NURS113-L4T1 Assessment

Spirituality is defined as: A. participating in religious services on a regular basis. B. a personal effort to find meaning and purpose in life. C. the process of being raised within a culture. D. a social group that claims to possess variable traits.

B Spirituality is a personal effort to find purpose and meaning in life. Religion refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe. Socialization is the process of being raised within a culture and acquiring the characteristics of that group. Ethnicity pertains to a social group within the social system that claims to possess variable traits.

The Doppler technique: A. is used to assess the apical pulse. B. augments Korotkoff sounds during blood pressure measurement. C. provides an easy and accurate measurement of the diastolic pressure. D. measures arterial oxygenation saturation.

B The Doppler technique may be used to locate peripheral pulse sites and for blood pressure measurement to augment Korotkoff sounds. A stethoscope is used to assess an apical pulse. The systolic blood pressure is more easily identified with the Doppler technique than the diastolic pressure. A pulse oximeter measures arterial oxygenation saturation.

The dorsa of the hands are used to determine: A. vibration. B. temperature. C. position of an organ. D. fine tactile discrimination.

B The dorsa (back) of hands and fingers are best for determining temperature because the skin is thinner than on the palms. The base of the fingers or ulnar surface of the hand is best for vibration. A grasping action of the fingers and thumb is the best way to detect the position, shape, and consistency of an organ or mass. The fingertips are best for fine tactile discrimination.

Most facial bones articulate at a suture. Which facial bone articulates at a joint? A Nasal bone B Mandible C Zygomatic bone D Maxilla

B The facial bones articulate at sutures (nasal bone, zygomatic bone, and maxilla) except for the mandible. The mandible articulates at the temporomandibular joint.

Which of the following pairs of sinuses is absent at birth, is fairly well developed between 7 and 8 years of age, and is fully developed after puberty? A Maxillary B Frontal C Sphenoid D Ethmoid

B The frontal sinuses are absent at birth, are fairly well developed between 7 and 8 years of age, and reach full size after puberty. The maxillary sinuses are present at birth and reach full size after all permanent teeth have erupted. The sphenoid sinuses are minute at birth and develop after puberty. The ethmoid sinuses are present at birth and grow rapidly between 6 and 8 years of age and after puberty.

Binaural interaction at the level of the brainstem permits: A interpretation of sound. B identification and location of the direction of the sound. C amplification of sound. D direction of sound toward the appropriate conduction pathway.

B The function at the brainstem level is binaural interaction, which permits locating the direction of a sound in space as well as identifying the sound.

Fine tactile discrimination is best achieved with the: A. opposition of the fingers and thumb. B. fingertips. C. back of the hands and fingers. D. base of the fingers.

B The grasping action of the fingers and thumb is used to detect the position, shape, and consistency of an organ or mass. The fingertips are best for fine tactile discrimination such as skin texture, swelling, pulsation, and presence of lumps. The dorsa (back) of hands and fingers are best for determining temperature because the skin is thinner than on the palms. The base of the fingers or ulnar surface of the hand is best for detecting vibration.

Which of the following is the most reliable indicator for chronic pain? A. Magnetic resonance imaging (MRI) results B. Patient self-report C. Tissue enzyme levels D. Blood drug levels

B The most important and reliable indicator for chronic pain is the patient's self-report. Chronic pain is transmitted on a cellular level, and current technology such as MRI cannot reliably detect this process. Chronic pain is transmitted on a cellular level, and current technology such as tissue enzyme levels cannot reliably detect this process. Chronic pain is transmitted on a cellular level, and blood drug levels cannot reliably detect this process.

When performing percussion, the examiner: A. strikes the flank area with the palm of the hand. B. strikes the stationary finger at the distal interphalangeal joint. C. strikes the stationary finger at the proximal interphalangeal joint. D. taps fingertips over bony processes.

B To perform percussion, the examiner strikes the stationary finger at the distal interphalangeal joint (just behind the nail bed).

Which of the following statements regarding the results obtained from use of the Snellen chart is true? A The smaller the denominator, the poorer the vision. B The larger the denominator, the poorer the vision. C The larger the numerator, the better the vision. D The smaller the numerator, the poorer the vision.

B Using the Snellen chart, the larger the denominator, the poorer the vision.

A common error in blood pressure measurement is: A. taking the blood pressure in an arm that is at the level of the heart. B. waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm. C. deflating the cuff about 2 mm Hg per heartbeat. D. using a blood pressure cuff whose bladder length is 80% of the arm circumference.

B Waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm will result in a falsely high diastolic pressure related to venous congestion in the forearm. The patient's arm should be positioned at the level of the heart when obtaining a blood pressure measurement. The cuff should be deflated at a rate of 2 mm Hg per heartbeat. The blood pressure cuff bladder length should be about 80% of the arm circumference.

If the tympanic membrane has white dense areas, the examiner suspects: A perforation from a ruptured membrane. B scarring from recurrent ear infections. C serous fluid from serous otitis media. D a fungal infection.

B White dense areas indicate scarring on the tympanic membrane from recurrent ear infections. Dark oval areas indicate perforation from a ruptured tympanic membrane. Air or fluid levels or air bubbles indicate serous fluid from serous otitis media. Black or white dots indicate a fungal infection.

Which statement is true for a patient who has pathology in Wernicke's area of the cerebrum? A) Receptive speech is affected B) The occipital lobe is involved. C) Vision processing is abnormal. D) An abnormal Romberg test is present.

Answer: A) Receptive speech is affected. The temporal, not parietal, lobe contains the Wernicke area, which is responsible for receptive speech and integration of somatic, visual, and auditory data.Vision processing occurs in the occipital lobe. The Romberg test is used to assess the equilibrium.

A 35-year-old client is admitted to the hospital for routine outpatient surgery. Before surgery, the nurse auscultates the client's chest for breath sounds. Identify the area where the nurse should expect to hear bronchovesicular breath sounds.

Bronchovesicular breath sounds are best heard next to the upper third of the sternum and between the scapulae. These breath sounds are equal in length during inspiration and expiration.

Which of the following statements describing a headache would warrant an immediate referral? A "This is the worst migraine of my life." B "This is the worst headache I've had since puberty." C "I have never had a headache like this before; it is so bad I can't function." D "I have had daily headaches for years."

C A sudden severe headache in an adult or child who has never had it before warrants an immediate referral. A sudden severe headache could indicate a subarachnoid hemorrhage.

When addressing a toddler during the interview, the health care provider should: A. ask the child, before the caretaker, about symptoms. B. use nonverbal communication. C. use short, simple, concrete sentences. D. use detailed explanations.

C A toddler's communication is direct, concrete, literal, and set in the present. The health care provider should use short, simple sentences with concrete explanations. For a younger child such as a toddler, the parent will provide all or most of the history. Nonverbal communication is the primary communication method for infants. Detailed explanations would be more appropriate for a school-age child, adolescent, or adult.

Risk factors that may lead to skin disease and breakdown include: A. loss of protective cushioning of the dermal skin layer. B. decreased vascular fragility. C. a lifetime of environmental trauma. D. increased thickness of the skin.

C Accumulating factors that place an aging person at risk for skin disease and breakdown include thinning of the skin, decrease in vascularity and nutrients, loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, social changes of aging, an increasingly sedentary lifestyle, and the chance of immobility. Aging results in the loss of protective cushioning of the subcutaneous layer of the skin. Aging results in decreased vascularity of the skin. Aging results in thinning of the skin.

What type of pain is short and self-limiting and dissipates after the injury heals? A. Chronic B. Persistent C. Acute D. Breakthrough

C Acute pain is short-term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals. Chronic pain lasts 6 months or longer; the pain persists after the predicted trajectory. Persistent pain is another term for chronic pain. Breakthrough pain starts again or escalates before the next scheduled analgesic dose.

A patient seeks care for "debilitating headaches that cause excessive absences at work." On further exploration, the nurse asks, "What makes the headaches worse?" With this question, the nurse is seeking information about: A. the patient's perception of pain. B. the nature or character of the headache. C. aggravating factors. D. relieving factors.

C Aggravating factors are determined by asking the patient what makes the pain worse. To determine the patient's perception of pain, the nurse would determine the meaning of the symptom by asking how it affects daily activities and what the patient thinks the pain means. The nature or character calls for specific descriptive terms to describe the pain. Relieving factors are determined by asking the patient what relieves the pain, what is the effect of any treatment, what the patient has tried, and what seems to help.

Which of the following tests provides a precise quantitative measure of hearing? A Tuning fork tests B Romberg test C Audiometer test D Whispered voice test

C An audiometer gives a precise quantitative measure of hearing by assessing the person's ability to hear sounds of varying frequency. The tuning fork tests (Weber and Rinne) are inaccurate and should not be used for general screening. The Romberg test assesses the ability of the vestibular apparatus in the inner ear to help maintain standing balance. The whispered voice test is nonquantitative; this test documents the presence of hearing loss but does not measure the degree of loss.

A nurse plans to assess a client's coordination and gate. The nurse ask the client to stand with feet together and eyes closed for 5-10 seconds without support. What assessment is the nurse using to test the client's coordination? A) Romberg B) Pronator Drift C) Weber test D) Point-to-Point movement

Answer: A) Romberg With the eyes open, three sensory systems provide input to the cerebellum to maintain truncal stability. These are vision, proprioception, and vestibular sense. If there is a mild lesion in the vestibular or proprioception systems, the patient is usually able to compensate with the eyes open. When the patient closes their eyes, however, visual input is removed and instability can be brought out. If there is a more severe proprioceptive or vestibular lesion, or if there is a midline cerebellar lesion causing truncal instability, the patient will be unable to maintain this position even with their eyes open. Note that instability can also be seen with lesions in other parts of the nervous system such as the upper or lower motor neurons or the basal ganglia, so these should be tested for separately in other parts of the exam. Pronator drift can indicate that the arm's motor control center on the opposite side of the brain isn't functioning properly. Weber test is for hearing. Point-to-Point movements does test for coordination by touching index finger to the nose several times.

While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). The nurse should document this sound as: A) S3 B) S1 C) PMI D) S4

Answer: A) S3. A third heart sound. S3 results from the impact of inflowing blood against a distended or incompliant ventricle in mid diastole. It is a low-frequency sound occurring ~120-150 msec after S2. To improve your chances of hearing an S3, roll the patient on his or her left side (the left lateral decubitus position) to swing the cardiac apex against the chest wall, bringing it closer to your stethoscope chest piece.

The nurse is palpating the precordial surface of an adult and notes a mild pulsation in the fifth intercostal space at the midclavicular line. What does this finding suggest to the nurse? A)This is a normal finding and the location of the point of maximum impulse (PMI) B)This is abnormal finding and needs to be reported immediately C)This is normal finding and the location of the pulmonic valve area D)This is a normal finding and the location of the tricuspid valve

Answer: A) This is a normal finding and the location of the point of maximum impulse (PMI). Mitral Area is located at the left ventricular area, 5th intercostal space at the midclavicular line. This is where you can find the Apical Pulse and usually can find the Point of Maximum Intensity (PMI). The Pulmonic Area is located at the second interspace to the left of the sternum. The Tricuspid Area is located at the right ventricular area, 4-5th interspace; lower half of the sternum.

What type of database is most appropriate when rapid collection of data is required and often compiled concurrently with lifesaving measures? A. Episodic B. Follow-up C. Emergency D. Complete

C An emergency database includes rapid collection of data often obtained concurrently with lifesaving measures. An episodic database is for a limited or short-term problem; this database concerns mainly one problem, one cue complex, or one body system. A follow-up database is used to follow up short-term or chronic health problems; the statuses of identified problems are evaluated at regular and appropriate intervals. A complete database includes a complete health history and a full physical examination; it describes the current and past health state and forms a baseline against which all future changes can be measured.

When preparing the physical setting for an interview, the interviewer should: A. set the room temperature between 64° F and 66° F. B. reduce noise by turning the volume on the television or radio down. C. conduct the interview at eye level and at a distance of 4 to 5 feet. D. stand next to the patient to convey a professional demeanor.

C Both the interviewer and the patient should be at eye level at a distance of 4 to 5 feet. The room temperature should be set at a comfortable level; a temperature between 64° F and 66° F is too cool. Turn off the television or radio and any unnecessary equipment to reduce noise. The interviewer and the patient should be comfortably seated; standing communicates haste and assumes superiority.

The CAGE test is a screening questionnaire that helps to identify: A. unhealthy lifestyle behaviors. B. personal response to stress. C. excessive or uncontrollable drinking. D. depression.

C CAGE is a screening questionnaire to identify excessive or uncontrolled drinking (C = Cut down; A = Annoyed; G = Guilty; E = Eye opener). The health history assesses lifestyle, including factors such as exercise, diet, risk reduction, and health promotion behaviors. Coping and stress management are assessed during the functional assessment of the complete health history. Depression is assessed during the review of systems and during the mental status assessment (mood and affect). The Geriatric Depression Scale, Short Form is an assessment instrument for use with older adults.

When inspecting the eyeballs of an African American individual, which of the following might the examiner expect to observe? A A slight misalignment of the eyeballs B A slight yellow discoloration of the sclera C Small brown macules on the sclera D A slight amount of drainage around the lacrimal apparatus

C Dark-skinned people may normally have small brown macules on the sclera.

When an otoscopic examination is performed on an older adult patient, the tympanic membrane may be: A pinker than that of a younger adult. B thinner than that of a younger adult. C whiter than that of a younger adult. D more mobile than that of a younger adult.

C During otoscopy, the tympanic membrane of an older adult may be whiter in color than that of a younger adult. The tympanic membrane may also appear more opaque and dull. A yellow-amber eardrum color occurs with otitis media with effusion. A red color occurs with acute otitis media. The tympanic membrane of an older adult may be thicker compared with that of a younger adult. Hypomobility is an early sign of acute otitis media.

Which of the following questions would the examiner ask to determine whether an individual has epistaxis? A "Do you have any difficulty with swallowing?" B "Have you ever noticed any unusual lesions on the inside of your mouth?" C "Do you experience nosebleeds?" D "Do you experience a runny nose frequently?"

C Epistaxis is the medical term for a nosebleed. Dysphagia is the medical term for difficulty swallowing. Rhinorrhea is the medical term for a runny nose.

The use of euphemisms to avoid reality or to hide feelings is known as: A. distancing language. B. sympathetic language. C. avoidance language. D. ethnocentric language.

C Euphemisms are used to avoid reality or to hide feelings. Using direct language is the best way to deal with frightening topics instead of using avoidance language. Distancing is the use of impersonal speech to put space between a threat and the self. Empathy means viewing the world from the other person's inner frame of reference. Empathy is therapeutic; sympathy is nontherapeutic. Ethnocentrism is the belief that one's ethnic or cultural group is more important or superior.

A 46-year old client is admitted for a rountine outpatient surgery. Before surgery, the nurse auscultates the client's chest for breath sounds. Identify the area where the nurse should expect to hear bronchiovesicular breath sounds? A) Upper third of the sternum and between the scapula. B) Midline to the umbilicus C) Largest lung surface area D) Over the trachea

Answer: A) Upper third of the sternum and between the scapula. Bronchiovesicular breath sounds are best heard next to the upper third of the sternum and between the sacpule. These breath sounds are equal in length during inspiration and expiration. They reflect a mixture of the pitch of the bronchial breath sounds heard near the trachea and the alveoli with the vesicular sound. Vesicular sounds are most commonly auscultated heard over the most of the lung surface, they are soft and low pitched with a rustling quality during inspiration and are even softer during expiration. Bronchial breath sounds can be auscultated over the trachea where they are considered normal, they are hollow, tubular sounds that are lower pitched.

A client asks the nurse, "What is the purpose of a physical examination?" Which response by the nurse is correct? Select all that apply. A) To supplement, confirm, or refute data obtained in the nursing history B) To obtain baseline data about the client's functional abilities C)To obtain data that will help establish nursing diagnoses and plans of care D) To determine if the client is telling the the truth about their health E)To evaluate the physiologic outcomes of health care and thus the progress of a client's health problem

Answer: A, B, C, E. These are some of the purposes of the physical examination: To obtain baseline data about the client's functional abilities; To supplement, confirm, or refute data obtained in the nursing history; To obtain data that will help establish nursing diagnoses and plans of care; To evaluate the physiologic outcomes of health care and thus the progress of a client's health problem; To make clinical judgments about a client's health status; To identify areas for health promotion and disease prevention; The nurse is not trying to determine if the client is being dishonest.

An 76-year old female client comes in the Emergency Department complaining of shortness of breath. When listening to the client's lungs, the nurse hears crackles during inspiration. What conditions might cause the nurse to hear crackles upon auscultation? Select all that apply. A) Acute respiratory distress syndrome (ARDS) B) Asthma C) Pneumonia D) Pulmonary edema E) Pectus Carinatum

Answer: A, C, D. Crackles are discontinuous, explosive, "popping" sounds that originate within the airways. They are significant as they imply either accumulation of fluid secretions or exudate within airways or inflammation and edema in the pulmonary tissue. Crackles, previously termed rales, can be heard in both phases of respiration. Early inspiratory and expiratory crackles are the hallmark of chronic bronchitis. Late inspiratory crackles may mean pneumonia, CHF, or atelectasis.

The night shift nurse reports that a client admitted with a COPD has normal capillary refill. What capillary refill time would the nurse expect to find if the client's refill time remains normal? A) 4-5 seconds B) 1-3 seconds C) 6-7 seconds D) 0-2 seconds

Answer: B) 1-3 seconds. The process whereby blood returns to a portion of the capillary system after its blood supply has been interrupted briefly. Capillary refilling is tested by pressing firmly on a fingernail and estimating the time required for blood to return after pressure is released. In a normal person with good cardiac output and digital perfusion, capillary refilling should take less than 3 seconds. A time of more than 3 seconds is considered a sign of sluggish digital circulation, and a time of 5 seconds is regarded as abnormal.

A nurse is assessing the muscle strength of a client admitted with right sided weakness. The nurse notes that there is slight mucsle movement, but no movement at the joint. How should the nurse document this assessment in the chart? A) 5/5: normal strength B) 1/5: muscle flicker, but no movement C) 3/5: movement possible against gravity, but not against resistance by the examiner D) 2/5: movement possible, but not against gravity

Answer: B) 1/5: muscle flicker, but no movement Patterns of weakness can help localize a lesion to a particular cortical or white matter region, spinal cord level, nerve root, peripheral nerve, or muscle. 0/5: no muscle movement 1/5: muscle flicker, but no joint movement 2/5: movement at the joint possible, but not against gravity 3/5: movement possible against gravity, but not against resistance by the examiner 4/5: movement possible against some resistance by the examiner , but less than normal 5/5: normal strength

The nurse has received shift report. Which client should the nurse assess first? A)Client with abdominal pain 4/10 on numeric scale, medication have been given B)Client with COPD whose oxygen saturation is 78% C)Client returning from a MRI with stable vital sign D)Client diagnosed with dehydration

Answer: B) Client with COPD whose oxygen saturation is 78% Airway - what could cause it to be blocked? Trauma, mucus, etc. One nursing dx is ineffective airway clearance. Breathing - anything having to do with the act of breathing -- respiration rate and depth (ineffective breathing pattern) or gas exchange in the lungs (ineffective gas exchange). Circulation - anything to do with the vascular system. Think bleeding, cardiac output, dehydration, fluid overload, etc. Decreased cardiac output, fluid volume deficit/excess, risk for bleeding. Then you go with Maslow's hierarchy for your prioritization. Pain before coping, food before love, etc.

A client comes to the clinic for a routine checkup. To check the client's gag reflex, the nurse should use which method? A) Have the client to cough B) Place the tongue blade lightly on the posterior aspect of the tongue C) Have client to place index finger in back of throat D) Place tongue blade lightly on the anterior aspect of the tongue

Answer: B) Place the tongue blade lightly on the posterior aspect of the tongue. A gag reflex can be elicited by mere light touching of the posterior wall of the oropharynx with a tongue blade. The patient should have immediate elevation of the palate, the muscles of the pharynx should constrict, and the patient should begin making gagging sounds indicating a normal gag reflex. If none of this happens the gag reflex has not returned. Having the client to cough, use their index finger, and placing tongue blade on anterior portion of the tongue does not allow the nurse to properly assess the gag reflex.

During a cardiovascular assessment the nurse notes that the client has a heart rhythm with a pause after each beat and a skip every third beat. What is the appropriate interpretation of these findings? A) Regular B) Regularly Irregular C) Atrial Fibrillation D) Irregularly Irregular

Answer: B) Regularly Irregular Regularly Irregular has a regular patterm overall with "skipped" beats. Regular is evenly spaced beats and may vary slightly with respiration. Irregularly Irregular is chaotic, with no real pattern, very difficult to measure rate accurately. Atrial fibrillation creates irregular, hectic signals for your heart.

A nurse is working in the clinic. A female client complains of tingling and numbness in hand and has been to weak to hold items in her hand. The nurse should use which assessment for carpal tunnel syndrome? A) Allen test B) Tinsel's Sign test C) Flexor Profundus test D) Collateral Ligament test

Answer: B) Tinsel's Sign test The nurse should use her middle finger or a reflex hammer to tap over the carpal tunnel. Pain, tingling, or electric sensations strongly suggest carpal tunnel syndrome. An Allen test is assess the radial/ulner arteries. Flexor Profundus test is to assess the flexor digitorum profundus of the finger. Collateral ligament testing is to assess the medial collateral ligament of the knee.

A nurse is conducting an physical assessment on a client's lungs. The nurse ask the client to say ninety-nine several times in a normal voice to feel vibrations that could suggest consolidation. What asasessment tests could the nurse perform using this method? Select all that apply. A) Egophony B) Bronchophony C)Tactile Fremitus D) Whispered Pectorilquy E) Diaphragmatic Excursion

Answer: B, C, D. Ask the patient to say "99" several times while auscultating the chest walls. Over consolidated areas "99" is understandable. This is because acoustic filtering is reduced in consolidated lung tissue, which allows better sound transmission. During auscultation, louder, clearer sounds are called bronchophony, the sound should be muffled and indistinct. You should only hear faint sounds or nothing at all with whispered pectorilquy, if you hear sounds clearly consolidation is present. Tactile fremitus uses the ball of the hand to feel vibrations transmitted through the airways to the lung. Increased tactile fremitus suggests consolidation of the underlying lung tissue.

A nurse is assessing a client in the Emergency Department with complaints of left shoulder pain. During range of motion, the client complained of increased pain. The nurse performs a Impingement sign test on the client to check the rotator cuff. The nurse must do which of the following to perform this test properly? A) Ask the client to slowly lower the arm after ROM B) Press firmly straight down with index finger or thumb C) Abduct the arm 90 degrees D) Palpate the scaphoid area

Answer: C) Abduct the arm 90 degrees Impingement sign test starts with the clients arm relaxed and the shoulder in the neutral rotation. Abduct the arm 90 degrees. Significant shoulder pain as the arm is raised suggests an impingement of the rotator cuff against the acromion. Asking the client to slowly lower the arm is the Drop arm test, if the client is unable to lower the arm slowly and smoothly the rotator cuff is torn. Pressing firmly straight down on the shoulder and palpating the scaphoid area is assessing for Snuffbox tenderness of the scaphoid.

The nurse is enters a client's room diagnosed with increased ICP. Upon, inspection the nurse notes the client in a flat supine position. The nurse knows that the best way to position the client with increased ICP is to? A) Keep the head of the bed flat. B) Maintain patient on the left side with the head supported on a pillow. C) Elevate the head of the bed to 30 degrees. D) Use a continuous-rotation bed to continuously change patient position

Answer: C) Elevate the head of the bed to 30 degrees. You should maintain the patient with increased ICP in the head-up position. Elevation of the head of the bed to 30 degrees enhances respiratory exchange and aids in decreasing cerebral edema. You should position the patient to prevent extreme neck flexion, which can cause venous obstruction and contribute to elevated ICP. Elevation of the head of the bed reduces sagittal sinus pressure, promotes drainage from the head through the valveless venous system in the jugular veins, and decreases the vascular congestion that can produce cerebral edema. However, raising the head of the bed above 30 degrees may decrease the cerebral perfusion pressure (CPP) by lowering systemic blood pressure. Careful evaluation of the effects of elevation of the head of the bed on the ICP is required.

A new nurse is being oriented to an orthopedic clinic. She hears a nurse report FABER test results to the physician after her assessment. The new nurse asked the experienced orthopedic nurse "What is a FABER test?" How should the experienced orthopedic nurse respond? A) "A FABER test reveals if their femur is broken." B) " Don't worry about that right." C) "That nurse is always trying to suck up to the physicians around here." D) " FABER stands for Flexion, ABduction, and External Rotation of the hip."

Answer: D) "FABER stands for Flexion, ABduction, and Extrenal Rotation of the hip." The experienced orthopedic nurse should explain what the test is and provide information on the assessment. During a FABER test the client should lie supine, place foot of the effected side on the opposite knee. Pain in the groin area indicates a problem with the hip and not the spine. Press down gently on the flexed knee and opposite anterior superior iliac crest. Pain in the sacroiliac area indicates a problem with the sacroiliac joints.

A patient admitted to the hospital with asthma has the following problems identified based on an admission health history and physical assessment. Which problem is a first-level priority? A. Ineffective self-health management B. Risk for infection C. Impaired gas exchange D. Readiness for enhanced spiritual well-being

C First-level priority problems are problems that are emergent, life-threatening, and immediate. Impaired gas exchange is an emergent and immediate problem. Third-level priority problems are problems that are important to the patient's health but can be addressed after more urgent health problems are addressed. Ineffective self-health management is an example of a third-level priority. Second-level priority problems are problems that are next in urgency; these problems require prompt intervention to forestall further deterioration. Risk for infection is an example of a second-level priority. Third-level priority problems are problems that are important to the patient's health but can be addressed after more urgent health problems are addressed. Wellness diagnoses are third-level priority problems.

Which of the following findings is associated with Horner syndrome? A Bilateral miosis B Bilateral mydriasis C A unilateral small regular pupil that reacts to light and accommodation D A unilateral dilated pupil with no reaction to light or accommodation

C Horner syndrome is caused by a lesion of the sympathetic nerve. An individual with Horner syndrome has a unilateral small regular pupil that reacts to light and accommodation. There is unilateral ptosis and absence of sweat on the same side.

An enlarged tongue (macroglossia) may accompany: A cleft palate. B hairy tongue. C Down syndrome. D fissured tongue.

C Macroglossia occurs with Down syndrome; it also occurs with cretinism, myxedema, and acromegaly. A transient swelling also occurs with local infections.

Each culture has its own healers who usually: A. speak at least two languages. B. own and operate specialty community clinics. C. cost less than traditional or biomedical providers. D. recommend folk practices that are dangerous.

C Most healers cost significantly less than healers practicing in the biomedical or scientific health care system. Most healers speak the person's native tongue. Most healers make house calls. Most health practices used by folk healers are not dangerous and are usually harmless.

Normal bowel sounds occur:

- 5 - 30 times a minute or - every 5 - 15 seconds

Listen for at least:

- 5 minutes in each quadrant before assuming bowel sounds r absent

Percuss for:

- air or - solids

Inspect the skin for:

- color - abnormalities - contour - tautness - abdomen for distension

To evaluate a client's cerebellar function, the nurse should ask:

1. "Do you have any problems with balance?"

To help assess a client's cerebral function, the nurse should ask:

1. "Have you noticed a change in your memory?"

The nurse is collecting data on a client who has a rash on his chest and upper arms. Which questions should the nurse ask in order to obtain more information about the client's rash?

1. "When did the rash start?", 2. "Are you allergic to any medications, foods, or pollen?", 4. "What have you been using to treat the rash?", 5. "Have you traveled outside of the country?"

The nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients with heart failure are? A) Pleural rub B) Stridor C) Wheezes D) Fine crackles

Answer: D) Fine crackles. Fine crackles are brief, discontinuous, popping lung sounds that are high-pitched. Crackles, previously termed rales, can be heard in both phases of respiration. Early inspiratory and expiratory crackles are the hallmark of chronic bronchitis. Late inspiratory crackles may mean pneumonia, CHF, or atelectasis. Pleural rubs are discontinuous or continuous, creaking or grating sounds. Because these sounds occur whenever the patient's chest wall moves, they appear on inspiration and expiration. Stridor is a loud, high-pitched crowing breath sound heard during inspiration but may also occur throughout the respiratory cycle most notably as a patient worsens. Stridor is caused by upper airway narrowing or obstruction. Causes of stridor are pertussis, croup, epiglottis, aspirations. Wheezes are adventitious lung sounds that are continuous with a musical quality.The proportion of the respiratory cycle occupied by the wheeze roughly corresponds to the degree of airway obstruction. Wheezes are caused by narrowing of the airways.

When assessing motor function of a patient admitted with a stroke, you notice mild weakness of the arm demonstrated by downward drifting of the extremity. How would you accurately document this assessment finding? A) Athetosis B) Hypotonia C) Hemiparesis D) Pronator drift

Answer: D) Pronator drift. Downward drifting of the arm or pronation of the palm is identified as pronator drift. Hemiparesis is weakness of one side of the body, hypotonia describes flaccid muscle tone, and athetosis is a slow, writhing, involuntary movement of the extremities. Athetosis is a continuous stream of slow, flowing, writhing involuntary movements. Hypotonia is the medical term for decreased muscle tone. Hemiparesis is weakness of the entire left or right side of the body.

A nurse asks a client to close her eyes, and then places a paper clip in the client's palm. The client correctly identifies the object. What neurological assessment did the nurse perform? A) Tactile discrimination B) Graphesthesia C) Extinction D) Stereognosis

Answer: D) Stereognosis Stereognosis is the act of recognizing objects by touching and manipulating them. Tactile discrimination is the ability to differentiate information received through the sense of touch. Graphesthesia is ability to feel writing on the skin. Extinction is failure to perceive touch on one side of the body when both sides are touched simultaneously. One- and two-point discrimination entail the ability to sense if one or two areas of the skin, respectively, are being stimulated by pressure.

The emergency department nurse obtains laboratory test results for a newly admitted client. Which result should she report to the physician immediately?

1. Cardiac troponin I level of 3.0 mcg/L

Which trait is the most important for ensuring that a nurse-manager is effective?

1. Communication skills

A 60-year-old client comes to the clinic seeking medical attention for a rash. The nurse assesses the rash and finds that the client's back and right side are covered with vesicles (elevated, round, blisterlike lesions that are filled with clear fluid). A vesicular rash may be associated with which conditions?

1. Contact dermatitis, 2. Herpes zoster, 3. Smallpox

A client is being discharged from the hospital after a total hip replacement. The physician has ordered home health services for the client. What's the most appropriate action for the nurse to take?

1. Contact the home health agency and provide a report of the client's condition and needs.

Which of the following planes divides the body longitudinally into anterior and posterior regions?

1. Frontal plane

All of the following components may be part of a client's medical record. Which one is the major source of subjective data about the client's health status?

1. Health history

The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling, and induration at the wound site. What do these signs suggest?

1. Infection

Order of abdominal assessment:

1. Inspect 2. Auscultate 3. Percuss 4. Palpate

When performing an abdominal assessment, the nurse should follow which examination sequence?

1. Inspection, auscultation, percussion, and palpation

The nurse is examining a client with suspected peritonitis. How does the nurse elicit rebound tenderness?

1. Pressing the affected area firmly with one hand, releasing pressure quickly, and noting any tenderness on release

A client undergoes a total abdominal hysterectomy. When checking the client 10 hours later, the nurse identifies which finding as an early sign of shock?

1. Restlessness

The nurse-manager asks the staff to decrease costs on the unit. Which practice would be the most beneficial in reducing costs?

1. Taking only necessary supplies into the clients' rooms

When routinely evaluating a client for any atypical signs or symptoms, the nurse should remember that:

1. aging can reduce the body's ability to regulate body temperature.

A client has lymphedema in both arms and the nurse must measure blood pressure using a thigh cuff. In reference to the client's baseline arm blood pressure, the nurse should expect the thigh to have a:

1. higher systolic blood pressure reading.

Vasodilation or vasoconstriction produced by an external cause will interfere with an accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should:

1. keep the client warm.

When auscultating a client's chest, the nurse assesses a second heart sound (S2). This sound results from:

1. opening of the mitral and tricuspid valves.

The nurse is caring for a client who has suffered a severe stroke. During data collection, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are:

1. progressively deeper breaths followed by shallower breaths with apneic periods.

The nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. When describing a healthy stoma, which statement should the nurse be sure to include?

2. "At first, the stoma may bleed slightly when touched."

The nurse has just received the shift report. Which client should the nurse assess first?

2. A 60-year-old client admitted with chronic obstructive pulmonary disease (COPD) whose oxygen saturation level is 84%

An 80-year-old client comes to the clinic complaining of shortness of breath. When listening to the client's lungs, the nurse hears crackles (intermittent, high- and low-pitched popping sounds in the lower bases of the lungs) during inspiration. In which conditions might the nurse auscultate crackles?

2. Acute respiratory distress syndrome, 3. Pneumonia, 4. Pulmonary edema

The nurse is obtaining a client's pulse rate. Which pulse feature should the nurse document?

2. Amplitude

The physician states that he'll refer his client to a home health agency after discharge from the hospital. When is the most appropriate time for a referral to be initiated for a hospitalized client?

2. As soon as the need is identified

Why should the nurse inspect first and then auscultate when collecting data on a pediatric client?

2. Because the child may cry as data collection proceeds, making auscultation difficult

Which reaction is a normal response to a corneal sensitivity test?

2. Blinking

A client has just undergone a bronchoscopy. Which nursing intervention is most important at this time?

2. Checking airway patency

After suctioning a tracheostomy, the nurse evaluates the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent?

2. Clear breath sounds and non-labored respirations

The nurse-manager has posted shift assignments on the unit. Which duty should the licensed practical nurse (LPN) refuse?

2. Conducting the admission assessment on a new client

The nurse is obtaining the health history of a client whose background differs from the nurse's. To develop culturally acceptable strategies for nursing care, the nurse should recognize which client factor?

2. Cultural influences

An elderly client who is 5' 4" and weighs 145 lb is admitted to the long-term care facility. The admitting nurse takes this report: The client sits for long periods in his wheelchair and has bowel and bladder incontinence. He is able to feed himself and has a fair appetite, eating best at breakfast and poorly thereafter. He doesn't have family members living near by and is often noted to be crying and depressed. He also frequently requires large doses of sedatives. Which factors place the client at risk for developing a pressure ulcer?

2. Incontinence, 3. Sitting for long periods of time, 4. Sedation

A 76-year-old client with no debilitating conditions belongs to which geriatric population?

2. Middle-old

A client reports abdominal pain. Which action would aid the nurse's investigation of this complaint?

2. Palpating the painful area last

A client comes to the clinic for a routine checkup. To check the client's gag reflex, the nurse should use which method?

2. Place a tongue blade lightly on the posterior aspect of the tongue.

A client states that he has 20/40 vision. Which statement about this client's vision is true?

2. The client can read from 20' (6 m) what a person with normal vision can read from 40'.

The nurse uses a stethoscope to auscultate a client's chest. Which statement about a stethoscope with a bell and diaphragm is true?

2. The diaphragm detects high-pitched sounds best.

The physician teaches a client about the need to increase her intake of calcium. At a follow-up appointment, the nurse asks the client which foods she has been consuming to increase her calcium intake. Which answer suggests that teaching about calcium-rich foods was effective?

2. Yogurt and kale

While collecting data on a newly admitted client, the nurse notes clear, thin nasal discharge. This type of nasal discharge may indicate:

2. cerebrospinal fluid leak.

The nurse is collecting data on a 47-year-old client who has come to the physician's office for his annual physical. The nurse should keep in mind that one of the first physical signs of aging is:

2. failing eyesight, especially close vision.

The ear canal of an adult:

2. slants downward.

When an emergency department nurse enters the room, the client complains that she's spitting up blood when she coughs. The nurse performs a quick review of the client's pertinent health history, which should include:

2. the history of the present problem, allergies, medications, and recent major operations.

Before a transesophageal echocardiogram, a client is given an oral topical anesthetic spray. Upon return from the procedure, the nurse observes that the client has no active gag reflex. In response, the nurse should:

2. withhold food and fluids.

The nurse is teaching a client about the safe use of an I.V. infusion pump that he'll require at home after discharge. Which statement by the client indicates the need for further teaching?

3. "If it shocks me, I'll wait 10 minutes before using it again."

An elderly client is scheduled for discharge from the hospital. Which statement by the client indicates that further teaching is needed?

3. "My daughter just recently waxed my hardwood floors."

The nurse measures a client's temperature at 102° F. What is the equivalent Centigrade temperature?

3. 38.9° C

When palpating the bladder of an adult client, the nurse should identify which finding as normal?

3. A nonpalpable bladder

The nurse is auscultating a client's chest. How can the nurse differentiate a pleural friction rub from other abnormal breath sounds?

3. A rub occurs during both inspiration and expiration and produces a squeaking or grating sound.

The nurse is preparing a client for surgery that's scheduled in 1 hour. During preparation, the client states that he doesn't understand the surgical procedure and wishes not to proceed with surgery. What action should the nurse take?

3. Ask the surgeon to speak with the client about his concerns before surgery.

To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), the nurse should palpate which pulse site?

3. Carotid

When inspecting a client's skin, the nurse finds a vesicle on the client's arm. Which description applies to a vesicle?

3. Circumscribed, elevated, and filled with serous fluid

The nurse is collecting data on a postoperative client. Which of the following should the nurse document as subjective data?

3. Client's description of pain

The nurse must check a client's splinted extremity for neurovascular damage. What should she do?

3. Compare the capillary refill of each extremity, making sure it's the same bilaterally.

When testing a client's pupils for accommodation, the nurse should interpret which findings as normal?

3. Constriction and convergence

When evaluating a client's body for warmth, the nurse should use which part of the hand?

3. Dorsal surface

Why shouldn't the nurse palpate both carotid arteries at the same time?

3. It may impair cerebral circulation

When checking the facial lacerations of a middle-aged client admitted to the facility 1 week ago, the nurse observes scabs around the lacerations. Scabs indicate which phase of wound healing?

3. Lag

At 8 a.m., the nurse collects data on a client who's scheduled for surgery at 10 a.m. During data collection, the nurse detects dyspnea, a nonproductive cough, and back pain. What should the nurse do next?

3. Notify the physician immediately of these findings.

To evaluate a client's posterior tibial pulse, where should the nurse palpate?

3. On the inner aspect of the ankle, below the medial malleolus

To evaluate a client's chief complaint, the nurse performs deep palpation. The purpose of deep palpation is to assess which of the following?

3. Organs

Which of the following correctly describes the anatomic position?

3. Palms are turned forward

A licensed practical nurse (LPN) is planning client assignments in a long-term care facility. Which task should she assign to another LPN?

3. Performing dressing changes

The physician orders contact precautions for a client with a draining wound. Which action should the nurse take to initiate these precautions?

3. Place an isolation cart containing gloves and gowns outside the client's room.

The nurse is monitoring a client for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use?

3. Potential for drug dependence

A client requests something to treat his constipation. The client's medication administration record contains an order for a laxative to be administered every other day as needed. Which assessment finding by the licensed practical nurse indicates the need to notify the registered nurse (RN) before administering the laxative?

3. Presence of blood in the client's stool

A client has been admitted to the hospital with signs of dehydration. Which action would be least beneficial in increasing the client's fluid intake?

3. Serving fluids in large amounts

A client comes to the clinic complaining of a sore throat and fever. To obtain a throat culture, the nurse asks the client to tilt his head back, open his mouth, and close his eyes. What should the nurse do next to obtain the specimen?

3. Swab the tonsillar areas from side to side, avoiding contact with the tongue, cheeks, and teeth.

The nurse plans to obtain client information from a primary source. Which of the following is a primary information source?

3. The client

A client with a recent history of a stroke has been discharged from the rehabilitation facility with a walker. During the client's return visit to the physician's office, the nurse assesses his gait. Which finding indicates the need for further teaching about walker use?

3. The client's arms are fully extended when using the walker.

Which of the following is the most common source of airway obstruction in an unconscious victim?

3. The tongue

The nurse correctly identifies which of the following as belonging to the dorsal cavity?

3. Vertebral canal

The nurse prepares to measure a client's blood pressure. What is the correct procedure for measuring blood pressure?

3. Wrapping the cuff around the limb, with the uninflated bladder covering about three-fourths of the limb circumference

The nurse is assessing an elderly client. When performing the assessment, the nurse should consider that one normal age-related change is:

3. diminished reflexes.

Tachycardia can result from:

3. fear, pain, or anger.

The nurse must evaluate skin turgor of an elderly client. While doing so, the nurse should remember that:

3. inelastic skin turgor is a normal part of aging.

When auscultating a client's abdomen, the nurse detects high-pitched gurgles over the lower right quadrant. Based on this finding, the nurse suspects:

3. nothing abnormal.

When examining a client with abdominal pain, the nurse should collect data on:

3. the symptomatic quadrant last.

A mother comes to the clinic with her 5-year-old son who's complaining of a fever and sore throat. The nurse documents the client's tonsils as 3+. This means they're:

3. touching the uvula.

A newly hired licensed practical nurse (LPN) is helping the charge nurse admit a client. The charge nurse asks the LPN if she understands the facility's rules of ethical conduct. Which statement by the LPN indicates the need for further teaching?

4. "I don't discuss advance directives unless the client initiates the conversation."

The nurse is collecting data on a client before surgery. Which statement by the client would alert the nurse to the presence of risk factors for postoperative complications?

4. "I've cut my smoking down from two packs to one pack per day."

A client complains of abdominal pain. To elicit as much information about the pain as possible, the nurse should ask:

4. "What does the pain feel like?"

When is the best time for the nurse to check a client for rebound tenderness?

4. At the end of the examination

Which pulse should the nurse palpate during rapid data collection of an unconscious adult?

4. Carotid

A client complains of lower abdominal pressure. The nurse notes a firm mass extending above the symphysis pubis. Which condition is the most likely cause of these findings?

4. Distended bladder

An elderly client tells the nurse that he doesn't want to take a bath. Which action by the nurse is most appropriate?

4. Explaining why a bath is important to overall health, and telling the client that she'll return in 30 minutes to help him bathe

A client comes to the clinic for diagnostic allergy testing. Why is an intradermal injection used for such testing?

4. Intradermal drugs diffuse slowly.

What should the nurse do before auscultating the lungs of a male client with chest hair?

4. Lightly wet the client's chest hair.

Why should an infant be quiet and seated upright when the nurse checks his fontanels?

4. Lying down and crying can cause the fontanels to bulge.

The nursing staff is devising methods to improve continuity of care. Which practice should they change to promote continuity of care?

4. Recorded shift report

Which statement regarding heart sounds is correct?

4. S1 is loudest at the apex, and S2 is loudest at the base.

The nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation by the nurse suggests that the client tolerated the activity without distress?

4. The client's pulse and respiratory rates increased moderately during ambulation.

Which statement about crackles is true?

4. They may be fine, medium, or coarse.

A child with rheumatic fever must have his heart rate measured while awake and while sleeping. Why are two readings necessary?

4. To compensate for the effects of activity on the heart rate

A client, age 75, is admitted to the facility. Because of the client's age, the nurse should modify data collection by:

4. allowing extra time for this task.

When collecting data on a geriatric client, the nurse expects to find various aging-related physiologic changes. These changes include:

4. delayed gastric emptying.

To avoid recording an erroneously low systolic blood pressure because of failure to recognize an auscultatory gap, the nurse should:

4. inflate the cuff at least another 30 mm Hg after the radial pulse becomes impalpable.

The nurse can auscultate for heart sounds more easily if the client is:

4. leaning forward.

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain, and venography reveals deep vein thrombosis (DVT). When checking this client, the nurse is most likely to detect:

4. left calf circumference 1" (2.5 cm) larger than the right.

An 82-year-old client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and hasn't been eating or drinking. When collecting data, the nurse would expect to find:

4. tachycardia.

The nurse is collecting data on a client who may be in the early stages of dehydration. Early manifestations of dehydration include:

4. thirst or confusion

The examiner notices a fine tremor when the patient sticks out his or her tongue. What disorder is consistent with this finding? A Hyperthyroidism B Diabetic ketoacidosis C Halitosis D Alcoholism

A A fine tremor of the tongue occurs with hyperthyroidism. A patient in diabetic ketoacidosis would have a sweet, fruity breath odor. Halitosis is a term used to describe any breath odor. A coarse tremor occurs with alcoholism.

To examine a toddler, the nurse should: A. allow the child to sit on the parent's lap. B. remove the child's clothing at the beginning of the examination. C. ask the child to decide whether parents or siblings should be present. D. perform the assessment from head to toes.

A A toddler should be sitting up on the parent's lap for the examination. An infant will not object to having clothing removed; a toddler does not like to take off his or her clothing. A school-age child has a sense of modesty; to maintain privacy, ask a child who is 11 or 12 years old to decide whether parents or siblings should be present. The sequence of the examination for a toddler should start with nonthreatening areas first; save distressing procedures such as assessment of the head, ears, nose, or throat for last.

Which of the following statements related to aggravating symptoms or triggers of headaches is true? A Alcohol consumption may precipitate the onset of cluster or migraine headaches. B Certain foods such as chocolate or cheese may precipitate the onset of tension headaches. C Premenstrual hormonal fluctuations may precipitate the onset of cluster headaches. D Poor posture may trigger a migraine headache.

A Aggravating symptoms or triggers for cluster headaches include alcohol consumption, stress, or wind or heat exposure. Aggravating symptoms or triggers for migraines include hormonal fluctuations, certain foods, letdown after stress, changes in sleep pattern, sensory stimuli, and changes in weather or physical activity. Aggravating symptoms or triggers for tension headaches include stress anxiety, depression, and poor posture.

Amplitude is: A. the intensity (soft or loud) of sound. B. the length of time the note lingers. C. the number of vibrations per second. D. the subjective difference in a sound's distinctive overtones.

A Amplitude is the intensity of sound. Duration is the length of time the note lingers. Pitch is the number of vibrations per second (high or low). Quality is the subjective difference owing to a sound's distinctive overtones.

The most appropriate introduction to use to start an interview with an older adult patient is: A. "Mr. Jones, I want to ask you some questions about your health so that we can plan your care." B. "David, I am here to ask you questions about your illness; we want to determine what is wrong." C. "Mr. Jones, is it okay if I ask you several questions this morning about your health?" D. "Because so many people have already asked you questions, I will just get the information from the chart."

A An older adult should be addressed by the last name; older adults may be offended by a younger person using their first names. The initial introduction should include the person's surname (unless a child) and the reason for the interview. "Mr. Jones, is it okay if I ask you several questions this morning about your health?" is a closed-ended question. "Because so many people have already asked you questions, I will just get the information from the chart" does not allow for free expression of ideas.

A funduscopic examination is an examination of the: A. inner ear. B. pharynx. C. internal structures of the eye. D. nasal turbinates.

A An ophthalmoscope is used for a funduscopic examination, which is an examination of the internal structures of the eye. An otoscope is used to visualize the ear canal and tympanic membrane. A flashlight or penlight and tongue depressor are used to examine the pharynx. An otoscope may also be used with a short, broad speculum to view the nasal turbinates and nares.

The location in the brain where optic nerve fibers from the temporal fields of vision cross over is identified as the: optic chiasm. fovea centralis. optic disc. choroid.

A At the optic chiasm, nasal fibers (from both temporal visual fields) cross over. The fovea centralis is the area of the retina that has the sharpest and keenest vision. The optic disc is the area in which fibers from the retina converge to form the optic nerve. The choroid is the middle vascular layer of the eye; the choroid has dark pigmentation to prevent light from reflecting internally and is heavily vascularized to deliver blood to the retina.

On examination of the mouth of an American Indian, the examiner notices the presence of a bifid uvula. How should this finding be interpreted? A This is an expected variation associated with this individual. B This condition is frequently associated with cleft palate. C This may indicate the presence of oral cancer. D This is rare and indicates other congenital anomalies may be present.

A Bifid uvula is a condition in which the uvula is split either completely or partially. This condition occurs in 18% of individuals in some American Indian groups. Bifid uvula may indicate a submucous cleft palate. Bifid uvula is not associated with oral cancer. The incidence of bifid uvula is common in American Indians.

Craniosynostosis is a severe deformity caused by: A premature closure of the sutures. B increased intracranial pressure. C a localized bone disease that softens, thickens, and deforms bone. D excess growth hormone or a deficit in thyroid hormone.

A Craniosynostosis is marked asymmetry that is due to a severe deformity caused by premature closure of the sutures and resulting in a long, narrow head. Hydrocephalus (obstruction of drainage of cerebrospinal fluid) results in excessive accumulation of cerebrospinal fluid, increasing intracranial pressure, and enlargement of the head. Paget disease (osteitis deformans) is a localized bone disease of unknown etiology that softens, thickens, and deforms bone. Acromegaly results from excessive secretion of growth hormone from the pituitary after puberty. Congenital hypothyroidism and myxedema are caused by thyroid hormone deficiency.

Decreased vision in an elderly patient may be due to which of the following conditions? A Macular degeneration B Retinoblastoma C Fixation D Presbyopia

A Decreased vision in elderly patients is most commonly caused by cataracts, glaucoma, or macular degeneration. Retinoblastoma is a malignant tumor of the retina that usually affects children younger than 6 years old. Fixation is a reflex direction of the eye toward an object attracting a person's attention; fixation is impaired by drugs, alcohol, fatigue, and inattention. The lens in an older adult loses elasticity and becomes hard and glasslike; this decreases the lens' ability to change shape to accommodate for near vision and is called presbyopia.

Deep palpation is used to: A. identify abdominal contents. B. evaluate surface characteristics. C. elicit deep tendon reflexes. D. determine the density of a structure.

A Deep palpation is used to identify abdominal contents. Light palpation is used to evaluate surface characteristics. Percussion with a reflex hammer is used to elicit deep tendon reflexes. Percussion is used to determine the density (air, fluid, or solid) of a structure by a characteristic note.

Assessment of self-esteem and self-concept is part of the functional assessment. Areas covered under self-esteem and self-concept include: A. education, financial status, and value-belief system. B. exercise and activity, leisure activities, and level of independence. C. family role, interpersonal relations, social support, and time spent alone. D. stressors, coping mechanisms, and change in past year.

A Functional assessment measures a person's self-care ability. The areas assessed under the self-esteem and self-concept section of the functional assessment include education, financial status, and value-belief system. These areas are related to the activity and exercise section of the functional assessment. These areas are related to the interpersonal relationships and resources section of the functional assessment. These areas are related to the coping and stress management section of the functional assessment.

What is the yin/yang theory of health? A. Health exists when all aspects of the person are in perfect balance. B. Health exists when physical, psychological, spiritual, and social needs are met. C. Health exists in the absence of illness. D. Health exists when there is optimal functioning.

A In the yin/yang theory, health is believed to exist when all aspects of the person are in perfect balance. In the hot/cold theory, health consists of a positive state of total well-being, including physical, psychological, spiritual, and social aspects of the person. The biomedical model of Western tradition views health as the absence of disease. In the biomedical or scientific theory, high-level wellness (or health) exists with optimal functioning of the human body.

Nonverbal communication is the primary form of communication for which group of individuals? A. Infants B. Preschoolers C. Adolescents D. Older adults

A Nonverbal communication is the primary communication method for infants. Preschoolers' communication is direct, concrete, literal, and set in the present. Adolescents should be treated with respect; the nurse should use open, honest, professional communication. Older adults may need special considerations related to physical limitations (e.g., adjusted pace to avoid fatigue, impaired hearing).

Which of the following is an example of objective data? A. Alert and oriented B. Dizziness C. An earache D. A sore throat

A Objective data is what the health professional observes; level of consciousness and orientation are observations. Subjective data is what the person says about himself or herself during history taking. Subjective data is what the person says about himself or herself during history taking. Subjective data is what the person says about himself or herself during history taking.

An example of an open-ended question or statement is: A. "Tell me about your pain." B. "On a scale of 1 to 10, how would you rate your pain?" C. "I can see that you are quite uncomfortable." D. "You are upset about the level of pain, right?"

A Open-ended questions and statements ask for narrative information; they state the topic to be discussed but only in general terms. "Tell me about your pain" encourages the person to respond in paragraphs and to give a spontaneous account in any order chosen. "On a scale of 1 to 10, how would you rate your pain?"; "I can see that you are quite uncomfortable"; and "You are upset about the level of pain, right?" are closed or direct questions. Closed or direct questions and statements ask for specific information. This type of question or statement will elicit a short, one- or two-word answer, a yes or no response, or a forced choice.

A flat macular hemorrhage is called a(n): A. purpura. B. ecchymosis. C. petechiae. D. hemangioma.

A Purpura is a flat, macular, red-to-purple hemorrhage that is a confluent and extensive patch of petechiae and ecchymoses greater than 3 mm. An ecchymosis is a hemorrhage that is greater than 3 mm. Petechiae are tiny punctate hemorrhages that are 1 to 3 mm; round and discrete; and dark red, purple, or brown caused by bleeding from superficial capillaries. Hemangiomas are vascular lesions caused by a benign proliferation of blood vessels in the dermis.

The tympanic membrane thermometer (TMT): A. provides an accurate measurement of core body temperature. B. senses the infrared emissions of the cerebral cortex. C. is not used in unconscious patients. D. accurately measures temperature in 20 to 30 seconds.

A The TMT accurately measures core body temperature. The TMT senses the infrared emissions of the tympanic membrane; the tympanic membrane shares the same vascular supply that perfuses the hypothalamus. The TMT is used with unconscious patients or patients in the emergency department, recovery areas, and labor and delivery units. The temperature is displayed in 2 to 3 seconds.

What information is included in greater detail when taking a health history on an infant? A. Nutritional data B. History of present illness C. Family history D. Environmental hazards

A The amount of nutritional information needed depends on the child's age; the younger the child is, the more detailed and specific the data should be. The health history is adapted to include information specific for the age and developmental stage of the child (e.g., mother's health during pregnancy, labor, and delivery and the perinatal period). The developmental history and nutritional data are important for current health of infants and children.

The external structure of the ear is identified as the: A auricle. B atrium. C aureole. D auriga.

A The auricle or pinna is the external structure of the ear. The atrium is the upper chamber of the heart.

The examiner should use handwashing instead of an alcohol-based hand rub: A. if the patient has an infection with Mycobacterium tuberculosis. B. if the patient has an infection with Clostridium difficile. C. if the patient has an infection with hepatitis B virus. D. if the patient is HIV positive.

A The examiner should use the mechanical action of soap-and-water handwashing when hands are visibly soiled and when patients are infected with spore-forming organisms (e.g., C. difficile or Bacillus anthracis). An alcohol-based hand rub would be effective against M. tuberculosis. An alcohol-based hand rub would be effective against hepatitis B virus. An alcohol-based hand rub would be effective against HIV.

Data collection for the general survey begins: A. at the first encounter. B. at the beginning of the physical examination. C. while taking vital signs. D. during the mental status examination.

A The general survey is initiated at the first encounter with the patient.

The lens of the eye functions as a: A refracting medium. B mediator of light. C sensory facilitator. D controller of intraocular pressure.

A The lens serves as a refracting medium, keeping a viewed object in continual focus on the retina. The muscle fibers of the iris function as the mediator of light. The cornea is very sensitive to touch. The intraocular pressure is determined by a balance between the amount of aqueous humor produced and resistance to its outflow at the angle of the anterior chamber.

What is the major cause of decreased saliva production in older adults? A Use of anticholinergic medications B Normal aging process C Decreased fluid intake D A diminished sense of taste and smell

A The major cause of decreased saliva flow is the use of medications that have anticholinergic effects. Normal aging is a secondary cause of decreased saliva flow. Decreased fluid intake is not the major cause of decreased saliva production in an older adult. Diminished sense of taste and smell associated with aging may decrease an older adult's interest in food and may contribute to malnutrition.

The components of a nail examination include: A. contour, consistency, and color. B. shape, surface, and circulation. C. clubbing, pitting, and grooving. D. texture, toughness, and translucency.

A The nails should be assessed for shape and contour, consistency, and color.

One of the purposes of the paranasal sinuses is to: A lighten the weight of the skull bones. B warm and moisten the inspired air. C amplify sound. D augment the sensory sensation of smell.

A The paranasal sinuses lighten the weight of the skull bones. Nasal mucosa and nasal turbinates warm, humidify, and filter the inhaled air. The paranasal sinuses serve as resonators for sound production. Olfactory receptors (responsible for the sensation of smell) are located in the nasal cavity and septum and merge into the olfactory nerve.

The position of the tympanic membrane in the neonate is more ________________, making it more difficult to visualize with the otoscope. A horizontal B vertical C perpendicular D oblique

A The position of the eardrum is more horizontal in the neonate, making it more difficult to see completely and harder to differentiate from the canal wall. By 1 month of age, the eardrum is in the oblique position similar to an older child, and examination is easier.

The "review of systems" in the health history is: A. an evaluation of past and present health state of each body system. B. a documentation of the problem as perceived by the patient. C. a record of objective findings. D. a short statement of general health status.

A The purpose of the review of systems is to evaluate the past and present health state of each body system, to double-check in case any significant data were omitted in the present illness section, and to evaluate health promotion practices. The reason for seeking care is a statement in the person's own words that describes the reason for the visit. This is typically known as a "chief complaint" or the reason for the health care visit. Objective data are the observations obtained by the health care professional during the physical examination. A short statement related to the patient's general health status is typically included in the complete physical assessment record.

A patient is admitted to the emergency department after a motor vehicle accident. The trachea is deviated to the left side. This finding is characteristic of: A right pneumothorax. B aortic arch aneurysm. C right pleural adhesion. D right-sided atelectasis.

A The trachea is normally midline; with a right pneumothorax, the trachea is deviated to the unaffected side (left). The trachea is pulled downward with systole of an aortic arch aneurysm. With a large right-sided pleural adhesion, the trachea is deviated to the affected side (right). With a large right-sided atelectasis, the trachea is deviated to the affected side (right).

Which of the following statements regarding language barriers and health care is true? A. There is a law that addresses language barriers and health care. B. Limited English proficiency is associated with a higher quality of care. C. English proficiency is associated with a lower quality of care. D. Patients with language barriers have a decreased risk of nonadherence to medication regimens.

A Title VI of the Civil Rights Act of 1964 provides people with limited English proficiency access to health care; these individuals cannot be denied health care services. Limited English proficiency is associated with a lower quality of care. English proficiency is associated with a higher quality of care. Patients with language barriers have an increased risk of nonadherence to medication regimens.

To determine if a dark-skinned patient is pale, the nurse should assess the color of the: A. conjunctivae. B. earlobes. C. palms of the hands. D. skin in the antecubital space.

A To detect pallor in a dark-skinned patient, the nurse should assess an area with the least pigmentation, such as the conjunctivae or mucous membranes.

What occurs during transduction (the first phase of nociceptive pain)? A. Pain signals move from the site of origin to the spinal cord. B. The pain impulse moves from the spinal cord to the brain. C. The brain interprets the pain signal. D. Chemical mediators are neutralized to decrease the perception of pain.

A Transduction is the first phase of nociceptive pain. During this phase, injured tissue releases chemicals that propagate the pain message; an action potential moves along an afferent fiber to the spinal cord. During transmission (the second phase), the pain impulse moves from the level of the spinal cord to the brain. The third phase is perception; the person has conscious awareness of a painful sensation. In phase four, modulation, the neurons from the brainstem release neurotransmitters that block the pain impulse.

What term refers to a linear skin lesion that runs along a nerve route? A. Zosteriform B. Annular C. Dermatome D. Shingles

A Zosteriform describes a lesion that has a linear arrangement along a nerve root. Annular describes a lesion that is circular and begins in the center and spreads to the periphery. A dermatome is an area of skin that is mainly supplied by a single spinal nerve. Shingles (herpes zoster) are small grouped vesicles that emerge along the route of a cutaneous sensory nerve, followed by pustules, and then crusts; shingles is caused by the herpes zoster virus.

Which of the following statements regarding cultural/racial differences in the treatment of pain is true? A. White individuals receive more analgesic therapy than black or Hispanic individuals with similar symptoms. B. Black and Hispanic individuals have been found to have a higher pain tolerance than white individuals. C. Pain modulation is more highly developed in black and Hispanic individuals. D. Neurotransmitters are more concentrated in white individuals than in black and Hispanic individuals.

A studies describe how black and Hispanic patients are often prescribed less analgesic therapy than white patients, although most of these differences are small. No evidence supports anything else.

When considering cultural competence, the nurse must develop knowledge of discrete areas to understand the health care needs of others. These discrete areas include understanding of: (Select all that apply.) A. his or her own heritage. B. cultural and ethnic values. C. the heritage of the nursing profession. D. the heritage of the patient. E. the heritage of the health care system.

A, C, D, E Discrete areas of knowledge for cultural competence include understanding of one's own heritage, the heritage of the nursing profession, the heritage of the patient, and the heritage of the health care system. Understanding cultural and ethnic values is not an area of knowledge for cultural competence.

An adult patient's pulse is 46 beats per minute. The term used to describe this rate is: A. tachycardia. B. bradycardia. C. weak and thready. D. sinus arrhythmia.

B A heart rate of less than 50 beats per minute in an adult is bradycardia. A heart rate of greater than 90 beats per minute in an adult is tachycardia. Weak and thready describes the force of the pulse reflecting a decreased stroke volume. Sinus arrhythmia is a pulse that is irregular; the heart rate varies with the respiratory cycle.

Which of the following is an expected response on the cover test? A The covered eye moves into a relaxed position. B The covered eye maintains its position when uncovered. C The uncovered eye is unable to maintain its gaze on a fixed object. D The covered eye jumps to reestablish fixation when it is uncovered.

B A normal response to the cover test is a steady fixed gaze. If muscle weakness is present, the covered eye will drift into a relaxed position. A normal response to the cover test is a steady fixed gaze. When the eye is uncovered, if it jumps to reestablish fixation, eye muscle weakness exists.

An older adult patient with dementia has a pain rating of 5 on the Pain Assessment in Advanced Dementia (PAINAD) scale. The nurse should: A. reassess the pain level in 3 to 4 hours. B. administer prescribed pain medication. C. ask the patient to verify the pain rating. D. use only nonpharmacologic pain relief interventions.

B A patient with a pain score of 4 or greater on the PAINAD scale should receive pain intervention. Patients with dementia can be given an analgesic trial or option. The nurse should not wait an additional 3 to 4 hours for another pain assessment. A patient with dementia may say "no" if asked about having pain even if he or she is having pain. Words lose their meaning with dementia. Nonpharmacologic pain relief interventions can be implemented with or without prescribed pain medication.

The nurse questions the reliability of the history provided by the patient. One method to verify information within the context of the interview is to: A. review previous medical records. B. rephrase the same questions later in the interview. C. ask the patient if there is someone who could verify information. D. call a family member to confirm information.

B A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. This option is not within the context of the interview. Although this may possibly lead to verification of information, asking the patient for corrobation of information from another individual is not within the context of the present interview. This would occur outside the context of the interview.

A slight protrusion of the eyeballs may be noticed when examining individuals who come from which ethnic/cultural group? A Asian B African American C Hispanic D American Indian

B African Americans normally may have a slight protrusion of the eyeball beyond the supraorbital ridge.

Kyphosis of the spine is common with aging. To compensate, older adults: A increase their center of gravity. B extend their heads and jaws forward. C stiffen their gait. D shuffle.

B An older adult may show an increased anterior cervical (concave or inward) curve when the head and jaw are extended forward to compensate for kyphosis of the spine.

Which of the following groups of individuals need to be tested for the presence of color blindness (deficiency)? A Black boys between the ages of 10 and 15 years B White boys between the ages of 4 and 8 years C Asian girls between the ages of 3 and 6 years D White girls between the ages of 4 and 8 years

B Color blindness is an inherited recessive X-linked trait affecting about 8% of white boys and 4% of black boys. Test only boys for color vision once between the ages of 4 and 8 years.

What is the source of deep somatic pain? A. Skin and subcutaneous tissues B. Bones and joints C. Pancreas D. Intestine

B Deep somatic pain comes from the blood vessels, joints, tendons, muscles, and bones. Cutaneous pain is derived from skin surface and subcutaneous tissues. Visceral pain originates from the larger interior organs such as the pancreas. Visceral pain originates from the larger interior organs such as the intestine.

Viewing the world from another person's inner frame of reference is called: A. reflection. B. empathy. C. clarification. D. sympathy.

B Empathy means viewing the world from the other person's inner frame of reference. Reflection is repeating part of what the person has just said. Clarification is used to summarize the person's words or to simplify the words to make them clearer. Sympathy is a social affinity in which one person stands with another person, closely understanding his or her feelings.

Endogenous obesity is: A. due to inadequate secretion of cortisol by the adrenal glands. B. caused by excess adrenocorticotropin production by the pituitary gland. C. characterized by evenly distributed excess body fat. D. a result of excessive secretion of growth hormone in adulthood.

B Endogenous obesity is caused by either the administration of adrenocorticotropin or excessive production of adrenocorticotropin by the pituitary. Adrenocorticotropin stimulates the adrenal cortex to secrete excess cortisol and causes Cushing syndrome, which is characterized by weight gain and edema with central trunk and cervical obesity. Excessive catabolism causes muscle wasting with thin arms and legs. Body fat is evenly distributed in exogenous obesity because of excessive caloric intake. Acromegaly is caused by an excessive secretion of growth hormone in adulthood.

Narrow palpebral fissures, epicanthal folds, and midfacial hypoplasia are characteristic of: A Down syndrome. B fetal alcohol syndrome. C chronic childhood allergies. D congenital hypothyroidism.

B Facial characteristics of fetal alcohol syndrome include narrow palpebral fissures, epicanthal folds, and midfacial hypoplasia. Facial characteristics of Down syndrome include upslanting eyes with inner epicanthal folds; flat nasal bridge; small, broad, flat nose; protruding thick tongue; and ear dysplasia. Facial characteristics of chronic allergies include exhausted face, blue shadows below the eyes, double or single crease on the lower eyelids, central facial pallor, open mouth breathing (malocclusion of the teeth and malformed jaw), and a transverse line on the nose. Facial characteristics of congenital hypothyroidism include low hairline, hirsute forehead, swollen eyelids, narrow palpebral fissures, widely spaced eyes, depressed nasal bridge, puffy face, thick tongue protruding through an open mouth, and a dull expression.

According to the holistic model, a narrow definition of holistic health includes: A. an optimal functioning of mind, body, and spirit within the environment. Incorrect B. the absence of disease. C. the response of the whole person to actual or potential problems. D. the internal and external environment.

B From a biomedical perspective, health is defined as the absence of disease or elimination of symptoms and signs of disease, whereas a holistic model approach examines mind, body, and spirit working interdependently within the environment to maintain health and well-being. Nursing has an expanded concept of health; holistic health includes the mind, body, and spirit as interdependent and functioning as a whole within the environment. Nursing diagnoses are clinical judgments about a person's response to an actual or potential health state. In a holistic model approach to health, both the internal and the external environment affect a patient's health and well-being.

Which of the following has been found to influence pain sensitivity in women? A. Age B. Hormonal changes C. Parity D. Weight

B Gender differences are influenced by societal expectation, hormones, and genetic makeup. Hormonal changes are found to have strong influences on pain sensitivity for women. Age has not been found to influence pain sensitivity in women. Parity has not been found to influence pain sensitivity in women. Weight has not been found to influence pain sensitivity in women.

Which of the following behaviors demonstrated by an individual may be indicative of hearing loss? A Not looking at the examiner when being questioned B Frequently asking for the question to be repeated C Talking in a high-pitched voice D Speaking slowly with well-articulated consonants

B Hearing loss is indicated when a person frequently asks to have statements repeated. Hearing loss is indicated when a person lip reads or watches faces and lips closely. Hearing loss is indicated when a person has a flat, monotonous tone of voice. Hearing loss is indicated when speech sounds are garbled, vowel sounds are distorted, and the person uses an inappropriately loud voice.

Which theory has been expanded in an attempt to study the degree to which a person's lifestyle reflects his or her traditional heritage? A. Behavior theory B. Heritage consistency C. Congruence mechanism D. Socialization experience

B Heritage consistency theory has been expanded in an attempt to study the degree to which a person's lifestyle reflects his or her traditional heritage. Behavior theory or behaviorism is a learning theory. Carl Rogers described the concepts of congruence and incongruence as important ideas in his theory of personality and human development. Socialization is the process of being raised within a culture and acquiring the characteristics of that group.

Neuropathic pain implies an abnormal: A. degree of pain interpretation. B. processing of the pain message. C. transmission of pain signals. D. modulation of pain signals.

B Neuropathic pain results from abnormal processing of the pain message. Neuropathic pain does not adhere to the typical and predictable phases inherent in nociceptive pain.

Pain signals are carried to the central nervous system by way of: A. perception. B. afferent fibers. C. modulation. D. referred pain.

B Nociceptors carry the pain signal to the central nervous system by two primary sensory (or afferent) fibers. Perception indicates the conscious awareness of a painful sensation. Modulation inhibits the pain message producing an analgesic effect. Referred pain is pain felt at a particular site that originates from another location.

An example of objective data is: A. a complaint of left knee pain. B. crepitation in the left knee joint. C. left knee has been swollen and hot for the past 3 days. D. a report of impaired mobility from left knee pain as evidenced by an inability to walk, swelling, and pain on passive range of motion.

B Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Crepitation is assessed by palpation. Subjective data is what the person says about himself or herself during history taking. Subjective data is what the person says about himself or herself during history taking. Subjective data is what the person says about himself or herself during history taking.

Which of the following symptoms is greatly influenced by a person's cultural heritage? A. Hearing loss B. Pain C. Breast lump D. Food intolerance

B Pain is a very private, subjective experience that is greatly influenced by cultural heritage. Expectations, manifestations, and management of pain all are embedded in a cultural context. Hearing loss is more common in whites than in blacks. The incidence of breast cancer varies with different cultural groups. Food intolerance varies with different cultural groups. For example, lactose intolerance is common in African Americans, American Indians, and Asian Americans.

Physical appearance includes statements that compare appearance with: A. mood and affect. B. stated age. C. gait. D. nutrition.

B Physical appearance includes statements that compare appearance with age, sex, level of consciousness, skin color, and facial features. Behavior is compared with mood and affect. Mobility is compared with gait. Body structure is compared with nutrition.

Parents or caretakers accompany children to the health care setting. Starting at ___ years of age, the interviewer asks the child directly about his or her presenting symptoms. A. 5 B. 7 C. 9 D. 11

B School-age children (starting at age 7) have the verbal ability to add important data to the history. The nurse should interview the parent and child together, but when a presenting symptom or sign exists, the nurse should ask the child about it first and then gather data from the parent.

A severe deficiency of thyroid hormone leading to nonpitting edema, coarse facial features, dry skin, and dry coarse hair is known as: A congenital hypothyroidism. B scleroderma. C myxedema. D Hashimoto thyroiditis.

C Myxedema (hypothyroidism) is a deficiency of thyroid hormone. If severe, the symptoms include nonpitting edema or myxedema; a puffy edematous face, especially around the eyes (periorbital edema); coarse facial features; dry skin; and dry coarse hair and eyebrows. Congenital hypothyroidism is a thyroid deficiency that occurs at an early age; characteristics include low hairline, hirsute forehead, swollen eyelids, narrow palpebral fissures, widely spaced eyes, depressed nasal bridge, puffy face, thick tongue protruding through an open mouth, and a dull expression. Scleroderma is a rare connective tissue disease characterized by chronic hardening and shrinking degenerative changes in the skin blood vessels, synovium, and skeletal muscles. Hashimoto thyroiditis is a condition with excess thyroid hormone production; symptoms include goiter, nervousness, fatigue, weight loss, muscle cramps, heat intolerance, tachycardia, shortness of breath, excessive sweating, fine muscle tremor, thin silky hair and skin, infrequent blinking, and a staring appearance.

Specialized nerve endings that are designed to detect painful sensations are: A. synapses. B. dorsal horns. C. nociceptors. D. C fibers.

C Nociceptors are specialized nerve endings designed to detect painful sensations from the periphery and transmit them to the central nervous system. A synapse is a region (or small gap) where nerve impulses are transmitted and received. The dorsal horn is a longitudinal subdivision of gray matter in the dorsal part of each lateral half of the spinal cord that receives terminals from some afferent fibers of the dorsal roots of the spinal nerves. C fibers are one of two primary sensory or afferent fibers that are unmyelinated and smaller; C fibers transmit the signal slowly.

While discussing the treatment plan, the nurse infers that the patient is uncomfortable asking the physician for a different treatment because of fear of the physician's reaction. In this situation, the nurse's verbal interpretation: A. affects the nurse-physician relationship. B. impedes further discussion. C. helps the patient understand personal feelings in relation to his or her verbal message. D. helps the nurse understand his or her own feelings in relation to the patient's verbal message.

C Patients may experience barriers to communication with a health care provider seen as an authority figure. The patient may not share personal feelings if fear is experienced. In this situation, the nurse identified the patient's personal feelings in relation to the patient's verbal message. The nurse-physician relationship is not the barrier to communication in this situation. The interpretation by the nurse will improve communication. The nurse's feelings are not the barrier to communication in this situation.

To perform an accurate assessment of respirations, the examiner should: A. inform the person of the procedure and count for 1 minute. B. count for 15 seconds while keeping fingers on the pulse and then multiply by four. C. count for 30 seconds after completing a pulse assessment and multiply by two. D. assess respirations for a full 2 minutes if an abnormality is suspected.

C Respirations should be counted for 30 seconds (if regular) and multiplied by two. The respirations should be counted after the pulse assessment. Patients have conscious control over respirations; the examiner should not mention that respirations will be counted. Avoid counting respirations for 15 seconds because the results can vary +4 or -4 with such a small number. Respirations should be counted for 1 minute if abnormalities are suspected.

An example of subjective data is: A. decreased range of motion. B. crepitation in the left knee joint. C. left knee has been swollen and hot for the past 3 days. D. arthritis.

C Subjective data is what the patient says about himself or herself during history taking. Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Range of motion is assessed by inspection. Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Crepitation is assessed by palpating. Arthritis is a medical diagnosis.

On the basis of median age: A. the non-Hispanic white population tends to be younger. B. the Hispanic population tends to be older. C. the Asian population tends to be younger. D. minorities tend to be older than non-Hispanic white populations.

C The Asian population is younger with a median age of 36 years. The non-Hispanic, single-race white population is older than the population as a whole; the respective median age is 40.2 years. The Hispanic population is much younger, with a median age of 27.7 years. Minorities tend to be younger than non-Hispanic white populations.

When taking a health history from an adolescent, the interviewer should: A. ask about violence and abuse before asking about alcohol and drug use. B. have at least one parent present during the interview. C. interview the youth alone with a parent in the waiting area. D. ask every youth about the use of condoms.

C The adolescent interview during the health history should be with the youth alone; a parent may wait in the waiting area and complete other past health questionnaire forms. Questions should move from expected and less threatening questions to questions that are more personal. Ask about alcohol and drug use before asking about safety (related to injury and violence). Questions about condom use would be appropriate only if the youth is sexually active. The HEEADSSS method of interviewing adolescents has essential questions, important questions, and situational questions.

The normal color of the optic disc is: A red. B creamy pink. C creamy yellow-orange to pink. D creamy red to yellow-orange.

C The color of a normal optic disc ranges from creamy yellow-orange to pink.

The duct in the parotid gland that opens into the mouth opposite the second molar is: A the Wharton duct. B the salivary duct. C the Stensen duct. D the sublingual duct.

C The duct in the parotid gland is the Stensen duct; it runs forward to open on the buccal mucosa opposite the second molar. The Wharton duct (for the submandibular gland) runs up and forward to the floor of the mouth and opens at either side of the frenulum. The mouth contains three pairs of salivary glands, which are the parotid gland, the submandibular gland, and the sublingual gland. The sublingual gland lies within the floor of the mouth under the tongue.

PQRSTU is a mnemonic that helps the clinician to remember to address characteristics specific to: A. severity of dementia. B. substance use and abuse. C. pain presentation. D. the ability to perform activities of daily living (ADLs).

C The eight critical characteristics of pain symptoms reported in the history are: P = provocative or palliative; Q = quality or quantity; R = region or radiation; S = severity scale; T = timing; and U = understand patient's perception. Tests used to assess for dementia include the Mini-Mental State Examination, the Set Test, the Short Portable Mental Status Questionnaire, the Mini-Cog, and the Blessed Orientation-Memory-Concentration Test. Functional assessment includes questions on substance use and abuse. Functional assessment measures a person's self-care ability including the ability to perform ADLs.

The extraocular muscles consist of four straight or ________ muscles and two slanting or ______ muscles. A palpebral; conjugate B superior; inferior C rectus; oblique D rectilinear; diagonal

C The four straight, or rectus, muscles are the superior, inferior, lateral, and medial rectus muscles. The two slanting, or oblique, muscles are the superior and inferior muscles.

The general survey consists of four distinct areas. These areas include: A. mental status, speech, behavior, and mood and affect. B. gait, range of motion, mental status, and behavior. C. physical appearance, body structure, mobility, and behavior. D. level of consciousness, personal hygiene, mental status, and physical condition.

C The general survey is a study of the whole person, covering the general health state and any obvious physical characteristics. The four areas of the general survey are physical appearance, body structure, mobility, and behavior. A general survey does not include assessment of mental status and physical condition.

While evaluating the health history, the nurse determines that the patient subscribes to the hot/cold theory of health. Which of the following would most likely describe this patient's view of wellness? A. Good is hot. B. Evil is hot. C. The humors must be balanced. D. The phlegm will be replaced with dryness.

C The hot/cold theory of health is based on humoral theory; the treatment of disease is based on the balance of the humors. Beverages, foods, herbs, medicines, and diseases are classified as hot or cold according to their perceived effects on the body, not their physical characteristics. Beverages, foods, herbs, medicines, and diseases are classified as hot or cold according to their perceived effects on the body, not their physical characteristics. The four humors of the body include the blood, phlegm, black bile, and yellow bile; the humors regulate basic bodily functions and are described in terms of temperature, dryness, and moisture. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors.

The labyrinth of the inner ear is responsible for maintaining the body's: A binaural interaction. B air conduction. C equilibrium. D pressure equalization.

C The labyrinth maintains the body's equilibrium. Binaural interaction is controlled by the brainstem and permits locating the direction of a sound. The normal pathway of hearing is by air conduction. The eustachian tube allows equalization of air pressure on each side of the tympanic membrane.

The nasal mucosa of an individual with rhinitis would be: A moist and pink. B swollen, boggy, and gray. C bright red and swollen. D pale with bright red bleeding.

C The nasal mucosa is bright red and swollen with rhinitis. Normally, the nasal mucosa is red with a smooth and moist surface. The nasal mucosa is swollen, boggy, pale, and gray with chronic allergies. Bright red bleeding occurs with epistaxis (bleeding from the nose).

The tympanic membrane of a child with acute otitis media would be: A flat and slightly pulled in at the center. B mobile and would flutter with the Valsalva maneuver. C bulging with a distinct red color. D shiny and translucent, with a pearly gray color.

C The tympanic membrane would be bulging and red with acute otitis media. A normal tympanic membrane is flat and slightly pulled in at the center. A normal tympanic membrane is mobile and flutters with the Valsalva maneuver. A normal tympanic membrane is shiny and translucent, with a pearly gray color.

An example of a primary lesion is a(n): A. erosion. B. ulcer. C. urticaria. D. port-wine stain.

C Urticaria is a primary lesion; a primary lesion is one that develops on previously unaltered skin. Erosions are secondary lesions; a secondary lesion is one that changes over time or changes because of a factor such as scratching or infection. Ulcers are secondary lesions; a secondary lesion is one that changes over time or changes because of a factor such as scratching or infection. A port-wine stain is a vascular lesion.

When recording information for the review of systems, the interviewer must document: A. physical findings, such as skin appearance, to support historic data. B. "negative" under the system heading. C. the presence or absence of all symptoms under the system heading. D. objective data that support the history of present illness.

C When recording information for the review of systems, the interviewer should record the presence or absence of all symptoms; otherwise it is unknown which factors were asked. Recording physical findings in the review of systems is incorrect; review of systems is limited to the patient's statements or subjective data. Writing "negative" after the system heading is also incorrect because it would be unknown which factors were asked. Recording objective data in the review of systems is incorrect; review of systems is limited to the patient's statements or subjective data.

Which of the following statements made by the interviewer would be an appropriate response? A. "I know just how you feel." B. "If I were you, I would have the surgery." C. "Why did you wait so long to make an appointment?" D. "Tell me what you mean by 'bad blood.'"

D "Tell me what you mean by 'bad blood'" is an appropriate communication technique referred to as seeking further clarification. "I know just how you feel" is an inappropriate communication technique referred to as false reassurance. "If I were you, I would have the surgery" is an inappropriate communication technique referred to as giving unwanted advice. "Why did you wait so long to make an appointment?" is an inappropriate communication technique referred to as using "Why" questions.

Bleeding into the periosteum during birth is known as: A caput succedaneum. B craniosynostosis. C molding. D cephalhematoma.

D A cephalhematoma is a subperiosteal hemorrhage resulting from birth trauma. A caput succedaneum is edematous swelling and ecchymosis of the presenting part of the head caused by birth trauma. Craniosynostosis is marked asymmetry that is due to a severe deformity caused by premature closure of the sutures and resulting in a long, narrow head. Molding of the cranial bones during passage through the birth canal makes the head asymmetric and ridges more prominent.

A complete database is: A. used to collect data rapidly and is often compiled concurrently with lifesaving measures. B. used for a limited or short-term problem usually consisting of one problem, one cue complex, or one body system. C. used to evaluate the cause or etiology of disease. D. used to perform a thorough or comprehensive health history and physical examination.

D A complete database includes a complete health history and a full physical examination; it describes the current and past health state and forms a baseline against which all future changes can be measured. An emergency database is rapid collection of data often obtained concurrently with lifesaving measures. An episodic database is for a limited or short-term problem; this database concerns mainly one problem, one cue complex, or one body system. Medical diagnoses are used to evaluate the cause or etiology of disease.

What type of database is most appropriate for an individual who is admitted to a long-term care facility? A. Episodic B. Follow-up C. Emergency D. Complete

D A complete database includes a complete health history and a full physical examination; it describes the current and past health state and forms a baseline against which all future changes can be measured. An episodic database is for a limited or short-term problem; this database concerns mainly one problem, one cue complex, or one body system. A follow-up database is used to follow up short-term or chronic health problems; the statuses of identified problems are evaluated at regular and appropriate intervals. An emergency database includes rapid collection of data often obtained concurrently with lifesaving measures.

Which of the following children is at risk of recurrent otitis media (OM)? A An 18-month-old infant who lives with a smoker B A 2-year-old child who has had two ear infections in the past 6 months C A 6-month-old infant who has a sibling who had tubes inserted at 3 years of age D An 18-month-old infant who has had three episodes of ear infections in a 5-month period

D A first episode of OM that occurs within 3 months of life increases risk of recurrent OM. Recurrent OM is three episodes within the past 3 months or four episodes within the past year.

The nurse records that the patient's pulse is 3+ or full and bounding. Which of the following could be the cause? A. Dehydration B. Shock C. Bleeding D. Anxiety

D A full, bounding pulse (3+) reflects an increased stroke volume, as with anxiety and exercise. A weak, thready pulse may reflect a decreased stroke volume, as with dehydration. A weak, thready pulse may reflect a decreased stroke volume, as with shock. A weak, thready pulse reflects a decreased stroke volume, as with bleeding.

A scooped-out, shallow depression in the skin is called a(n): A. ulcer. B. excoriation. C. fissure. D. erosion.

D An ulcer is a deeper depression extending into the dermis. An excoriation is a self-inflicted abrasion that is superficial. A fissure is a narrow opening of tissue or skin. An erosion is a scooped-out, shallow depression in the skin.

At the end of the examination, the examiner should: A. complete documentation before leaving the examination room. B. have findings confirmed by another provider. C. compare objective and subjective data for discrepancies. D. review the findings with the patient.

D At the end of the examination, the examiner should summarize the findings and share necessary information with the patient. The examiner may take short notes during the examination; complete documentation should occur after leaving the examination room. The examiner should have findings confirmed only if the finding is abnormal and requires confirmation from another examiner. Subjective and objective data should be compared throughout the history and physical examination.

When taking the health history, the patient complains of pruritus. What is a common cause of this symptom? A. Excessive bruising B. Hyperpigmentation C. Melasma D. Drug reactions

D Drug reactions can lead to pruritus or itching. Excessive bruising can occur in response to a traumatic event or a coagulation abnormality. It is associated with erythema, not pruritus. Hyperpigmentation is related to color changes. Melasma (also known as chloasma or the mask of pregnancy) is a facial skin discoloration related to hormones of pregnancy.

What disease is characterized by a flat, expressionless, or masklike face; a staring gaze; oily skin; and elevated eyebrows? A Acromegaly B Scleroderma C Cushing syndrome D Parkinson disease

D Facial characteristics of Parkinson disease include a flat, expressionless face that is masklike with elevated eyebrows, a staring gaze, oily skin, and drooling. Facial characteristics of acromegaly include an elongated head, a massive face, a prominent nose and lower jaw, a heavy eyebrow ridge, and coarse facial features. Facial characteristics of scleroderma include hard, shiny skin on the forehead and cheeks; thin, pursed lips with radial furrowing; absent skinfolds; muscle atrophy of the face and neck; and absence of expression. Facial characteristics of Cushing syndrome include a plethoric, rounded, "moonlike" face; prominent jowls; red cheeks; and hirsutism on the upper lip, lower cheeks, and chin.

Functions of the skin include: A. production of vitamin C. B. temperature regulation. C. production of new cells by melanocytes. D. secretion of a drying substance called sebum.

D Functions of the skin include protection, prevention of penetration, perception (of touch, pain, temperature, and pressure), temperature regulation, identification, communication, wound repair, absorption and excretion, and production of vitamin D. The skin produces vitamin D, not vitamin C. The basal cell layer of the epidermis forms new skin cells. Melanocytes produce melanin, which gives brown tones to the skin and hair. Sebum is produced by the sebaceous glands to lubricate the skin and hair.

A student nurse has been assigned to teach fourth graders about hygiene. While preparing, the student nurse adds information about the sweat glands. Which of the following should be included while discussing this topic? A. There are two types of sweat glands: eccrine glands and sebaceous glands. B. The evaporation of sweat, a dilute saline solution, increases body temperature. C. Eccrine glands produce sweat and are mainly located in the axillae, anogenital area, and navel. D. Newborn infants do not sweat and use compensatory mechanisms to control body temperature.

D Newborn infants' eccrine glands do not secrete sweat in response to heat until the first few months of life; newborn temperature regulation is ineffective. There are two types of sweat glands: eccrine glands and apocrine glands. The evaporation of sweat reduces body temperature. The apocrine glands produce a thick, milky secretion and open into the hair follicles; they are located mainly in the axillae, anogenital area, nipples, and navel.

A nursing diagnosis is best described as: A. a determination of the etiology of disease. B. a pattern of coping. C. an individual's perception of health. D. a concise statement of actual or potential health concerns or level of wellness.

D Nursing diagnoses are clinical judgments about a person's response to an actual or potential health state. Medical diagnoses determine the cause or etiology of disease. Coping patterns include methods to relieve stress. Health perception is how the person describes and defines personal health.

Which of the following is included in documenting a history source? A. Appearance, dress, and hygiene B. Cognition and literacy level C. Documented relationship of support systems D. Reliability of informant

D The source of history is a record of who furnishes the information, how reliable the informant seems, and how willing he or she is to communicate. In addition, there should be a note of any special circumstances, such as the use of an interpreter. Appearance, dress, and hygiene are observations included in the general survey. Cognition and literacy level are part of the mental status assessment. Interpersonal relationships and resources such as support systems are assessed during the functional assessment of the complete health history.

A medical diagnosis is used to evaluate: A. a person's state of health. B. the response of the whole person to actual or potential health problems. C. a person's culture. D. the cause of disease.

D. Medical diagnoses are used to evaluate the cause or etiology of disease. Nursing diagnoses are clinical judgments about a person's response to an actual or potential health state. Nursing diagnoses are used to evaluate the response of the whole person to actual or potential health problems. The holistic model of health care is used in nursing, and culture is an important factor to consider in a nursing assessment.

An adolescent boy comes to the emergency department seeking medical attention for severe pain located in the area of the appendix. Identify the area where the nurse would expect the pain to localize.

Pain and tenderness during an acute attack of appendicitis localizes in the right lower quadrant, midway between the umbilicus and the crest of the ilium.

A 40-year-old client is admitted with a diagnosis of new-onset atrial fibrillation. To obtain an accurate pulse count, the nurse counts the apical heart rate. Identify the area where the nurse should place the stethoscope to best hear the apical rate.

The apical heart rate is best heard at the point of maximal impulse, which is generally in the fifth intercostal space at the midclavicular line.

The nurse finds a client lying on the floor of the hospital corridor. After determining unconsciousness and breathlessness, and providing two ventilations, the nurse checks the client's carotid artery for a pulse. Identify the area where the nurse can best palpate the carotid pulse.

The carotid artery is located in the neck in the groove between the trachea and the sternocleidomastoid muscle. It's the artery of choice for determining a pulse in this situation because it's usually the most accessible.

An elderly client is admitted to the hospital for a fractured hip. He has a history of aortic stenosis. Identify the area where the nurse should place the stethoscope to best hear the murmur.

The murmur of aortic stenosis is low-pitched, rough, and rasping. It's loudest in the second intercostal space, to the right of the sternum.

Which of the following is considered when preparing to examine an older adult? A. Base the pace of the examination on the patient's needs and abilities. B. Avoid physical touch to avoid making the older adult uncomfortable. C. Be aware that loss will result in poor coping mechanisms. D. Confusion is a normal, expected finding in an older adult.

The pace of the examination should be adjusted to match the possible slowed pace of the aging person. Use physical touch (if it is not a cultural contraindication) to offset the disadvantages of diminishing vision and hearing. Be aware that loss is inevitable, and adaptation to loss affects health status. Confusion with a sudden onset may signify a disease state and is not a normal process of aging.

A diabetic client comes to the clinic for medical attention because of numbness and tingling in his lower extremities. The nurse obtains the client's vital signs and palpates the dorsalis pedis pulse. Identify the area where the nurse places her fingers to palpate the pedal pulse.

The pedal pulse is located on the top portion of the foot. Because clients with diabetes have complications related to circulation in the lower extremities, health care providers should palpate pedal pulses and check capillary refill.

An adolescent client seeks medical attention because of a sore throat and probable mononucleosis. The nurse palpates the client's submandibular lymph nodes for enlargement. Identify the area where the nurse should palpate to best feel these nodes.

The submandibular lymph nodes are located beneath the mandible, or lower jaw, halfway to the chin. These nodes may be enlarged in a client with a throat infection or mononucleosis.

An elderly client comes to the clinic complaining of hearing loss. The nurse performs Weber's test to assess the client's ability to hear. Identify the location where the nurse should place the tuning fork to perform this test.

To perform Weber's test, the tuning fork should be struck and then placed on the midline of the head. Weber's test determines if sound is heard equally in both ears. If the client hears the sound louder in one ear, he probably has unequal hearing loss that requires further intervention.

Ascultate in:

all abdominal quadrants

Ascultate for:

bowel sounds

Ascultate for bowel sounds b4:

percussion and palpation

Palpate for:

tenderness