Physical Assessment Questions (1)
A nurse refers to the Glasgow Coma Scale when assessing a patient's level of consciousness. Place the following statements related to verbal response in the Glasgow Coma Scale in order from behaviors that support alertness to those that support unresponsiveness a. No response b. Oriented, converses c. Disoriented, converses d. Uses inappropriate words e. Makes incomprehensible sounds
ANSWER: B, C, D, E, A
Edrophonium IV is administered to a patient suspected of having myasthenia gravis. Within 30 seconds after administration of the edrophonium, the patient experiences a cholinergic reaction with increased muscle weakness, bradycardia, diaphoresis, and hypotension. The primary health-care provider prescribes atropine sulfate 1 mg IV STAT. The vial of atropine sulfate indicates 0.5 mg/mL. Calculate how many milliliters of atropine sulfate the nurse should administer. (WHOLE NUMBER) Answer:_________________mL
ANSWER: 2 mL Desired/Have 1 mg/0.5 mg = x mL/1 mL 0.5x = 1 mL x= 1/0.5 x=2 mL
A nurse is caring for a patient who had surgery for a hysterectomy 2 days ago. After reviewing the patient's medical record, which piece of data should cause the nurse the most concern? a. Respirations 10 breaths per minute b. Vomited after eating 6 ounces of soup c. IV infiltration in left hand d. Temperature: 99.4*F
ANSWER: A A respiratory rate of 10 or below is a concern. the patient is receiving hydromorphone, an opiod, which depresses the CNS. A respiratory rate is depressed when an opioid medication is excessive. The dose of hydromorphone may need to be reduced
Which of the following can cause urine to appear red? a. Beets b. Strawberries c. Red Food Dye d. Cherry gelatine
ANSWER: A Betacyanin, a pigment that gives beets their purplish red color, is excreted in the urine and feces of some people when it is nonmetabolized (a genetically determined trait) This bright red pigment turns the urine and feces red for several days after eating beets.
A nurse plans to take a patient's radial pulse. Which method of examination should be used by the nurse? a. Palpation b. Inspection c. Percussion d. Auscultation
ANSWER: A Palpation, the examination of the body using the sense of touch, is used to obtain the heart rate at a pulse site. When measuring a pulse, an artery is compressed slightly by the fingers so that the pulsating artery is held between the finger and a bone or firm structure
A patient is admitted to the emergency department with difficulty breathing. Which patient response identified by the nurse causes the most concern? a. Low pulse oximetry b. Wheezing on expiration c. Shortness of breath on exertion d. Using accessory muscles of respiration
ANSWER: A Pulse oximetry is a noninvasive procedure to measure the oxygen saturation of the blood. The expected value is 95% or more. If a patient's pulse oximetry result is low, the patient is hypoxic and needs medical interventioin.
Which nursing action is common to all instruments when taking a temperature? a. Ensure that the instrument is clean b. Place a disposable sheath over the probe c. Wash with cool soap and water after use d. Check that it is below ninety six degrees before insertion.
ANSWER: A This is an acceptable medical sepsis practice. All instruments, regardless of their type, must be clean before and after use.
A nurse is performing a psychosocial assessment. Which assessment should be identified as a subtle indicator of depression? a. Unkempt appearance b. Anxious behavior c. Tense posture d. Crying
ANSWER: A When people are depressed they frequently do not have the physical or psychic energy to perform the activities of daily living and often exhibit an unkempt appearance. A dishevelled, untidy appearance is a covert, subtle indication of depression.
A nurse must assess for the presence of bowel sounds in a postoperative patient. Which technique should the nurse employ to obtain accurate results when auscultating the patient's abdomen? a. Listen for several minutes in each quadrant of the abdomen b. Place a warmed stethoscope on the surface of the abdomen c. Perform auscultation before palpation of the abdomen d. Start at the left lower quadrant of the abdomen
ANSWER: C Bowel sounds are auscultated before palpation and percussion because these techniques stimulate the intestines and thus cause an increase in peristalsis and a false increase in bowel sounds
A nurse is assessing a patient who states "I feel cold." Which mechanism that helps regulate body temperature will increase body heat? a. Vasodilation b. Evaporation c. Shivering d. Radiation
ANSWER: C Shivering generates heat causing muscle contraction, which increases the metabolic rate by 100% to 200%
A nurse is assessing a patient's heart rate by palpating the carotid artery. Which action should the nurse implement when assessing a pulse at this site? a. Monitor for a full minute b. Palpate just below the ear c. Press gently while palpating the site d. Massage the site before assessing for rate
ANSWER: C The carotid artery should be palpated with a light touch to prevent interference to blood flow to the brain and stimulation of the carotid sinus that can cause a reflex drop in the heart rate.
Which method of examination is being used when the nurse's hands are used to assess the temperature of a patient's skin? a. Palpation b. Inspection c. Percussion d. Observation
ANSWER: a Gross temperature assessments (e.g., cold, cool, warm, hot) can be obtained by palpation. Palpation is the examination of the body using the sense of touch. Sensory nerves in the fingers transmit messages through the spinal cord to the cerebral cortex, where they are interpreted by the nurse.
A nurse is unable to palpate a patients brachial pulse. WHich pulse should the nurse assess to determine adequate brachial blood flow in this patient? a. Radial b. Carotid c. Femoral d. Popliteal
ANSWER: a The brachial artery splits (bifurcates) into the radial and ulnar arteries. When there is an adequate radial pulse, the brachial artery must be patent.
When evaluating the vital signs of a group of patients the nurse takes into consideration the circadian rhythm of body temperature. At which time of day is body temperature usually at it's lowest? a. 4 p.m. to 6 p.m. b. 4 a.m. to 6 a.m. c. 8 p.m. to 10 p.m. d. 8 a.m. to 10 p.m.
ANSWER: b Diurnal variations (circadian rhythms) vary throughout the day with the lowest body temperature usually occurring between 4 a.m. to 6 a.m. The metabolic rate is at it's lowest while the person is sleeping
A nurse is assessing a patient's bilateral pulses for symmetry. Which pulse site should not be assessed on both sides of the body at the same time? a. Radial b. Carotid c. Femoral d. Brachial
ANSWER: b It is unsafe to palpate both carotid arteries at the same time. Slight compression of both carotid arteries can interfere with blood flow to the brain. In addition, excessive compression of the carotid arteries can stimulate the carotid sinuses, which causes a reflex drop in the heart rate
A patient has a 101*F fever for the past 24 hours. How often should the nurse monitor the patient's temperature? a. Every 2 hours b. Every 4 hours c. Every 6 hours d. Every 8 hours
ANSWER: b This is an appropriate interval of time for routine monitoring of body temperature. It is frequent enough to identify trends in changes in the body temperature while limiting necessary assessments
A nurse is caring for a patient who is experiencing an increase in signs and symptoms associated with multiple sclerosis. Which term describes a recurrence of signs and symptoms associated with a chronic disease? a. Variance b. Remission c. Adaptation d. Exacerbation
ANSWER: d An exacerbation is the period during a chronic illness when signs and symptoms reappear after a remission or absence of symptoms
A nurse identifies that a patient with a fever has cool skin. Which additional signs confirm the onset (cold or chill phase) of a fever? SELECT ALL THAT APPLY a. Goosebumps on the skin b. Decreased shivering c. Cyanotic nail beds d. Flushed skin e. Sweating
ANSWER: A, C A-Contraction of the arrector pili muscles (goose bumps), an attempt by the body to trap air around body hairs, is associated with the onset phase (cold or chill phase) of a fever. During this phase, the body responds to pyrogens by conserving heat to raise the body's temperature and reset the body's thermostat C-Cyanosis of the nail beds occurs during the onset phase (cold or chill phase) of a fever. Vasoconstriction and shivering are the body's attempt to conserve heat.
A nurse in the clinic must obtain the vital signs of each patient via an electronic thermometer before patients are assessed by the primary health-care provider. Which patient characteristics indicate that the nurse should take the patient's temperature via rectal, rather than the oral, route? SELECT ALL THAT APPLY a. Mouth breather b. History of vomiting c. Presence of confusion d. Intolerance of the semi-fowler position e. seven-year-old child level of intelligence
ANSWER: A, C A-Mouth breathing allows environmental air to enter the mouth, which may result in an inaccurately low reading. To take an oral temperature the instrument must remain under the tongue of a closed mouth until the reading is obtained. This can take as little as several seconds (electronic thermometers) or as long as 3 to 4 minutes (plastic thermometers) C-Taking oral temperature when a patient is confused is unsafe. A patient who is confuse may bite down on an oral thermometer and cause injury to the mouth
A patient with hypertension is given discharge instructions to take the blood pressure every day. A nurse is evaluating a family member taking the patient's blood pressure as part of the patient's discharge teaching plan. Which behaviors indicate that the family member needs additional teaching? SELECT ALL THAT APPLY a. Positions the arm higher than the level of the heart b. Places the diaphragm of the stethoscope over the brachial artery c. Applies the center of the bladder of the cuff directly over an artery d. Releases the valve on the manometer so that the gauge drops 10 mm Hg per heartbeat e. Inserts the earpieces of the stehoscope into the ears so they tilt slightly backward
ANSWER: A, D, E A-A blood pressure should be taken with the arm supported at the level of the heart. If the arm is above the level of the heart, the blood pressure reading will be inaccurately decreased, and if the arm is below the level of the heart or not supported, the blood pressure reading will be inaccurately increased D-This may result in an inaccurate reading. The valve on the manometer should be opened to allow the gauge to drop 2 to 3 mm Hg per heartbeat E-The earpieces of the stethoscope should be placed into the ears so that they tilt slightly forward, not backward. This ensures that the openings in the earpieces of the stethoscope are facing toward the ear canal for uninterrupted transmission of sounds
A nurse is planning care for a patient who has intolerance to activity. Which is the FIRST assessment that should be made by the nurse? a. Range of motion b. Pattern of vital signs c. Impact on functional health patterns d. Influence on the other family members
ANSWER: B Activity intolerance is related to the inability to maintain adequate oxygenation to body cells, which is associated with respiratory and cardiovascular problems. Obtaining the vital signs (e.g. pulse, respirations, and blood pressure) will provide valuable information about these symptoms
The nurse must take a patient's rectal temperature. Which should the nurse do? a. Take the temperature for 5 minutes b. Wear gloves throughout the procedure c. Place the patient in the right lateral position d. Insert the thermometer 2 inches into the patient's anus
ANSWER: B Gloves, personal protective pieces of equipment, are the best way the nurse is protected from contracting or transmitting a pathogen
A nurse in the emergency department is engaging in an initial assessment of a patient. Which assessment takes priority? a. Blood pressure b. Airway clearance c. Breathing pattern d. Circulatory status
ANSWER: B Patient assessment must always be conducted in order of priority of needs. In an emergency, the ABCs of assessment are AIRWAY, BREATHING, and CIRCULATION. A clear airway is essential for life and therefore has priority
A nurse is assessing a postoperative patient for signs of hemorrhage. Which clinical manifestations are indicative of shock? SELECT ALL THAT APPLY a. Hyperemia b. Hypotension c. Irregular pulse d. Fast respirations e. cold, clammy skin
ANSWER: B, D, E
A patient has lost approximately 2 units of blood during a vaginal delivery. For which responses to this blood loss should the nurse assess this patient? SELECT ALL THAT APPLY a. Increased urinary output b. rapid shallow breathing c. Hypertension d. Tachycardia e. Bradypnea
ANSWER: B, D, E B-With a decrease in circulating red blood cells, the respiratory rate will increase to meet oxygen needs D-Tachycardia occurs with hemorrhage as the body attempts to bring more oxygen cells via the circulation E-Rapid breathing, not bradypnea, occurs with hemorrhage as the respiratory rate increases to meet oxygen needs
A nurse is teaching a cancer prevention community health class.. Which recommended cancer screening guideline for asymptomatic people not at risk for cancer should the nurse include? a. Pap smear annually for females 13 years of age and older b. Mammogram annually for women 30 years of age or older c. Colonoscopy at 50 years of age and every 10 years thereafter d. Prostate-specific antigen yearly for men 30 years of age and older
ANSWER: C A colonoscopy should be performed at age 50 and every 10 years thereafter. This is the age when the risk for colon cancer increases.
A nurse concludes that a patient is experiencing pyrexia. Which assessment precipitated this conclusion? a. Mental confusion b. Increased appetite c. Rectal temperature of 101*F d. Heart rate of 50 bpm
ANSWER: C A rectal temperature of 101*F (38.3*C) or oral temperature of 100*F (37.8*C) is a common human response that indicates pyrexia (fever)
Which assessment requires the nurse to assess the patient further? a. 18-year-old woman with a pulse rate of 140 after riding 2 miles on an exercise bike b. 50-year-old man with a BP of 112/60 mm Hg on awakening this morning c. 65-year-old man with a respiratory rate if 10 d. 40-year-old woman with a pulse of 88
ANSWER: C A respiratory rate of 10 is below the expected respiratory rate for an adult should be assessed further. The expected respiratory rate is 12 to 20 breaths per minute
The nurse is obtaining a patient's blood pressure. Which formation is most important for the nurse to document? a. Staff member who took the blood pressure b. Patient's tolerance to having the blood pressure taken c. Position of the patient if the patient is not in a sitting position d. Difference between palpated and auscultated systolic readings
ANSWER: C The patient's position when the blood pressure is measured may influence results. Generally, systolic and diastolic readings are lower in the horizontal than in the sitting position. There is a lower reading in the uppermost arm when a person is in a lateral recumbent position. A change from the horizontal to an upright position may result in a temporary decrease (5 to 10 mm Hg) in blood pressure; when this decrease exceeds 25 mm Hg systolic or 10 mm Hg diastolic, it is called orthostatic hypotension
Which is common to the collection of specimens for culture and sensitivity tests regardless of their source? a. Preservative media must be used b. Two specimens should be obtained c. Surgical asepsis must be maintained d. A morning specimen should be collected
ANSWER: C The results of culture and sensitivity tests are faulty and erroneous if the collection container or inappropriate collection technique introduces extraneous microorganisms that falsify and misrepresent results. Surgical asepsis (sterile technique) must be maintained
A nurse obtains the blood pressure of several adults. Which blood pressure result should cause the MOST concern? a. 102/70 mm Hg b. 140/90 mm Hg c. 125/85 mm Hg d. 118/75 mm Hg
ANSWER: C This blood pressure is within the parameters of stage 1 hypertension and the most concern. A systolic reading of 140 to 159 mm Hg or a Diastolic reading of 90 to 99 mm Hg indicates stage 1 hypertension.
A patient has a serious vitamin K definciency. For which clinical manifestations should the nurse assess the patient? SELECT ALL THAT APPLY a. Bone pain b. Skin lesions c. Bleeding gums d. Ecchymotic area e. Muscle weakness
ANSWER: C, D C-A disruption in the clotting mechanism of the body can result in bleeding. Vitamin K plays an essential role in the production of the clotting factors II (prothrombin), VII, IX, and X. D. An ecchymotic area is caused by extravasation of blood into skin or mucous membranes. In this patient's situation, it is caused by a disruption in the clotting mechanism of the body as a result of a vitamin K deficiency.
A nurse concludes that a patient has inadequate nutrition. Which patient adaptations support this conclusion? SELECT ALL THAT APPLY a. Presence of surface papillae on the tongue b. Reddish-pink mucous membranes c. Cachectic appearance d. Spoon-shaped nails e. Shiny eyes
ANSWER: C, D C-Cachexia is general ill health and malnutrition marked by weakness and excessive leanness (emaciation) D-Fingernails that curve inward like spoons can be caused by iron deficiency, vitamin B12 deficiency, or anemia
A nurse is interviewing a newly admitted patient. Which words used by the patient describe data associated with the defervescence phase (fever abatement, flush phase) of a fever? SELECT ALL THAT APPLY a. Cold b. Achy c. Warm d. Sweaty e. Thirsty
ANSWER: C, D C-Feeling warm is associated with the defervescence phase (fever abatement, flush phase) of a fever because of sudden vasodilation. D-Feeling sweaty occurs during the defervescence phase (fever abatement, flush phase) of a fever because of the body's heat loss response
Which physical examination method should a nurse use when assessing for borborygmi? a. Palpation b. Inspection c. Percussion d. Auscultation
ANSWER: D Auscultation is the process of listening to sounds produced by the body. It is performed directly by just listening with the ears or indirectly by using a stethoscope that amplifies the sounds and conveys them to the nurse's ears. Active intestinal peristalsis causes rumbling, gurgling, and tinkling abdominal sounds known as bowel sounds (BORBORYGMI)
When evaluating the vital signs of a group of patients the nurse takes into consideration the circadian rhythm of body temperature. At which time of day is body temperature usually at its highest? a. 12 a.m. to 2 a.m. b. 6 a.m. to 8 a.m. c. 4 p.m. to 6 p.m d. 8 p.m. to 10 p.m.
ANSWER: D Diurnal variations (circadian rhythms) vary throughout the day, with the highest body temperature usually occurring between 8 p.m. and midnight.
A nurse in the emergency department is caring for a patient who is diagnosed with hypothermia. The presence of which factor in the patient's history may have precipitated this condition? a. Heat stroke b. Inability to sweat c. Excessive exercise d. High alcohol intake
ANSWER: D Excessive alcohol intake interferes with thermoregulation by providing a false sense of warmth, inhibiting shivering and causing vasodilation, which promotes heat loss. In addition, it impairs judgement, which increases the risk of making inappropriate self care decisions
Which usually is unrelated to a nursing physical assessment? a. Posture and gait b. Balance and strength c. Hygiene and grooming d. Blood and urine values
ANSWER: D Ordering and assessing urine and blood values are not in the independent practice of nursing. These assessments are dependent or interdependent functions of the nurse and are covered by specific orders or standing orders, respectively
An adult patient's vital signs are: Oral temperature 99*F, pulse 88 bpm with a regular rhythm, respirations 16 breaths per minute and deep, and blood pressure 180/110 mm Hg. Which sign should cause concern? a. Pulse b. Respirations c. Temperature d. Blood Pressure
ANSWER: D The blood pressure is more than the expected systolic value of less than 120 mm Hg and a diastolic value less than 80 mm Hg and, out of the options p[resented, should cause the most concern. A blood pressure reading more than 160 or a diastolic reading more than 100 indicates stage II hypertension
A patient has an elevated temperature and reports feeling cold. Which additional physical changes should the nurse expect during the onset phase (cold or chill phase) of a fever? SELECT ALL THAT APPLY a. Restlessness with confusion b. Decreased respiratory rate c. Profuse perspiration d. Pale, cold skin e. Shivering
ANSWER: D, E D- Pale, cold skin occurs during the onset phase (cold or chill phase) of a fever because of vasoconstriction, which is an attempt to conserve body heat E- Shivering occurs during the onset phase (cold or chill phase) of a fever. Fever is caused by the release of inflammatory mediators (pyrogens) that cause the hypothalamus to reset the set point of temperature. When this happens the body feels cold and shivering occurs. Shivering involves muscle contractions that produces heat, which increases the temperature to the new hypothalamic set point.
A nurse is monitoring the status of postoperative patients. Which vital sign will change first when a postoperative patient has internal bleeding? a. Body temperature b. Blood pressure c. Pulse pressure d. Heart rate
ANSWER: d The initial stage of shock begins when baroreceptors in the aortic arch and the carotid sinuses detect a drop in the mean arterial pressure. The sympathetic nervous system responds by constricting peripheral vessels and increasing the heart and respiratory rates. During the compensatory stage of shock, the effects of epinephrine and norepinephrine continue with stimulation of alpha-adrenergic fibers causing vasoconstriction of vessels supplying the skin and abdominal viscera and beta-adrenergic fibers causing vasodilation of vessels supplying the heart, skeletal muscles, and respiratory system.