the prostate gland. Teach testicular self-examination.

Inspect the perianal area Obtain a stool specimen Teach testicular self-examination

Which intervention does the nurse perform while assessing the breasts in a patient? Percuss the costovertebral angle Palpate the epitrochlear nodes Stand closely and check for Romberg sign Inspect the supraclavicular and infraclavicular areas

Inspect the supraclavicular and infraclavicular areas

A nurse is providing instructions to the mother of a toddler regarding the prevention of burn injuries in the toddler. Which instruction is the priority to provide to the mother?

Keep coffee cups on the counter above the child's reach.

The nurse wants to palpate the rectal walls and the prostate gland of a bedridden male patient. In which position does the nurse place the patient to ensure proper assessment? Supine position Lithotomy position Prone position with widely extended legs Left lateral position with the right leg drawn up

Left lateral position with the right leg drawn up.

A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home?

Most people who die in house fires die of smoke inhalation rather than burns.

What best describes the nurse's role in disaster preparedness?

Multiple roles, including triage and the distribution of resources

Which assessment includes size, shape, and strength parameters? Breast examination Abdominal examination Cardiovascular examination Musculoskeletal examination

Musculoskeletal examination

The nurse finds a positive Babinski reflex in an adult during a physical assessment. What could be the reason for such an abnormality? Neurologic impairment Cardiovascular impairment Musculoskeletal impairment Gastrointestinal impairment

Neurological impairment

Which actions should the nurse perform to help prevent occupational safety hazards? Select all that apply.

Only operate equipment the nurse is familiar with. Use equipment only for the use for which it was intended. Use three-pronged electric plugs whenever possible.

The telehealth nurse receives a call stating that upon entering a family member's home, two people have been found semi-conscious with a bright cherry red skin color. They are reporting nausea and headache, and are unable to move. Which initial direction will the nurse provide?

Open doors and windows.

The student nurse is assessing the neck of a patient under the supervision of a nurse educator. Which intervention by the student nurse needs correction? Palpation of the trachea in the midline Palpation of the cervical lymph nodes Assessment for functioning of cranial nerve XI Palpation of the carotid pulse on both sides at a time

Palpation of the carotid pulse on both sides at a time

During the examination of a patient's heart, the nurse documents "No abnormal thrill." Which assessment did the nurse perform on the patient? Palpation of the precordium Palpation of the apical pulse Palpation of the femoral pulse Palpation of the cervical lymph node

Palpation of the precordium.

A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure would be a priority recommendation for this client?

Placing the client in a bed with a bed alarm

The nurse is assisting the health care provider in performing a vaginal, pelvic, and rectal examination of a patient. Which intervention does the nurse perform in this situation? Positioning the patient in a prone position Positioning the patient in a sitting position Positioning the patient in a supine position Positioning the patient in a lithotomy position

Positioning the patient in a lithotomy position

What is the primary role of the nurse in the care of clients who experience domestic violence?

Providing prompt recognition of the potential or actual threat to safety

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take?

Pull the fire alarm lever.

The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock?

Refrain from using extension cords.

The nurse on a medical-surgical unit notices smoke from a client's room. Upon entering, the nurse notes that the curtain in the room is on fire. What should be the nurse's first action?

Remove the client from the room.

A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan?

Restrain the baby in a car seat.

The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What nursing diagnosis would provide the clearest justification for the use of physical restraints during this client's care?

Risk for Injury Related to Agitation

The nurse is creating a plan of care for the older adult who has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care?

Risk for Poisoning related to poor eyesight and the inability to read medication labels

The student nurse is examining the external genitalia in a female patient under the supervision of the nurse. Which action of the student nurse needs correction? Draping the patient appropriately before starting the procedure Positioning the patient in the lithotomy position on the examination table Sitting on a stool near the foot of the table to perform speculum examination Sitting on a stool near the foot of the table to perform bimanual examination

Sitting on a stool near the foot of hte table to perform bimanual examination.

While assessing a male patient, the nurse asks the patient to close his eyes and places a familiar object in his hand. The nurse then asks the patient to identify the object. What does the nurse check through this assessment? Red reflex Stereognosis Babinski reflex Cerebellar function

Stereognosis

Which is a normal assessment finding in an adult patient? Babinski sign is positive in an adult. The testicle feels like a hard-boiled egg. The liver is 4 cm in the right midclavicular line. The cervix and uterus are freely movable on palpation.

The cervix and uterus are freely moveable on palpation.

The nurse is performing breast examination on a female patient. Which position of the patient does the nurse find most suitable during the assessment? Prone position Supine position Sitting position Lithotomy position

Supine position

The nurse asks a patient to bend the head forward and back, turn the head to either side, and to shrug the shoulders. What does the nurse assess from these tests? The patient's sense of balance The symmetry of the face and neck The functioning of cranial nerve XI The cerebellar function of the upper extremities

The functioning of cranial nerve XI

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation?

The hospital must bear any costs incurred for treating the client's injury.

The school nurse is preparing a presentation about safety promotion for middle school students. Which topic should the nurse plan to include?

The importance of consistent seat belt use

What would the nurse assess using a speculum during the examination of the nose? Select all that apply. The external nose The nasal septum The nasal mucosa The nasal turbinates The patency of the nostrils

The nasal septum The nasal mucosa The nasal turbinates

The nurse is planning to test the functioning of the extraocular muscles in a patient with vision problems. Which interventions does the nurse perform during the test? Select all that apply. The nurse darkens the room. The nurse checks the corneal light reflex. The nurse uses the confrontation technique. The nurse assesses with an ophthalmoscope. The nurse asks the patient to perform the six cardinal positions of gaze.

The nurse checks the corneal light reflex. The nurse asks the patient to perform the six cardinal positions of gaze.

An adult patient has a body temperature of 98.6° F (37° C), shallow breathing with a respiratory rate of 16 breaths/minute (BPM), excessive cough, and blood pressure of 142/100 mm Hg. What does the nurse infer about the patient's condition? The patient has hypertension and bradypnea. The patient has hypotension and ineffective airway clearance. The patient has hypotension and normal body temperature. The patient has hypertension and ineffective airway clearance.

The patient has hypertension and ineffective airway clearance.

While examining a patient, the nurse suspects that the patient may have injury to cranial nerve XII. Which finding enabled the nurse to reach this conclusion? The patient is unable to speak properly. The patient is unable to raise the soft palate. The patient is unable to stick out the tongue. The patient is unable to swallow solid foods.

The patient is unable to stick out the tongue.

A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow?

Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.

Which factor is related to the highest proportion of falls in long-term care settings?

Toileting

While assessing the genitalia of a male patient, the nurse finds a hard mass on palpation of the scrotal sac. Which intervention should the nurse perform in this situation? Transilluminate the scrotal sac. Check for the presence of Romberg sign. Prepare the patient for surgery immediately. Report immediately to the health care provider.

Transilluminate the scrotal sac

A nurse is teaching parents about Internet safety for children. Which actions are recommended guidelines for Internet use? Select all that apply.

Use filtering software to block objectionable information. Investigate any public chat rooms used by the children. Be alert for downloaded files with suffixes that indicate images or pictures.

The school nurse is educating 7th grade children about safety. Which recommendation is most appropriate for this age group?

Use protective sporting equipment

While collecting data, the nurse uses the Snellen chart. What does the nurse examine in the patient? Vision acuity Stereognosis Facial symmetry Costovertebral angle

Vision acuity

The nurse plans to assess the deep tendon reflexes of a patient. Which reflexes does the nurse check? Select all that apply. Red reflex Biceps reflex Achilles reflex Patellar reflex Babinski reflex

biceps reflex Achilles reflex Patellar reflex

A staff development nurse is providing an in-service to a group of nurses on the use of restraints in health care facilities. What is an example of a chemical restraint?

a dose of an antipsychotic

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate?

administration of an antipsychotic agent to alter the client's behavior

The nurse recognizes that assessment for sensory-perceptual alterations is a priority for which client?

an 84-year-old male with four recent driving violations

A nurse visits an older adult client at home and assesses the safety of the client's environment. Which article can be a threat to the client's safety?

area rugs kept on the stairs without carpet

A 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to:

automobile accidents.

When educating a family on fire safety, it is important to:

have a meeting place outside the home.

Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning?

keeping medications in clearly labeled containers

The nurse educator has just completed a lecture regarding older adults and hazards in the home. The nurse educator recognizes that the education was effective when the students state that common dangers in the home setting of an older adult include:

polypharmacy and use of multiple extension cords.

The nurse is working at a local elementary school. A mother arrives to pick up her 6-year-old son and has her 2-year-old daughter in tow. Based on the nurse's developmental knowledge of toddlers, which behavior would most concern the nurse?

the 2-year-old leaning against the screen of a window in a classroom