HA - Module 2

5. The nurse is assessing an older adults advanced activities of daily living (AADLs), which would include: a. Recreational activities. b. Meal preparation. c. Balancing the checkbook. d. Self-grooming activities.

ANS: A AADLs are activities that an older adult performs such as occupational and recreational activities. Self- grooming activities are basic ADLs; meal preparation and balancing the checkbook are considered IADLs. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

12. The nurse knows that the best time to assess a womans blood pressure during an initial prenatal visit is: a. At the end of the examination when she will be the most relaxed. b. At the beginning of the interview as a nonthreatening method of gaining rapport. c. During the middle of the physical examination when she is the most comfortable. d. Before beginning the pelvic examination because her blood pressure will be higher after the pelvic examination.

ANS: A Assessing the womans blood pressure at the end of the examination, when it is hoped that she will be most relaxed, is the best time to assess blood pressure. The other options are not correct. MSC: Client Needs: Safe and Effective Care Environment: Management of Care

9. An 85-year-old man has been hospitalized after a fall at home, and his 86-year-old wife is at his bedside. She tells the nurse that she is his primary caregiver. The nurse should assess the caregiver for signs of possible caregiver burnout, such as: a. Depression. b. Weight gain. c. Hypertension. d. Social phobias.

ANS: A Caregiver burden is the perceived strain by the person who cares for an older adult or for a person who is chronically ill or disabled. Caregiver burnout is linked to the caregivers ability to cope and handle stress. Signs of possible caregiver burnout include multiple somatic complaints, increased stress and anxiety, social isolation, depression, and weight loss. Screening caregivers for depression may also be appropriate. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

11. The nurse is reviewing the principles of nociception. During which phase of nociception does the conscious awareness of a painful sensation occur? a. Perception b. Modulation c. Transduction d. Transmission

ANS: A Perception is the third phase of nociception and indicates the conscious awareness of a painful sensation. During this phase, the sensation is recognized by higher cortical structures and identified as pain. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Physiologic Integrity: Basic Care and Comfort

7. A patient will be ready to be discharged from the hospital soon, and the patients family members are concerned about whether the patient is able to walk safely outside alone. The nurse will perform which test to assess this? a. Get Up and Go Test b. Performance ADLs c. Physical Performance Test d. Tinetti Gait and Balance Evaluation

ANS: A The Get Up and Go Test is a reliable and valid test to quantify functional mobility. The test is quick, requires little training and no special equipment, and is appropriate to use in many settings including hospitals and clinics. This instrument has been shown to predict a persons ability to go safely outside alone. The Performance of ADLs test has a trained observer actually observing as a patient performs various ADLs. The Physical Performance Test assesses upper body fine motor and coarse motor activities, as well as balance, mobility, coordination, and endurance. The Tinetti Gait and Balance Evaluation assesses gait and balance and provides information about fall risk. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance

28. During auscultation of fetal heart tones (FHTs), the nurse determines that the heart rate is 136 beats per minute. The nurses next action should be to: a. Document the results, which are within normal range. b. Take the maternal pulse to verify these findings as the uterine souffle. c. Have the patient change positions and count the FHTs again. d. Immediately notify the physician for possible fetal distress.

ANS: A The normal fetal heart rate is between 110 and 160 beats per minute. The nurse should document the results as within the normal range. The other options are not correct. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

17. When performing an examination of a woman who is 34 weeks pregnant, the nurse notices a midline linear protrusion in the abdomen over the area of the rectus abdominis muscles as the woman raises her head and shoulders off of the bed. Which response by the nurse is correct? a. The presence of diastasis recti should be documented. b. This condition should be discussed with the physician because it will most likely need to be surgically repaired. c. The possibility that the woman has a hernia attributable to the increased pressure within the abdomen from the pregnancy should be suspected. d. The woman should be told that she may have a difficult time with delivery because of the weakness in her abdominal muscles.

ANS: A The separation of the abdominal muscles is called diastasis recti and frequently occurs during pregnancy. The rectus abdominis muscles will return together after pregnancy with abdominal exercise. This condition is not a true hernia. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

14. Which finding is considered normal and expected when the nurse is performing a physical examination on a pregnant woman? a. Palpable, full thyroid b. Edema in one lower leg c. Significant diffuse enlargement of the thyroid d. Pale mucous membranes of the mouth

ANS: A The thyroid may be palpable during pregnancy. It should feel full, but smooth. Significant diffuse enlargement occurs with hyperthyroidism, thyroiditis, and hypothyroidism. Pale mucous membranes may indicate anemia. Bilateral lower extremity edema is common in pregnancy, but edema with pain in only one leg occurs with deep vein thrombosis. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

2. The nurse is preparing to perform a functional assessment of an older patient and knows that a good approach would be to: a. Observe the patients ability to perform the tasks. b. Ask the patients wife how he does when performing tasks. c. Review the medical record for information on the patients abilities. d. Ask the patients physician for information on the patients abilities.

ANS: A Two approaches are used to perform a functional assessment: (1) asking individuals about their ability to perform the tasks (self-reports), or (2) actually observing their ability to perform the tasks. For persons with memory problems, the use of surrogate reporters (proxy reports), such as family members or caregivers, may be necessary, keeping in mind that they may either overestimate or underestimate the persons actual abilities. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

1. During assessment of a patients pain, the nurse is aware that certain nonverbal behaviors are associated with chronic pain. Which of these behaviors are associated with chronic pain? Select all that apply. a. Sleeping b. Moaning c. Diaphoresis d. Bracing e. Restlessness f. Rubbing

ANS: A, D, F Behaviors that have been associated with chronic pain include bracing, rubbing, diminished activity, sighing, and changes in appetite. In addition, those with chronic pain may sleep in an attempt at distraction. The other behaviors are associated with acute pain. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Basic Care and Comfort

6. When using the various instruments to assess an older persons ADLs, the nurse needs to remember that a disadvantage of these instruments includes: a. Reliability of the tools. b. Self or proxy reporting of functional activities. c. Lack of confidentiality during the assessment. d. Insufficient details concerning the deficiencies identified.

ANS: B A disadvantage of many of the ADL and IADL instruments is the self or proxy reporting of functional activities. The other responses are not correct. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance

12. When assessing the intensity of a patients pain, which question by the nurse is appropriate? a. What makes your pain better or worse? b. How much pain do you have now? c. How does pain limit your activities? d. What does your pain feel like?

ANS: B Asking the patient how much pain do you have? is an assessment of the intensity of a patients pain; various intensity scales can be used. Asking what makes ones pain better or worse assesses alleviating or aggravating factors. Asking whether pain limits ones activities assesses the degree of impairment and quality of life. Asking what does your pain feel like assesses the quality of pain. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Physiologic Integrity: Basic Care and Comfort

26. A 25-year-old woman is in the clinic for her first prenatal visit. The nurse will prepare to obtain which laboratory screening test at this time? a. Urine toxicology b. Complete blood cell count c. Alpha-fetoprotein d. Carrier screening for cystic fibrosis

ANS: B At the onset of pregnancy, a routine prenatal panel usually includes a complete blood cell count, serologic testing, rubella antibodies, hepatitis B screening, blood type and Rhesus factor, and antibody screen. A clean- catch urine sample is collected for urinalysis to rule out cystitis. Urine toxicology, although beneficial for women if active substance abuse is suspected or known, is not routinely performed. In the second trimester, maternal serum is analyzed for alpha-fetoprotein. Carrier screening for cystic fibrosis is offered to check whether a person carries the abnormal gene that causes cystic fibrosis but is not part of routine testing. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

15. When auscultating the anterior thorax of a pregnant woman, the nurse notices the presence of a murmur over the second, third, and fourth intercostal spaces. The murmur is continuous but can be obliterated by pressure with the stethoscope or finger on the thorax just lateral to the murmur. The nurse interprets this finding to be: a. Murmur of aortic stenosis. b. Most likely a mammary souffle. c. Associated with aortic insufficiency. d. Indication of a patent ductus arteriosus.

ANS: B Blood flow through the blood vessels, specifically the internal mammary artery, can often be heard over the second, third, and fourth intercostal spaces. This finding is called a mammary souf le, but it may be mistaken for a cardiac murmur. The other options are incorrect. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Health Promotion and Maintenance

13. When examining the face of a woman who is 28 weeks pregnant, the nurse notices the presence of a butterfly-shaped increase in pigmentation on the face. The proper term for this finding in the documentation is: a. Striae. b. Chloasma. c. Linea nigra. d. Mask of pregnancy.

ANS: B Chloasma is a butterfly-shaped increase in pigmentation on the face. It is known as the mask of pregnancy, but when documenting, the nurse should use the correct medical term, chloasma. Striae is the term for stretch marks. The linea nigra is a hyperpigmented line that begins at the sternal notch and extends down the abdomen through the umbilicus to the pubis. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

27. A woman at 25 weeks gestation comes to the clinic for her prenatal visit. The nurse notices that her face and lower extremities are swollen, and her blood pressure is 154/94 mm Hg. The woman states that she has had headaches and blurry vision but thought she was just tired. What should the nurse suspect? a. Eclampsia b. Preeclampsia c. Diabetes type 1 d. Preterm labor

ANS: B Classic symptoms of preeclampsia include elevated blood pressure (greater than 140 mm Hg systolic or 90 mm Hg diastolic in a woman with previously normal blood pressure) and proteinuria. Onset and worsening symptoms may be sudden, and subjective signs include headaches and visual changes. Eclampsia is manifested by generalized tonic-clonic seizures. These symptoms are not indicative of diabetes mellitus (type 1 or 2) or preterm labor. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

12. During a functional assessment of an older persons home environment, which statement or question by the nurse is most appropriate regarding common environmental hazards? a. These low toilet seats are safe because they are nearer to the ground in case of falls. b. Do you have a relative or friend who can help to install grab bars in your shower? c. These small rugs are ideal for preventing you from slipping on the hard floor. d. It would be safer to keep the lighting low in this room to avoid glare in your eyes.

ANS: B Environmental hazards within the home can be a potential constraint on the older persons day-to-day functioning. Common environmental hazards, including inadequate lighting, loose throw rugs, curled carpet edges, obstructed hallways, cords in walkways, lack of grab bars in tub and shower, and low and loose toilet seats, are hazards that could lead to an increased risk of falls and fractures. Environmental modifications can promote mobility and reduce the likelihood of the older adult falling. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

4. A patient is being seen at the clinic for her 10-week prenatal visit. She asks when she will be able to hear the babys heartbeat. The nurse should reply: a. The babys heartbeat is not usually heard until the second trimester. b. The babys heartbeat may be heard anywhere from the ninth to the twelfth week. c. It is often difficult to hear the heartbeat at this point, but we can try. d. It is normal to hear the heartbeat at 6 weeks. We may be able to hear it today.

ANS: B Fetal heart tones can be heard with the use of the Doppler device between 9 and 12 weeks. The other responses are incorrect. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

24. A patient who is 24 weeks pregnant asks about wearing a seat belt while driving. Which response by the nurse is correct? a. Seat belts should not be worn during pregnancy. b. Place the lap belt below the uterus and use the shoulder strap at the same time. c. Place the lap belt below the uterus but omit the shoulder strap during pregnancy. d. Place the lap belt at your waist above the uterus and use the shoulder strap at the same time.

ANS: B For maternal and fetal safety, the nurse should instruct the woman to place the lap belt below the uterus and to use the shoulder strap. The other instructions are incorrect. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

11. An older patient has been admitted to the intensive care unit (ICU) after falling at home. Within 8 hours, his condition has stabilized and he is transferred to a medical unit. The family is wondering whether he will be able to go back home. Which assessment instrument is most appropriate for the nurse to choose at this time? a. Lawton IADL instrument b. Hospital Admission Risk Profile (HARP) c. Mini-Cog d. NEECHAM Confusion Scale

ANS: B Hospital-acquired functional decline may occur within 2 days of a hospital admission. The HARP helps identify older adults who are at greatest risk of losing their ability to perform ADLs or mobility at this critical time. The Lawton IADL measures instrumental activities of daily living, which may be difficult to observe in the hospital setting. The Mini-Cog is an assessment of mental status. The NEECHAM Confusion Scale is used to assess for delirium. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

16. When the nurse is assessing the deep tendon reflexes (DTRs) on a woman who is 32 weeks pregnant, which of these would be considered a normal finding on a 0 to 4+ scale? a. Absent DTRs b. 2+ c. 4+ d. Brisk reflexes and the presence of clonus

ANS: B Normally during pregnancy, the DTRs are 1+ to 2+ and bilaterally equal. Brisk or greater than 2+ DTRs and the presence of clonus are abnormal and may be associated with an elevated blood pressure and cerebral edema in the preeclamptic woman. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

13. When beginning to assess a persons spirituality, which question by the nurse would be most appropriate? a. Do you believe in God? b. How does your spirituality relate to your health care decisions? c. What religious faith do you follow? d. Do you believe in the power of prayer?

ANS: B Open-ended questions provide a foundation for future discussions. The other responses are easily answered by one-word replies and are closed questions. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity

4. The nurse is preparing to use the Lawton IADL instrument as part of an assessment. Which statement about the Lawton IADL instrument is true? a. The nurse uses direct observation to implement this tool. b. The Lawton IADL instrument is designed as a self-report measure of performance rather than ability. c. This instrument is not useful in the acute hospital setting. d. This tool is best used for those residing in an institutional setting.

ANS: B The Lawton IADL instrument is designed as a self-report measure of performance rather than ability. Direct testing is often not feasible, such as demonstrating the ability to prepare food while a hospital inpatient. Attention to the final score is less important than identifying a persons strengths and areas where assistance is needed. The instrument is useful in acute hospital settings for discharge planning and continuously in outpatient settings. It would not be useful for those residing in institutional settings because many of these tasks are already being managed for the resident. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

11. When assessing a woman who is in her third trimester of pregnancy, the nurse looks for the classic symptoms associated with preeclampsia, which include: a. Edema, headaches, and seizures. b. Elevated blood pressure and proteinuria. c. Elevated liver enzymes and high platelet counts. d. Decreased blood pressure and edema.

ANS: B The classic symptoms of preeclampsia are hypertension and proteinuria. Headaches may occur with worsening symptoms, and seizures may occur if preeclampsia is left untreated and leads to eclampsia. A serious variant of preeclampsia, the hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome, is an ominous picture. Edema is a common occurrence in pregnancy. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

25. During a health history interview, a 38-year-old woman shares that she is thinking about having another baby. The nurse knows which statement to be true regarding pregnancy after 35 years of age? a. Fertility does not start to decline until age 40 years. b. Occurrence of Down syndrome is significantly more frequent after the age of 35 years. c. Genetic counseling and prenatal screening are not routine until after age 40 years. d. Women older than 35 years who are pregnant have the same rate of pregnancy-related complications as those who are younger than 35 years.

ANS: B The risk of Down syndrome increases as the woman ages, from approximately 1 in 1250 at age 25 years to 1 in 400 at age 35 years. Fertility declines with advancing maternal age. Women 35 years and older or with a history of a genetic abnormality are offered genetic counseling and the options of prenatal diagnostic screening tests. Because the incidence of chronic diseases increases with age, women older than 35 years who are pregnant more often have medical complications such as diabetes, obesity, and hypertension. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

10. When assessing a patients pain, the nurse knows that an example of visceral pain would be: a. Hip fracture. b. Cholecystitis. c. Second-degree burns. d. Pain after a leg amputation.

ANS: B Visceral pain originates from the larger interior organs, such as the gallbladder, liver, or kidneys. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

1. The nurse is assessing the abilities of an older adult. Which activities are considered IADLs?Select all that apply. a. Feeding oneself b. Preparing a meal c. Balancing a checkbook d. Walking e. Toileting f. Grocery shopping

ANS: B, C, F Typically, IADL tasks include shopping, meal preparation, housekeeping, laundry, managing finances, taking medications, and using transportation. The other options listed are ADLs related to self-care. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

2. During an admission assessment of a patient with dementia, the nurse assesses for pain because the patient has recently had several falls. Which of these are appropriate for the nurse to assess in a patient with dementia? Select all that apply. a. Ask the patient, Do you have pain? b. Assess the patients breathing independent of vocalization. c. Note whether the patient is calling out, groaning, or crying. d. Have the patient rate pain on a 1-to-10 scale. e. Observe the patients body language for pacing and agitation.

ANS: B, C, E Patients with dementia may say no when, in reality, they are very uncomfortable because words have lost their meaning. Patients with dementia become less able to identify and describe pain over time, although pain is still present. People with dementia communicate pain through their behaviors. Agitation, pacing, and repetitive yelling may indicate pain and not a worsening of the dementia. (See the Pain Assessment in Advanced Dementia [PAINAD] scale, which may also be used to assess pain in persons with dementia.)

1. When evaluating a patients pain, the nurse knows that an example of acute pain would be: a. Arthritic pain. b. Fibromyalgia. c. Kidney stones. d. Low back pain.

ANS: C Acute pain is short-term and dissipates after an injury heals, such as with kidney stones. The other conditions are examples of chronic pain during which the pain continues for 6 months or longer and does not stop when the injury heals. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Physiologic Integrity: Basic Care and Comfort

18. The nurse is palpating the fundus of a pregnant woman. Which statement about palpation of the fundus is true? a. The fundus should be hard and slightly tender to palpation during the first trimester. b. Fetal movement may not be felt by the examiner until the end of the second trimester. c. After 20 weeks gestation, the number of centimeters should approximate the number of weeks gestation. d. Fundal height is usually less than the number of weeks gestation, unless an abnormal condition such as excessive amniotic fluid is present.

ANS: C After 20 weeks gestation, the number of centimeters should approximate the number of weeks gestation. In addition, at 20 weeks gestation, the examiner may be able to feel fetal movement and the head can be balloted. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance

9. The nurse auscultates a functional systolic murmur, grade II/IV, on a woman in week 30 of her pregnancy. The remainder of her physical assessment is within normal limits. The nurse would: a. Consider this finding abnormal, and refer her for additional consultation. b. Ask the woman to run briefly in place and then assess for an increase in intensity of the murmur. c. Know that this finding is normal and is a result of the increase in blood volume during pregnancy. d. Ask the woman to restrict her activities and return to the clinic in 1 week for re-evaluation.

ANS: C Because of the increase in blood volume, a functional systolic murmur, grade II/IV or less, can be heard in 95% of pregnant women. The other actions are not appropriate. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Health Promotion and Maintenance

6. During the examination of a woman in her second trimester of pregnancy, the nurse notices the presence of a small amount of yellow drainage from the nipples. The nurse knows that this is: a. An indication that the womans milk is coming in. b. A sign of possible breast cancer in a pregnant woman. c. Most likely colostrum and considered a normal finding at this stage of the pregnancy. d. Too early in the pregnancy for lactation to begin and refers the woman to a specialist.

ANS: C During the second trimester, colostrum, the precursor of milk, may be expressed from the nipples. Colostrum is yellow and contains more minerals and protein but less sugar and fat than mature milk. The other options are incorrect. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Health Promotion and Maintenance

3. A woman who is 8 weeks pregnant is visiting the clinic for a checkup. Her systolic blood pressure is 30 mm Hg higher than her prepregnancy systolic blood pressure. The nurse should: a. Consider this a normal finding. Test Bank - Physical Examination and Health Assessment 8e (by Jarvis) 457 b. Expect the blood pressure to decrease as the estrogen levels increase throughout the pregnancy. c. Consider this an abnormal finding because blood pressure is typically lower at this point in the pregnancy. d. Recommend that she decrease her salt intake in an attempt to decrease her peripheral vascular resistance.

ANS: C During the seventh gestational week, blood pressure begins to drop as a result of falling peripheral vascular resistance. Early in the first trimester, blood pressure values are similar to those of prepregnancy measurements. In this case, the womans blood pressure is higher than it should be. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Health Promotion and Maintenance

10. During a morning assessment, the nurse notices that an older patient is less attentive and is unable to recall yesterdays events. Which test is appropriate for assessing the patients mental status? a. Geriatric Depression Scale, short form b. Rapid Disability Rating Scale-2 c. Mini-Cog d. Get Up and Go Test

ANS: C For nurses in various settings, cognitive assessments provide continuing comparisons to the individuals baseline to detect any acute changes in mental status. The Mini-Cog is a mental status test that tests immediate and delayed recall and visuospatial abilities. The Geriatric Depression Scale, short form, assesses for depression and changes in the level of depression, not mental status. The Rapid Disability Rating Scale-2 measures what the person can actually do versus what he or she could do, but not mental status. The Get Up and Go Test assesses functional mobility, not mental status. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

14. The nurse knows that which statement istrue regarding the pain experienced by infants? a. Pain in infants can only be assessed by physiologic changes, such as an increased heart rate. b. The FPS-R can be used to assess pain in infants. c. A procedure that induces pain in adults will also induce pain in the infant. d. Infants feel pain less than do adults.

ANS: C If a procedure or disease process causes pain in an adult, then it will also cause pain in an infant. Physiologic changes cannot be exclusively used to confirm or deny pain because other factors, such as medications, fluid status, or stress may cause physiologic changes. The FPS-R can be used starting at age 4 years. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Physiologic Integrity: Basic Care and Comfort

14. The nurse is preparing to assess an older adult and discovers that the older adult is in severe pain. Which statement about pain and the older adult is true? a. Pain is inevitable with aging. b. Older adults with cognitive impairments feel less pain. c. Alleviating pain should be a priority over other aspects of the assessment. d. The assessment should take priority so that care decisions can be made.

ANS: C If the older adult is experiencing pain or discomfort, then the depth of knowledge gathered through the assessments will suffer. Alleviating pain should be a priority over other aspects of the assessment. Remembering that older adults with cognitive impairment do not feel less pain is paramount. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Physiologic Integrity: Basic Care and Comfort

19. The nurse is palpating the abdomen of a woman who is 35 weeks pregnant and notices that the fetal head is facing downward toward the pelvis. The nurse would document this as fetal: a. Lie. b. Variety. c. Attitude. d. Presentation.

ANS: D Fetal presentation describes the part of the fetus that is entering the pelvis first.Fetal lie is orientation of the fetal spine to the maternal spine. Fetal attitude is the position of fetal parts in relation to each other, and fetal variety is the location of the fetal back to the maternal pelvis. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

2. Which statement indicates that the nurse understands the pain experienced by an older adult? a. Older adults must learn to tolerate pain. b. Pain is a normal process of aging and is to be expected. c. Pain indicates a pathologic condition or an injury and is not a normal process of aging. d. Older individuals perceive pain to a lesser degree than do younger individuals.

ANS: C Pain indicates a pathologic condition or an injury and should never be considered something that an older adult should expect or tolerate. Pain is not a normal process of aging, and no evidence suggests that pain perception is reduced with aging. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Basic Care and Comfort

8. A patient who is 20 weeks pregnant tells the nurse that she feels more shortness of breath as her pregnancy progresses. The nurse recognizes which statement to be true? a. High levels of estrogen cause shortness of breath. b. Feelings of shortness of breath are abnormal during pregnancy. c. Hormones of pregnancy cause an increased respiratory effort. d. The patient should get more exercise in an attempt to increase her respiratory reserve.

ANS: C Progesterone and estrogen cause an increase in respiratory effort during pregnancy by increasing tidal volume. Increased tidal volume causes a slight drop in partial pressure of arterial carbon dioxide (PaCO2 ), causing the woman to have dyspnea occasionally. The other options are not correct. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

4. A patient states that the pain medication is not working and rates his postoperative pain at a 10 on a 1-to-10 scale. Which of these assessment findings indicates an acute pain response to poorly controlled pain? a. Confusion b. Hyperventilation c. Increased blood pressure and pulse d. Depression

ANS: C Responses to poorly controlled acute pain include tachycardia, elevated blood pressure, and hypoventilation. Confusion and depression are associated with poorly controlled chronic pain. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Physiologic Integrity: Basic Care and Comfort

3. The nurse needs to assess a patients ability to perform activities of daily living (ADLs) and should choose which tool for this assessment? a. Direct Assessment of Functional Abilities (DAFA) b. Lawton Instrumental Activities of Daily Living (IADL) scale c. Barthel Index d. Older Americans Resources and Services Multidimensional Functional Assessment QuestionnaireIADL (OMFAQ-IADL)

ANS: C The Barthel Index is used to assess ADLs. The other options are used to measure IADLs. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance

5. A patient who is in her first trimester of pregnancy tells the nurse that she is experiencing significant nausea and vomiting and asks when it will improve. The nurse should reply: a. Did your mother have significant nausea and vomiting? b. Many women experience nausea and vomiting until the third trimester. c. Usually, by the beginning of the second trimester, the nausea and vomiting improve. d. At approximately the time you begin to feel the baby move, the nausea and vomiting will subside.

ANS: C The nausea, vomiting, and fatigue of pregnancy improve by the 12th week. Quickening, when the mother recognizes fetal movement, occurs at approximately 18 to 20 weeks. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

22. A patients pregnancy test is positive, and she wants to know when the baby is due. The first day of her last menstrual period was June 14, and that period ended June 20. Using the Ngele rule, what is her expected date of delivery? a. March 7 b. March 14 c. March 21 d. March 27

ANS: C To determine the expected date of delivery using the Ngele rule, 7 days are added to the first day of the last menstrual period; then 3 months are subtracted. Therefore, adding 7 days to June 14 would be June 21 and subtracting 3 months would make the expected delivery date March 21. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

1. During a group prenatal teaching session, the nurse teaches Kegel exercises. Which statements would be appropriate for this teaching session? Select all that apply. a. Kegel exercises help keep your uterus strong during the pregnancy. b. Kegel exercises should be performed twice a day. c. Kegel exercises should be performed 50 to 100 times a day. d. To perform Kegel exercises, slowly squeeze to a peak at the count of eight, and then slowly release to a count of eight. e. To perform Kegel exercises, rapidly perform alternating squeeze-release exercises up to the count of eight.

ANS: C, D Kegel exercises can be performed to prepare for and to recover from birth. The nurse should direct the woman to squeeze slowly to a peak at the count of eight and then to release slowly to the count of eight. The nurse can prescribe this exercise to be performed 50 to 100 times a day. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

5. A 60-year-old woman has developed reflexive sympathetic dystrophy after arthroscopic repair of her shoulder. A key feature of this condition is that the: a. Affected extremity will eventually regain its function. b. Pain is felt at one site but originates from another location. c. Patients pain will be associated with nausea, pallor, and diaphoresis. d. Slightest touch, such as a sleeve brushing against her arm, causes severe and intense pain.

ANS: D A key feature of reflexive sympathetic dystrophy is that a typically innocuous stimulus can create a severe, intensely painful response. The affected extremity becomes less functional over time. Test Bank - Physical Examination and Health Assessment 8e (by Jarvis) 134 DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Physiologic Integrity: Basic Care and Comfort

13. A patient is complaining of severe knee pain after twisting it during a basketball game and is requesting pain medication. Which action by the nurse is appropriate? a. Completing the physical examination first and then giving the pain medication b. Telling the patient that the pain medication must wait until after the x-ray images are completed c. Evaluating the full range of motion of the knee and then medicating for pain d. Administering pain medication and then proceeding with the assessment

ANS: D According to the American Pain Society (1992), In cases in which the cause of acute pain is uncertain, establishing a diagnosis is a priority, but symptomatic treatment of pain should be given while the investigation is proceeding. With occasional exceptions, (e.g., the initial examination of the patient with an acute condition of the abdomen), it is rarely justified to defer analgesia until a diagnosis is made. In fact, a comfortable patient is better able to cooperate with diagnostic procedures. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Physiologic Integrity: Basic Care and Comfort

15. A patient has been admitted to the hospital with vertebral fractures related to osteoporosis. She is in extreme pain. This type of pain would be classified as: a. Referred. b. Cutaneous. c. Visceral. d. Deep somatic.

ANS: D Deep somatic pain comes from sources such as the blood vessels, joints, tendons, muscles, and bone. Referred pain is felt at one site but originates from another location. Cutaneous pain is derived from the skin surface and subcutaneous tissues. Visceral pain originates from the larger, interior organs. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Basic Care and Comfort

10. A woman who is 28 weeks pregnant has bilateral edema in her lower legs after working 8 hours a day as a cashier at a local grocery store. She is worried about her legs. What is the nurses best response? a. You will be at risk for development of varicose veins when your legs are edematous. b. I would like to listen to your heart sounds. Edema can indicate a problem with your heart. c. Edema is usually the result of too much salt and fluids in your diet. You may need to cut down on salty foods. d. As your baby grows, it slows blood return from your legs, causing the swelling. This often occurs with prolonged standing.

ANS: D Edema of the lower extremities occurs because of the enlarging fetus, which impairs venous return. Prolonged standing worsens the edema. Typically, the bilateral, dependent edema experienced with pregnancy is not the result of a cardiac pathologic condition. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance

1. The nurse is assessing an older adults functional ability. Which definition correctly describes ones functional ability? Functional ability: a. Is the measure of the expected changes of aging that one is experiencing. b. Refers to the individuals motivation to live independently. c. Refers to the level of cognition present in an older person. d. Refers to ones ability to perform activities necessary to live in modern society.

ANS: D Functional ability refers to ones ability to perform activities necessary to live in modern society and can include driving, using the telephone, or performing personal tasks such as bathing and toileting. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance

23. During the assessment of a woman in her 22nd week of pregnancy, the nurse is unable to hear fetal heart tones with the fetoscope. The nurse should: a. Immediately notify the physician, then wait 10 minutes and try again. b. Ask the woman if she has felt the baby move today. c. Wait 10 minutes, and try again. d. Use ultrasound to verify cardiac activity.

ANS: D If no fetal heart tones are heard during auscultation with a fetoscope, then the nurse should verify cardiac activity using ultrasonography. An ultrasound should be immediately done and before notifying the physician or causing the woman distress by asking about fetal movement. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

8. The nurse is assessing the forms of support an older patient has before she is discharged. Which of these examples is an informal source of support? a. Local senior center b. Patients Medicare check c. Meals on Wheels meal delivery service d. Patients neighbor, who visits with her daily

ANS: D Informal support includes family and close, long-time friends and is usually provided free of charge. Formal supports include programs such as social welfare and other social service and health care delivery agencies such as home health care. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity

8. The nurse is reviewing the principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system? a. Visceral b. Referred c. Cutaneous d. Neuropathic

ANS: D Neuropathic pain implies an abnormal processing of the pain message. The other types of pain are named according to their sources. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

7. A patient has had arthritic pain in her hips for several years since a hip fracture. She is able to move around in her room and has not offered any complaints so far this morning. However, when asked, she states that her pain is bad this morning and rates it at an 8 on a 1-to-10 scale. What does the nurse suspect? The patient: a. Is addicted to her pain medications and cannot obtain pain relief. b. Does not want to trouble the nursing staff with her complaints. c. Is not in pain but rates it high to receive pain medication. d. Has experienced chronic pain for years and has adapted to it.

ANS: D Persons with chronic pain typically try to give little indication that they are in pain and, over time, adapt to the pain. As a result, they are at risk for underdetection. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

2. A female patient has nausea, breast tenderness, fatigue, and amenorrhea. Her last menstrual period was 6 weeks ago. The nurse interprets that this patient is experiencing __________ signs of pregnancy. a. Positive b. Possible c. Probable d. Presumptive

ANS: D Presumptive signs of pregnancy are those that the woman experiences and include amenorrhea, breast tenderness, fatigue, nausea, and increased urinary frequency. Probable signs are those that are detected by the examiner, such as an enlarged uterus or changes in the cervix. Positive signs of pregnancy are those that document direct evidence of the fetus such as fetal heart tones or positive cardiac activity on ultrasound

1. Which of these statements best describes the action of the hormone progesterone during pregnancy? a. Progesterone produces the hormone human chorionic gonadotropin. b. Duct formation in the breast is stimulated by progesterone. c. Progesterone promotes sloughing of the endometrial wall. d. Progesterone maintains the endometrium around the fetus.

ANS: D Progesterone prevents the sloughing of the endometrial wall and maintains the endometrium around the fetus. Progesterone increases the alveoli in the breast and keeps the uterus in a quiescent state. The other options are not correct. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: General

3. A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, It hurts so bad. Which pain assessment tool would be the best choice when assessing this childs pain? a. Descriptor Scale b. Numeric rating scale c. Brief Pain Inventory d. Faces Pain ScaleRevised (FPS-R)

ANS: D Rating scales can be introduced at the age of 4 or 5 years. The FPS-R is designed for use by children and asks the child to choose a face that shows how much hurt (or pain) you have now. Young children should not be asked to rate pain by using numbers. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Basic Care and Comfort

7. A woman in her second trimester of pregnancy complains of heartburn and indigestion. When discussing this with the woman, the nurse considers which explanation for these problems? a. Tone and motility of the gastrointestinal tract increase during the second trimester. b. Sluggish emptying of the gallbladder, resulting from the effects of progesterone, often causes heartburn. c. Lower blood pressure at this time decreases blood flow to the stomach and gastrointestinal tract. d. Enlarging uterus and altered esophageal sphincter tone predispose the woman to have heartburn.

ANS: D Stomach displacement from the enlarging uterus plus altered esophageal sphincter and gastric tone as a result of progesterone predispose the woman to heartburn. The tone and motility of the gastrointestinal tract are decreased, not increased, during pregnancy. Emptying of the gallbladder may become more sluggish during pregnancy but is not related to indigestion. Rather, some women are predisposed to gallstone formation. A lower blood pressure may occur during the second semester, but it does not affect digestion. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

20. The nurse is palpating the uterus of a woman who is 8 weeks pregnant. Which finding would be considered to be most consistent with this stage of pregnancy? a. The uterus seems slightly enlarged and softened. b. It reaches the pelvic brim and is approximately the size of a grapefruit. c. The uterus rises above the pelvic brim and is approximately the size of a cantaloupe. d. It is about the size of an avocado, approximately 8 cm across the fundus.

ANS: D The 8-week pregnant uterus is approximately the size of an avocado, 7 to 8 cm across the fundus. The 6-week pregnant uterus is slightly enlarged and softened. The 10-week pregnant uterus is approximately the size of a grapefruit and may reach the pelvic brim. The 12-week pregnant uterus will fill the pelvis. At 12 weeks, the uterus is sized from the abdomen. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance

21. Which of these correctly describes the average length of pregnancy? a. 38 weeks b. 9 lunar months c. 280 days from the last day of the last menstrual period d. 280 days from the first day of the last menstrual period

ANS: D The average length of pregnancy is 280 days from the first day of the last menstrual period, which is equal to 40 weeks, 10 lunar months, or roughly 9 calendar months. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

6. The nurse is assessing a patients pain. The nurse knows that the most reliable indicator of pain would be the: a. Patients vital signs. b. Physical examination. c. Results of a computerized axial tomographic scan. d. Subjective report.

ANS: D The subjective report is the most reliable indicator of pain. Physical examination findings can lend support, but the clinician cannot exclusively base the diagnosis of pain on physical assessment findings. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

9. When assessing the quality of a patients pain, the nurse should ask which question? a. When did the pain start? b. Is the pain a stabbing pain? c. Is it a sharp pain or dull pain? d. What does your pain feel like?

ANS: D To assess the quality of a persons pain, the patient is asked to describe the pain in his or her own words. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care

29. During a womans 34th week of pregnancy, she is told that she has preeclampsia. The nurse knows which statement concerning preeclampsia is true? a. Preeclampsia has little effect on the fetus. b. Edema is one of the main indications of preeclampsia. c. Eclampsia only occurs before delivery of the baby. d. Untreated preeclampsia may contribute to restriction of fetal growth.

ANS: D Untreated preeclampsia may progress to eclampsia, which is manifested by generalized tonic-clonic seizures. Eclampsia may develop as late as 10 days postpartum. Before the syndrome becomes clinically manifested, it is affecting the placenta through vasospasm and a series of small infarctions. The placentas capacity to deliver oxygen and nutrients may be seriously diminished, and fetal growth may be restricted. Edema is common in pregnancy and is not an indicator of preeclampsia. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation MULTIPLE RESPONSE