HEALTH ASSESSMENT

Which question with the nurse ask a patient according to the cage questionnaire to assess alcohol abuse?

" do you feel guilty about drinking?" " are you annoyed by those who criticize your drinking?" "Have you ever tried cutting down on your drinking?"

Statement made by the nurse indicating a correct understanding of physical examination positioning?

" while assessing a patient's heart, I'll ask the patient to assume the lateral recumbent position "

Which physical assessment technique involves the use of a stethoscope?

Auscultation

Which information would the nurse include in a teaching session to new orienting nurses about keeping a physical examination well organized?

Carry out painful procedures of the end of the examination

Which Determination would the nurse most likely be trying to make by asking a patient if there has been trauma to the nose?

Causes of septal deviation and asymmetry of the external nose

Which condition will cause a patient's nails to have a large angle and a softening of the nailbed?

Chronic deoxygenation problem

Which patient position promotes relaxation of abdominal muscles during a physical examination?

Dorsal Recumbent

Which characteristic of adventitious sounds heard louder during expiration?

Hi - pitch, continuous musical sounds

While assessing a victim of intimate partner violence, which common physical indicator with the nurse anticipate? Overmedicated Undermedicated Human bite marks Pain while urinating

Human bite marks

Tuberculosis statements made by patient

I am addicted to smoking I am losing weight unintentionally My grandfather suffered from TB

Which technique with the nurse used to assess the elasticity of the patient skin?

I grasping the skin of the forearm with the fingertips and releasing it

Which parents statement indicates successful teaching regarding care for a child who has frequent nosebleeds?

I should make my child sit up and lean forward when a nose bleed occurs

Which term describes a circumscribed elevated solid mass that is deep and firm with a diameter of 1 to 2 cm?

Nodule

Which factor causes body odor?

Poor hygiene and hyperhidrosis and bromhidrosis

Which pulse is difficult to palpating in a normal patient?

Popliteal pulse

Which function is the responsibility of the immune system and lymph nodes?

Protect the body from foreign antigens Remove damage cells from circulation Provide a partial barrier to malignant cell growth

Which sound is considered an adventitious (abnormal) breath sound?

Rhonchi, crackles, wheezes

For which reason with the nurse instruct the student nurse to avoid deep palpation during physical assessment?

Rib fractures

Which position is preferred for performing a rectal examination on a patient?

Sims'

Which characteristic of the skin is measured using the dorsum of the hand?

Temperature

Which parameter can be measured by lightly grasping the body part with the fingertips?

Turgor and elasticity

Which lesion is the result of a mosquito bite?

Wheal A wheal is a irregularly shaped, superficial localized edema that varies in size and is caused by a hive or a mosquito bite.

Which statement indicates a correct understanding of the difference between percussion and palpitation?

"Percussion is the use of only the fingers to vibrate the underlying tissues and organs, where as palpation involves the use of different parts of the hand to assess body parts."

At which distance in centimeters with the nurse directed patient to sit or stand during the assessment of extraocular movements?

60cm

At what angle with the nurse elevate the head of the examination table so that the patient is comfortable during the physical assessment?

30°

Pallor of the face, conjunctiva, nail beds, and palms of the hands is a finding that would alert the nurse to which condition in a patient?

Anemia

Which common imaginary line is observed in anterior and lateral chest landmarks?

Anterior auxiliary line

Which action with the nurse take while examining a child?

Ask a child's parents open ended questions

Which scale would be used to weigh in obese patient who had extensive surgery and is nonweightbearing for 24 hours?

Bed and chair

Which assessment finding is a clinical indicator of abuse in an older adult?

Bedsores, Excoriation on wrist or legs, hematomas at various healing stages

Which skin discoloration would alert the nurse to hypoxia?

Bluish

Which color of the lips indicates carbon monoxide poisoning?

Bright red

Which breath sounds heard only over the trachea and a healthy individual?

Bronchial

Which sounds are considered normal breath sounds?

Bronchial

Which type of breath sound is created by the air moving through the larger airways in a healthy individual?

Bronchovesicular

Which type of breath sound is usually created by the air moving to the larger airways in a healthy individual?

Bronchovesicular

Which I finding would alert the nurse that the patient is experiencing hyperthyroidism?

Bulging

What early discolorations of teeth would alert the nurse that the patient may be developing caries?

Chalky white

Which type of muscles do women commonly used to breathe?

Costal

Which sounds are heard over the right and left lung bases?

Crackles

Which sounds are heard over the right and left lung bases? Crackles Sibilant wheezes Sonorous wheezes Pleural friction rub

Crackles

Which sounds are only heard during inspiration?

Crackles

Which sounds most commonly auscultated at the basis of the lungs during inspiration?

Crackles

Which eye abnormality would be caused by a neuromuscular injury?

Crossed

The nurse would further assess for which condition when a patient's breath has a sweet and fruity odor?

Diabetic acidosis

Which statement is true about a pleural friction rub?

Dry or grating sounds are characteristics of pleural friction rub

Characteristics of pleural friction rub

Dry, rubbing or grating sound Does not clear with coughing Heard loudest over lower lateral anterior surface

Which area of the hand with the nurse use in palpating the liver?

Entire Palmar surface of the hand and Palmar surface of the fingers

Which action made by a nurse during psychological preparation of a patient before physical examination can limit the patient's communication ability?

Exhibiting a quiet, formal behavior

Which color is a normal tympanic membrane?

Gray

Which finding difference between an anterior and posterior thorax assessment?

Heart and breasts Anterior findings differ from posterior findings because of the presence of heart and female breast tissue in the anterior region. The ribs, sternum, and vertebral column may not be a reason for a difference between anterior and posterior findings.

Which information will the nurse use to guide the examination of a patient's integumentary system?

History of allergies, history of trauma to the skin, past medical history, medications used at home

Which alteration causes the patient to be unable to focus eyes on an object simultaneously, making the eyes looked crossed?

Impairment of extraocular muscles

Which finding indicates strabismus in a patient?

Inability to focus both eyes on an object simultaneously

Technique with the nurse use to assess the patient's thyroid gland?

Inspect the neck for the presence of obvious masses

Which assessment finding would the nurse observe in a patient who is nystagmus?

Involuntary and rhythmical oscillations of the eyes

Which rationale explains why a patient with congenital heart disease develops clubbing?

It is caused by insufficient oxygenation at the periphery

If the nurse suspects mucus accumulation in the lungs, which part of the lungs should be given attention when performing a physical exam?

Lower lobes

Which component of the air is located in the external region?

Mastoid

Which imaginary line is observed in the anterior chest landmark?

Midclavicular line

When examining a patient from behind, which anatomic chest wall imaginary line extends down from the center of the neck?

Midsternal

Which factor affects a patient's ability to assume various positions during a physical examination?

Mobility, physical strength, ease of breathing

Which area of the nose with the nurse assessed to determine evidence of a nosebleed?

Mucosa

The nurse palpated the tactile fremitus and detected abnormalities. The nurse suspects Accumulation of fluid in the lungs. Which tone in the patient would confirm the suspicion?

Normal tone

Which action during palpation made by the new nurse would require correction by the charge nurse? Palpates tender areas first Encourages the patient to take slow, deep breath's Ask a patient to point to more sensitive areas Warms hands before touching patient

Palpates tender areas first

Which technique is the nurse performing when using the sense of touch with the service of the hand to collect clinical data about a patient skin?

Palpation

Which assessment technique will the nurse use when examining a patient's head and neck?

Palpation and inspection

Which physical examination technique is used to measure length swelling?

Palpation using the pads of the fingers

Which physical examination technique is required when assessing a patient?

Palpitation and percussion and auscultation

Which behavioral finding would alert the nurse to possible older-adult abuse?

Physical and/or cognitive impairment

Which information with the nurse she was a young mother to help her quickly evaluate whether her child has a fever?

Place the back of the hand against the child's forehead

Which scale is used to weight infants?

Platform

Which Adventitious sounds are heard if there is an inflammation of the plural membrane?

Pleural friction rub

Which sounds are heard loudest over the anterolateral surface of the lung?

Pleural friction rub

Which term is used for an abnormal drooping of the lid over the pupil?

Ptosis

Which behavioral finding in children indicates possible abuse?

Regressed behavior

When the patient's urine smells of ammonia, which condition with the nurse assess for?

Renal failure and urinary tract infection

The patient reports having a sore throat, coughing, and sneezing. In a focused assessment, which finding supports the patients reported symptoms related to upper respiratory infection?

Retropharyngeal lymph nodes are enlarged and firm

Which body part is the best site for the nurse to inspect for jaundice?

Sclera

Which position can be well tolerated by the patient with respiratory difficulties while performing a physical assessment of the anterior thorax and lungs?

Sitting

Which position is appropriate to assess the posterior thorax?

Sitting

Which position would the nurse instruct the patient with a cough to assume for a proper physical examination?

Sitting

Which position is usually recommended when the nurse is assessing a patient's heart and lungs?

Sitting and dorsal recumbent

Risk factors for heart disease

Smoking Lack of Exercise Alcohol Ingestion

Which criterion is being measured by the nurse is the Palmer surface of his or her fingers (Finger pads) to palpate the skin?

Tenderness

Bronchovesicular

The bronchovesicular sounds are blowing sounds that are medium pitched and of medium intensity

Which statement regarding the lacrimal apparatus is true?

The nasal lacrimal duct sometimes blocks the flow of tears

Characteristics of the hair are associated with diabetes and thyroid -itis?

Thinning and alopecia

Which interpretation would the nurse make after observing a patient skin that lifts easily and falls immediately back to its resting position?

This indicates a normal skin finding

Which rationale explains the reason a nurse would ask a patient about snoring at night?

To identify septal deviation

At which location are low pitch (Ronchi) sounds heard?

Trachea and bronchi

Which location are low pitch sounds heard?

Trachea and bronchi

Which technique indicates the nurse has a correct understanding of using palpation to examine different areas of the body?

Use the Palmer surface of the hand to assess excursion of the thorax Use the pads of the fingertips to examine any swelling in the thyroid gland Use the entire Palmer surface of the hand to examine the size, shape, and tenderness of the liver.

Which cancer screening is recommended for a 30-year-old female patient?

Uterine and ovarian and endometrial

Examining a patient from behind, which anatomic chest wall imaginary line extends down the center of the neck?

Vertebral

Which type of normal breath sound is observed during a lateral thorax examination?

Vesicular

Vesicular breath sounds

Vesicular breath sounds are created by air moving through small airways

Which statement regarding the neck assessment is accurate?

Visual inspection and palpitation are included in the exam

Which lesion is an example of nodule?

Wart