Quiz #7 HA

An older patient asks the community health nurse if he/she needs blood pressure medication because the "top number of the blood pressure (BP) has been around 140." Which is the nurse's best response? A. "Let me talk to your health care provider about your BP." B. "It is normal for older adults to have an increased systolic BP." C. "What concerns you the most about needing to take BP medication?" D. "It is common to have BP variations due to metabolic changes as you get older."

B. "It is normal for older adults to have an increased systolic BP."

Neck rotation on each side should be: A. 120 degrees B. 70 degrees C. 10 degrees D. 45 degrees

B. 70 degrees

Which element of the assessment should be performed after assessment of the patient's back, posterior chest, and lungs? A. Weber test B. Palpation of apical pulse C. Palpation of posterior chest D. Inspection of spine and scapula

B. Palpation of apical pulse

Which elements are included in the assessment of the mouth and pharynx? A. Palpating the thyroid B. Testing the gag reflex C. Inspecting the septum D. Assessing the carotid pulse

B. Testing the gag reflex

The healthcare provider palpates the prostate gland and seminal vesicles with the patient standing as part of which element of the examination? A. Spinal B. Rectal C. Neurologic D. Abdominal/Genital

D. Abdominal/Genital

For which reflex is the normal response plantar flexion of the foot? A. Brachioradialis B. Patellar C. Triceps D. Achilles

D. Achilles

Which of the following is part of monitoring and care? A. Explain that no additional screening will ever be needed. B. Stay in the room while the patient is returning to street clothes. C. Keep the patient's glasses until they are back in street clothes. D. Ask the patient if she/he has any questions or concerns about the exam.

D. Ask the patient if she/he has any questions or concerns about the exam.

Palpation of the thyroid and cervical lymph nodes is included in examination of which part of the body? A. Eyes B. Neck C. Mouth D. Pharynx

B. Neck

Which of the following cranial nerves is assessed by observing the patient making specific facial movements? A. Cranial Nerve VII B. Cranial nerve XI C. Olfactory nerve D. Acoustic nerve

A. Cranial Nerve VII

A nurse is assessing a patient's neck with the patient seated. Which of the following is considered an unexpected finding? A. Jugular vein distention B. Midline trachea C. Lack of bruits in carotid arteries D. Thyroid symmetry bilaterally

A. Jugular vein distention

What would be included in the admission assessment for a patient using the FANCAPES tool? A. Skin turgor B. Skin integrity C. Albumin level D. History of falls E. Presence of incontinence

A. Skin turgor C. Albumin level E. Presence of incontinence

Which components are included in the functional assessment? Select all that apply. A. Social assessment B. Injury assessment C. Physical examination D. Evaluation of activities of daily living E. Comprehensive history

A. Social assessment C. Physical examination D. Evaluation of activities of daily living E. Comprehensive history

Which elements are included in the assessment of the hips of an adult patient? Select all that apply. A. Testing range of motion B. Palpating popliteal pulse C. Auscultating systematically D. Percussing for finger bone dullness E. Palpating for stability of joint

A. Testing range of motion E. Palpating for stability of joint

The home health nurse has made multiple visits to the home of a 78-year-old female patient and her daughter. Previous visits have been unremarkable. During this visit, which situations might lead the nurse to question the family's economic stability? Select all that apply. A. The house is stifling, and the air conditioner is turned off. B. The daughter asks how many home visits will be paid for by Medicare. C. Although warm, the house is clean with clear pathways to the bathroom. D. When questioned about meals, the patient replies that she has been eating only cereal. E. When reviewing the patient's medications, she states that she no longer needs her blood pressure medicine and has opted not to refill it.

A. The house is stifling, and the air conditioner is turned off. B. The daughter asks how many home visits will be paid for by Medicare. D. When questioned about meals, the patient replies that she has been eating only cereal. E. When reviewing the patient's medications, she states that she no longer needs her blood pressure medicine and has opted not to refill it.

An 88-year-old female is brought to her health care provider's office by her two children. The patient's husband has recently been moved to a nursing home. Her children are concerned about her withdrawal from the family and consistently staying in her room. In performing a social assessment, which questions would help the health care provider differentiate between an informal, a semiformal, and a formal support system? Select all that apply. A. Asking how often she visits with her family would relate to a semiformal support system. B. Determining which friends come to visit would be reflective of an informal support system. C. Asking about assistance from Health and Human Services would reflect a formal support system. D. Questions regarding participating in community activities would reflect a semiformal support system. E. Determining which sort of home health care the patient receives would reflect a semiformal support system.

B. Determining which friends come to visit would be reflective of an informal support system. C. Asking about assistance from Health and Human Services would reflect a formal support system. D. Questions regarding participating in community activities would reflect a semiformal support system.

On which elements should the nurse focus when performing the physical examination component of the functional assessment? Select all that apply. A. Determining caregiver's abilities B. Evaluating coordination and gait C. Assessing for dyspnea with exertion D. Asking about use of a cane or walker E. Measuring blood pressure while the patient is seated and standing

B. Evaluating coordination and gait C. Assessing for dyspnea with exertion E. Measuring blood pressure while the patient is seated and standing

Which element of the examination is best performed while the adult patient is reclining at 45 degrees? A. Testing range of motion of feet, ankles, and knees B. Inspecting jugular venous distention and pulsation C. Performing bimanual palpation of uterus and cervix D. Observing the patient move from lying down to a seated position

B. Inspecting jugular venous distention and pulsation

Which element of the assessment should be performed with the patient seated and wearing a gown? A. Percussion of the posterior chest B. Inspection of facial symmetry C. Auscultation of heart and lungs D. Palpation of axillary lymph nodes

B. Inspection of facial symmetry

Why is it important to have equipment and supplies organized before the exam? A. It makes you look smarter to the patient. B. It avoids interruptions and delays. C. In case you are out of a supply, you can skip that part of the exam. D. It lets you focus on the testing instead of the patient's response.

B. It avoids interruptions and delays.

What is the purpose of having the patient clench his teeth and smile? A. It tests two-point discrimination. B. It tests CN VII and lets you observe tooth occlusion. C. It tests the abdominal reflexes. D. It tests CN III, IV, and VI.

B. It tests CN VII and lets you observe tooth occlusion.

A geriatric nurse is preparing to assess an 85-year-old female for cognitive functioning. Which tool might be appropriate to use? Select all that apply. A. NSSQ B. MMSE C. SPMSQ D. Mini-Cog E. Family APGAR

B. MMSE C. SPMSQ D. Mini-Cog

A 78-year-old gentleman is brought to the emergency room with severe confusion. He has recently been discharged after treatment for congestive heart failure. The practitioner begins to perform a mental status exam, and the family questions why the practitioner is not looking at the condition of his heart. Which response would be the best response by the practitioner? A. "Currently, I am not concerned with the status of his cardiac system. B. "Well, as we all know, mental impairment is not a normal, age-related process. We need to determine which behaviors are impaired so we can provide proper interventions." C. "Since confusion is not a normal part of aging, we need to determine what issues are leading to his confusion. This mental health assessment will help us determine how we can best help." D. "Most older adults become confused at some point, should they live long enough. Before we begin to address his physical issues, we need him to calm down and cooperate with our examinations."

C. "Since confusion is not a normal part of aging, we need to determine what issues are leading to his confusion. This mental health assessment will help us determine how we can best help."

Which of the following is not included in a head-to-toe assessment? A. Near vision test B. Testing the spinal reflexes C. Exercise stress test D. Balance tests

C. Exercise stress test

Observing the patient's gait and testing balance are included in which element of the adult head-to-toe examination with patient standing? A. Spinal B. Abdominal C. Neurologic D. Musculoskeletal

C. Neurologic

In which arteries are bruits considered normal? A. Carotid arteries B. Temporal arteries C. Aortic artery D. None of the above

D. None of the above

During a home visit with an 89-year-old recently widowed male, which observations would be valuable in determining if the patient is depressed? A. Ability to recall events B. Awareness of environment C. Presence or absence of delusions D. Observations related to mood or affect E. General physical appearance, grooming, and hygiene

D. Observations related to mood or affect E. General physical appearance, grooming, and hygiene

Which element of the functional assessment should be included during the review of systems? A. Blood pressure B. Ability to bathe C. Neurologic function D. Signs of dementia

D. Signs of dementia

A nurse is inspecting the patient's ears with an otoscope. Which of the following findings would be considered normal? A. A small plastic bead B. Brownish black tympanic membrane C. Perforation of the tympanic membrane D. Small amount of cerumen

D. Small amount of cerumen