Health Assessment Exam #2
The client is recovering from orthopedic surgery on a fractured arm. The nurse realizes that skeletal muscles provide which of the following functions? 1. Provide a body framework 2. Provide movement 3. Maintain posture 4. Generate heat 5. Calcium storage
2, 3, 4
The nurse realizes which structure of the GI system is the primary site of absorption? a) Stomach b) Duodenum c) Large intestine d) Sigmoid e) Small intestine
e) Small intestine
Hyperactive bowel sounds are: a. High pitched b. Rushing c. Tinkling d. All of the above
d. All of the above
The nurse is assessing a client with suspected rheumatoid arthritis. Which of the following musculoskeletal changes would contribute to a positive diagnosis? (Select all that apply.) 1. Ulnar deviation 2. Bouchard's nodes 3. Heberden's nodes 4. Swan-neck deformity 5. Symmetrical loss of function in extremities
1, 4, 5
The nurse is caring for a client having problems with emotional appropriateness as a result of a brain injury. What area area has most likely been damaged. 1. Frontal lobe 2. Occipital lobe 3. Posterior lobe 4. Cerebellum 5. Parietal lobe
1.
Rating Muscle Strength
0. Zero. - No muscle contraction 1. Trace - Palpable muscle contractions but no movement 2. Poor - Full ROM w/out gravity (Passive ROM) 3. Fair - Full ROM w/gravity 4. Good - Full ROM against gravity w/ moderate resistance 5. Normal - Full ROM against gravity w/full resistance
An older adult client says, "I can't seem to hear as well as I could when I was younger." Which diagnosis does the nurse anticipate for this client? 1. Presbycusis. 2. Mastoiditis. 3. Otitis media. 4. Otitis externa.
1
The client is experiencing the effects of a recent cerebrovascular accident (CVA). The client is unable to smell. Which cranial nerve was most likely affected by the CVA? 1. Cranial nerve I. 2. Cranial nerve XII. 3. Cranial nerve VIII. 4. Cranial nerve VII.
1
The nurse is admitting a client with suspected meningitis. During the assessment, the nurse asks the client to flex the chin down toward the chest. The client verbalizes pain and stiffness during this action. The nurse would document this as which of the following? 1. Muscle spasms 2. Neck strain 3. Nuchal rigidity 4. Brudzinski's sign
3
Which structure attaches the tongue to the floor of the mouth? 1. Hard palate. 2. Papillae. 3. Frenulum. 4. Alveoli sockets.
3
A nurse notes in a client pallor and cyanosis of the oral cavity and lips. Based on the findings the nurse would identify the client's need for A.Oxygen B. Blood transfusion C.Skin care to prevent chafing D. Fluid resuscitation
A. Oxygen Whereas pallor may indicate anemia that requires blood transfusions, the cyanosis is a key assessment finding that will indicate hypoxia and the need for oxygen. Skin chafing and fluid resuscitation are not related to this physical finding.
In which of the following ethnic groups has the lowest incidence of osteoporosis? A) African Americans B) Whites C) Asians D) American Indians
African Americans
A client complains of a severe headache. During the exam, the client expresses severe pain across the bridge of the nose, on the forehead, and beneath both eyes when these ares are palpated. These findings are indicative of A.Migraine headaches B.Sinusitis of allergies C.Unrelated to the client's complaint D. Nasal obstruction
B. Sinusitis of allergies Pain is common over the nose, forehead, and beneath the eyes when an infection or inflammation is present in the sinuses. ALthough the pressure and congestion of the sinuses may contribute to the client's headache, the assessment findings do not correspond with symptoms of migraine headaches. These tend to be more diffuse across the head and not localized in the sinus area. Nasal obstruction would present with swollen or red nasal mucosa accompanied by the inability to move air through the nasal passage.
The nurse is palpating a pregnant client's thyroid and finds that she has slight enlargement of the gland. The nurse appropriately documents A.this condition as Grave's disease B. the size, shape, and location of the finding C. this finding as normal D. pathological hyperthyroidism
B. the size, shape, and location of the finding Although a slightly enlarged thyroid can be a normal finding in pregnancy, and palpable mass should be documented according to size, shape, and location. It may be a normal finding in pregnancy, but any diagnosis will be made by the physician. Grave's disease causes most pathological hyperthyroidism in pregnancy, but diagnosing a condition is beyond the scope of nursing practice.
The nurse is presenting a class to young adults about the risks of smoking and chewing tobacco. One of the participants asks what physical signs would be present if one developed cancer of the mouth related to chewing tobacco. The nurse would respond by stating the physical findings include A.Pallor of the oral mucosa B.Excessive salivation C.Ulcer on lower lip or tongue D.Tender lymph nodes of the neck
C. Ulcer on lower lip or tongue One of the earliest signs of cancer of the mouth is an ulcer or lesion in the oral mucosa. Pallor is present with anemia or hypoxia, excessive salivation does not occur, and tender lymph nodes occur during an inflammatory or infectious process, which is not typically present as a sign of oral cancer.
When examining a patient's eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system: A. causes pupillary constriction B. adjusts the eye for near vision C. elevates the eyelid and dilates the pupil D. causes constriction of the ciliary body
C. elevates the eyelid and dilates the pupil
The nurse is assessing the eyes of a client and notes a drooping of the left eyelid. The nurse would correctly chart which of the following conditions? A.nystagmus B. strabismus C. ptosis D. diplopia
C. ptosis Ptosis, or a drooped lid, is usually related to weakness of the muscles. Nystagmus is the constant involuntary movement of the eyeball. Strabismus causes deviation of one or both eyes and is caused by lack of muscular coordination. Diplopia is double vision.
During a checkup, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray because of her allergies. She also states that it does not work as well as it used to when she first started using it. The best response by the nurse would be: a."You should never use over-the-counter nasal sprays because of the risk of addiction." b."You should try switching to another brand of medication to prevent this problem." c."Continuing to use this spray is important to keep your allergies under control." d."Using these nasal medications irritates the lining of the nose and may cause rebound swelling."
D The misuse of over-the-counter nasal medications irritates the mucosa, causing rebound swelling, which is a common problem.
The knee joint is the articulation of three bones, the: A) femur, fibula, and patella. B) femur, radius, and olecranon process. C) fibula, tibia, and patella. D) femur, tibia, and patella.
femur, tibia, and patella.
A nurse notices that a patient has ascites, which indicates the presence of: a) fluid. b) feces. c) flatus. d) fibroid tumors.
a) fluid.
Methods to enhance abdominal wall relaxation during examination include: a) a cool environment. b) having the patient place arms above the head. c) examining painful areas first. d) positioning the patient with the knees bent.
d) positioning the patient with the knees bent.
Just before going home, a new mother asks the nurse about the infant's umbilical cord. Which of these statements is correct? a) "It should fall off by 10 to 14 days." b) "It will soften before it falls off." c) "It contains two veins and one artery." d) "Skin will cover the area within 1 week."
a) "It should fall off by 10 to 14 days."
The nurse is reviewing statistics for lactose intolerance. In the United States, the incidence of lactose intolerance is higher in adults of which ethnic group? a) African-Americans b) Hispanics c) Whites d) Asians
a) African-Americans
During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be manifested by: a) projectile vomiting. b) hypoactive bowel activity. c) palpable olive-sized mass in right lower quadrant. d) pronounced peristaltic waves crossing from right to left.
a) projectile vomiting.
Shifting dullness is a test for: a. Ascites b. Splenic enlargement c. Inflammation of the kidney d. hepatomegaly
a. Ascites
When examining a patient's CN function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the: a. Sternomastoid and trapezius. b. Spinal accessory and omohyoid. c. Trapezius and sternomandibular. d. Sternomandibular and spinal accessory.
a. Sternomastoid and trapezius. The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory.
The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patient's T 4 and T 3 hormone levels are elevated. Which of these findings would the nurse most likely find on examination? a. Tachycardia b. Constipation c. Rapid dyspnea d. Atrophied nodular thyroid gland
a. Tachycardia T 4 and T 3 are thyroid hormones that stimulate the rate of cellular metabolism, resulting in tachycardia. With an enlarged thyroid gland as in hyperthyroidism, the nurse might expect to find diffuse enlargement (goiter) or a nodular lump but not an atrophied gland. Dyspnea and constipation are not findings associated with hyperthyroidism. Dyspnea: difficult/labored breathing
A patient's laboratory data reveal an elevated thyroxine (T 4 ) level. The nurse would proceed with an examination of the _____ gland. a. Thyroid b. Parotid c. Adrenal d. Parathyroid
a. Thyroid The thyroid gland is a highly vascular endocrine gland that secretes T 4 and triiodothyronine (T 3 ). The other glands do not secrete T 4. Elevated Thyroxine=hyperthyroidism
Auscultation of the abdomen may reveal bruits of the ___ arteries. a. aortic, renal, iliac, and femoral b. jugular, aortic, carotid, and femoral c. pulmonic, aortic, and portal d. renal, iliac, internal jugular, and basilic
a. aortic, renal, iliac, and femoral
A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation? a) The spleen can be enlarged as a result of trauma. b) The spleen is normally felt upon routine palpation. c) If an enlarged spleen is noticed, then the nurse should palpate thoroughly to determine size. d) An enlarged spleen should not be palpated because it can rupture easily.
d) An enlarged spleen should not be palpated because it can rupture easily.
Which structure is located in the left lower quadrant of the abdomen? a) Liver b) Duodenum c) Gallbladder d) Sigmoid colon
d) Sigmoid colon
The nurse notices that a patient's submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the patient's: a. Infraclavicular area. b. Supraclavicular area. c. Area distal to the enlarged node. d. Area proximal to the enlarged node.
d. Area proximal to the enlarged node. When nodes are abnormal, the nurse should check the area into which they drain for the source of the problem. The area proximal (upstream) to the location of the abnormal node should be explored. Submental: under chin
The nurse is performing range of motion of the cervical spine and asks the client to touch the chest with the chin. The nurse is assessing which of the following movements? a. Rotation b. Hyperextension c. Lateral flexion d. Flexion
d. Flexion Rationale: Flexion causes a decrease in the angle from the chin to the chest, whereas hyperextension would cause an increase in this angle, such as looking up toward the ceiling. Attempting to touch each shoulder with the ear on that side would be lateral flexion, and turning the head to face each shoulder would be rotation.
The production of red blood cells in the bone marrow is called: A) hematopoiesis. B) hemolysis. C) hemoptysis. D) hemianopsia.
hematopoiesis.
Heberden and Bouchard nodes are hard and nontender and are associated with: A) osteoarthritis. B) rheumatoid arthritis. C) Dupuytren contracture. D) metacarpophalangeal bursitis.
osteoarthritis.
The musculoskeletal system functions include: A) protection and storage. B) movement and elimination. C) storage and control. D) propulsion and preservation.
protection and storage.
When assessing for the presence of a herniated nucleus pulposus, the examiner would: A) raise each of the patient's legs straight while keeping the knee extended. B) ask the patient to bend over and touch the floor while keeping the legs straight. C) instruct the patient to do a knee bend. D) abduct and adduct the patient's legs while keeping the knee extended.
raise each of the patient's legs straight while keeping the knee extended.
The nurse is caring for a client with a right femur fracture. The nurse would correctly identify the femur as which of the following bone types? 1. Short 2. Long 3. Flat 4. Irregular
2
The nurse is examining a toddler client. The toddler has a fever and the nurse notes the ear canal is red and swollen, and the presence of purulent drainage. Based on this assessment data, which diagnosis does the nurse anticipate? 1. Otitis media. 2. Otitis externa. 3. Hemotympanum. 4. Tophi.
2
The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of: a.Acquired immunodeficiency syndrome (AIDS). b.Measles. c.Leukemia. d.Carcinoma.
A Oral Kaposi's sarcoma is a bruiselike, dark red or violet, confluent macule that usually occurs on the hard palate. It may appear on the soft palate or gingival margin. Oral lesions may be among the earliest lesions to develop with AIDS.
A 70-year-old man is visiting the clinic for difficulty in passing urine. In the health history, he indicates that he has to urinate frequently, especially at night. He has burning when he urinates and has noticed pain in his back. Considering this history, what might the nurse expect to find during the physical assessment? a.Asymmetric, hard, and fixed prostate gland b.Occult blood and perianal pain to palpation c.Symmetrically enlarged, soft prostate gland d.Soft nodule protruding from the rectal mucosa
A Subjective symptoms of carcinoma of the prostate include frequency, nocturia, hematuria, weak stream, hesitancy, pain or burning on urination, and continuous pain in lower back, pelvis, and thighs. Objective symptoms of carcinoma of the prostate include a malignant neoplasm that often starts as a single hard nodule on the posterior surface, producing asymmetry and a change in consistency. As it invades normal tissue, multiple hard nodules appear, or the entire gland feels stone hard and fixed.
The nurse is performing a digital examination of a patient's prostate gland and notices that a normal prostate gland includes which of the following characteristics? Select all that apply. a.1 cm protrusion into the rectum b.Heart-shaped with a palpable central groove c.Flat shape with no palpable groove d.Boggy with a soft consistency e.Smooth surface, elastic, and rubbery consistency f.Fixed mobility
A, B, E The size of a normal prostate gland should be 2.5 cm long by 4 cm wide and should not protrude more than 1 cm into the rectum. The prostate should be heart-shaped, with a palpable central groove, a smooth surface, and elastic with a rubbery consistency. Abnormal findings include a flat shape with no palpable groove, boggy with a soft consistency, and fixed mobility.
During a digital examination of the rectum, the nurse notices that the patient has hard feces in the rectum. The patient complains of feeling "full," has a distended abdomen, and states that she has not had a bowel movement "for several days." The nurse suspects which condition? a.Rectal polyp b.Fecal impaction c.Rectal abscess d.Rectal prolapse
B A fecal impaction is a collection of hard, desiccated feces in the rectum. The obstruction often results from decreased bowel motility, in which more water is reabsorbed from the stool.
During an assessment, a patient mentions that "I just can't smell like I used to. I can barely smell the roses in my garden. Why is that?" For which possible causes of changes in the sense of smell will the nurse assess? Select all that apply. a.Chronic alcohol use b.Cigarette smoking c.Frequent episodes of strep throat d.Chronic allergies e.Aging f.Herpes simplex virus I
B, D, E The sense of smell diminishes with cigarette smoking, chronic allergies, and aging. Chronic alcohol use, a history of strep throat, and herpes simplex virus I are not associated with changes in the sense of smell.
A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings? a.Epistaxis b.Rhinorrhea c.Dysphagia d.Xerostomia
C Dysphagia is difficulty with swallowing and may occur with a variety of disorders, including stroke and other neurologic diseases. Rhinorrhea is a runny nose, epistaxis is a bloody nose, and xerostomia is a dry mouth.
Normal assessment findings of an infant's fontanel include A. A molded form B. Normal, round shape C. Even with the skull D. Palpable suture lines
C. Even with the skull The anterior fontanel is diamond shaped and the posterior is triangular in shape, and they should be firm and even with the scalp -- slight pulsations are normal. Molding occurs as the baby's head moves through the vaginal canal during delivery and will be influenced by the presenting part of the head and type of delivery. The baby's head has a more normal, round shape after several days. Suture lines are open, as are the fontanels.
The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure? A.Thickness or bulging of the lens B.Posterior chamber as it accommodates an increase in fluid C.Contraction of the ciliary body in response to the aqueous within the eye D.Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber
D. Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber
During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least: a) 1 minute. b) 5 minutes. c) 10 minutes. d) 2 minutes in each quadrant.
b) 5 minutes.
A patient complains that while studying for an examination he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. The nurse suspects that he may be suffering from: a. Hypertension. b. Cluster headaches. c. Tension headaches. d. Migraine headaches.
d. Migraine headaches. Migraine headaches tend to be supraorbital, retroorbital, or frontotemporal with a throbbing quality. They are severe in quality and are relieved by lying down. Migraines are associated with a family history of migraine headaches.
A dull percussion note forward of the left midaxillary line is: a. normal, an expected finding during splenic percussion b. expected between the 8th and 12th ribs c. found if the examination follows a large meal d. indicative of splenic enlargement
d. indicative of splenic enlargement
Striae, which occur when the elastic fibers in the reticular layer of the skin are broken following rapid or prolonged stretching, have a distinct color when of long duration. This color is: a. pink b. blue c. purple-blue d. silvery white
d. silvery white
The nurse is preparing to assess the abdomen of a hospitilized client 2 days after abdominal surgery. The nurse should first a) Palpate the incision site b) Auscultate for bowel sounds c) Percuss for tympany d) Inspect the abdominal area
d) Inspect the abdominal area
If assessing a client for kidney tenderness, where would you begin? a) Right upper quadrant b) Left upper quadrant c) External oblique angle d) Costovertebral angle
d) Costovertebral angle
The nurse is aware that a change may occur in the GI system of an aging adult is? a) Increased saliva b) Decreased peristalsis c) Increased esophageal emptying d) Decreased gastric acid secretion
d) Decreased gastric acid secretion
A client comes to the emergency department complaining of a painful injury to the right knee received while playing basketball. The nurse would include which of the following in the examination of this client? (Select all that apply.) 1. Inspection 2. Palpation 3. Bulge sign testing 4. Ballottement 5. Percussion
1, 2, 3, 4
The emergency department triage nurse is assessing a child who has a history of a cough and nasal congestion for the last three days. When assessing patency of the nares, the nurse notes that the child is unable to breathe through the right nostril. Which interpretation of the assessment data by the nurse is the most appropriate? 1. Produced by severe nasal inflammation or obstruction. 2. Normal for a child. 3. A result of chronic allergies. 4. A result of sinusitis.
1
The nurse in the photograph is performing an assessment on which of the following cranial nerves? (smelling) 1. Olfactory nerve (cranial nerve I) 2. Optic nerve (cranial nerve II) 3. Oculomotor nerve (cranial nerve III) 4. Trochlear nerve (cranial nerve IV)
1
The nurse is interviewing a client and notes that the left eyelid is drooping. The nurse would correctly chart which of the following conditions? 1. Ptosis 2. Nystagmus 3. Strabismus 4. Myopia
1
The nurse is preparing a neurological health seminar for the staff on the unit. Which of the following statements would the nurse include in the teaching plan? Select all that apply. 1. Older adults experience more accidents and injuries. 2. Alcohol or drug use increases the risk for accidents and injury. 3. Head injuries are more common in adults than children. 4. Epilepsy occurs only in children under age 15.
1, 2
During the focused interview, the client confides in the nurse issues with anxiety. During the physical assessment, which findings support the presence of anxiety? Standard Text: Select all that apply. 1. The client complains of pain when the tragus is gently manipulated. 2. The client has several small ulcers on her lip. 3. Pale nasal mucosa 4. Small sores are noted within the mouth. 5. Perforated nasal septum
1, 2, 4
The nurse is assessing a client that experienced a head injury and assigns a Glascow Coma Scale rating of 3. The nurse would correctly note which of the following for this client? (Select all that apply.) 1. No response with eyes with commands 2. No verbal response 3. Pupil response sluggish 4. No motor movement 5. Pupils fixed and dilated
1, 2, 4
The client admits to cleaning his ears with a cotton-tipped applicator. As a consequence, the client has developed impacted cerumen and unilateral hearing loss. As the nurse prepares the client's plan of care, which nursing diagnosis is most applicable? 1. Acute pain. 2. Knowledge deficit. 3. Acute confusion. 4. Unilateral neglect.
2
The nurse educator is teaching a group of students about cultural differences to consider when conducting an ear, nose, and throat assessment. Which statement by a nursing student indicates appropriate understanding of the information presented? 1. "Asians are more likely to experience greater difficulty with otitis media than people from other cultures." 2. "Sometimes in Asians and Native Americans, their ear wax looks dry and dark." 3. "Asians have a higher risk of having issues associated with cleft lips and cleft palates." 4. "Asians have a high incidence of tooth decay."
2
The nurse is assessing several children in a pediatric clinic. Which child is experiencing a development delay? 1. The 6-year-old child has lost two deciduous teeth. 2. The 26-month-old child has one baby tooth. 3. The 4-month-old infant is drooling. 4. The 2-month-old infant's salivary glands are not producing saliva.
2
The nurse is assessing the oral mucosa of a pregnant female and notes enlargement of the gums. The client states that regular oral hygiene is performed and that she does not understand why this has occurred. Which response by the nurse is the most appropriate? 1. "You may have oral cancer." 2. "You are experiencing a normal change during pregnancy." 3. "You may have leukoplakia." 4. "You need to decrease the frequency of your oral hygiene."
2
The nurse is discharging an infant who was brought to the emergency department for the treatment of an ear infection and fever. Which statements will the nurse include in the discharge teaching? Standard Text: Select all that apply. 1. "The baby's last bottle before bedtime should only contain water." 2. "It is important not to prop the baby's bottle during feeding." 3. "You must rinse the baby's mouth right after the baby falls asleep." 4. "You must perform oral hygiene more frequently throughout the day." 5. "The last bottle of the evening should not be given just before the baby goes to sleep."
2, 5
A 38-week pregnant client is complaining of lower back pain. The nurse notes a slight lordosis and waddling gait in the client. The nurse would correctly choose which of the following actions in this situation? 1. Suggest the client begin bed rest. 2. Notify the healthcare provider of the findings. 3. Document the findings as normal. 4. Ask the client if she has been lifting.
3
A young adult is seen in the clinic complaining of a lump the left wrist, but states it is not painful. The nurse notes a round mass on the back of the wrist. The nurse would suspect which of the following? 1. Rheumatoid arthritis 2. Osteoarthritis 3. Ganglion 4. Carpal tunnel syndrom
3
The nurse is admitting a client with suspected meningitis and notes a positive Brudzinski's sign has been noted in the history and physical. To validate this assessment finding, the nurse would note which of the following? 1. Seizure activity 2. Neck pain and stiffness 3. Flexion of the legs and thighs 4. Neck extension
3
The nurse is assessing a client to determine tremors associated with Parkinson's disease. The nurse would correctly observe for which of the following movements? 1. Fasciculations 2. Chorea 3. Rhythmic shaking 4. Athetoid movements
3
The nurse is assessing the oral cavity of a client and notes a blackish, furry-looking coating on the tongue. Which question to the client is most appropriate based on this initial data? 1. "Have you eaten licorice lately?" 2. "How often do you brush your tongue?" 3. "Have you recently taken antibiotics?" 4. "Have you ever had this happen before?"
3
The nurse is caring for an elderly client. The nurse would expect which of the following in the musculoskeletal system of an older adult? 1. Difficulty with dexterity 2. Increased bone production 3. Risk for fractures 4. Pain when ambulating
3
The nurse is conducting a hearing assessment on an older adult client with impacted cerumen noted in the right ear canal. When performing the Weber test, which would the nurse expect to learn? 1. Air conduction is longer than bone conduction. 2. Bone conduction is longer than air conduction. 3. Sound lateralized to the right ear. 4. The client is unable to maintain balance while standing.
3
The nurse is triaging a client and notes pallor and cyanosis of the oral cavity and lips. Which action by the nurse is the priority based on the assessment data? 1. Administer IV fluids. 2. Provide oral hygiene. 3. Administer oxygen. 4. Provide a warm drink.
3
The nurse is performing a focused interview with a client who has been cleaning the ears with a cotton-tipped applicator. Which complications of this practice will the nurse include in the teaching session for this client? Standard Text: Select all that apply. 1. Increasing risk of developing otitis externa. 2. Developing tophi along the outer rim of the ears. 3. Perforating the tympanic membrane. 4. Needing tympanostomy tubes. 5. Impacting cerumen.
3, 5
The client's chief complaint is pain in the foot. The nurse notes a deviation of the great toe from the midline and crowding of the remaining toes. There is enlargement and inflammation noted in the area. The nurse would suspect which of the following conditions in this situation? 1. Flat foot 2. Gouty arthritis 3. Hammertoe 4. Bunion
4
The nurse asks the client to pull the toes up towards the nose during an examination of the lower extremities. The nurse is assessing which of the following movements? 1. Inversion 2. Plantar flexion 3. Eversion 4. Dorsiflexion
4
The nurse is assessing the patellar reflex on a client and obtains no reflexive activity. The client is alert and oriented. The nurse should do which of the following in this situation? 1. Document the findings as normal. 2. Notify the healthcare provider immediately. 3. Look at the medication records for central nervous system depressants. 4. Retest the reflex after having the client use distraction during the exam.
4
The nurse is explaining discussing the Rinne test to a group of student nurses. Which statement by the nurse is most appropriate? 1. "This test requires the use of an otoscope." 2. "The test is performed by whispering statements a few feet away from the client." 3. "The test is used to determine if a client hears sound in one ear better than the other." 4. "This test compares air and bone conduction of sound using a tuning fork."
4
The nurse is caring for a client with a traumatic brain injury. The client has begun to experience bradycardia. What area of the brain is likely responsible for the changes in heart rate? 1. Frontal lobe 2. Occipital lobe 3. Temporal lobe 4. Cerebellum 5. Brain Stem
5
During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of: a.Dehydration. b.Irritation by gastric juices. c.A normal oral assessment. d.Side effects from nausea medication
A Dry mouth occurs with dehydration or fever. The tongue has deep vertical fissures.
During a health history of a patient who complains of chronic constipation, the patient asks the nurse about high-fiber foods. The nurse relates that an example of a high-fiber food would be: a.Broccoli. b.Hamburger. c.Iceberg lettuce. d.Yogurt.
A High-fiber foods are either soluble type (e.g., beans, prunes, barley, broccoli) or insoluble type (e.g., cereals, wheat germ). The other examples are not considered high-fiber foods.
The mother of a 5-year-old girl tells the nurse that she has noticed her daughter "scratching at her bottom a lot the last few days." During the assessment, the nurse finds redness and raised skin in the anal area. This finding most likely indicates: a.Pinworms. b.Chickenpox. c.Constipation. d.Bacterial infection.
A In children, pinworms are a common cause of intense itching and irritated anal skin. The other options are not correct.
The nurse is performing an oral assessment on a 40-year-old Black patient and notices the presence of a 1 cm, nontender, grayish-white lesion on the left buccal mucosa. Which one of these statements is true? This lesion is: a.Leukoedema and is common in dark-pigmented persons. b.The result of hyperpigmentation and is normal. c.Torus palatinus and would normally be found only in smokers. d.Indicative of cancer and should be immediately tested.
A Leukoedema, a grayish-white benign lesion occurring on the buccal mucosa, is most often observed in Blacks.
A 62-year-old man is experiencing fever, chills, malaise, urinary frequency, and urgency. He also reports urethral discharge and a dull aching pain in the perineal and rectal area. These symptoms are most consistent with which condition? a.Prostatitis b.Polyps c.Carcinoma of the prostate d.BPH
A The common presenting symptoms of prostatitis are fever, chills, malaise, and urinary frequency and urgency. The individual may also have dysuria, urethral discharge, and a dull aching pain in the perineal and rectal area. These symptoms are not consistent with polyps.
When assessing the tongue of an adult, the nurse knows that an abnormal finding would be: a.Smooth glossy dorsal surface. b.Thin white coating over the tongue. c.Raised papillae on the dorsal surface. d.Visible venous patterns on the ventral surface.
A The dorsal surface of the tongue is normally roughened from papillae. A thin white coating may be present. The ventral surface may show veins. Smooth, glossy areas may indicate atrophic glossitis (see Table 16-5).
The nurse is caring for a newborn infant. Thirty hours after birth, the infant passes a dark green meconium stool. The nurse recognizes this is important because the: a.Stool indicates anal patency. b.Dark green color indicates occult blood in the stool. c.Meconium stool can be reflective of distress in the newborn. d.Newborn should have passed the first stool within 12 hours after birth.
A The first stool passed by the newborn is dark green meconium and occurs within 24 to 48 hours of birth, indicating anal patency. The other responses are not correct.
Which characteristic of the prostate gland would the nurse recognize as an abnormal finding while palpating the prostate gland through the rectum? a.Palpable central groove b.Tenderness to palpation c.Heart shaped d.Elastic and rubbery consistency
B The normal prostate gland should feel smooth, elastic, and rubbery; slightly movable; heart-shaped with a palpable central groove; and not be tender to palpation.
The salivary gland that is the largest and located in the cheek in front of the ear is the _________ gland. a.Parotid b.Stensen's c.Sublingual d.Submandibular
A The mouth contains three pairs of salivary glands. The largest, the parotid gland, lies within the cheeks in front of the ear extending from the zygomatic arch down to the angle of the jaw. The Stensen's duct (not gland) drains the parotid gland onto the buccal mucosa opposite the second molar. The sublingual gland is located within the floor of the mouth under the tongue. The submandibular gland lies beneath the mandible at the angle of the jaw.
The nurse is preparing to palpate the rectum and should use which of these techniques? The nurse should: a.Flex the finger, and slowly insert it toward the umbilicus. b.First instruct the patient that this procedure will be painful. c.Insert an extended index finger at a right angle to the anus. d.Place the finger directly into the anus to overcome the tight sphincter.
A The nurse should gently place the pad of the index finger against the anal verge. The nurse will feel the sphincter tighten and then relax. As it relaxes, the nurse should flex the tip of the finger and slowly insert it into the anal canal in a direction toward the umbilicus. The nurse should never approach the anus at right angles with the index finger extended; doing so would cause pain. The nurse should instruct the patient that palpation is not painful but may feel like needing to move the bowels.
The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient? a."Are you aware of having any allergies?" b."Do you have an elevated temperature?" c."Have you had any symptoms of a cold?" d."Have you been having frequent nosebleeds?"
A With chronic allergies, the mucosa looks swollen, boggy, pale, and gray. Elevated body temperature, colds, and nosebleeds do not cause these mucosal changes.
1. The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? A) Dullness B) Tympany C) Resonance D) Hyperresonance
ANS: A The liver is located in the right upper quadrant and would elicit a dull percussion note
30. Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites? A) Dullness across the abdomen B) Flatness in the right upper quadrant C) Hyperresonance in the left upper quadrant D) Tympany in the right and left lower quadrants
ANS: A The presence of fluid causes a dull sound to percussion. A large amount of ascitic fluid would produce a dull sound to percussion
15. The nurse is assessing the abdomen of a pregnant woman who is complaining of having "acid indigestion" all the time. The nurse knows that esophageal reflux during pregnancy can cause: A) diarrhea. B) pyrosis. C) dysphagia. D) constipation.
ANS: B Pyrosis, or heartburn (not constipation), is caused by esophageal reflux during pregnancy. The other options are not correct
31. A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate? A) "No need to worry. Most men your age develop hernias." B) "A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles." C) "This hernia is a result of prenatal growth abnormalities that are just now causing problems." D) "I'll have to have your physician explain this to you."
ANS: B The nurse should explain that a hernia is a protrusion of the abdominal viscera through an abnormal opening in the muscle wall
14. During an abdominal assessment, the nurse would consider which of these findings as normal? A) The presence of a bruit in the femoral area B) A tympanic percussion note in the umbilical region C) A palpable spleen between the ninth and eleventh ribs in the left midaxillary line D) A dull percussion note in the left upper quadrant at the midclavicular line
ANS: B Tympany should predominate in all four quadrants of the abdomen because air in the intestines rises to the surface when the person is supine. Vascular bruits are not usually present. Normally the spleen is not palpable. Dullness would not be found in the area of lung resonance (left upper quadrant at the midclavicular line)
41. The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply. A. Test for Murphy's sign. B. Test for Blumberg's sign. C. Test for shifting dullness. D. Perform iliopsoas muscle test. E. Test for fluid wave.
ANS: B, D Testing for Blumberg's sign (rebound tenderness) and performing the iliopsoas muscle test should be used to assess for appendicitis. Murphy's sign is used to assess for an inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is done to assess for ascites
26. The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm? A) A bruit is absent. B) Femoral pulses are increased. C) A pulsating mass is usually present. D) Most are located below the umbilicus.
ANS: C Most aortic aneurysms are palpable during routine examination and feel like a pulsating mass. A bruit will be audible, and femoral pulses are present but decreased. Such aneurysms are located in the upper abdomen just to the left of midline
9. While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are: A) pulsations of the renal arteries. B) pulsations of the inferior vena cava. C) normal abdominal aortic pulsations. D) increased peristalsis from a bowel obstruction.
ANS: C Normally, one may see the pulsations from the aorta beneath the skin in the epigastric area, particularly in thin persons with good muscle wall relaxation.
40. During a health history, the patient tells the nurse, "I have pain all the time in my stomach. It's worse two hours after I eat, but it gets better if I eat again!" The nurse suspects that the patient has which condition, based on these symptoms? A) Appendicitis B) Gastric ulcer C) Duodenal ulcer D) Cholecystitis
ANS: C Pain associated with duodenal ulcers occurs 2 to 3 hours after a meal, yet it is relieved by more food. Chronic pain associated with gastric ulcers occurs usually on an empty stomach. Severe, acute pain would occur with appendicitis and cholecystitis
18. A patient is complaining of a sharp pain along the costovertebral angles. The nurse knows that this symptom is most often indicative of: A) ovary infection. B) liver enlargement. C) kidney inflammation. D) spleen enlargement.
ANS: C Sharp pain along the costovertebral angles occurs with inflammation of the kidney or paranephric area. The other options are not correct
22. During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures? A) Spleen B) Sigmoid C) Appendix D) Gallbladder
ANS: C The appendix is located in the right lower quadrant, and when the iliopsoas muscle is inflamed (which occurs with an inflamed or perforated appendix), pain is felt in the right lower quadrant
37. During an assessment the nurse notices that a patient's umbilicus is enlarged and everted. It is midline, and there is no change in skin color. The nurse recognizes that the patient may have which condition? A) Intra-abdominal bleeding B) Constipation C) Umbilical hernia D) An abdominal tumor
ANS: C The umbilicus is normally midline and inverted, with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. The other responses are incorrect.
A patient's abdomen is bulging and stretched in appearance. The nurse should describe this finding as: A) obese. B) herniated. C) scaphoid. D) protuberant.
ANS: D A protuberant abdomen is rounded, bulging, and stretched. See Figure 21-7. A scaphoid abdomencaves inward
32. A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of about 10 cm. The nurse should: A) document the presence of hepatomegaly. B) ask additional history questions regarding his alcohol intake. C) describe this as an enlarged liver and refer him to a physician. D) consider this a normal finding and proceed with the examination.
ANS: D The average liver span in the midclavicular line is 6 to 12 cm. Men and taller individuals are at the upper end of this range. Women and shorter individuals are at the lower end of this range. A liver span of 10 cm is within normal limits for this individual
Which statement concerning the sphincters is correct? a.The internal sphincter is under voluntary control. b.The external sphincter is under voluntary control. c.Both sphincters remain slightly relaxed at all times. d.The internal sphincter surrounds the external sphincter.
B The external sphincter surrounds the internal sphincter but also has a small section overriding the tip of the internal sphincter at the opening. The external sphincter is under voluntary control. Except for the passing of feces and gas, the sphincters keep the anal canal tightly closed.
A 40-year-old black man is in the office for his annual physical examination. Which statement regarding the PSA blood test is true, according to the American Cancer Society? The PSA: a.Should be performed with this visit. b.Should be performed at age 45 years. c.Should be performed at age 50 years. d.Is only necessary if a family history of prostate cancer exists.
B According to the American Cancer Society (2006), the PSA blood test should be performed annually for black men beginning at age 45 years and annually for all other men over age 50 years.
During a discussion for a men's health group, the nurse relates that the group with the highest incidence of prostate cancer is: a.Asian Americans. b.Blacks. c.American Indians. d.Hispanics.
B According to the American Cancer Society (2010), black men have a higher rate of prostate cancer than other racial groups.
During an oral examination of a 4-year-old Native-American child, the nurse notices that her uvula is partially split. Which of these statements is accurate? a.This condition is a cleft palate and is common in Native Americans. b.A bifid uvula may occur in some Native-American groups. c.This condition is due to an injury and should be reported to the authorities. d.A bifid uvula is palatinus, which frequently occurs in Native Americans.
B Bifid uvula, a condition in which the uvula is split either completely or partially, occurs in some Native-American groups.
A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds areas of buccal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is: a.Aphthous ulcers. b.Candidiasis. c.Leukoplakia. d.Koplik spots.
B Candidiasis is a white, cheesy, curdlike patch on the buccal mucosa and tongue. It scrapes off, leaving a raw, red surface that easily bleeds. It also occurs after the use of antibiotics or corticosteroids and in persons who are immunosuppressed. (See Table 16-4 for descriptions of the other lesions.)
After completing an assessment of a 60-year-old man with a family history of colon cancer, the nurse discusses with him early detection measures for colon cancer. The nurse should mention the need for a(n): a.Annual proctoscopy. b.Colonoscopy every 10 years. c.Fecal test for blood every 6 months. d.DREs every 2 years.
B Early detection measures for colon cancer include a DRE performed annually after age 50 years, an annual fecal occult blood test after age 50 years, a sigmoidoscopic examination every 5 years or a colonoscopy every 10 years after age 50 years, and a PSA blood test annually for men over 50 years old, except beginning at age 45 years for black men
A 30-year-old woman is visiting the clinic because of "pain in my bottom when I have a bowel movement." The nurse should assess for which problem? a.Pinworms b.Hemorrhoids c.Colon cancer d.Fecal incontinence
B Having painful bowel movements, known as dyschezia, may be attributable to a local condition (hemorrhoid or fissure) or constipation. The other responses are not correct.
The structure that secretes a thin, milky alkaline fluid to enhance the viability of sperm is the: a.Cowper gland. b.Prostate gland. c.Median sulcus. d.Bulbourethral gland.
B In men, the prostate gland secretes a thin milky alkaline fluid that enhances sperm viability. The Cowper glands (also known as bulbourethral glands) secrete a clear, viscid mucus. The median sulcus is a groove that divides the lobes of the prostate gland and does not secrete fluid.
When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process? a.Teeth appearing shorter b.Tongue that looks smoother in appearance c.Buccal mucosa that is beefy red in appearance d.Small, painless lump on the dorsum of the tongue
B In the aging adult, the tongue looks smoother because of papillary atrophy. The teeth are slightly yellowed and appear longer because of the recession of gingival margins.
A woman who is in the second trimester of pregnancy mentions that she has had "more nosebleeds than ever" since she became pregnant. The nurse recognizes that this is a result of: a.A problem with the patient's coagulation system. b.Increased vascularity in the upper respiratory tract as a result of the pregnancy. c.Increased susceptibility to colds and nasal irritation. d.Inappropriate use of nasal sprays.
B Nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity in the upper respiratory tract.
The nurse is performing an examination of the anus and rectum. Which of these statements is correct and important to remember during this examination? a.The rectum is approximately 8 cm long. b.The anorectal junction cannot be palpated. c.Above the anal canal, the rectum turns anteriorly. d.No sensory nerves are in the anal canal or rectum.
B The anal columns are folds of mucosa that extend vertically down from the rectum and end in the anorectal junction. This junction is not palpable but is visible on proctoscopy. The rectum is 12 cm long; just above the anal canal, the rectum dilates and turns posteriorly.
The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct? a.Inserting the speculum at least 3 cm into the vestibule b.Avoiding touching the nasal septum with the speculum c.Gently displacing the nose to the side that is being examined d.Keeping the speculum tip medial to avoid touching the floor of the nares
B The correct technique for using an otoscope is to insert the apparatus into the nasal vestibule, avoiding pressure on the sensitive nasal septum. The tip of the nose should be lifted up before inserting the speculum.
The primary purpose of the ciliated mucous membrane in the nose is to: a.Warm the inhaled air. b.Filter out dust and bacteria. c.Filter coarse particles from inhaled air. d.Facilitate the movement of air through the nares.
B The nasal hairs filter the coarsest matter from inhaled air, whereas the mucous blanket filters out dust and bacteria. The rich blood supply of the nasal mucosa warms the inhaled air.
The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation? a.No sensation b.Firm pressure c.Pain during palpation d.Pain sensation behind eyes
B The person should feel firm pressure but no pain. Sinus areas are tender to palpation in persons with chronic allergies or an acute infection (sinusitis).
In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is correct response to these findings? a.Refer the patient to a throat specialist. b.No response is needed; this appearance is normal for the tonsils. c.Continue with the assessment, looking for any other abnormal findings. d.Obtain a throat culture on the patient for possible streptococcal (strep) infection.
B The tonsils are the same color as the surrounding mucous membrane, although they look more granular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood until puberty and then involutes.
While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response? a."While sitting up, place a cold compress over your nose." b."Sit up with your head tilted forward and pinch your nose." c."Just allow the bleeding to stop on its own, but don't blow your nose." d."Lie on your back with your head tilted back and pinch your nose."
B With a nosebleed, the person should sit up with the head tilted forward and pinch the nose between the thumb and forefinger for 5 to 15 minutes.
While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess? a.Nutritional status b.When the patient first noticed the lesion c.Whether the patient has had a recent cold d.Whether the patient has had any recent exposure to sick animals
B With carcinoma, the initial lesion is round and indurated, but then it becomes crusted and ulcerated with an elevated border. Most cancers occur between the outer and middle thirds of the lip. Any lesion that is still unhealed after 2 weeks should be referred
The nurse notices that a patient has had a pale, yellow, greasy stool, or steatorrhea, and recalls that this is caused by: a.Occult bleeding. b.Absent bile pigment. c.Increased fat content. d.Ingestion of bismuth preparations.
C Steatorrhea (pale, yellow, greasy stool) is caused by increased fat content in the stools, as in malabsorption syndrome. Occult bleeding and ingestion of bismuth products cause a black stool, and absent bile pigment causes a gray-tan stool.
The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? a."We will need to get a biopsy to determine the cause." b."This is an overgrowth of hair and will go away in a few days." c."Black, hairy tongue is a fungal infection caused by all the antibiotics you have received." d."This is probably caused by the same bacteria you had in your lungs."
C A black, hairy tongue is not really hair but the elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue. It occurs after the use of antibiotics, which inhibit normal bacteria and allow a proliferation of fungus.
A patient who is visiting the clinic complains of having "stomach pains for 2 weeks" and describes his stools as being "soft and black" for approximately the last 10 days. He denies taking any medications. The nurse is aware that these symptoms are mostly indicative of: a.Excessive fat caused by malabsorption. b.Increased iron intake, resulting from a change in diet. c.Occult blood, resulting from gastrointestinal bleeding. d.Absent bile pigment from liver problems.
C Black stools may be tarry as a result of occult blood (melena) from gastrointestinal bleeding or nontarry from ingestion of iron medications (not diet). Excessive fat causes the stool to become frothy. The absence of bile pigment causes clay-colored stools.
The nurse is assessing a 3 year old for "drainage from the nose." On assessment, a purulent drainage that has a very foul odor is noted from the left naris and no drainage is observed from the right naris. The child is afebrile with no other symptoms. What should the nurse do next? a.Refer to the physician for an antibiotic order. b.Have the mother bring the child back in 1 week. c.Perform an otoscopic examination of the left nares. d.Tell the mother that this drainage is normal for a child of this age.
C Children are prone to put an object up the nose, producing unilateral purulent drainage with a foul odor. Because some risk for aspiration exists, removal should be prompt.
During an assessment of a 26 year old at the clinic for "a spot on my lip I think is cancer," the nurse notices a group of clear vesicles with an erythematous base around them located at the lip-skin border. The patient mentions that she just returned from Hawaii. What would be the most appropriate response by the nurse? a.Tell the patient she needs to see a skin specialist. b.Discuss the benefits of having a biopsy performed on any unusual lesion. c.Tell the patient that these vesicles are indicative of herpes simplex I or cold sores and that they will heal in 4 to 10 days. d.Tell the patient that these vesicles are most likely the result of a riboflavin deficiency and discuss nutrition.
C Cold sores are groups of clear vesicles with a surrounding erythematous base. These evolve into pustules or crusts and heal in 4 to 10 days. The most likely site is the lip-skin junction. Infection often recurs in the same site. Recurrent herpes infections may be precipitated by sunlight, fever, colds, or allergy.
Immediately after birth, the nurse is unable to suction the nares of a newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next? a.Attempt to suction again with a bulb syringe. b.Wait a few minutes, and try again once the infant stops crying. c.Recognize that this situation requires immediate intervention. d.Contact the physician to schedule an appointment for the infant at his or her next hospital visit.
C Determining the patency of the nares in the immediate newborn period is essential because most newborns are obligate nose breathers. Nares blocked with amniotic fluid are gently suctioned with a bulb syringe. If obstruction is suspected, then a small lumen (5 to 10 Fr) catheter is passed down each naris to confirm patency. The inability to pass a catheter through the nasal cavity indicates choanal atresia, which requires immediate intervention.
When examining the nares of a 45-year-old patient who has complaints of rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notices the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these conditions is most likely the cause? a.Nasal polyps b.Acute sinusitis c.Allergic rhinitis d.Acute rhinitis
C Rhinorrhea, itching of the nose and eyes, and sneezing are present with allergic rhinitis. On physical examination, serous edema is noted, and the turbinates usually appear pale with a smooth, glistening surface. (See Table 16-1 for descriptions of the other conditions.)
A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has: a.Posterior epistaxis. b.Frontal sinusitis. c.Maxillary sinusitis. d.Nasal polyps.
C Signs of maxillary sinusitis include facial pain after upper respiratory infection, red swollen nasal mucosa, swollen turbinates, and purulent discharge. The person also has fever, chills, and malaise. With maxillary sinusitis, dull throbbing pain occurs in the cheeks and teeth on the same side, and pain with palpation is present. With frontal sinusitis, pain is above the supraorbital ridge.
During an oral assessment of a 30-year-old Black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding? a.Check the patient's hemoglobin for anemia. b.Assess for other signs of insufficient oxygen supply. c.Proceed with the assessment, knowing that this appearance is a normal finding. d.Ask if he has been exposed to an excessive amount of carbon monoxide.
C Some Blacks may have bluish lips and a dark line on the gingival margin; this appearance is a normal finding.
A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. The nurse's best response would be: a."How many teeth did you have at this age?" b."All 20 deciduous teeth are expected to erupt by age 4 years." c."This is a normal number of teeth for an 18 month old." d."Normally, by age 2 years, 16 deciduous teeth are expected."
C The guidelines for the number of teeth for children younger than 2 years old are as follows: the child's age in months minus the number 6 should be equal to the expected number of deciduous teeth. Normally, all 20 teeth are in by 2 years old. In this instance, the child is 18 months old, minus 6, equals 12 deciduous teeth expected.
The projections in the nasal cavity that increase the surface area are called the: a.Meatus. b.Septum. c.Turbinates. d.Kiesselbach plexus.
C The lateral walls of each nasal cavity contain three parallel bony projections: the superior, middle, and inferior turbinates. These increase the surface area, making more blood vessels and mucous membrane available to warm, humidify, and filter the inhaled air.
The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. During an inspection of his mouth, the nurse should look for: a.Swollen, red tonsils. b.Ulcerations on the hard palate. c.Bruising on the buccal mucosa or gums. d.Small yellow papules along the hard palate.
C The nurse should notice any bruising or laceration on the buccal mucosa or gums of an infant or young child. Trauma may indicate child abuse from a forced feeding of a bottle or spoon.
The nurse is examining only the rectal area of a woman and should place the woman in what position? a.Lithotomy b.Prone c.Left lateral decubitus d.Bending over the table while standing
C The nurse should place the female patient in the lithotomy position if the genitalia are being examined as well. The left lateral decubitus position is used for the rectal area alone.
While assessing a patient who is hospitalized and bedridden, the nurse notices that the patient has been incontinent of stool. The stool is loose and gray-tan in color. The nurse recognizes that this finding indicates which of the following? a.Occult blood b.Inflammation c.Absent bile pigment d.Ingestion of iron preparations
C The presence of gray-tan stool indicates absent bile pigment, which can occur with obstructive jaundice. The ingestion of iron preparations and the presence of occult blood turns the stools to a black color. Jellylike mucus shreds mixed in the stool would indicate inflammation.
The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient? a.Hypertrophy of the gums b.Increased production of saliva c.Decreased ability to identify odors d.Finer and less prominent nasal hair
C The sense of smell may be reduced because of a decrease in the number of olfactory nerve fibers. Nasal hairs grow coarser and stiffer with aging. The gums may recede with aging, not hypertrophy, and saliva production decreases.
A 46-year-old man requires an assessment of his sigmoid colon. Which instrument or technique is most appropriate for this examination? a.Proctoscope b.Ultrasound c.Colonoscope d.Rectal examination with an examining finger
C The sigmoid colon is 40 cm long, and the nurse knows that it is accessible to examination only with the colonoscope. The other responses are not appropriate for an examination of the entire sigmoid colon.
During an assessment of the newborn, the nurse expects to see which finding when the anal area is slightly stroked? a.Jerking of the legs b.Flexion of the knees c.Quick contraction of the sphincter d.Relaxation of the external sphincter
C To assess sphincter tone, the nurse should check the anal reflex by gently stroking the anal area and noticing a quick contraction of the sphincter. The other responses are not correct.
A patient has been diagnosed with strep throat. The nurse is aware that without treatment, which complication may occur? a.Rubella b.Leukoplakia c.Rheumatic fever d.Scarlet fever
C Untreated strep throat may lead to rheumatic fever. When performing a health history, the patient should be asked whether his or her sore throat has been documented as streptococcal.
A 10 year old is at the clinic for a sore throat that has lasted 6 days. Which of these findings would be consistent with an acute infection? a.Tonsils 1+/1-4+ and pink; the same color as the oral mucosa b.Tonsils 2+/1-4+ with small plugs of white debris c.Tonsils 3+/1-4+ with large white spots d.Tonsils 3+/1-4+ with pale coloring
C With an acute infection, tonsils are bright red and swollen and may have exudate or large white spots. Tonsils are enlarged to 2+, 3+, or 4+ with an acute infection.
The nurse is performing a neurological assessment on a client experiencing vertigo. The nurse wants to perform the Romberg test. The nurse would correctly provide which set of instructions to the client? A."Walk across the room by placing one foot in front of the other heel to toes." B. "Walk on your toes, then on your heels." C."Stand with your feet together, arms at sides, and eyes open." D."Touch your finger to your nose alternating hands."
C. "Stand with your feet together, arms at sides, and eyes open." "Stand with your feet together, arms at sides, and eyes open" describes the Romberg test, which is used to determine coordination and equilibrium. "Walk across the room by placing one foot in front of the other heel to toes" describes tandem walking, which is used to observe posture, and "Touch your fingers to your nose alternating hands" is called the finger-to-nose test and is used to assess coordination and equilibrium.
The nurse is auscultating the temporal artery and hears a soft blowing sound. Which term will the nurse use when documenting this finding? 1. Bruit. 2. Murmur. 3. Stenosis. 4. Occlusion.
Correct Answer: 1 A bruit can be heard through the bell of the stethoscope as a soft, blowing sound and is indicative of narrowing of the vessel. This is an abnormal sound.
During a focused assessment and interview regarding the client's head and neck, the client reveals the occurrence of severe headaches intermittently over a three-day period. The client denies any aura, but admits to severe and unilateral pain over the right side of the face along with nasal congestion. Which diagnosis does the nurse anticipate based on this assessment data? 1. Cluster headache. 2. Classic migraine. 3. Tension headache. 4. Hydrocephalus.
Correct Answer: 1 Rationale 1: Cluster headaches can occur over time. They have no associated aura, are often unilateral, and can be excruciating. Nasal congestion is commonly associated with this type of headache.
The nurse is assessing a client who reports the occurrence of sudden, intermittent headaches for the past several months. The client states that the headaches come after seeing flashes of lights and experiencing nausea. Based on this data, which diagnosis does the nurse anticipate for this client? 1. Migraine headaches. 2. Cluster headaches. 3. Tension headaches. 4. Increased intracranial pressure.
Correct Answer: 1 Rationale 1: Migraine headaches are often preceded by an aura during which the client may feel depressed, restless, or irritable; see spots or flashes of light; and feel nausea.
Which information is true regarding the assessment of the thyroid or thyroid function in an infant or child? 1. To accurately assess thyroid function, the nurse should assess the child's growth and development in comparison to others in the child's age group. 2. The thyroid gland is easily palpable in an infant. 3. Assess the child for abnormal hair growth because this may indicate thyroid dysfunction. 4. Assess the child for melasma because this will indicate thyroid dysfunction.
Correct Answer: 1 The best way to assess thyroid function in an infant or child is to assess his growth and development in comparison to other people in his age group
The nurse is performing an assessment of the client's head and neck. The client requests information about the assessment of her lymph nodes. Which response by the nurse is the most appropriate? 1. "Sometimes, enlarged lymph nodes indicate an infection." 2. "All of your lymph nodes should be easily palpable." 3. "The lymph system makes antibiotics to treat infection." 4. "When one lymph node is identified as being enlarged, this is always an abnormal finding."
Correct Answer: 1 The lymph nodes are part of the lymphatic system and provide the body with protection against infection. It is true that sometimes when the nurse is able to palpate enlarged lymph nodes this indicates that the client has developed an infection.
The nurse is examining a client's neck. Which techniques are appropriate when palpating the trachea? Standard Text: Select all that apply. 1. Palpate while the client is swallowing. 2. Slide the thumb and index finger upward on each side of the trachea. 3. Palpate the midline of the neck to feel the cricoid cartilage. 4. Ask the client to open and close her mouth. 5. Stand behind the client and ask her to turn her head slightly to the right.
Correct Answer: 1, 2, 3
While assessing a client, the nurse notes the client is irritable, anxious, and has lost 12 pounds over the last two months. The client's eyes appear to bulge from their sockets. Based on this data, which assessment findings does the nurse anticipate for this client? Standard Text: Select all that apply. 1. Blood pressure: 162/92 mmHg. 2. Apical pulse: 120. 3. Respiratory rate is 10 breaths per minute 4. Pupils: constricted. 5. Client complains of feeling very warm.
Correct Answer: 1, 2, 5
The nurse is assessing an infant diagnosed with Down syndrome. During the physical assessment, which data does the nurse anticipate? Standard Text: Select all that apply. 1. Slanted eyes. 2. Cleft palate and lip. 3. Protruding tongue. 4. Shortened neck. 5. Drooping eyelids.
Correct Answer: 1, 3, 4
The nurse is preparing an educational seminar about Healthy People 2020. Which topics will the nurse include in the educational seminar? Standard Text: Select all that apply. 1. The parents of a newborn should be educated about the clinical manifestations associated with hyperthyroidism. 2. Thyroid disease more frequently affects males versus females. 3. Immigrants may have an increased risk of disorders related to thyroid function. 4. Depression in older adults may be linked to hypothyroidism. 5. The iodine added to some medications can be linked to hypothyroidism in the clients who use these medications.
Correct Answer: 1, 3, 4
A client complains of daily headaches. Which items will the nurse include in the focused interview for this client to learn more about the client's headaches? Standard Text: Select all that apply. 1. "Rate your pain on a scale from 0 to 10, with 0 being no pain and 10 the worst." 2. "Daily headaches are not of any concern." 3. "Is there anything that relieves the pain, like resting or medication?" 4. "Is the pain sharp, dull, steady, or throbbing?" 5. "Have you had a recent cold or infection?"
Correct Answer: 1, 3, 4, 5
The client is complaining of pain in the temporomandibular joint. During the nurse's assessment of this client, which pieces of information does the nurse expect to find? Standard Text: Select all that apply. 1. The client has been under a great deal of stress due to a recent divorce. 2. The client has developed hypothyroidism. 3. The client has lost tooth enamel due to nighttime teeth grinding. 4. The client has developed hypotension. 5. The client has developed severe tension headaches.
Correct Answer: 1, 3, 5
The nurse is planning care for a client with hypothyroidism. Which is the priority nursing diagnosis for this client? 1. Risk for constipation related to metabolic imbalance. 2. Activity intolerance related to fatigue. 3. Risk for injury related to confusion and lethargy. 4. Altered nutrition, less than body requirements.
Correct Answer: 2 Feeling tired, exhausted, and not having enough energy to perform even small tasks is a typical complaint from clients suffering from hypothyroidism.
Which action by the nurse is appropriate when palpating the client's lymph nodes during the physical assessment? 1. Assessing each side separately. 2. Applying gentle, circular pressure. 3. Applying strong, deep pressure. 4. Attempting to push the nodes into the muscle.
Correct Answer: 2 Palpation of the lymph nodes should be done by exerting gentle, circular pressure using the finger pads of both hands.
The nurse is planning care for an older adult client. Which topic will the nurse include in the teaching session when discussing thyroid function? 1. Eliminating the use of alcohol. 2. Monitoring of hormone levels annually. 3. Providing information about congenital abnormalities. 4. Educating about birth control options.
Correct Answer: 2 Production of thyroid hormone decreases with age, and older adults, regardless of gender, should have annual thyroid screening and monitoring of thyroid hormone levels.
The nurse is assessing a newborn and notes an enlarged head with prominent scalp veins visible. Based on this data, which diagnosis does the nurse suspect? 1. Craniosynostosis. 2. Hydrocephalus. 3. Acromegaly. 4. Fetal alcohol syndrome
Correct Answer: 2 Rationale 2: Hydrocephalus is enlargement of the head caused by inadequate drainage of cerebrospinal fluid.
Which country has decreased their population's risk of developing thyroid disease by adding iodine to salt? 1. India. 2. United States. 3. Australia. 4. China.
Correct Answer: 2 The use of iodized salt has reduced iodine deficiency and thyroid problems for people who live in the United States.
The nurse notes the client's thyroid gland is enlarged during the physical assessment. While reviewing the client's history, the nurse notes that the client has a history of a goiter. Based on this information, which question is the priority during the focused interview? 1. "Where do you purchase your medication?" 2. "What type of salt do you use in your diet?" 3. "Do you work around chemicals?" 4. "How long have you had this problem?"
Correct Answer: 2 Thyroid disease is common where iodine is limited and deficient amounts of iodine can cause a goiter to develop. Use of iodized salt in the U.S. has generally eliminated iodine deficiencies.
The pediatric nurse is conducting physical assessments during a shift in the outpatient clinic. Which findings are considered abnormal? Standard Text: Select all that apply. 1. The 2-week-old newborn whose fontanels are slightly pulsing. 2. The 2-year-old child's anterior fontanel remains unclosed. 3. The 1-month-old infant's posterior fontanel has closed. 4. The 10-month-old infant's anterior fontanel is shaped like a triangle. 5. The 6-month-old infant's anterior fontanel is soft and flat.
Correct Answer: 2, 3, 4
The nurse is auscultating the thyroid gland and notes a bruit. Which conclusion by the nurse is appropriate based on this assessment finding? 1. Stenosis of the thyroid artery. 2. A normal finding. 3. Indicates increased blood flow. 4. Occurs with hypothyroidism.
Correct Answer: 3 If the thyroid is enlarged, blood flows through the arteries at an accelerated rate, producing a soft, rushing sound and is detected with the bell of the stethoscope as a bruit.
The nurse is performing a physical examination on a 2-day-old newborn and notes flattened areas on each side of the head. The mother expresses concern about the infant's appearance. Which response by the nurse is appropriate? 1. "The baby will likely need a neurologic evaluation." 2. "The baby will need plastic surgery." 3. "This is normal and will resolve in a few days." 4. "What shape is your husband's head?"
Correct Answer: 3 Infants born by vaginal delivery experience molding, which is shaping of the head as it passes through the vaginal canal. This will resolve in several days.
The nurse is assessing the 1-month-old infant's fontanels and notes they are sunken. Based on this data, which conclusion is most appropriate? 1. Infection. 2. Thyroid disease. 3. Dehydration. 4. Fetal Alcohol Syndrome.
Correct Answer: 3 Sunken or depressed fontanels in an infant can indicate dehydration.
The nurse is preparing to assess an adult client. The focus of the exam will be on the head and neck. Which statement by the nurse is appropriate when preparing the client for the thyroid examination? 1. "Please lie down while I assess your thyroid gland." 2. "When I assess your thyroid gland, you can expect to feel strong pressure." 3. "I will stand behind you while palpating your thyroid gland." 4. "Please chew this mint so that I can assess your thyroid gland."
Correct Answer: 3 The nurse will stand behind the client while palpating the thyroid gland.
The client presents with unilateral facial paralysis and the nurse suspects Bell's palsy. After client teaching, which client statement would indicate the need for further education? 1. "This may have occurred as a result of a viral infection." 2. "This will probably disappear on its own in several weeks." 3. "The onset of Bell's palsy is very slow and the effects can linger for several months." 4. "Your cranial nerve VII is not functioning appropriately."
Correct Answer: 3 The onset is sudden and there aren't lingering effects after the condition resolves in several weeks after onset.
The nurse is assessing the client's neck. Which finding is considered an abnormality? 1. The client's carotid arteries are visibly pulsating. 2. The neck is symmetrical. 3. The tracheal cartilage does not move when the client swallows. 4. The thyroid has no palpable nodules.
Correct Answer: 3 The tracheal cartilage should move when the client swallows.
The nurse is assessing the client's head and neck. The nurse provides the client with a glass of water. Which structure is the nurse assessing while observing the client drinking the water? 1. Temporomandibular joint. 2. Lymph nodes. 3. Temporal artery. 4. Trachea.
Correct Answer: 4 The nurse will ask the client to drink from the glass of water when the nurse is ready to assess the hyoid bone, tracheal cartilage, and thyroid as the client swallows.
The client has an enlarged lymph node in front of the right ear. Which phrase will the nurse use to document this finding in the medical record? 1. Right-sided occipital lymph node enlarged. 2. Right-sided submaxillary lymph node enlarged. 3. Right-sided deep cervical lymph node enlarged. 4. Right-sided preauricular lymph node enlarged.
Correct Answer: 4 The preauricular lymph node is located in front of the ear.
During an assessment of a 20-year-old man, the nurse finds a small palpable lesion with a tuft of hair located directly over the coccyx. The nurse knows that this lesion would most likely be a: a.Rectal polyp. b.Pruritus ani. c.Carcinoma. d.Pilonidal cyst.
D A pilonidal cyst or sinus is a hair-containing cyst or sinus located in the midline over the coccyx or lower sacrum. It often opens as a dimple with a visible tuft of hair and, possibly, an erythematous halo. (See Table 25-1 for more information, and also for the description of a pruritus ani. .)
While performing a rectal examination, the nurse notices a firm, irregularly shaped mass. What should the nurse do next? a.Continue with the examination, and document the finding in the chart. b.Instruct the patient to return for a repeat assessment in 1 month. c.Tell the patient that a mass was felt, but it is nothing to worry about. d.Report the finding, and refer the patient to a specialist for further examination.
D A firm or hard mass with an irregular shape or rolled edges may signify carcinoma. Any mass that is discovered should be promptly reported for further examination. The other responses are not correct.
A mother brings her 4-month-old infant to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since 1 month of age. The infant has no health problems. On physical examination, the nurse notices a 0.5-cm, fleshy, elevated area in the middle of the upper lip. No evidence of inflammation or drainage is observed. What would the nurse tell this mother? a."This area of irritation is caused from teething and is nothing to worry about." b."This finding is abnormal and should be evaluated by another health care provider." c."This area of irritation is the result of chronic drooling and should resolve within the next month or two." d."This elevated area is a sucking tubercle caused from the friction of breastfeeding or bottle-feeding and is normal."
D A normal finding in infants is the sucking tubercle, a small pad in the middle of the upper lip from the friction of breastfeeding or bottle-feeding. This condition is not caused by irritation, teething, or excessive drooling, and evaluation by another health care provider is not warranted.
A 32-year-old woman is at the clinic for "little white bumps in my mouth." During the assessment, the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient? a."These spots indicate an infection such as strep throat." b."These bumps could be indicative of a serious lesion, so I will refer you to a specialist." c."This condition is called leukoplakia and can be caused by chronic irritation such as with smoking." d."These bumps are Fordyce granules, which are sebaceous cysts and are not a serious condition."
D Fordyce granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and are not significant. Chalky, white raised patches would indicate leukoplakia. In strep throat, the examiner would see tonsils that are bright red, swollen, and may have exudates or white spots.
A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started bleeding. What would be an appropriate response by the nurse? a."Your condition is probably due to a vitamin C deficiency." b."I'm not sure what causes swollen and bleeding gums, but let me know if it's not better in a few weeks." c."You need to make an appointment with your dentist as soon as possible to have this checked." d."Swollen and bleeding gums can be caused by the change in hormonal balance in your system during pregnancy."
D Gum margins are red and swollen and easily bleed with gingivitis. A changing hormonal balance may cause this condition to occur in pregnancy and puberty.
During an examination, the nurse asks the patient to perform the Valsalva maneuver and notices that the patient has a moist, red, doughnut-shaped protrusion from the anus. The nurse knows that this finding is consistent with a: a.Rectal polyp. b.Hemorrhoid. c.Rectal fissure. d.Rectal prolapse.
D In rectal prolapse, the rectal mucous membrane protrudes through the anus, appearing as a moist red doughnut with radiating lines. It occurs after a Valsalva maneuver, such as straining at passing stool or with exercising
The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, "I think she is getting her first tooth because she has started drooling a lot." The nurse's best response would be: a."You're right, drooling is usually a sign of the first tooth." b."It would be unusual for a 3 month old to be getting her first tooth." c."This could be the sign of a problem with the salivary glands." d."She is just starting to salivate and hasn't learned to swallow the saliva."
D In the infant, salivation starts at 3 months. The baby will drool for a few months before learning to swallow the saliva. This drooling does not herald the eruption of the first tooth, although many parents think it does.
The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which statement is true in relation to a newborn infant? a.Sphenoid sinuses are full size at birth. b.Maxillary sinuses reach full size after puberty. c.Frontal sinuses are fairly well developed at birth. d.Maxillary and ethmoid sinuses are the only sinuses present at birth.
D Only the maxillary and ethmoid sinuses are present at birth. The sphenoid sinuses are minute at birth and develop after puberty. The frontal sinuses are absent at birth, are fairly well developed at age 7 to 8 years, and reach full size after puberty.
While obtaining a health history from the mother of a 1-year-old child, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, "It makes a great pacifier." The best response by the nurse would be: a."You're right. Bottles make very good pacifiers." b."Using a bottle as a pacifier is better for the teeth than thumb-sucking." c."It's okay to use a bottle as long as it contains milk and not juice." d."Prolonged use of a bottle can increase the risk for tooth decay and ear infections."
D Prolonged bottle use during the day or when going to sleep places the infant at risk for tooth decay and middle ear infections.
Which statement concerning the anal canal is true? The anal canal: a.Is approximately 2 cm long in the adult. b.Slants backward toward the sacrum. c.Contains hair and sebaceous glands. d.Is the outlet for the gastrointestinal tract.
D The anal canal is the outlet for the gastrointestinal tract and is approximately 3.8 cm long in the adult. It is lined with a modified skin that does not contain hair or sebaceous glands, and it slants forward toward the umbilicus.
While performing an assessment of the perianal area of a patient, the nurse notices that the pigmentation of anus is darker than the surrounding skin, the anal opening is closed, and a skin sac that is shiny and blue is noted. The patient mentioned that he has had pain with bowel movements and has occasionally noted some spots of blood. What would this assessment and history most likely indicate? a.Anal fistula b.Pilonidal cyst c.Rectal prolapse d.Thrombosed hemorrhoid
D The anus normally looks moist and hairless, with coarse folded skin that is more pigmented than the perianal skin, and the anal opening is tightly closed. The shiny blue skin sac indicates a thrombosed hemorrhoid.
The tissue that connects the tongue to the floor of the mouth is the: a.Uvula. b.Palate. c.Papillae. d.Frenulum.
D The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth. The uvula is the free projection hanging down from the middle of the soft palate. The palate is the arching roof of the mouth. Papillae are the rough, bumpy elevations on the tongue's dorsal surface.
During the assessment of an 18-month-old infant, the mother expresses concern to the nurse about the infant's inability to toilet train. What would be the nurse's best response? a."Some children are just more difficult to train, so I wouldn't worry about it yet." b."Have you considered reading any of the books on toilet training? They can be very helpful." c."This could mean that there is a problem in your baby's development. We'll watch her closely for the next few months." d."The nerves that will allow your baby to have control over the passing of stools are not developed until at least 18 to 24 months of age."
D The infant passes stools by reflex. Voluntary control of the external anal sphincter cannot occur until the nerves supplying the area have become fully myelinated, usually around 1 to 2 years of age. Toilet training usually starts after the age of 2 years.
A 13-year-old girl is visiting the clinic for a sports physical examination. The nurse should remember to include which of these tests in the examination? a.Testing for occult blood b.Valsalva maneuver c.Internal palpation of the anus d.Inspection of the perianal area
D The perianal region of the school-aged child and adolescent should be inspected during the examination of the genitalia. Internal palpation is not routinely performed at this age. Testing for occult blood and performing the Valsalva maneuver are also not necessary.
A 60-year-old man has just been told that he has benign prostatic hypertrophy (BPH). He has a friend who just died from cancer of the prostate. He is concerned this will happen to him. How should the nurse respond? a."The swelling in your prostate is only temporary and will go away." b."We will treat you with chemotherapy so we can control the cancer." c."It would be very unusual for a man your age to have cancer of the prostate." d."The enlargement of your prostate is caused by hormonal changes, and not cancer."
D The prostate gland commonly starts to enlarge during the middle adult years. BPH is present in 1 in 10 men at the age of 40 years and increases with age. It is believed that the hypertrophy is caused by hormonal imbalance that leads to the proliferation of benign adenomas. The other responses are not appropriate.
During the taking of a health history, the patient states, "It really hurts back there, and sometimes it itches, too. I have even seen blood on the tissue when I have a bowel movement. Is there something there?" The nurse should expect to see which of these upon examination of the anus? a.Rectal prolapse b.Internal hemorrhoid c.External hemorrhoid that has resolved d.External hemorrhoid that is thrombosed
D These symptoms are consistent with an external hemorrhoid. An external hemorrhoid, when thrombosed, contains clotted blood and becomes a painful, swollen, shiny blue mass that itches and bleeds with defecation. When the external hemorrhoid resolves, it leaves a flabby, painless skin sac around the anal orifice. An internal hemorrhoid is not palpable but may appear as a red mucosal mass when the person performs a Valsalva maneuver. A rectal prolapse appears as a moist, red doughnut with radiating lines.
The nurse is performing an assessment. Which of these findings would cause the greatest concern? a.Painful vesicle inside the cheek for 2 days b.Presence of moist, nontender Stensen's ducts c.Stippled gingival margins that snugly adhere to the teeth d.Ulceration on the side of the tongue with rolled edges
D Ulceration on the side or base of the tongue or under the tongue raises the suspicion of cancer and must be investigated. The risk of early metastasis is present because of rich lymphatic drainage. The vesicle may be an aphthous ulcer, which is painful but not dangerous. The other responses are normal findings.
A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in the health history would be: a."Do you use a fluoride supplement?" b."Have you had tonsillitis in the last year?" c."At what age did you get your first tooth?" d."Have you noticed any dryness in your mouth?"
D Xerostomia (dry mouth) is a side effect of many drugs taken by older people, including antidepressants, anticholinergics, antispasmodics, antihypertensives, antipsychotics, and bronchodilators.
The nurse is caring for a client with a traumatic brain injury (TBI). The client begins to experience bradycardia. Which area of the brain is likely responsible for the changes in heart rate? **brain image
Rationale: The brain stem is responsible for control of the vital signs. Global Rationale: The brain stem is responsible for control of the vital signs.
While assessing the abdomen, the nurse palpates a pulsating mass. The nurse interprets this finding as an abdominal aneurysm. What other assessment findings would the nurse expect? (Select all that apply) a) An epigastric bruit b) Femoral pulses are increased c) Femoral pulses are decreased d) Hypoactive bowel sounds e) Cool extremities
a) An epigastric bruit c) Femoral pulses are decreased e) Cool extremities
The nurse is planning to assess the abdomen of an adult male. What should be done first? a) Ask client to empty bladder b) Place the client in side-lying position c) Ask client to hold his breath for a few seconds d) Tell client to raise arms above the head
a) Ask client to empty bladder
The 79-year-old female tells the nurse, "I don't drink as much water as I should because it makes me have to go to the bathroom." What is this client prone to developing? a) Constipation b) Hemorrhoids c) Diarrhea d) Acid indigestion
a) Constipation
The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? a) Dullness b) Tympany c) Resonance d) Hyperresonance
a) Dullness
Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites? a) Dullness across the abdomen b) Flatness in the right upper quadrant c) Hyperresonance in the left upper quadrant d) Tympany in the right and left lower quadrants
a) Dullness across the abdomen
Which organs are located in the right upper quadrant? Select all that apply a) Liver b) Gallbladder c) Duodenum d) Head of pancreas e) Spleen f) Right adrenal gland
a) Liver b) Gallbladder c) Duodenum
Which of these are accessory organs to the GI system? Select all that apply a) Liver b) Spleen c) Pancreas d) Kidney e) Gallbladder f) Salivary glands
a) Liver c) Pancreas e) Gallbladder f) Salivary glands
After assessing a client, the nurse writes "striae present bilateral costal margins." What should the nurse do with this information? a) Nothing. This is a normal finding. b) Suggest the client see a general surgeon. c) Ask the client if they've experienced any recent emotional events. d) Notify the physician.
a) Nothing. This is a normal finding.
The colon originates in this abdominal area of the a) Right lower quadrant b) Right upper quadrant c) Left lower quadrant d) Left upper quadrant
a) Right lower quadrant
To percuss the liver of an adult, where should the nurse begin the assessment? a) Right upper quadrant b) Right lower quadrant c) Left upper quadrant d) Left lower quadrant
a) Right upper quadrant
When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved? a) Spleen b) Sigmoid colon c) Appendix d) Gallbladder
a) Spleen
What is hematemesis evidence of? a) Stomach ulcers b) Pancreatic ulcers c) Decreased gastric motility d) Abdominal tumors
a) Stomach ulcers
The primary function of the gallbladder is to a) Store and excrete bile b) Aid in the digestion of protein c) Produce alkaline hormones d) Produce hormones
a) Store and excrete bile
If a clients umbilicus is enlarged and to the left - what is this indicitive of? a) Umbilical hernia b) Ascites c) Intraabdominal bleeding d) Pancreatitis
a) Umbilical hernia
During report, the student nurse hears that a patient has "hepatomegaly" and recognizes that this term refers to: a) an enlarged liver. b) an enlarged spleen. c) distended bowel. d) excessive diarrhea.
a) an enlarged liver.
The symptoms occurring with lactose intolerance include: a) bloating and flatulence. b) gray stools. c) hematemesis. d) anorexia.
a) bloating and flatulence.
Older adults have: a) decreased salivation leading to dry mouth. b) increased gastric acid secretion. c) increased liver size. d) decreased incidence of gallstones.
a) decreased salivation leading to dry mouth.
During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement? a. Using gentle pressure, palpate with both hands to compare the two sides. b. Using strong pressure, palpate with both hands to compare the two sides. c. Gently pinch each node between one's thumb and forefinger, and then move down the neck muscle. d. Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern.
a. Using gentle pressure, palpate with both hands to compare the two sides. Using gentle pressure is recommended because strong pressure can push the nodes into the neck muscles. Palpating with both hands to compare the two sides symmetrically is usually most efficient.
Auscultation of the abdomen is begun in the right lower quadrant (RLQ) because: a. bowel sounds are always normaly present here b. peristalsis through the descending colon is usually active c. tis is the location of the pyloric sphincter d. vascular sounds are best heard in this area
a. bowel sounds are always normaly present here
Right upper quadrant tenderness may indicate pathology in the: a. liver, pancreas, or ascending colon b. liver and stomach c. sigmoid colon, spleen, or rectum d. appendix or ileocecal valve
a. liver, pancreas, or ascending colon
The nurse is assessing a patient for possible peptic ulcer disease and knows that which condition often causes this problem? a) Hypertension b) Streptococcus infections c) History of constipation and frequent laxative use d) Frequent use of nonsteroidal anti inflammatory drugs
d) Frequent use of nonsteroidal anti inflammatory drugs
The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? a) "We need to determine areas of tenderness before using percussion and palpation." b) "It prevents distortion of bowel sounds that might occur after percussion and palpation." c) "It allows the patient more time to relax and therefore be more comfortable with the physical examination." d) "This prevents distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation."
b) "It prevents distortion of bowel sounds that might occur after percussion and palpation."
The abdomen normally moves when breathing until the age of ____ years. a) 4 b) 7 c) 14 d) 75
b) 7
A client has experienced hematemesis, what is this? a) Blood in the urine b) Blood in the vomit c) Blood in the stool d) Blood in the sputum
b) Blood in the vomit
A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition? a) Obturator test b) Test for Murphy's sign c) Assess for rebound tenderness d) Iliopsoas muscle test
b) Test for Murphy's sign
The nurse is assessing the abdomen of an aging adult. Which of these statements regarding the aging adult and abdominal assessment is true? a) The abdominal tone is increased. b) The abdominal musculature is thinner. c) Abdominal rigidity with acute abdominal conditions is more common. d) The aging person complains of more pain with an acute abdominal condition than a younger person would.
b) The abdominal musculature is thinner.
A nurse is listening to bowel sounds. Which of the following is true of bowel sounds? a) They are usually loud, high-pitch , rushing, tinkling b) They are usually high-pitched, gurgling, irregular c) They are usually low-pitched, gurgling, regular d) They are usually low-pitched and irregular
b) They are usually high-pitched, gurgling, irregular
A client comes to the hospital with nausea, vomiting, and ongoing sciatic pain. Which of the following should be included in the focus interview with this client? a) Bowel habits b) Use of pain medication c) Blood pressure levels d) Review of other chronic diseases
b) Use of pain medication
Pyrosis is: a) an inflammation of the peritoneum. b) a burning sensation in the upper abdomen. c) a congenital narrowing of the pyloric sphincter. d) an abnormally sunken abdominal wall.
b) a burning sensation in the upper abdomen.
An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to: a) increased gastric acid secretion. b) decreased gastric acid secretion. c) delayed gastrointestinal emptying time. d) increased gastrointestinal emptying time.
b) decreased gastric acid secretion.
The nurse knows that during an abdominal assessment, deep palpation is used to determine: a) bowel motility. b) enlarged organs. c) superficial tenderness. d) overall impression of skin surface and superficial musculature.
b) enlarged organs.
The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should: a) examine the tender area first. b) examine the tender area last. c) avoid palpating the tender area. d) palpate the tender area first and then auscultate for bowel sounds.
b) examine the tender area last.
A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: a) diarrhea. b) peritonitis. c) laxative use. d) gastroenteritis.
b) peritonitis.
A patient reports excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice each day. The nurse should suspect: a. Hypertension. b. Cluster headaches. c. Tension headaches. d. Migraine headaches.
b. Cluster headaches. Cluster headaches produce pain around the eye, temple, forehead, and cheek and are unilateral and always on the same side of the head. They are excruciating and occur once or twice per day and last to 2 hours each. Tension Headaches: mild, all around head Migraine: one/both sides, throbbing/pulsating, moderate/severe pain
A patient says that she has recently noticed a lump in the front of her neck below her "Adam's apple" that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule): a. Is tender. b. Is mobile and not hard. c. Disappears when the patient smiles. d. Is hard and fixed to the surrounding structures.
b. Is mobile and not hard. Painless, rapidly growing nodules may be cancerous, especially the appearance of a single nodule in a young person. However, cancerous nodules tend to be hard and fixed to surrounding structures, not mobile.
The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally: a. Shotty. b. Nonpalpable. c. Large, firm, and fixed to the tissue. d. Rubbery, discrete, and mobile.
b. Nonpalpable. Most lymph nodes are nonpalpable in adults. The palpability of lymph nodes decreases with age. Normal nodes feel movable, discrete, soft, and nontender.
A patient has come in for an examination and states, "I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is?" The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his: a. Thyroid gland. b. Parotid gland. c. Occipital lymph node. d. Submental lymph node.
b. Parotid gland. Swelling of the parotid gland is evident below the angle of the jaw and is most visible when the head is extended. Painful inflammation occurs with mumps, and swelling also occurs with abscesses or tumors. Swelling occurs anterior to the lower ear lobe.
A male patient with a history of acquired immunodeficiency syndrome (AIDS) has come in for an examination and he states, "I think that I have the mumps." The nurse would begin by examining the: a. Thyroid gland. b. Parotid gland. c. Cervical lymph nodes. d. Mouth and skin for lesions.
b. Parotid gland. The parotid gland may become swollen with the onset of mumps, and parotid enlargement has been found with human immunodeficiency virus (HIV). Mumps/Parotitis: viral infection that affects the salivary glands that's easily prevented by a vaccine.
The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is aware that this means that the patient's trachea is: a. Pulled to the affected side. b. Pushed to the unaffected side. c. Pulled downward. d. Pulled downward in a rhythmic pattern.
b. Pushed to the unaffected side. The trachea is pushed to the unaffected side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, or a pneumothorax. The trachea is pulled to the affected side with large atelectasis, pleural adhesions, or fibrosis. Tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm.
A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN ______ and proceeds with the examination by _____________. a. XI; palpating the anterior and posterior triangles b. XI; asking the patient to shrug her shoulders against resistance c. XII; percussing the sternomastoid and submandibular neck muscles d. XII; assessing for a positive Romberg sign
b. XI; asking the patient to shrug her shoulders against resistance The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory. The innervated muscles assist with head rotation and head flexion, movement of the shoulders, and extension and turning of the head. Romberg Test: neurological function for balance; DUI test
Murphy's sign is best described as: a. the pain felt when the hand of the examiner is rapidly removed from an inflamed appendix b. pain felt when taking a deep breath when the examiner's fingers are on the approximate location of the inflamed gallbladder c. a sharp pain felt by the patient when one hand of the examiner is used to thump the other at the costovertebral angle d. not a valid examination technique
b. pain felt when taking a deep breath when the examiner's fingers are on the approximate location of the inflamed gallbladder
The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm? a) A bruit is absent. b) Femoral pulses are increased. c) A pulsating mass is usually present. d) Most are located below the umbilicus.
c) A pulsating mass is usually present.
The nurse assessing an older client who has lost 5 lbs since her last visit 1 year ago. The client tells the nurse her husband died 2 months ago. The nurse should assess for a) Peptic ulcer b) Bulimia c) Appetite changes d) Pancreatic disorders
c) Appetite changes
The pancreas of an adult is located a) Below the diaphragm and below right costal margin b) High and deep under the diaphragm - can't be palpated c) Deep in the upper adbomen and is not normally palpable d) Posterior to the left midaxillary line and posterior to the stomach
c) Deep in the upper adbomen and is not normally palpable
A client tells the nurse, "I get stomach burning when I drink wine." Of what is this information an indication? a) Gallstones b) Intestinal ulcerations c) Gastrointestinal irritation d) Stomach bleeding
c) Gastrointestinal irritation
The nurse is planning to palpate a client's bladder. Which area of the abdomen should this palpation be done? a) Right hypochondriac region b) Left lumbar region c) Hypogastric region d) RLQ
c) Hypogastric region
The nurse is aware that the correct procedure for an abdominal assessment is? a) Inspection, palpation, percussion, auscultation b) Inspection, percussion, palpation, auscultation c) Inspection, auscultation, percussion, palpation d) Inspection, palpation auscultation, percussion
c) Inspection, auscultation, percussion, palpation
To palpate the spleen, where should you begin the assessment? a) Right upper quadrant b) Right lower quadrant c) Left upper quadrant d) Left lower quadrant
c) Left upper quadrant
To palpate tenderness of an adult's appendix, where should you begin? a) Left lower quadrant b) Left upper quadrant c) Right lower quadrant d) Right upper quadrant
c) Right lower quadrant
The client tells the nurse, "I've had diarrhea ever since my mother was admitted to the hospital with a heart attack." What can the nurse say to the client about this information? a) Are you having any other problems? b) What hospital is your mother in? c) Stress can cause the bowels to act up. d) How's your mother doing now?
c) Stress can cause the bowels to act up.
The nurse is preparing to examine a client's abdomen. Which of the following landmarks could be considered a thoracic structure? a) Umbilicus b) Iliac crests c) Xiphoid process d) Pubic bone
c) Xiphoid process
Pyloric stenosis is a(n): a) abnormal enlargement of the pyloric sphincter. b) inflammation of the pyloric sphincter. c) congenital narrowing of the pyloric sphincter. d) abnormal opening in the pyloric sphincter.
c) congenital narrowing of the pyloric sphincter.
A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has: a) aphasia. b) dysphasia. c) dysphagia. d) anorexia.
c) dysphagia.
The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would be: a) gallbladder disease. b) overuse of laxatives. c) gastrointestinal bleeding. d) localized bleeding around the anus.
c) gastrointestinal bleeding.
The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include: a) flatness, resonance, and dullness. b) resonance, dullness, and tympany. c) tympany, hyperresonance, and dullness. d) resonance, hyperresonance, and flatness.
c) tympany, hyperresonance, and dullness.
The four layers of large, flat abdominal muscles form the: a) linea alba. b) rectus abdominus. c) ventral abdominal wall. d) viscera.
c) ventral abdominal wall.
A physician tells the nurse that a patient's vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is: a. Just above the diaphragm. b. Just lateral to the knee cap. c. At the level of the C7 vertebra. d. At the level of the T11 vertebra.
c. At the level of the C7 vertebra. The C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable when the head is flexed.
26. During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for: a. Exophthalmos. b. Bowed long bones. c. Coarse facial features. d. Acorn-shaped cranium.
c. Coarse facial features. Acromegaly is excessive secretion of growth hormone that creates an enlarged skull and thickened cranial bones. Patients will have elongated heads, massive faces, prominent noses and lower jaws, heavy eyebrow ridges, and coarse facial features. Exophthalmos is associated with hyperthyroidism. Bowed long bones and an acorn-shaped cranium result from Paget disease. Bowed Long Bones: shortening of bones
The nurse is assessing range of motion and notes a grating sound when examining the shoulder joint. The nurse would correctly document which of the following choices? a. Limited range of motion of the shoulder joint b. Shoulder deformity c. Crepitus of the shoulder joint d. Shoulder atrophy
c. Crepitus of the shoulder joint Rationale: Crepitus is a grating sound caused by bone fragments in joints and is suggestive of degenerative disease, trauma, or inflammatory conditions. Limited motion would be documented by describing the inability of the joint to move in the normal ranges, and shoulder deformity and atrophy are not conclusive with this information.
During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be: a. Clumped. b. Unilateral. c. Firm but freely movable. d. Firm and nontender.
c. Firm but freely movable. Acutely infected lymph nodes are bilateral, enlarged, warm, tender, and firm but freely movable. Unilaterally enlarged nodes that are firm and nontender may indicate cancer. Lymphadenopathy: disease of swollen/enlarged or increase in lymph nodes
A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give her? a. Diets low in protein and high in carbohydrates may cause enhanced facial bones. b. Bones can become more noticeable if the person does not use a dermatologically approved moisturizer. c. More noticeable facial bones are probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin. d. Facial skin becomes more elastic with age. This increased elasticity causes the skin to be more taught, drawing attention to the facial bones.
c. More noticeable facial bones are probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin. The facial bones and orbits appear more prominent in the aging adult, and the facial skin sags, which is attributable to decreased elasticity, decreased subcutaneous fat, and decreased moisture in the skin.
A woman comes to the clinic and states, "I've been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry." The nurse will assess for other signs and symptoms of: a. Cachexia. b. Parkinson syndrome. c. Myxedema. d. Scleroderma.
c. Myxedema. Myxedema (hypothyroidism) is a deficiency of thyroid hormone that, when severe, causes a nonpitting edema or myxedema. The patient will have a puffy edematous face, especially around the eyes (periorbital edema); coarse facial features; dry skin; and dry, coarse hair and eyebrows. Cachexia: weakness & wasting of the body due to chronic illness Parkinson Syndrome: deficiency of dopamine Scleroderma: hardening & tightening of skin
When examining the face of a patient, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the ___________ and ___________ glands. a. Occipital; submental b. Parotid; jugulodigastric c. Parotid; submandibular d. Submandibular; occipital
c. Parotid; submandibular Two pairs of salivary glands accessible to examination on the face are the parotid glands, which are in the cheeks over the mandible, anterior to and below the ear; and the submandibular glands, which are beneath the mandible at the angle of the jaw. The parotid glands are normally nonpalpable.
A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a __________ sound that is heard best with the __________ of the stethoscope. a. Low gurgling; diaphragm b. Loud, whooshing, blowing; bell c. Soft, whooshing, pulsatile; bell d. High-pitched tinkling; diaphragm
c. Soft, whooshing, pulsatile; bell If the thyroid gland is enlarged, then the nurse should auscultate it for the presence of a bruit, which is a soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope.
During an examination, the nurse finds that a patient's left temporal artery is tortuous and feels hardened and tender, compared with the right temporal artery. The nurse suspects which condition? a. Crepitation b. Mastoiditis c. Temporal arteritis d. Bell palsy
c. Temporal arteritis With temporal arteritis, the artery appears more tortuous and feels hardened and tender. These assessment findings are not consistent with the other responses.
A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. He would probably be more comfortable with the nurse examining his thyroid gland from: a. Behind with the nurse's hands placed firmly around his neck. b. The side with the nurse's eyes averted toward the ceiling and thumbs on his neck. c. The front with the nurse's thumbs placed on either side of his trachea and his head tilted forward. d. The front with the nurse's thumbs placed on either side of his trachea and his head tilted backward.
c. The front with the nurse's thumbs placed on either side of his trachea and his head tilted forward. Examining this patient's thyroid gland from the back may be unsettling for him. It would be best to examine his thyroid gland using the anterior approach, asking him to tip his head forward and to the right and then to the left.
Tenderness during abdominal palpation is expected when palpating: a. the liver edge b. the spleen c. the sigmoid colon d. the kidneys
c. the sigmoid colon
The physician has ordered a urinalysis, but the patient states "I don't have to go now." The nurse is concerned about urinary retention and palpates the bladder for distention. How should the nurse assess for this condition? a) Percuss and palpate the lumbar region b) Inspect and palpate the epigastric region c) Auscultate and percuss the inguinal region d) Percuss and palpate the hypogastric region
d) Percuss and palpate the hypogastric region
The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? a) Percuss and palpate in the lumbar region. b) Inspect and palpate in the epigastric region. c) Auscultate and percuss in the inguinal region. d) Percuss and palpate the midline area above the suprapubic bone.
d) Percuss and palpate the midline area above the suprapubic bone.
To detect diastasis recti, the nurse should have the patient perform which of these maneuvers? a) Relax in the supine position. b) Raise the arms in the left lateral position. c) Raise the arms over the head while supine. d) Raise the head while remaining supine.
d) Raise the head while remaining supine.
The nurse auscultates borborygmi on a client. What does this finding indicate to the nurse? a) The client is anorexic. b) The client had a full breakfast. c) The client is obese. d) The client is hungry.
d) The client is hungry.
The mother of an 18-month-old child tells the nurse, "I can see his belly rumbling. Is this normal?" Which of the following can the nurse respond to this client? a) No. This is not normal. b) There is a good pediatric gastroenterologist that I know who can help you. c) This means his gallbladder is digesting fats. d) The muscles of the abdomen are thin in babies. So you will see this.
d) The muscles of the abdomen are thin in babies. So you will see this.
During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with: a) splenomegaly. b) distended bladder. c) constipation. d) ascites.
d) ascites.
The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a _____ profile. a) flat b) convex c) bulging d) concave
d) concave
The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to: a) a loud continuous hum. b) a peritoneal friction rub. c) hypoactive bowel sounds. d) hyperactive bowel sounds.
d) hyperactive bowel sounds.
The range of normal liver span in the right midclavicular line in the adult is: a. 2-6 cm b. 4-8 cm c. 8-14 cm d. 6-12 cm
d. 6-12 cm
A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he has: a. Cushing syndrome. b. Parkinson disease. c. Bell palsy. d. Experienced a cerebrovascular accident (CVA) or stroke.
d. Experienced a cerebrovascular accident (CVA) or stroke. With an upper motor neuron lesion, as with a CVA, the patient will have paralysis of lower facial muscles, but the upper half of the face will not be affected owing to the intact nerve from the unaffected hemisphere. The person is still able to wrinkle the forehead and close the eyes. Cushing Syndrome: excessive secretion of ACTH Parkinson Disease: deficiency of neurotransmitter dopamine Bell Palsy: CN VII paralysis of a facial muscle
The nurse is aware that the four areas in the body where lymph nodes are accessible are the: a. Head, breasts, groin, and abdomen. b. Arms, breasts, inguinal area, and legs. c. Head and neck, arms, breasts, and axillae. d. Head and neck, arms, inguinal area, and axillae.
d. Head and neck, arms, inguinal area, and axillae. Nodes are located throughout the body, but they are accessible to examination only in four areas: head and neck, arms, inguinal region, and axillae.
A 19-year-old college student is brought to the emergency department with a severe headache he describes as, "Like nothing I've ever had before." His temperature is 40° C, and he has a stiff neck. The nurse looks for other signs and symptoms of which problem? a. Head injury b. Cluster headache c. Migraine headache d. Meningeal inflammation
d. Meningeal inflammation The acute onset of neck stiffness and pain along with headache and fever occurs with meningeal inflammation. A severe headache in an adult or child who has never had it before is a red flag. Head injury and cluster or migraine headaches are not associated with a fever or stiff neck.
Crepitation is an audible sound that is produced by: A) roughened articular surfaces moving over each other. B) tendons or ligaments that slip over bones during motion. C) joints that are stretched when placed in hyperflexion or hyperextension. D) flexion and extension of an inflamed bursa.
roughened articular surfaces moving over each other.
The client's chief complaint is inability to move the fourth and fifth fingers during the nurse's interview. The nurse notes severe flexion in both of the affected fingers and upon palpation, but there are no complaints of pain from the client. The nurse would suspect which of the following conditions in this situation? 1. Dupuytren's contracture 2. Carpal tunnel syndrome 3. Bursitis 4. Osteoarthritis
1
The nurse is assessing a client with a suspected femur fracture. Which of the following findings would most support this diagnosis? 1. External rotation of the lower leg and foot 2. Internal rotation of the lower leg and foot 3. Limited hip internal rotation 4. Limited hip external rotation
1
The nurse is assessing cranial nerve XI (spinal accessory). Which of the following statements would the nurse say to the client? 1. "Shrug your shoulders and turn your head against my hand." 2. "Stick out your tongue and move it from side to side." 3. "Taste these foods and decide which is sweet and which is sour." 4. "Smell these items and identify what they are."
1
The nurse is assessing the client's nasal mucosa and notes the presence of a thin, watery discharge. The client complains of sneezing and nasal congestion. Based on this data, which does the nurse suspect? 1. Rhinitis. 2. Perforated septum. 3. Previous epistaxis. 4. Nasal polyps.
1
The nurse is interviewing a client that states he does not have any feeling on right side of the body. After confirmation of this subjective data, the nurse would correctly document which of the following? 1. Anesthesia 2. Analgesia 3. Hypalgesia 4. Hypoesthesia
1
The nurse is providing discharge instructions to the mother of a child admitted for fever of unknown origin. Which of the following statements, if made by the mother, would indicate the need for further instruction? 1. "I should use Tylenol or aspirin to bring down the temperature." 2. "I should contact the doctor if I cannot wake up my child." 3. "I should observe how much my child urinates." 4. "I should monitor my child's intake of fluids throughout the day."
1
The nurse notes an exaggerated lumbar curve while inspecting the spine of a client. The nurse would correctly document which of the following choices? 1. Lordosis 2. Scoliosis 3. Kyphosis 4. Flattened curve
1
The nursing is performing an otoscopic examination on an adult client and is unable to visualize the tympanic membrane. Which action by the nurse is appropriate in this situation? 1. Pull the pinna up and back, then reinsert the otoscope. 2. Tell the client to move away from the speculum if they experience any pain as the otoscope is advanced. 3. Reinsert the otoscope quickly and press against both sides of the inner auditory canal. 4. Pull the pinna down and back, then reinsert the otoscope.
1
The nursing student is planning to observe the registered nurse complete a focused interview on a client being admitted to the facility with complaints of leg pain. Which of the following statements by the student nurse indicates the need for further education? 1. "The focused interview will be guided by the physical assessment that was completed by the healthcare provider prior to admission." 2. "Subjective information is contained in the focused assessment." 3. "The age, gender, and past medical history of the client are used to guide the questions in the focused assessment." 4. "A focus interview on the musculoskeletal system is individualized for each client."
1
The nurse is discharging a client with osteoarthritis. Which of the following would the nurse include in the teaching plan? (Select all that apply.) 1. Obesity increases the risks of bone, muscle, and joint disorders. 2. Musculoskeletal health is influenced by the diet. 3. Exercise is important in the prevention of osteoarthritis. 4. Smoking and alcohol contribute to the development of osteoarthritis. 5. As the condition progresses the hands may develop contractures that resemble swan necks
1, 2, 3
The nurse is reviewing questions to include in a focused assessment on a client who has presented to the clinic with complaints of back pain. Which of the following questions should be included in the interview? (Select all that apply.) 1. "How long have you been experiencing this pain?" 2. "What activities seem to increase your pain?" 3. "Do any members of your family have neurological problems?" 4. "What things do you do to relieve your pain?" 5. "Are you able to perform your employment responsibilities since the pain began?"
1, 2, 3, 4, 5
The nurse is caring for a client with a knee injury. The nurse would correctly identify the knee as which of the following joint types? 1. Saddle 2. Hinge 3. Pivot 4. Plane
2
The student nurse is reviewing the cranial nerves. The student recognizes some of the nerves are exclusively sensory nerves. Which of the following cranial nerves belong to this group? (Select all that apply.) 1. Olfactory nerve (cranial nerve I) 2. Optic nerve (cranial nerve II) 3. Trochlear nerve (cranial nerve IV) 4. Trigeminal nerve (cranial nerve V) 5. Vestibulocochlear (cranial nerve VIII) 6. Facial nerve (cranial nerve VII)
1, 2, 5
During the focused interview, the client admits to regularly abusing cocaine. Which clinical manifestations support the regular use of cocaine? Standard Text: Select all that apply. 1. The nurse notes that the nasal septum has perforated. 2. Temporomandibular joint pain when the client opens and closes the mouth. 3. The septum is noted to be very pale in color. 4. Yeast infection of nasal mucosa and in mouth. 5. Difficulty swallowing water.
1, 3
The client comes to the medical office complaining of tinnitus and bilateral hearing loss. After reviewing the client's medical record, the nurse determines that recently prescribed medication could be the cause for the assessment data. Which medications in the medical record could be responsible for the client's assessment data? Standard Text: Select all that apply. 1. Streptomycin. 2. Steroid inhalers. 3. Aspirin. 4. Neomycin. 5. Acetaminophen.
1, 3, 4
The student nurse is assessing the client's lateral flexion. Which of the following instructions by the student to the client indicates the need for further instruction? (Select all that apply.) 1. "Tilt your head back and look at the ceiling." 2. "Lean your head to the side and attempt to touch your ear to your shoulder." 3. "Touch your chin to your chest." 4. "Attempt to raise your shoulders up toward your ears." 5. "Attempt to rotate your head in a circular manner."
1, 3, 4, 5
A client arrives in the emergency department with complaints of intermittent nosebleeds over the past two days. Which are priority assessments for the nurse to implement when providing care to this client? Standard Text: Select all that apply. 1. Request information from the client regarding increased propensity for bruising or bleeding. 2. Assess the tonsils for redness or swelling. 3. Obtain a blood pressure. 4. Check for deviated septum. 5. Request information from the client to determine if there was any recent thin, watery drainage from the nose.
1, 3, 5
The nurse is examining a client's ears and notes that right ear is occluded with wax. Which actions by the nurse are appropriate to facilitate removal of the cerumen from the client's ear? Standard Text: Select all that apply. 1. Irrigating with warm mineral oil, peroxide, and flushing with warm water. 2. Inserting a sharp instrument to break up the ear wax. 3. Irrigating with a cold solution. 4. Inserting a cerumen spoon to remove the wax. 5. Irrigating with warm sudsy water.
1, 4
The nurse is performing a neurological assessment and needs to test cranial nerves. The nurse asks the client to close both eyes and report when a touch with a wisp of cotton is felt. The nurse is assessing the function of which of the following cranial nerves? 1. Trigeminal nerve (cranial nerve V) 2. Abducens nerve (cranial nerve VI) 3. Facial nerve (cranial nerve VII) 4. Optic nerve (cranial nerve II)
1.
A client presents in the healthcare provider's office with complaints of headache and malaise. During the assessment, the nurse notes the client is experiencing severe pain when palpating behind the ears. Based on this data, which diagnosis does the nurse anticipate? 1. Sinusitis. 2. Mastoiditis. 3. Chronic allergies. 4. Anemia.
2
A young mother brings an infant to the pediatric clinic. The infant has had a fever and is pulling at the left ear. Based on this data, which disorder does the nurse suspect? 1. Sinusitis. 2. Otitis media. 3. Tonsillitis. 4. Otitis externa.
2
The client has been brought via ambulance to the emergency department (ED) following a motor vehicle accident. The nurse notes that the client's ear is draining clear fluid. Which is the priority nursing action? 1. Requesting information from the client regarding any chronic allergies. 2. Testing the drainage for glucose. 3. Asking the client if there have been recent middle ear infections. 4. Irrigating the ear with warm mineral oil or peroxide, and flushing with warm water.
2
The client's chief complaint is numbness and tingling in the hands when interviewed by the nurse. The client complains of numbness and tingling in the arms when bending the wrist downward and pressing the backs of the hands together. The nurse would suspect which of the following conditions in this situation? 1. Arthritis of the wrists 2. Carpal tunnel syndrome 3. Crepitus of the wrists 4. Dupuytren's contracture
2
The client's chief complaint is tenderness and stiffness in the wrist and elbow when interviewed by the nurse. The client reports the discomfort is worsened with activity. The nurse would suspect which of the following conditions in this situation? 1. Carpal tunnel syndrome 2. Osteoarthritis 3. Crepitus of the wrists 4. Dupuytren's contracture
2
The nurse is assessing cognitive function in a client who experienced a cerebral vascular accident. The nurse should focus on which of the following? 1. Ability to smell items while eyes are closed 2. Orientation to time, place, and person 3. Ability to walk with a smooth, steady gait 4. Ability to speak clearly
2
The nurse is assessing the tympanic membrane of a client and notes the presence of a darkened area. Based on this assessment data, which does the nurse suspect? 1. Acute otitis media. 2. Recent trauma. 3. Blocked Eustachian tubes. 4. History of frequent middle ear infections.
2
The nurse is interviewing a client with suspected Lyme disease. Which of the following questions would be a priority in this situation? 1. "When was your last seizure?" 2. "Have you been hiking or camping lately?" 3. "What has your temperature been running?" 4. "Do you have an appetite?"
2
The nurse is observing a client's ambulation abilities and notes a scissors gait. The nurse would suspect which of the following disorders in this client? 1. Parkinson's disease 2. Multiple sclerosis 3. Myasthenia gravis 4. Muscular dystrophy
2
The nurse is performing the Romberg test and asks the client to stand with the feet together and eyes closed. The nurse notes the findings are normal. Which of the following client responses occurred in this situation? The client: 1. Swayed from side to side 2. Had minimal swaying. 3. Felt moderately dizzy. 4. Had complete loss of balance.
2
The nurse is preparing to assess a client's spine for abnormalities. The nurse would ask the client to do which of the following steps to gather the most information with this assessment? 1. Sit down, then stand as the nurse looks from the front of the client. 2. Stand, bend forward slowly, then to the right and left while the nurse looks from the back. 3. Bend over, stand tall, and stretch arms over the head. 4. Sit down, then lean forward and dangle the arms at the sides of the body.
2
The nurse notes a child sitting in reverse tailor position during a well-child examination. The nurse would correctly choose which of the following actions in this situation? 1. Notify the healthcare provider so that X-rays can be obtained. 2. Explain to the parent that this can cause joint stress. 3. Continue with the examination. 4. Assess the child for back problems.
2
The nurse notes asymmetry of the iliac crests and gluteal folds while inspecting the spine of a client. The client's spine has a slight curvature to the right, but denies complaints of pain. The nurse would correctly document which of the following choices? 1. Kyphosis 2. Scoliosis 3. Spinal list 4. Lordosis
2
The client has developed anosmia. The nurse educates the client about the possible causes of this condition. Which topics are appropriate for the nurse to include in the teaching session with the client? Standard Text: Select all that apply. 1. Commonly associated with gingivitis. 2. Possibly linked to heredity. 3. Related to a diet deficient in zinc. 4. An indicator of a neurological problem. 5. Caused by dental caries.
2, 3, 4
The nurse is caring for an elderly client. The nurse would expect which of the following bone to occur with aging? (Select all that apply) 1. No bone changes are associated with aging 2. Reduced osteoblast production 3. Decreased calcium absorption 4. Reduction in bone density
2, 3, 4
The nurse assesses a client and finds that a grating sound is present when a joint is bent and straightened. The nurse would correctly document this finding as which of the following? 1. Subluxation 2. Grinding 3. Crepitation 4. Joint dislocation
3
The nurse educates the client about the major functions of the nose and sinuses. Which structure is specifically responsible for filtering, moistening, and warming air that enters the lower portion of the respiratory tract? 1. Olfactory cells. 2. Columella. 3. Turbinates. 4. Nares.
3
The nurse is admitting a client with a shoulder dislocation. The client tells the nurse that the healthcare provider has told her she has a dislocated shoulder. The client asks the nurse what this diagnosis means. The nurse would respond with which of the following statements? 1. "I cannot tell you without your healthcare provider's permission." 2. "You have a muscle tear at the shoulder." 3. "Your shoulder bone has come apart from the shoulder joint." 4. "Your shoulder is fractured and separated from the joint."
3
The nurse is planning a program to promote Healthy People 2020 focus areas relating to osteoporosis. Which of the following would appropriately serve as a primary prevention program? 1. The development of a program to address available medication therapies for the individual with osteoporosis. 2. Community screening programs to identify individuals who have early onset osteoporosis. 3. Community education programs to discuss methods that can be implemented to reduce the chance of developing osteoporosis. 4. The development of community support programs for individuals who have been diagnosed with osteoporosis.
3
The nurse notes swelling and tenderness of the olecranon process during palpation. The client's chief complaint is pain upon movement of the forearm and wrist. The nurse would correctly suspect which of the following conditions in this situation? 1. Arthritis 2. Bursitis 3. Epicondylitis 4. Crepitus
3
The nurse is caring for a client who was admitted to the medical unit. The healthcare provider states that the client's Romberg test is positive. In order to meet this client's elimination needs, which interventions will the nurse implement? 1. Allow the client to walk independently. 2. Obtain an order for a catheter. 3. Limit fluid intake. 4. Obtain a bedside commode.
4
The nurse is educating a group of adolescents about the risks of chewing tobacco. When describing the manifestation of oral cancer, which information will the nurse include? 1. Bleeding and inflamed gums. 2. Smooth and shiny tongue. 3. Red, swollen tonsils. 4. Ulcerations on the lip or under the tongue.
4
The nurse is examining a client with a chief complaint of pain in the right great toe. The nurse notes hardened nodules on the lateral aspect of the toe, as well as redness and swelling. The nurse would suspect which of the following? 1. Bunion 2. Synovitis 3. Hammertoe 4. Gout
4
The nurse is performing a focused interview with the client and asks the client if there has been any drainage from the ears. The client responds, "Yes." Which statement by the health care provider indicates that the client may have developed acute otitis media? 1. "The ear canal itself is really red, raw, and sore." 2. "I noticed that the drainage looked clear, like water." 3. "The drainage looks like what is draining from my nose, kind of clear and mucous-like." 4. "It is kind of yellowish-reddish color."
4
The nurse notes full range of motion against gravity with moderate resistance when assessing muscle strength of the upper extremities in a client. The nurse would correctly document which of the following choices? 0. Zero. 1. Trace 2. Poor 3. Fair 4. Good 5. Normal
4
Which of the following cranial nerves is being evaluated by this activity being demonstrated? (Moving the tongue) 1. Trigeminal nerve (cranial nerve V) 2. Facial nerve (cranial nerve VII) 3. Vagus nerve (cranial nerve X) 4. Hypoglossal nerve (cranial nerve XII)
4
The nurse has assessed a client and notes diminished reflexes. The nurse would correctly document which of the following? 1. 4+/0-4+ 2. 3+/0-4+ 3. 2+/0-4+ 4. 1+/0-4+
4 0 no rsponse 1+ dimished 2+ normal 3+ brisk, above normal 4+ hyperactive
The divisions of the spinal vertebrae include: A) Cervical, thoracic, scaphoid, sacral, and clavicular. B) Scapular, clavicular, lumbar, scaphoid, and fasciculi. C) Cervical, thoracic, lumbar, sacral, and coccygeal. D) Cervical, lumbar, iliac, synovial, and capsular.
Cervical, thoracic, lumbar, sacral, and coccygeal.
While interviewing a client the nurse notes the client's eyes moving involuntarily. Which term will the nurse use to document this finding in the medical record? 1. Nystagmus. 2. Presbyopia. 3. Anosmia. 4. Polyneuritis.
Correct Answer: 1 Rationale 1: Nystagmus is an abnormal, involuntary eye movement. Rationale 2: Presbyopia is an eye disorder in which the individual loses the ability to see objects that are near. Rationale 3: Anosmia refers to the absence of the sense of smell. Rationale 4: Polyneuritis refers to nerve inflammation.
The nurse is providing education to a group of pregnant women. Which should the nurse stress as the greatest tool in the prevention of low-birth-weight babies? 1. Early prenatal care. 2. Eating a balanced diet. 3. Avoiding stress. 4. Regular exercise.
Correct Answer: 1 Rationale 1: Obtaining prenatal care is the most important activity a pregnant woman can engage in to aid in providing a positive outcome for an unborn child. Prenatal care will include screening for complications of pregnancy, education, and monitoring of health status. Rationale 2: A balanced diet is important during pregnancy but not all complications of pregnancy are nutrition related. Rationale 3: Avoidance of stress is beneficial during pregnancy but will not prevent the majority of pregnancy-related complications. Rationale 4: With monitoring and approval of the healthcare provider, regular exercise is beneficial to the pregnant woman. Exercise, however, does not prevent the greatest number of pregnancy-related complications.
The nurse performing reflex testing on a client uses the reflex hammer to gently strike the forearm about two inches above the wrist. Which reflex is the nurse assessing with this technique? 1. Brachioradialis. 2. Biceps. 3. Triceps. 4. Achilles.
Correct Answer: 1 Rationale 1: The brachioradialis reflex is initiated by striking the forearm just above the wrist. Rationale 2: The biceps reflex is initiated by striking the biceps tendon, while the triceps reflex is initiated by striking just above the olecranon process. Rationale 3: The triceps reflex is initiated by striking just above the olecranon process. Rationale 4: The Achilles reflex is initiated by dorsiflexion of the foot and striking the Achilles tendon.
The nurse is performing a neurological assessment and needs to test cranial nerves. The nurse asks the client to close both eyes and report when a touch with a wisp of cotton is felt on their face. Which cranial nerve is the nurse assessing? 1. Trigeminal nerve (cranial nerve V). 2. Abducens nerve (cranial nerve VI). 3. Facial nerve (cranial nerve VII). 4. Optic nerve (cranial nerve II).
Correct Answer: 1 Rationale 1: The cranial nerve V (trigeminal nerve) is responsible for facial sensations and may be assessed by a wisp of cotton on the face. Rationale 2: The cranial nerve VI (abducens nerve) is related to muscle movement of the eye. Rationale 3: The cranial nerve VII (facial nerve) is related to facial movements and the sensation of taste. Rationale 4: The cranial nerve II (optic nerve) is related to vision
The nurse is reviewing the cranial nerves prior to a PRN shift on a neurological unit. Upon the review, the nurse notes that some of the nerves are exclusively sensory nerves. Which cranial nerves belong to this group? SATA 1. Olfactory nerve (cranial nerve I). 2. Optic nerve (cranial nerve II). 3. Trochlear nerve (cranial nerve IV). 4. Trigeminal nerve (cranial nerve V). 5. Facial nerve (cranial nerve VII).
Correct Answer: 1, 2 Rationale 1: The olfactory nerve is a sensory nerve and is responsible for the sense of smell. The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. The optic nerve is a sensory nerve responsible for vision. Rationale 2: The optic nerve is a sensory nerve responsible for vision. The cranial nerves may be classified by function. The nerves may be sensory, motor or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. The olfactory nerve is a sensory nerve and is responsible for the sense of smell. Rationale 3: The trochlear nerve is a motor nerve responsible for eye movement. The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. Rationale 4: The trigeminal nerve is a mixed nerve is responsible for sensory impulses from the lower eyelid, nasal cavity and palate. Motor actions of the trigeminal nerve involve teeth clenching and movement of the mandible. The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. Rationale 5: The facial nerve is a mixed nerve responsible for taste, facial movements, and the production of tears and salivary stimulation. The cranial nerves may be classified by function. The nerves may be sensory, motor or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities.
The nurse is preparing to conduct a focused interview on a client who is experiencing back pain. Which questions will the nurse include in this focused interview? Standard Text: Select all that apply. 1. "How long have you been experiencing this pain?" 2. "What activities seem to increase your pain?" 3. "Are your children physically active?" 4. "What things do you do to relieve your pain?" 5. "Are you receiving worker's compensation?"
Correct Answer: 1, 2, 4 Rationale 1: When investigating pain the nurse will need to assess characteristics of the pain, including duration. The focused interview is used to guide the physical assessment. The information obtained is considered in relation to norms and expectations for the system being reviewed. Rationale 2: Investigation of the pain will include information about factors associated with both activities that increase pain and those that relieve it. The focused interview is used to guide the physical assessment. The information obtained is considered in relation to norms and expectations for the system being reviewed. Rationale 3: Information regarding the activity of the client's children is not appropriate. The focused interview is used to guide the physical assessment. The information obtained is considered in relation to norms and expectations for the system being reviewed. Rationale 4: Activities that will relieve the pain should be included in the focused assessment. The focused interview is used to guide the physical assessment. The information obtained is considered in relation to norms and expectations for the system being reviewed. Rationale 5: The nurse does not need to know if the client is receiving worker's compensation in order to complete the assessment process. The focused interview is used to guide the physical assessment. The information obtained is considered in relation to norms and expectations for the system being reviewed.
The nurse is performing a neurological assessment and needs to assess for vibration, as well as sharp and dull sensation. Which objects will the nurse use to complete this assessment? Select all that apply. 1. Tuning fork. 2. Paper clip. 3. Safety pin. 4. Cotton ball. 5. Tongue blade.
Correct Answer: 1, 3, 4
The nurse is performing a neurological assessment on a client and needs to use stereognosis. Which instruction would the nurse provide for the client? 1. "Tell me if you feel one or two objects touching you with your eyes closed." 2. "Identify the object in your hand with your eyes closed." 3. "Identify the number being traced in your hand with your eyes closed." 4. "Open and close your hand each time I tell you to."
Correct Answer: 2 Rationale 1: Asking the client to identify the presence of objects touching them is not an example of stereognosis. Rationale 2: Stereognosis is the ability to identify an object without seeing it. It is illustrated by asking the client to identify objects placed in the hands with the eyes closed. Rationale 3: Asking the client to identify the presence of objects touching them is not an example of stereognosis. Graphesthesia is the ability to perceive writing on the skin. Rationale 4: Asking the client to open and close the hand may be used to assess the ability to follow commands to assess hand strength. This is not an example of stereognosis.
The nurse notes fanning of the toes when the sole of the foot is stimulated during assessment of the plantar reflex. Which is appropriate for the nurse to use when documenting this finding in the medical record? 1. Hyperreflexia. 2. Babinski response. 3. Brudzinski sign. 4. Nuchal rigidity.
Correct Answer: 2 Rationale 1: Hyperreflexia refers to a reflex that is abnormally strong. Rationale 2: The Babinski response is fanning of the toes with the great toe pointing downward when the sole of the foot is stimulated. This response is considered abnormal in adults. Rationale 3: Brudzinski sign refers to flexion of the legs and thighs when the neck is flexed and is an assessment used to confirm meningitis. Rationale 4: Nuchal rigidity refers to stiffness of the neck and is most often seen in meningitis.
The nurse is assessing a client that experienced a head injury using the Glasgow Coma Scale. Which findings are scored using the best motor response portion of the scale? Select all that apply. 1. No response with eyes to commands. 2. Abnormal flexion to pain. 3. Pupil response sluggish. 4. Abnormal extension to pain. 5. Pupils fixed and dilated.
Correct Answer: 2, 4 Rationale 1: No response with eyes to commands. This finding is for the eye opening portion of the scale. The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. Rationale 2: No verbal response. This finding is for the motor response portion of the scale. The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. Rationale 3: Pupil response sluggish. This finding is for the eye opening portion of the scale. The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. Rationale 4: No motor movement. This finding is for the motor response portion of the scale. The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. Rationale 5: Pupils fixed and dilated. This finding is for the eye opening portion of the scale. The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool.
The nurse is reviewing the history and physical on a client and notes a history of syncope. Based on this finding, which should the nurse implement for this client? 1. Soft diet. 2. Seizure precautions. 3. Fall precautions. 4. Intake and output.
Correct Answer: 3 Rationale 1: Dietary changes may be indicated for problems with chewing or swallowing but not for syncope. Rationale 2: Seizure precautions may be indicated for an individual with a seizure-related disorder but not for the presence of syncope. Rationale 3: Syncope is a sudden, brief loss of consciousness, and the nurse would need to provide safety for a client experiencing this condition. Rationale 4: Intake and output may be assessed for a variety of conditions but are not directly needed by the client experiencing episodes of syncope.
The nurse observes drainage from a client's ears after a head injury, and suspects a cerebral spinal fluid (CSF) leak. Which description of the fluid supports the nurse's suspicion? 1. Yellow without sediment. 2. Blood-tinged without sediment. 3. Clear, colorless. 4. Pink without sediment.
Correct Answer: 3 Rationale 1: Yellow drainage is not consistent with cerebral spinal fluid. It is important to recognize CSF as clear and colorless. Due to its appearance, it can be mistaken for normal drainage such as rhinorrhea. Rationale 2: Blood-tinged fluid is not consistent with cerebral spinal fluid. It is important to recognize CSF as clear and colorless. Due to its appearance, it can be mistaken for normal drainage such as rhinorrhea. Rationale 3: It is important to recognize CSF as clear and colorless. Due to its appearance, it can be mistaken for normal drainage such as rhinorrhea. Rationale 4: Pink drainage without sediment is not consistent with cerebral spinal fluid. It is important to recognize CSF as clear and colorless.
The nurse is interviewing a client who tells the nurse of experiencing decreased sensation on the left side of the body. After confirmation of this subjective data, which term will the nurse use when documenting this finding in the medical record? 1. Anesthesia. 2. Analgesia. 3. Hypalgesia. 4. Hypoesthesia.
Correct Answer: 4 Rationale 1: Anesthesia is the inability to perceive the sense of touch. Rationale 2: Analgesia is the absence of painful stimuli. Rationale 3: Hypalgesia is a decreased pain sensation. Rationale 4: Hypoesthesia is a decreased, but not absent, sensation.
The nurse notes that a client has difficulty with ambulation due to an unsteady gait. Which term will the nurse use to document this finding in the medical record? 1. Flaccidity. 2. Paralysis. 3. Hemiparesis. 4. Ataxia.
Correct Answer: 4 Rationale 1: Flaccidity refers to muscle tone. The flaccid body part is not toned but is limp. Rationale 2: Paralysis refers to the inability to move parts of the body. Rationale 3: Hemiparesis refers to a weakness on one side of the body. Rationale 4: Ataxia refers to the loss of balance or coordination.
The nurse is caring for a client experiencing vertigo and plans to perform the Romberg test during the assessment. Which instruction from the nurse regarding this test is the most appropriate? 1. "Touch your finger to your nose, alternating hands." 2. "Walk across the room by placing one foot in front of the other, heel to toes." 3. "Walk on your toes, then on your heels, then on your toes again." 4. "Stand with your feet together, arms at sides, and eyes open."
Correct Answer: 4 Rationale 1: Touching the finger to the nose with alternating hands is referred to as the finger-to-nose test and is used to assess coordination and equilibrium but is not the same as the Romberg test. Rationale 2: Walking across the room in this manner describes tandem walking. This technique is used to observe gait. Rationale 3: Walking in this manner enables the examiner to assess posture. The examiner should note the client's stance and the degree of stiffness or relaxation. Rationale 4: The Romberg test is used to assess coordination and equilibrium. During the test the client is asked to close her eyes. The degree of swaying demonstrated is evaluated.
When testing for muscle strength, the examiner should: A) observe muscles for the degree of contraction when the individual lifts a heavy object. B) apply an opposing force when the individual puts a joint in flexion or extension. C) measure the degree of force that it takes to overcome joint flexion or extension. D) estimate the degree of flexion and extension in each joint.
apply an opposing force when the individual puts a joint in flexion or extension.
Bundles of muscle fibers that compose skeletal muscle are identified as: A) fasciculi. B) fasciculations. C) ligaments. D) tendons.
fasciculi
