Chapter 20 Health History and Physical Assessment Adaptive Quizzing

A patient developed a hernia after a surgery. What is the most probable reason for this complication?

A hernia is a complication of abdominal surgery. The other complications of abdominal surgery include intestinal obstruction and altered bowel function. Prostatectomy has complications of urinary incontinence, sexual dysfunction, and poor body image. Complications of lung resection or lobectomy of the lung include difficulty breathing, fatigue, and generalized weakness. Surgery involving the brain or spinal cord such as removal of meningioma has a risk of impaired cognitive function, motor sensory alterations, altered vision, as well as swallowing, language, bowel, and bladder control issues.

Which risk factors may be responsible for causing glaucoma in a patient? Select all that apply.

Glaucoma involves the gradual loss of eyesight due to optic neuropathy associated with an increase in intraocular pressure. The risk factors associated with glaucoma include myopia, diabetes, migraine, and low blood pressure. Hypercholesterolemia is a risk factor for macular degeneration, not glaucoma.

During a physical examination, which area of the body should the nurse assess for cyanosis in a patient? Select all that apply.

In cyanosis, deoxygenated hemoglobin increases in the body and produces a bluish discoloration of the skin and mucous membranes. For the assessment of cyanosis, the skin, nailbeds, and mucous membranes are observed. Cyanosis is not found in the sclera of the eye. The inside of the throat is not the best place to assess for cyanosis because it is the least accessible area that can reliably show bluish discoloration. Text Reference - pp. 341-390

A patient is admitted to the hospital with cirrhosis of the liver. A nurse performs a physical assessment on the patient. Which body areas should the nurse inspect for jaundice? Select all that apply

Jaundice is a yellow hue to the skin, mucous membranes, or eyes of both light- and dark-skinned individuals. The yellow pigment results from excess bilirubin, a by-product of red blood cell destruction, or liver failure. The best place to evaluate a patient for jaundice is the sclera or, on darker-skinned individuals, the hard palate. The tip of the nose and the ankles and feet may not show bilirubin deposition

How should the patient be positioned to best palpate for lumps or tumors during an examination of the right breast?

Lying on the back allows breast tissue to relax; raising the arm over the patient's head causes the breast tissue to flatten, and palpation can more accurately locate any nodules or tumors, especially cancerous tumors that are fixed against the chest wall. Text Reference - pp. 341-390

Which of the following physical examination techniques are most helpful when assessing a patient? Select all that apply.

Palpation, percussion, and auscultation are all techniques the nurse uses during a physical examination. Palpation refers to assessing by touch. Percussion involves assessment by tapping the skin with the fingertips to vibrate underlying tissues and organs. Auscultation involves listening to body sounds to detect variations from normal functioning. Evaluation and visualization are not formal techniques of physical examination.

A nurse is educating a group of teenagers about hygiene and self-care. What causes body odor? Select all that apply.

Poor hygiene and excessive perspiration are causes of body odor because these conditions all cause multiplication of bacteria. Increased bacterial activity causes body odor. Sedentary lifestyle, immunization status, and tight-fitting clothing do not cause body odor, as these conditions do not promote bacterial activity or bacterial growth.

Which sign best indicates strabismus in a patient?

Strabismus is a condition in which the patient is unable to focus both eyes on an object simultaneously. In this condition, the patient's eyes appear crossed. Cataracts or macular degeneration of the eye causes blurred vision. Impairment of near vision due to aging is a sign of presbyopia. If the patient cannot see close objects but can see distance objects, the condition is called hyperopia. Text Reference - pp. 341-390

A nurse has to position a patient in the lithotomy position. Which statement about the lithotomy position is true? Select all that apply.

The lithotomy position is the best position for facilitating insertion of a vaginal speculum. It gives maximum exposure of the female genitalia and is useful in gynecological procedures. The patient is made to lie supine and her legs are raised and flexed at the knee. This position doesn't help in detecting murmurs. Murmurs are best heard in the lateral recumbent position. The patient is made to lie laterally with flexion of hip and knee in Sim's position.

During the physical examination of a patient, the nurse listens to the heart sounds to detect variations from normal. Which physical examination technique is the nurse performing?

The nurse performs auscultation. Auscultation involves listening to the sounds of the body to detect abnormalities. Palpation is used to make judgments about abnormal and normal findings of the skin or underlying tissue, muscle, and bones. In the inspection technique, the nurse observes the size, shape, color, symmetry, position, and abnormality of various body parts. Percussion involves tapping the skin with the fingertips to vibrate the underlying tissues and organs. Text Reference - pp. 336-338

Which cranial nerve is responsible for the sense of smell?

The olfactory cranial nerve is responsible for the sense of smell. The vagus nerve is responsible for the sensation of the pharynx. The trochlear nerve is responsible for downward and inward eye movements. The trigeminal nerve is responsible for the sensory nerve innervation of the face. Text Reference - pp. 380-381 (Table 20-9)

A nurse is examining a patient in the examination room. At what angle should the nurse elevate the head of the examination table so that the patient is comfortable?

While performing an examination of the patient's head, the table should be elevated at an angle of 30 degrees. This inclined position is most comfortable for the patient's head and neck and is also suitable for the assessment Text Reference - pp. 333-336