HEALTH ASSESSMENT FINAL

The normal respiration rate of a healthy adult is

12-20 bpm

Select the correct pulse force scale.

3+ = full, bounding 2+ = NORMAL 1+ = weak, thready 0= absent

The nurse is reviewing a patient's medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma?

7 or less

Orthostatic hypotension refers to

A decrease in BP when the patient stands up

In a response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information?

Alcohol can interact with all medications and make some diseases worse.

The nurse has used interpretation regarding a patient's statement or actions. What should the nurse do after using this technique?

Allow the patient time to confirm or correct the inference

A man is at the clinic for a physical examination. He states that he is "very anxious" about the physical examination. What steps can the nurse take to make him more comfortable?

Appear unhurried and confident when examining him

During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse recognizes this whining could indicate a problem with what structure?

Appendix

During an assessment, the nurse notices that a patient is handing a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate?

Ask the patient about the item and its significance

A 65-year-old patient with a history of heart failure comes to the clinic stating "I keep waking up from sleep with shortness of breath". Which action by the nurse is most appropriate?

Assess for other signs and symptoms of paroxysmal nocturnal dyspnea

A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. What technique should the nurse use to assess for a bruit?

Auscultate the thyroid with the bell of the stethoscope

The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct?

Avoid touching the nasal septum with the speculum

A 16 year old boy has just been admitted to the hospital for overnight observation after being in an automobile accident. What is the best approach for the nurse to use to communicate with him?

Be totally honest with him, even if the information is unpleasant

During an assessment of a 68-year-old man with the recent onset of right sided weakness, the nurse here's a blowing, swishing sound with the build a stethoscope over the left carotid artery. What does this finding indicate?

Blood flow turbulence

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. What should the nurse look for during an inspection of this child's mouth?

Bruising on the buccal mucosa or gums

When auscultating over a patient's femoral arteries, the nurse notices the presence of bruits on the left side. Which statement about bruits is accurate?

Bruits occur with turbulent blood flow, indicating partial occlusion of the artery.

Which critical thinking skill helps the nurse see relationships among the data?

Clustering related cues

The nurse is conducting an interview in an outpatient clinic and is using a computer to record data. Which are the best uses of the computer in this situation? (Select all that apply)

Collect the patient's data in a direct face-to-face manner, Type the data into the computer after the narrative is fully explored, Allow the patient to see the monitor during typing

A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional findings?

Color variation

During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. What does this finding indicate?

Crepitus

During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating "the specific and distinct knowledge, beliefs, customs, and skills acquired by members of a society" reflects which term?

Culture

The nurse is reviewing the characteristics of culture. Which statement is correct regarding the development of one's culture?

Culture is learned through language acquisition and socialization

The nurse percusses over the lungs of a patient with pneumonia. If the patient has atelectasis, what sound with the nurse hear?

Dullness

The nurse uses the profile sign during an assessment. What does this technique detect?

Early clubbing

After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of the concept of ethnicity with which statement?

Ethnicity pertains to a social group within the social system that claims shared values and traditions

The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment?

Examine the tender area last

During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse?

Fifth left intercostal space at the midclavicular line

The nurse is explaining to a student nurse the four areas in the body where lymph nodes are accessible. Which areas should the nurse include in her explanation to the student?

Head and Neck, arms, inguinal area, and axillae

A mother brings her newborn in for an assessment and ask, "Is there something wrong with the baby? His head seems so big. Which statement is true regarding the relative proportions of the head and trunk of the newborn?

Head circumference should be greater than chest circumference at birth

When reviewing the demographics of ethnic groups in the United States, the nurse recalls that which is the largest and fastest growing population?

Hispanics

During a mental status examination, the nurse wants to assess a patient's affect. Which question should the nurse ask?

How do you feel today?

The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane?

Hypomobility

When the nurse enters the room to begin a patient assessment, he/she knows that the first step is always

Inspection

The nurse is describing a weak, thready pulse on the documentation flowsheet. Which statement is correct?

Is hard to palpate, may fade in and out, and is easily obliterated by pressure.

A patient with a middle ear infection ask the nurse, "What does the middle ear do?" Which is the best response by the nurse?

It conducts vibrations of sound to the inner ear

A 13 year old girl is interested in obtaining information about the cause of her acne. What should the nurse include in the information about acne?

It is caused by increased sebum production

A female nurse is interviewing a male patient who is near the same age as the nurse. During the interview, the patient makes an overly sexual comment. Which is the best response by the nurse?

Make it clear that it is best to maintain a professional relationship and communicate that the nurse accepts the person and understands the need to be self-assertive, but sexual advances cannot be tolerated

A woman has just entered the emergency department after being battered by her husband. The nurse needs to get some information from her to begin treatment. What is the best choice for an opening phase of the interview with this patient?

Mrs. H., my name is Mrs. C. I'll need to ask you a few questions about what happened.

During an examination, the nurse can assess mental status by which activity?

Observing the patient and inferring health or dysfunction

During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This is an example of what behavior?

Obsessive compulsive disorder

During an assessment of the sclera of a black patient, the nurse would consider which of these an expected finding?

Pallor near the outer canthus of the lower lid

When examining the ear with an otoscope, how should the tympanic membrane look?

Pearly gray and slightly concave

A patient's abdomen is bulging and stretched in appearance. How should the nurse document this finding?

Protuberant

The nurse is preparing to do an otoscope exam on a 2-year-old child. Which one of these reflects the correct procedure?

Pulling the pinna down

The nurse is testing a patient's visual accommodation. How is accomodation assessed?

Pupillary constriction when looking at a near object

Which adjustment in the physical environment should the nurse make to promote the success of an interview?

Reduces noise by turning off televisions and radios

The nurse educator is preparing an education module on skin, hair, and nails for the nursing staff. Which of these statements about the epidermal layer of the skin should be included in the module?

Replaced every 4 weeks

A patient has been diagnosed with strep throat. The nurse is aware that without treatment, which complication may occur?

Rheumatic fever

A 42-year old woman states that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse confirms the presence of these "dots." How should the nurse document these findings?

Senile angiomas

Major risk factors for hypertension include which of the following:

Smoking, obesity, family history, stress

Percussion is used for what when assessing a client?

To assess underlying structures

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?

Tonsils 3+/1-4+ with large white spots

A female patient does not speak English well, and the nurse needs to choose and interpreter. Which of the following would be the most appropriate choice?

Trained interpreter

The nurse is performing in an abdominal assessment. What types of percussion notes can be heard during abdominal assessment?

Tympany, hyperresonance, and dullness

The nurse is performing an eye assessment on an 80- year old patient. Which of these findings is considered abnormal?

Unequal pupillary constriction in response to light

When using your hands to palpate a client, you should

Warn them , be slow and systematic

During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?

When part of the lung is obstructed or collapsed

During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate?

Whether the inversion is a recent change should be determined

During percussion, the nurse here's a dull percussion note elicited over a lung lobe. What is the most likely cause of this finding?

increased density of lung tissue

The nurse is evaluating a patient who is experiencing pain from kidney stones. The patient describes his pain as a sudden onset pain that in now getting better. Which phase of nociceptive pain is this patient likely in?

modulation

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include which findings?

muffled voice sounds and symmetrical tactile fremitus

The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding?

plantar reflex present (normal)

When performing a musculoskeletal assessment, what is the correct approach?

proximal to distal

During the taking of the health history, a patient tells the nurse that "it feels like the room is spinning around me." How should the nurse document this finding?

vertigo

The most important step that the nurse can take to prevent the transmission of microorganisms in the hospital setting is to:

wash hands before and after contact with each patient

After completing an assessment of a 60 year old white male with a family history of colon cancer, the nurse discusses with him the early detection measures for colon cancer. What should the nurse include in the instructions?

colonoscopy every 5 years

A 50 year old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurological examination?

complete neurological examination

A patient states, "I can hear a crunching or grating sound when I kneel." She also states that "it is very difficult to get out of bed in the morning because of stiffness and pain in my joints." The nurse should assess for signs of what problem?

crepitation

After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. What type of assessment data is this?

Objective

Which of these individuals would the nurse consider at highest risk for a suicide attempt?

Older adult man who tells the nurse that he is going to join his wife in heaven tomorrow and plans to use a gun

The nurse asks, "I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here." Based on this question, the nurse is at which phase of the interview process?

Opening/introducing the interview

The nurse is examining a patient's retina with an ophthalmoscope. Which finding is considered normal?

Optic disc that is yellow-orange color

The nurse would use bimanual palpation technique in which situation?

Palpating the kidneys and uterus.

The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations

Palpation

When assessing a patient's pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. What did these findings indicate?

Paradoxus

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?

Percuss and palpate the midline area above the suprapubic bone.

How should the nurse perform an exam of a 2-year-old child with a suspected ear infection?

Perform the otoscopic examination at the end of the assessment

A patient tells the nurse that he is very nervous, nauseous, and "feels hot." What type of assessment data is this?

Subjective

What data should the nurse collect during the interview portion of a health assessment?

Subjective data, physical data, historical data, objective data

The nurse is assessing a patient's pain. The nurse knows that the most reliable indicator of pain would be the

Subjective report

What does an individual who believes the magicoreligious theory of illness and disease believe is the cause of his or her illness?

Supernatural forces/witchcraft

The nurse is palpating a female patient's breast during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation?

Supine with the arms raised over the head

The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase

Takes time & reveals a surprising amount of information.

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. What should the nurse suspect?

Tension Headaches

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?

Test for Murphy's sign

A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, "It hurts so bad." Which pain assessment tool would be the best choice when assessing this child's pain

The Faces Pain Scale

The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response?

The infant turns his or her head to localize the sound

The nurse is assessing a patient with possible cardiomyopathy and assess the hepatojugular reflux. If heart failure is present, then the nurse should recognize which finding while pushing on the right upper quadrant of the patient's abdomen, just below the rib cage?

The jugular veins will remain elevated as long as pressure on the abdomen is maintained.

A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant of the possibility of fluid loss because of which of these factors?

The newborn's skin is more permeable than that of the adult

When taking a health history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of these would be the best question for obtaining this information?

do you have any warning signs before your seizure starts?

During an inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. What does the finding most likely indicate?

enlargement of the right ventricle.

When the nurse is testing the triceps reflex, what is the expected response?

extension of the forearm

A new mother calls the clinic to report that part of her left breast is red, swollen, tender, very hot, and hard. She has a fever of 38.3* C. She also has had symptoms of influenza, such as chills, sweating, and feeling tired. The nurse notices that she has been breastfeeding for 1 month. From her description, what condition does the nurse suspect?

mastitis

Which statement would be most appropriate when the nurse is introducing the topic of sexual relationships during a health interview?

often women have questions about their sexual relationship and how it affects their health. Do you have any questions?

The nurse is performing a neurological assessment on a 41 year old woman with a history of diabetes. When testing her ability to feel the vibrations of the tuning fork, the nurse noticed that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what should the nurse suspect?

peripheral neuropathy

The nurse is teaching a class on preventing osteoporosis to a group of perimenopausal women. Which of these actions is the best way to prevent or delay bone loss in this group?

physical activity, such as fast walking

When the nurse asks a 68 year old patient to stand with his feet together and arms at his sides with his eyes closed, he starts to sway and moves his feet farther apart. How should the nurse document this finding?

positive Romberg test

A 21 year old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes?

reflexes will be normal

During a general survey, the client appears older than stated. The nurse recognizes that this could be caused by

chronic illness

The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test?

To evaluate the adequacy of collateral circulation before cannulating the radial artery

What is the primary purpose of the ciliated mucous membrane in the nose?

To filter out dust and bacteria

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. What response by the nurse is appropriate?

"A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles."

A 35 year old woman is at the clinic for a gynecologic examination. During the examination, she asks the nurse, "How often so I need to have this Pap test done?" Which reply by the nurse is correct?

"After age 30, if you have 3 consecutive normal Pap tests, then you may be screened every 2 to 3 years."

When assessing the intensity of a patient's pain, which question by the nurse is appropriate?

"How much pain do you have now?"

The nurse is describing how to perform a testicular self examination to a patient. Which statement is most appropriate?

"If you notice an enlarged testicle or a painless lump, call your health care provider."

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?

"It prevents distortion of the bowel sounds that might occur after percussion and palpation."

Which statement indicates that the nurse understands the pain experienced by an older adult?

"Pain indicates pathology or injury and is not a normal process of aging."

A 45-year-old man is in the clinic for a routine physical examination. During the recording of his health history, the patient states that he has been having difficulty sleeping."I'll be sleeping great, and then I wake up and feel like I can't can't get my breath."Which is the best response by the nurse?

-"Do you have any history of problems with your heart?"

A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow with an irregular pattern, at a rate of 12 respirations per minute. The nurse interprets this respiration pattern as which of the following?

Hypoventilation

The nurse is assessing orientation in a 79 year old patient. Which of the responses would lead the nurse to conclude that this patient is oriented?

I know my name is John. I am at the hospital in Spokane. I couldn't tell you what date it is, but I know that it is February of a new year--2010.

The nurse is caring for a client who is very modest. The client asks the nurse to listen to her heart sounds over her shirt. Before continuing, the nurses best educational response would be?

I need to listen underneath your shirt to accurately hear your heart sounds

Pathologic pain develops by two main processes:

Nociceptive & Neuropathic

Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast?

I'm able to transfer myself from the wheelchair to the bed without help.

The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the documentation states that the radio pulses are 2+. The nurse recognizes that this reading indicates what type of pulse?

Normal

In an interview, the nurse may find it necessary to take notes to aid his or her memory. Which statement is true regarding note-taking?

Note-taking may impede the nurse's observation of the patient's nonverbal behaviors

The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history?

To provide a database of subjective information about the patient's past and current health

Which technique is correct when the nurse is assessing the radial pulse of a patient? The pulse is counted for:

1 minute if the rhythm is regular

How should the nurse document mild, slight pitting edema in the ankles of a pregnant patient?

1+/ 0-4+

The nurse is performing a physical assessment on a newly admitted patient. Which is an example of objective information obtained during the physical assessment?

2 × 5 cm scar on the right lower forearm.

During an abdominal assessment, the nurse is unable to hear battle sounds in a patient's abdomen. How long should the nurse listen before reporting absent bowel sounds?

5 minutes

When assessing muscle strength, the nurse observed that a patient has complete range of motion against gravity with full resistance. What grade of muscle strength should the nurse record using a 0-5 point scale?

5+

The nurse is auscultating the chess in an adult. Which technique is correct?

Use the diaphragm of the stethoscope held firmly against the chest.

During an examination, the nurse know that the best way to palpate the lymph nodes in the neck is described by which statement?

Using gentle pressure, palpate with both hands to compare the two sides

The nurse knows that which statement is true regarding the pain experienced by infants?

A procedure that induces pain in adults will also induce pain in the infant.

The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm?

A pulsating mass is usually present

The nurse is conducting a class for new graduate nurses. While teaching the class, what should the nurse keep in mind regarding what novice nurses, without a background of skills and experience from which to draw upon, are more likely to base their decisions on?

A set of rules

When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process?

A tongue that looks smoother in appearance

The nurse is preparing to teach a class on cardiovascular assessment. When explaining a thrill, what should the nurse include in the teaching?

A vibration that is palpable

The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for conducting nerve impulses to the brain from the organ of corti?

VIII

The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure?

Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber

The nurse is preparing to assess the ankle - brachial index of a patient. Which statement about the ABI is true?

An ABI of 0.9 to 0.7 indicates the presence of peripheral vascular disease and mile claudication

A 75 year old woman is at the office for a preoperative interview. The nurse is aware that the interview may take longer than interviews with younger people. What is the reason for this?

An aged person has a longer story to tell

The nurse is bathing an 80 year old man and notices that his skin in wrinkled, thin, lax, and dry. This finding would be r/t which factor in the older adult?

An increased loss of elastin and a decrease in subcutaneous fat

The nursing process is a sequential method of problem solving that nurses use and includes which steps?

Assessment, diagnosis, outcome identification, planning, implementation, and evaluation

When performing a genital examination on a 25 year old man, the nurse noticed deeply pigmented, wrinkled scrotal skin with large sebaceous follicles. On the basis of this information, how should the nurse proceed?

Consider this finding as normal, and proceed with the examination.

When assessing a patient's lungs, what should the nurse recall about the left lung?

Consists of two lobes

The nurse educator is preparing an education module on skin, hair, nails for the nursing staff. Which of the statements about the dermal layer of the skin should be included in this module?

Contains sensory receptors

A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse's best response?

Can you point to where it hurts?

In performing an assessment of a woman's axillary lymph system, the nurse should assess which of these nodes?

Central, lateral, pectoral, and subscapular

The nurse is performing an assessment on an adult. The adults vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next?

Consider this a delayed capillary refill time, and investigate further.

A 2-week old infant can fixate on an object but cannot follow a light or bright toy. What should the nurse do?

Consider this a normal finding

The nurse is conducting a heritage assessment. Which question is most appropriate for this assessment?

Do you mostly participate in the religious traditions of your family?

The nurse is obtaining a history from a 30 year old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient?

Do you perform testicular self-exams?

Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient?

Dark retinal background

What do the patient's record, laboratory studies, objective data, and subjective data combine to form?

Database

The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient?

Decreased ability to identify odors

Which is a normal finding when assessing the respiratory system of an older adult?

Decreased mobility of the thorax.

During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects what condition?

Dehydration

The physician comments that a patient has abdominal borborygmi . What is the best description of this term?

Hyperactive bowel sounds

When preparing for an examination, why would a nurse bring a gooseneck light into the examination room?

For tangential lighting to assess pulsations and body contour better

Blood pressure is the measurement of which of the following:

Force of blood pushing against the side of the vessel wall

The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status?

Gathering mental status information during the health history interview is usually sufficient

The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination?

Gathering mental status information during the health history/check consciousness

The nurse discovers speech problems in a patient during an assessment. The patient has spontaneous speech, but it is mostly absent or is reduced to a few stereotypical words or sounds. This finding reflects which types of aphasia?

Global

In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect?

Hyperreflexia

During a recent interview, a patient diagnosed with schizophrenia shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the content. What is the best description of this behavior?

Inappropriate affect

A patient states that the pain medication is "not working" and rates his postoperative pain at a 10 on a 1-to-10 scale. Which of these assessment findings indicates an acute pain response to poorly controlled pain?

Increased blood pressure and pulse

The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem?

Individual with shortness of breath and respiratory distress

What does the review of systems provide the nurse?

Information regarding health promotion practices

During ocular examinations, what should the nurse keep in mind regarding the movement of the extraocular muscles?

Is stimulated by CN's: III, IV, and VI

During an assessment of a 20 year old Asian patient, the nurse notices that he has dry, flaky, whte, cerumen in his canal. What is the significance of this finding?

It is normal to find, no further follow-up is necessary

A patient is newly diagnosed with benign breast disease. The nurse recognizes which statement about benign breast disease to be true?

It makes it more difficult to examine the breasts

During a follow-up visit, the nurse discovers that a patient has not been taking his insulin on a regular basis. The nurse asks, "Why haven't you taken your insulin?" Which statement is an appropriate evaluation of this situation?

It may put the patient on the defensive

The client comes to the clinic, stating that he/she is having pain. When examining the patient's history, the nurse notices multiple sclerosis. The nurse knows to expect what type of pain?

Neuropathic pain

The nurse needs to palpate the temporomandibular joint for crepitation. Where is this joint located?

Just below the temporal artery and anterior to the tragus

During an interview, the patient states he has the sensation that "everything around him is spinning" What part of the ear should the nurse recognize is responsible for sensation?

Labyrinth

The nurse noted from the medical record that the patient has a lesion that is confluent. What should the nurse expect to find upon examination?

Lesions that run together

A patient drifts off to sleep when she is not being stimulated. The nurse can easily arouse her by calling her name, but the patient remains drowsy during the conversation. What is the best description of this patient's level of consciousness?

Lethargic

When the nurse is auscultating the carotid artery for bruits, we should these statements reflects the correct technique?

Lightly apply the bell of the stethoscope over the carotid artery, and while listening, have the patient take a breath, exhale, and hold it briefly.

The nurse is preparing to auscultate for heart sounds. Which technique is correct?

Listen by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex.

During auscultation of breath sounds, the nurse to correctly use a stethoscope in which of the following ways?

Listen to at least one full respiration in each location

As the nurse auscultates his client, he prepares to listen with his stethoscope. Which of the following is true regarding auscultation with a stethoscope?

Listening to at least 1 full respiration in each location

A 68-year old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision is normal. What do these findings suggest?

Macular degeneration

The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which statement is true in relation to a newborn infant?

Maxillary and ethmoid sinuses are the only sinuses present at birth

The nurse is assessing a 75 year old man. What should the nurse expect when performing the mental status portion of the assessment?

May take a little longer to respond, but his general knowledge and abilities should not have declined.

During an assessment of an older adult, the nurse should expect to which finding as a normal physiologic change associated with the aging process?

Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure

The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease?

Person who has been on bed rest for 4 days

A patient tells the nurse that he is allergic to penicillin. What is the best response by the nurse?

Please describe what happens to you when you take penicillin.

In a patient who has anisocoria, what would the nurse expect to observe?

Pupils of unequal size

The nurse is examining a patient who is complaining of "feeling cold." Which is a mechanism of heat loss in the body?

Radiation

The nurse is percussion a client's thorax, he/she knows that percussion over areas of air causes a

Resonant sound

In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history?

Smoking, hypertension, obesity, diabetes, high cholesterol

What factors control Blood Pressure condition?

Smoking, obese, too much salt, lack of physical activity, stress, old age, gender

When examining a patient's CN function, what muscle should the nurse assess to assess the function of CN XI?

Sternomastoid and trapezius

When listening to a patient's breath sounds, the nurse is unsure of a sound that is heard. Which action should the nurse take next?

Validate the data by asking a coworker to listen to the breath sounds

A 19 year old woman comes to the clinic at the instance of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and and heavy black makeup. Which is an appropriate conclusion for the nurse to draw?

This is normal for her

During an examination, the nurse notes a supernumerary nipple just under the patient's left breast. The patient tells the nurse that she always thought it was a mole. Which statement about this finding is correct?

This variation is normal and not a significant finding

When observing a patient's verbal and nonverbal communication, the nurse notices a discrepancy. What action should the nurse take in this situation?

The nurse should focus on the patient's nonverbal behaviors because there are often more reflective of a patient's true feelings

The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true?

The outer layer of the eye is very sensitive to touch

The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true?

The right side of the brain interprets the vision for the O.D

When inspecting the anterior chest and an adult, the nurse should include which assessment?

The shape and configuration of the chest wall.

The nurse is reviewing the hot/cold theory of health and illness. Which statement best describes the basic tenets of this theory?

The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors of the body

A 70 year old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, "What causes these liver spots?" Which is the best response from the nurse?

They are clusters of melanocytes that appear after extensive exposure to sunlight

The nurse is listening to Bowel sounds. Which of these statements is true of bowel sounds?

They are usually high-pitched, gurgling, irregular sounds.

The nurse is providing instructions to newly hired graduates for the mini-mental status examination (MMSE). Which statement best describes this examination?

This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness

A 45-year old farmer comes in for a skin evaluation and complains of hair loss on his head. His hair seems to be breaking off in patches, and he noticed some scaling on his head. What does the nurse suspect?

Tinea capitis

In performing a voice test to assess hearing, which of these actions would the nurse perform?

Whisper a set of random numbers and letters, then ask the pt to repeat them

During an examination, the nurse finds that a patient has excessive dryness of the skin. How should the nurse document this finding?

Xerosis

The nurse notices a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. The nurse should expect the reading to

Yield a falsely high blood pressure

When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90°. What should the nurse recognize about this finding?

a normal finding in a healthy adult

A teenage girl has arrived reporting pain in her left wrist. She was playing basketball when she fell and landed on her left hand. The nurse examines her hand. Which finding would lead the nurse to expect a fracture?

a sharp pain that increases with movement

What does testing kinesthesia assess?

ability to sense motion of a joint or limb

To palpate the temporomandibular joint, where should the nurse place his or her fingers?

anterior to the tragus of the ear

The nurse suspects that a patient had carpal tunnel syndrome and wants to perform the Phalen test. What instructions should the nurse give the patient to perform this test?

ask the person to hold both hands back to back while flexing the wrists 90 degrees for 60 seconds

The nurse should use what test to check for large amounts of fluid around the patella?

ballottement

During the assessment of an 80 year old patient, the nurse noticed his hands show tremors when he reaches for something and his head is always nodding. No associated rigidity is observed with movement. Which of these statements is most accurate?

benign senile tremors occasionally occur.

Which of the following statements is true regarding the internal structures of the breast?

fibrous , glandular, and adipose tissue

During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. How do acutely infected nodes typically appear?

firm, but freely moveable

The nurse is preparing to palpate the rectum and should use which of these techniques?

flex the finger and insert slowly to the umbilicus

A nurse notices that a patient has abdominal ascites. What does this finding indicate?

fluid

What is the tissue that connects the tongue to the floor of the mouth called?

frenulum

A 70 year old woman tells the nurse that every time she gets up in the morning or after she's been sitting for a while she gets "really dizzy" and feels like she's going to fall over. What is the best response by the nurse?

get up slowly when you've been lying or sitting

The findings from the assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of the bed is elevated 45°. What does this finding indicate?

increased pressure in the right side of his heart.

The skills needed to be used for physical examination are:

inspection, palpation, percussion, auscultation

A 62 year old man states that his physician told him that he has an "inguinal hernia." He asks the nurse to explain what a hernia is. Which response by the nurse is best?

loop of bowel protruding through a weak spot in the musculature of abdominal wall

A woman who is 8 months pregnant comments that she has noticed a change in her posture and is having lower back pain. The nurse tells her that during pregnancy, women have a posture shift to compensate for the enlarging fetus. What is the term for this shift in posture?

lordosis

A patient has been diagnosed with osteoporosis and asks the nurse, "what is osteoporosis?" What is the best explanation by the nurse?

loss of bone density

The nurse is observing the auscultation technique of a student nurse. What is the correct method to use when progressing from one auscultatory site on the thorax to another?

side-to-side

During an examination, how would the nurse expect the cervical os of a woman who has never had children to appear?

small and round

The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding?

stereognosis

The nurse has completed the musculoskeletal examination of a patient's knee and has found a positive bulge sign. How does the nurse interpret this finding?

swelling from fluid in the suprapatellar pouch

When palpating the prostate gland through the rectum, which finding would the nurse recognize as abnormal?

tender to palpation

The mother of a 2-year-old toddler is concerned about the upcoming placement of tympanostomy tubes in her son's ears. The nurse would include which of these statements in the teaching plan?

the purpose of the tubes is to decrease the pressure and allow for drainage

An 85 year old patient comments during his annual physical examination that he seems to be getting shorter as he ages. Why does height decrease with aging?

the vertebral column shortens

What are the projections in the nasal cavity that increase the surface area called?

turbinates

When auscultating the lungs of an adult patient, the nurse notes that low pitch, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. How should the nurse interpret these findings?

vesicular breath sounds and are normal in that location.

During an assessment, the nurse knows that the patient apical impulses laterally displays and is palpable over a wide area. What does this finding indicate?

volume overload, as in mitral regurgitation.