Health Assesment FInal (HESI)

What are the phases of the nursing process?

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Which action will the nurse take to manage the interview and the physical assessment?

he patient may feel exposed and uncomfortable in the gown during the physical assessment. Therefore, the nurse establishes a rapport with the patient before asking the patient to change into a gown. The nurse should not take extensive notes during the interview, because it will impede observation of the patient's nonverbal behavior. The patient may not be comfortable if the nurse uses the patient's first name. Therefore, the nurse should ask the patient's preference for how he or she would prefer to be addressed. Saying that all health care workers will have access to the medical record will make the patient anxious. Therefore, the nurse should explain that medical records are kept confidential but can be accessed by the health care professionals involved in the patient's care.

Which statement made by the student nurse about the "evaluation" phase of the nursing process indicates effective learning?

*The nurse evaluates the efficacy of the nursing interventions in meeting the patient's outcomes in the evaluation phase.* This is accomplished by comparing the outcome criteria with the patient's actions and behaviors. The evaluation phase does not end the plan of care. If the outcomes have not been met, the nurse needs to reassess the patient, plan new outcomes, plan and implement the new interventions, and evaluate the outcome once again. The evaluation phase helps assess the efficacy of the entire care plan and not just individual nursing interventions. The nurse will plan new patient outcomes if all goals are not met in the evaluation phase

The nurse assesses that a 3-year-old child has a Babinski reflex. What risk does this child have?

A Babinski reflex usually disappears by 24 months of age. Therefore, when a 3-year-old child has a Babinski reflex, it indicates that the child may be at risk for neuromuscular disorders. The Babinski reflex does not help to assess the genital functioning in the child. The nurse would determine genital functioning in the child by assessing urinary output. The Babinski reflex does not help to determine the functioning of the cornea, retina, and other parts of eye. This would be assessed by examining the eyes with an ophthalmoscope. The nurse would not suspect that the child has risk of cardiovascular disorders because presence of a Babinski reflex does not indicate that the child has impaired cardiac functioning. The cardiovascular system would be assessed by auscultation of the heart.

What distance between two individuals indicates the intimate zone

A distance of 1 foot indicates the intimate zone. The distance of 1.5 feet to 4 feet indicates personal distance. The nurse should not be talking to the patient from these distances. *The social distance includes 4 to 12 feet. The nurse should always communicate with the patient at this distance range.* The distance of 12 feet and above indicates public distance.

Which equipment would the nurse use to measure the range of motion of a shoulder joint?

A goniometer is used to measure the angular joint range of motion of the patient. A monofilament is used to test sensations in the foot during a neurologic examination. An ophthalmoscope is used to examine the internal structures of the eye. A Doppler sonometer is used to augment pulse or blood pressure sounds during cardiovascular assessment.

After auscultating the precordium of a patient, the nurse suspects that the patient has pulmonic hypertension. Which finding would the nurse observe in the patient?

A lifting impulse occurs with right ventricular hypertrophy, as in pulmonic disease and pulmonic hypertension. This may be due to the presence of an enlarged right ventricle, which results in the posterior rotation of the left ventricle. A thrill in the right intercostal space is characteristic of aortic stenosis and systemic hypertension. A thrill in the left intercostal spaces is palpable in the patient with pulmonic hypertension. A lateral displacement of apical impulse occurs with left ventricular hypertrophy.

While assessing the body structure of a patient, the nurse suspects that the patient has arthritis. Which finding would support this?

A patient suffering from arthritis will most likely have stiffness in the spine and neck. If the rigidity is severe, then the patient will move the spine and the neck as one single unit. Slumped shoulders and a deflated body posture may be an indication of depression or bad posture, but not necessarily arthritis. Protuberant abdomen, commonly known as toddlers' lordosis, is a normal finding in a toddler and would not be related to arthritis. A normal "plumb line" through the anterior ear, shoulder, hip, patella, and ankle indicates a normal finding.

The nurse is caring for a patient with pneumonia who has an oral endotracheal tube. The patient suddenly begins banging the bed rails, making sounds, and pointing toward the endotracheal tube. After assessing the patient, the nurse finds that the patient has difficulty breathing. What is the best nursing intervention in this situation?

A patient who has an endotracheal tube may be unable to breathe because of accumulation of mucus in the tube, and this patient may urgently try to get the nurse's attention for help. In this situation, the nurse should suction the tube in order to restore respiration in the patient. The endotracheal tube helps to maintain a patent airway and promotes respiration, so if the patient is unable to breathe the nurse should not remove the endotracheal tube. The diameter of the oral endotracheal tube is greater than that of a nasal tube, so the nurse should avoid inserting the tube through the nose because it can damage the nasal mucosa. Administration of an analgesic may decrease the pain but does not restore respiration in the patient.

While assessing a patient with renal disease, the nurse determines the patient's ankle brachial index. What is the rationale behind this intervention?

A patient with a renal disorder is at an increased risk of peripheral artery disease because of the accumulation of fluid in the lower extremities and narrowing of the blood vessels in the lower limbs. The ankle brachial index is a diagnostic tool that helps screen for peripheral artery disease and identify narrowing of blood vessels by comparing the blood pressure in the ankle with the blood pressure in the arm. The nurse would measure the patient's blood glucose levels to diagnose diabetes mellitus. Leukocytopenia is caused by a decrease in the number of white blood cells, so the nurse checks the patient's white blood cell count to diagnose leukocytopenia. The nurse should monitor the patient's rate of respiration and oxygen saturation levels to diagnose respiratory disorders.

What is the best way for the nurse to obtain a patient's family history

A patient's family history includes details about the patient's family members. The best way to obtain the data is to send a detailed questionnaire to the patient when the patient makes an appointment. This practice provides ample time for the patient to gather the data, contacting other family members as needed. The nurse cannot rely solely on information from previous hospital visits because this information may be incomplete. The nurse should obtain the family history information from the patient rather than going directly to the patient's family, because this practice may violate the patient's privacy. Not all patients live with extended families, so it may not be beneficial or appropriate for the nurse to do a home visit in order to collect the data.

A patient reports to the nurse that he is having trouble seeing nearby objects. Which type of reflex is associated with this type of adaptation?

A person who has a problem adapting the eyes to see objects nearby may have a problem in accommodation. Accommodation is adaptation of the eye for near vision. It is done by increasing the curvature of the lens through movement of the ciliary muscles. When one of the pupils is exposed to a bright light, a direct light reflex causes constriction of that pupil, and a consensual light reflex causes simultaneous constriction of the other pupil. Fixation is a reflex direction of the eye toward an object attracting our attention.

While assessing a child, the nurse finds that the child has a recurring ear infection. Which intervention does the nurse expect to be most beneficial for the child

Accumulation of fluid in the middle ear increases the risk of ear infections in the patient. Therefore, to reduce the risk of infection, tympanostomy tubes should be placed in the patient's ears. These tubes increase fluid outflow and reduce bacterial growth in the ear. The Papanicolaou test helps to detect cervical cancer in girls and women. This test is recommended mostly in women older than 21 years. Therefore, this test is not beneficial for a child with an ear infection. Simvastatin and fish oil lower lipid levels and prevent obesity. These medications do not reduce the risk of an ear infection in a child.

An older adult patient reports sudden, intense eye pain and sees halos around lights. On examination, the nurse observes a cloudy cornea and a dilated pupil. What does the nurse suspect from the patient's signs and symptoms?

Acute glaucoma occurs with a sudden increase in intraocular pressure from blocked outflow from the anterior chamber. The person experiences a sudden clouding of vision, sudden eye pain, and halos around lights. Infection of the conjunctiva is conjunctivitis and is due to a viral or bacterial infection. In iritis or circumcorneal redness, a deep, dull-red halo is observed around the iris and cornea; it is a vascular disorder caused by trauma or an infection. Horner's syndrome is a lesion of the sympathetic nerve.

During the otoscopic examination of a patient, the nurse sees that the superior part of the patient's eardrum is bright red and bulging. What does the nurse infer from this finding?

Acute otitis media is an acute inflammation of the middle ear, which may result in vasodilatation and accumulation of fluid. This may cause a bright red and bulging eardrum. Skull fracture may result in bleeding from the inner ear and may cause a bluish or dark red discoloration of the eardrum. Chronic otitis media is characterized by the presence of a thick, yellow amber-colored eardrum due to severe inflammation and the formation of pus. Fungal ear infections are characterized by the presence of black or white spots on the eardrum.

Which mental disorder is associated with agnosia?

Agnosia refers to the loss of the ability to recognize objects, persons, sounds, or smells. Such dysfunction, however, is not associated with a defect in the corresponding sensory organs, indicating that agnosia is a result of a brain lesion or an illness affecting that region of the brain. A patient with dementia has memory loss; this patient gradually loses most cognitive functions, and thus may develop agnosia during the course of the illness. A person with anxiety experiences fear and apprehension concerning perceived impending danger. Hallucinations refer to unreal imaginary sensory perceptions. Depression is a state in which a patient feels sad and gloomy.

What are the common causes of liver cirrhosis?

Alcohol abuse and viral hepatitis are both common causes of liver cirrhosis. Alcohol metabolism takes place in the liver and excessive consumption of it can overload the liver and cause inflammation or cirrhosis. Viral hepatitis is a viral infection of the liver that leads to scarring and liver cirrhosis. Tuberculosis is a bacterial infection and has no relation to liver cirrhosis. Illicit drug use does not cause liver cirrhosis, but may affect the cardiovascular system, respiratory system, and brain. This may also lead to other complications, such as euphoria, dizziness, and loss of appetite. Alcohol withdrawal causes insomnia, depression, and irritability. These symptoms do not have any relation to liver cirrhosis.

The nurse uses the Clinical Institute Withdrawal Assessment (CIWA) for a patient who is undergoing withdrawal therapy for alcohol abuse. The nurse checks for tactile disturbances in the patient by asking, "Do you feel like bugs are crawling on your skin?" The nurse gives a score of 7 after the assessment. Which finding in the patient led the nurse to give such score?

Alcohol withdrawal causes tactile disturbances, tremors, and autonomic hyperactivity. The patient with tactile disturbances may feel itching, numbness and bugs crawling on the skin. A score of 7 indicates that the patient has continuous hallucinations. A patient with severe hallucinations should be assigned a score of 5. A score of 4 indicates moderate hallucinations, and 6 indicates extreme severe hallucinations.

The nurse is conducting an interview of an immigrant adolescent who does not understand English. The nurse asks an ad hoc interpreter to interpret the information. What outcome might occur when using such an interpreter

An ad hoc interpreter is a friend or relative of the patient. The violation of confidentiality occurs while using an ad hoc interpreter because such a person may share information with others. An ad hoc interpreter is a friend, and the patient would be less stressed while talking about the problems with such an interpreter. The overall health outcomes may not improve with an ad hoc interpreter because the interpreter may not understand medical jargon and may be unable to communicate what the nurse wants to convey. Increased achievement of the health outcomes may result in increased satisfaction in the patient.

While assessing an agitated alcoholic patient, the nurse gives a score of 7 on the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA Ar). What could be the reason for this score?

An alcoholic patient appears unsteady due to loss of coordination. A score of 7 during the agitation assessment indicates that the patient paces back and forth during most of it. If the patient exhibits normal activity, then the score is zero. A score of 4 indicates moderate fidgeting in the patient. If the patient has somewhat normal activity, then the nurse should give a score of 1.

The nurse measures the body mass index (BMI) of a patient at 34, but concludes that the measurement is not a reliable method to accurately assess the patient's body fat. Why did the nurse make this conclusion?

BMI is the ratio of weight to height and indicates a person's body fat. In very muscular patients BMI may not be a reliable measurement, however, because the calculations will overestimate the patient' body fat. BMI gives a clue about dyslipidemia, which is an abnormal amount of lipids present in the body. This condition in the patient does not interfere with the assessment of body fat by using BMI. Abdominal ascites is the accumulation of body fluids in the peritoneal cavity. Abdominal ascites does not interfere with the assessment of body fat by using BMI. A large waist circumference indicates various risks, such as for diabetes and hypertension. This does not interfere with BMI results.

The health care provider asks the nurse to stop monitoring the blood pressure, pulse, respirations, and oxygen saturation in an alcohol-abusing patient based on the rating of Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar). What is the reason for the health care provider's decision?

Based on the total score of Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar), the nurse should monitor blood pressure, pulse, respirations and oxygen saturation in the patient who manifests alcohol withdrawal symptoms. If the total CIWA-Ar score is less than 8 for 72 hours, the nurse can stop monitoring; this score indicates the patient is retaining his or her original physical condition. If the total score is less than 12 for 72 hours, the nurse should monitor conditions in order to observe variations; this score indicates some abnormality in the patient's condition. A total score between 11 and 15 for 72 hours indicates that scheduled medicines should be provided to the patient. Therefore, the nurse should monitor the patient's condition.

Which is a positive Chadwick's sign in a pregnant patient?

Chadwick's sign is an indication of pregnancy. The vaginal wall and the cervix become bluish or purplish in color. The vaginal wall and the cervix have a congested look due to increased vascularity and engorgement. Significant softening of the vaginal portion of the cervix occurs due to increased vascularization in a pregnant woman. This vascularization is the result of hypertrophy and engorgement of the vessels below the growing uterus. It is called Hegar's sign. Pregnancy-induced hypertension occurs in patients who are obese or who are over 35 years of age. However, this disorder is not related to Chadwick's sign. Softening of the cervix during pregnancy is called Goodell's sign.

A 30-year-old patient tells the nurse, "I have bright red, raised dots on my torso, which have grown in size and number as I got older." For which condition would the nurse screen in this patient?

Cherry angioma is a skin bruise characterized by small, red lesions on the trunk. These lesions will increase in number and size with age, and are insignificant. Anasarca, toxic alopecia, and alopecia areata are not associated with bright red spots on the trunk. Anasarca is associated with the presence of bilateral edema all over the body. Toxic alopecia is associated with chemotherapy-induced hair loss that results in patchy balding. Alopecia areata is associated with sudden and severe hair loss that results in a round or oval balding patch on the scalp.

A patient who had been in an accident is admitted to the hospital. The nurse, while assessing, asks whether the patient has pain in the shoulder area. The patient says that there is no pain, but grimaces when the nurse palpates the shoulder. Which verbal response should the nurse use in this situation?

Confrontation helps in clarifying the inconsistent information. Here, the patient denies shoulder pain, but grimaces when the nurse palpates the shoulder. Therefore, the nurse should use the confrontation type of verbal response for clarification. Empathy helps in increasing the rapport with the patient. Reflection is a type of verbal response that encourages the patient to elaborate the problem, but here the patient is not clearly expressing the problem. Explanation is another type of verbal response in which the nurse tries to share factual information with the patient.

While reviewing the blood test reports of a pregnant patient, the nurse finds that the patient has a decreased platelet count and an increased serum creatinine level. The patient's blood pressure is 150/100 mm Hg. Which other finding would the nurse expect?

Decreased platelet count, increased serum creatinine level, and increased blood pressure are the signs of preeclampsia. Preeclampsia is also characterized by increased levels of protein in the urine. Therefore, increased levels of protein in the urine would confirm that the patient has preeclampsia. A decreased platelet count and increased serum creatinine level may indirectly indicate diabetes mellitus in the patient. However, a patient with gestational diabetes would have increased sugar or ketone levels in their urine. The patient with preeclampsia usually has decreased urinary output.

While assessing a newborn, the nurse finds epicanthal folds and large spacing between the eyes. Based on this finding, which condition is this infant at risk for?

Down syndrome is a congenital disorder and is characterized by skin folds of the upper eyelid (also known as epicanthal folds), white spots around the iris edges, and hypertelorism. Hypertelorism is an abnormal distance between two eyes. Therefore, an infant with Down syndrome may have epicanthal folds and hypertelorism. Frontal bossing may cause hypertelorism in the infant with Down syndrome. Meningitis is the inflammation of the protective membranes of the brain, and affects the development of the child. Therefore, the infant with meningitis may have bilaterally irregular pupils. Sympathetic nerve damage may cause Horner's syndrome in the infant. However, it manifests as a drooped eyelid, also known as ptosis, but not hypertelorism and epicanthal folds. The infant with central nervous system injury may not have hypertelorism, which is a developmental abnormality.

The nurse is caring for a patient with epistaxis. Which symptom is most likely to be seen in this patient?

Epistaxis is bleeding from the anterior nasal septum. It is rarely severe and can be easily controlled. Causes include nose picking, forceful coughing or sneezing, fracture, and coagulation disorder. Loss of the sense of smell is called anosmia. It is due to an inflammation of the nasal mucosa, blockage of nasal passages, or a destruction of one temporal lobe of the brain. Anosmia can be temporary or permanent. A hole in the septum is usually caused by snorting cocaine or methamphetamine. Chronic infection, trauma from continual picking of crusts, or nasal surgery may also result in perforated septum. Acute sinusitis may result in thick, creamy nasal drainage.

A patient with shortness of breath visits the hospital. The nurse finds that the patient uses a hearing aid. Under which section should the nurse record information about the hearing aid?

Health promotion devices such as hearing aids and mobility aids are recorded under the review of systems section. The hearing aid is recorded as a health promotion tip under the review of ears section. Present health includes the current health status of the patient. Biographic data include general information regarding the patient such as occupation, ethnicity, and health practices. Functional assessment deals with the patient's daily living activities.

Which finding would the nurse consider normal during the examination of a pregnant patient?

In a pregnant patient, the enlarged uterus causes the displacement of the stomach. The esophageal sphincter and gastric tone are also altered as a result of increased progesterone secretion. This may cause heartburn. The intestines are displaced by the growing uterus. Intestinal tone and motility are decreased as well, which often leads to constipation. Normally, the mucous membranes should be dark pink and moist. Pale mucous membranes indicate anemia. The thyroid may be palpable; it feels full but smooth during normal pregnancy. Solitary nodules indicate neoplasm. Polyps are abnormal growths rising from the lining of the large intestine. These can occur in both males and females and are not related to pregnancy.

The nurse is performing a clinical breast examination (CBE) on a patient. Which assessment finding should the nurse refer for further investigation?

It is common to have a slight asymmetry in the breasts; however, a recent increase in the size of one of the breasts needs further investigation. It may signify new growth or inflammation. The skin is normally smooth and of even color. Pale linear striae or stretch marks may be seen on the skin surface of a patient after pregnancy. A pregnant patient may have a fine blue vascular network on the skin.

Where are Montgomery's glands located?

Montgomery's glands are small and elevated sebaceous glands located in the areola. They secrete a protective lipid material during lactation. The axilla contains lymph nodes; more than 75% lymph drains into the ipsilateral axillary nodes. Glandular tissue contains 15 to 20 lobes radiating from the nipple, and these are composed of lobules. Within each lobule are clusters of alveoli that produce milk. The nipple is indented with tiny milk duct openings.

What are the purposes of obtaining a patient's health history?

Knowing the patient's healthy history helps to establish a rapport between the patient and the nurse because it helps the nurse understand the patient better. The patient's health history will help the nurse to diagnose health problems and how the patient responds to those problems. This will help to diagnose the patient's health needs. The health history helps the nurse to understand the patient's strengths, coping skills, and response to the environment. This helps to provide a complete picture of the patient. The health history helps to collect subjective data. However, it will not help to document the findings of the physical assessment, which are objective data. The nurse does not aim to understand the patient's medical knowledge by obtaining the patient's health history. Instead, the nurse tries to understand the patient's health concerns.

While communicating with the nurse, a patient appears to be cheerful and upbeat and admits to feeling happy. Ten minutes later, however, the patient starts to cry. The nurse is successful in calming the patient, but then gets up to leave. This makes the patient yell at the nurse. Which mood abnormality does the patient's behavior indicate?

Lability is a mood and affects abnormality in which the patient exhibits rapid shift of emotions. A labile patient may express happiness, sadness, and anger consequently in rapid succession. Rage is a mood and affects abnormality in which the patient is furious and loses control over him- or herself. Irritability is the state in which a patient is annoyed and impatient. Depression refers to a sad, gloomy, and dejected mood.

The nurse is palpating the lymph nodes of a patient. What finding would indicate the nodes may be cancerous?

Lymph nodes connect together and give a matted appearance in the patient with malignancy or tuberculosis. Rubbery nodes indicate Hodgkin lymphoma and may indicate cancer. Nontender nodes indicate cancer. The nodes are not mobile in malignancy. Mobile nodes are the characteristic of acute infection and HIV. Bilateral nodes may indicate acute infection of mononucleosis.

Which assessment finding does the nurse associate with a diagnosis of peau d'orange?

Lymphatic obstruction produces edema, causing the skin on the breast to thicken and exaggerating the hair follicles. The skin begins to look like an orange peel or pigskin. This condition is referred to as peau d'orange. A dimple or skin tether is a sign of retraction. This dimpling is visible at rest, with compression, or with lifting of the arms. Deviation in nipple pointing occurs due to fibrosis in the mammary ducts, which pulls the nipple angle towards it. There is swelling behind the nipple, which causes it to tilt laterally. Fixation is a condition in which the breast looks asymmetrical, distorted, and has limited mobility with the elevated arm maneuver. The breast appears to be fixed to the chest wall.

What does the nurse include under the medication reconciliation section while documenting the complete health history of a patient

Medication reconciliation is a section in the health history form that compares the current prescribed drug list of a patient with the patient's previous list. This helps in minimizing errors and promoting safety. Side effects of previously administered drugs should be included in the reconciliation report because this information may help in providing immediate interventions if the condition worsens with time. Drug-drug interactions may either increase or decrease the desired pharmacologic action so these details should also be documented and reported. Comparison of drug names and the dosing schedule are recorded in the medication reconciliation section to discover medication administration errors. Indications of a prescribed drug are not documented in the reconciliation report. Drug allergies are included in the history section rather than the medication reconciliation section.

What instructions does the nurse provide to an obese patient to promote weight loss

Monitoring the body weight regularly helps a patient assess the impact of any lifestyle and dietary changes. The patient should consume a diet of no more than 1500 kcal/day, because this enables the patient to get adequate calories and prevents fat deposition in the body. Eating just 950 kcal/day may not provide the patient with adequate nutrition and this can cause other complications during the weight loss process. The nurse instructs the patient to exercise half an hour a day, 5 days a week; it may not be safe for the patient to exercise every day for a full hour until he or she is in better physical shape.

While assessing a patient with pulmonic stenosis, the nurse hears medium pitched murmurs in the left second intercostal space. Which finding does the nurse observe in the patient?

Murmurs can be heard in the left intercostal space in the patient with pulmonic stenosis. Calcification of the pulmonic valve in the patient with pulmonic stenosis may result in the enlargement of the right ventricle. The fourth heart sound, S4, occurs after the diastole due to resistance of the ventricles to fill with blood. It commonly occurs in the presence of an enlarged right ventricle. Pathologic S3 occurs due to the backward flow of blood into the left atrium in the patient with mitral regurgitation. A fixed split S2 occurs in the patient with atrial septal defect due to the earlier closure of the aortic valves than the pulmonic valves. An accentuated S1 occurs with mitral stenosis.

The nurse shines a light on the roof of the patient's mouth to examine the palate. Which finding would need further investigation?

Normally, the anterior palate is white with irregular transverse rugae. If the anterior palate appears yellow or muddy yellow, it is an indication of jaundice and needs further investigation. The uvula normally looks like a fleshy pendant hanging in the middle. A bifid uvula or uvula that appears to be split into two is normal in American Indians. Torus palatinus is a nodular bony ridge down the middle of the hard palate and is a normal variation. It is a benign growth that appears after puberty in American Indians, Inuits, and Asians. The posterior soft palate is normally pink, smooth, and upwardly movable.

The nurse documents normocephalic as an assessment finding. What did the nurse assess in the patient?

Normocephalic indicates that the patient has a normal sized head or cranium. Flat and symmetric are words that would describe the patient's abdomen. The nurse uses words like alert, oriented, or coherent thought to describe a patient's mental status. The nurse assesses the optic nerve during an eye examination.

What measures does the nurse use to obtain objective data? Select all that apply.

Objective data refers to the information gathered by inspection, percussion, palpation, and auscultation during the physical examination. The nurse also reviews the patient's laboratory reports for abnormalities while gathering objective data. The nurse reviews previous medical records to gather objective data. Subjective data is obtained by speaking to members of the patient's family. The patient also provides subjective data during an interview with the nurse.

A patient with a severe muscle cramp tells the nurse, "The pain is a little better when I massage the muscle or apply a cold pack." Which criterion of the PQRST method of pain assessment is addressed in the patient's statement?

PQRST is a pain assessment scale; it stands for Provocation/Palliation, Quality/Quantity, Region/Radiation, Severity Scale, and Timing. Because the patient is describing methods that provide comfort and relieve the pain, it indicates that the patient is addressing Provocation/Palliation. If the patient reports about severity of pain on a scale of 0 to 10, then it indicates that the patient is addressing Severity. When addressing the Quality/Quantity of the pain, the patient describes the pain felt. If the patient reports about the site of pain, then the patient is addressing Region/Radiation.

While examining the facial features of a patient, the nurse suspects cachexia. Which findings would support this diagnosis?

Patients with chronic diseases such as cancer may have physical wasting with loss of weight and muscle mass, resulting in cachexia. The features that characterize cachexia are sunken eyes and hollow cheeks. Red cheeks, moonlike face, and a heavy eyebrow ridge do not characterize cachexia. The presence of red cheeks and a moonlike face are the characteristic features of Cushing syndrome. The presence of a heavy eyebrow ridge is the characteristic feature of a patient with acromegaly.

Which phase of the nociceptive pain signifies the conscious awareness of a painful sensation in the patient?

Perception is the third phase of nociceptive pain and it signifies the conscious awareness of a painful sensation in the patient. During this phase, the limbic system interprets the noxious stimuli and elicits emotional responses to pain in the patient. During the modulation phase, the body slowly reduces the pain by stopping the processing of a painful stimulus. During the transduction phase, the pain signals are transmitted from the site of injury to the spinal cord. During the transmission phase, the pain signals move from the spinal cord to the brain; they do not elicit emotional responses to pain.

What is the characteristic feature of the preoperational stage of Piaget's theory?

Piaget proposed different stages of cognitive development. Different stages have different characteristic features. Children in the preoperational stage start developing symbolic thinking. Thus, these children engage in imaginative play. Children in the concrete operational stage understand the concepts of classification and conservation. Thus, logical thinking is a characteristic feature of concrete operations stage. Children in the formal operations stage develop abstract thinking and tend to have futuristic ideas. These children have a broad and theoretical perspective.

Which age of a child will be included in the preoperational stage of cognitive development according to Piaget?

Piaget's cognitive-developmental theory helps determine the cognitive development of the child. The child who is in the age group of 2 to 6 years is in the preoperational stage of cognitive development. Therefore, a 3-year-old child will be in the preoperational stage. The child within the age group of 0 to 2 years is in the sensorimotor stage of cognitive development. A child within the age group of 7 to 11 years is in the concrete operation stage, whereas the child who is older than 12 is in the formal operation stage of cognitive development.

The nursing instructor is teaching about presbycusis. Which statement by the student nurse indicates effective learning?

Presbycusis is the progressive sensorineural loss due to nerve degradation in the inner ear. It most commonly occurs with aging. Presbycusis is not associated with logging of water in the ear, obstruction of the eustachian tube, or absence of breastfeeding in the first three months. Logging of water in the ear results in swimmer's ear, or otitis externa, due to the presence of excessive moisture in the ear. The presence of inflammation in the ear indicates that the patient has otitis media. It is caused by an obstruction in the eustachian tube. Neonates who are not breastfed for the first three months of age have low immunity and have a higher risk of developing otitis media, but not presbycusis.

The nurse is performing an otoscopic examination in a preschooler. The child refuses to sit still on the chair and does not cooperate with the nurse during the examination. Which intervention should the nurse use to gain the child's cooperation?

Preschoolers demonstrate exploring behavior and may refrain from sitting still during an examination. In order to gain the child's cooperation, the nurse should allow the child to handle the otoscope and test the parent's ear. This intervention decreases the child's curiosity and enables the child to get involved in the test. If the nurse restrains the child, the child may become afraid of the nurse. Doing this would not facilitate a trusting relationship with the nurse, and the child may not cooperate. Asking the parents to hold the child very firmly is a type of physical restraint. This may injure the child, so the nurse should not ask the parents to do this. The child also may feel rejected if the nurse talks in a stern voice. Behaving in this way does not help the nurse gain the child's cooperation.

While caring for a patient with coronary artery disease, the nurse finds that the patient has chest pain, hypertension, lower limb edema and difficulty breathing. Which condition would the nurse consider a third-level priority problem?

Prioritizing care is an essential nursing skill, and the nurse should be able to categorize the patient's symptoms according to their severity. Conditions such as lower limb edema that do not require an immediate intervention and are not fatal are categorized as third-level priority problems. Cardiovascular disorders, such as chest pain and hypertension, are considered second-level priority problems, because they require immediate treatment. Respiratory disorders are considered first-level priority problems, because they can be fatal and require immediate treatment.

A pregnant patient tells the nurse, "I haven't felt any fetal movements yet, and I think I may have miscarried." Which response, if made by the nurse would be inappropriate?

Providing false assurance to the patient may diminish rapport with the patient. The patient suspects that she may have had a miscarriage; therefore, before assessing the patient thoroughly, the nurse should not give false assurance to the patient that the patient and the fetus are fine. The nurse's asking whether the patient needs something indicates that the nurse has a caring approach toward the patient. Expressing that it may be hard to wait for the health care provider indicates that the nurse is providing psychological support to the patient. Asking whether the patient would like to talk about anything indicates that the nurse is facilitating the patient's communication.

While examining the skin of a patient, the nurse finds silver mica-like scales on the patient's elbows and knees. Which condition does the nurse suspect?

Psoriasis is an autoimmune disease characterized by the presence of dry, silver mica-like scales on the elbows and knees. The scales are formed by the shedding of excess keratin cells. Cheilosis, ecchymosis, and candidiasis are not associated with silver mica-like scales. Cheilosis is associated with scaly lips and fissures at the corners of the mouth. Ecchymosis is associated with a purplish patch resulting from extravasation of blood into the skin. It appears more than 3 mm in diameter. Candidiasis is associated with the presence of scalding red, moist patches with sharply demarcated borders.

The nurse is assessing a patient with cyanosis who has numbness and bluish discoloration of the skin. Which other signs and symptoms in the patient would support the diagnosis of Raynaud's phenomenon? Select all that apply.

Raynaud's phenomenon is a peripheral vascular disease in the arms that is associated with impaired blood supply and changes in skin color. Impaired blood supply causes reduced venous return and accumulation of fluid, leading to swelling in the arms. The patient may also feel numbness and burning because of reduced blood supply. Pallor is due to arteriospasm and reduced blood supply. These changes can be seen during the first stage of the disorder but not after the second stage. Because the patient is in the second stage, as evidenced by numbness and cynosis, the nurse would not find paleness of the palms. Raynaud's phenomenon is associated with vasodilation that leads to a decrease in blood pressure, not an increase in blood pressure. Patients with Raynaud's phenomenon may have reduced body temperature due to cold, but not an increase in body temperature.

After assessing a patient, the nurse concludes that the patient has strabismus. Which finding supports the nurse's conclusion?

Strabismus refers to the improper alignment of the eyes, resulting in squinting or crossed eyes. In the child with strabismus, the brain may suppress the functioning of the weak eye to prevent diplopia. This may lead to disconjugate vision in the patient. A patient with retinal damage may observe blind spots in his or her line of vision. A patient with a neuromuscular disorder may have diplopia or the perception of double vision. Photophobia refers to the patient's inability to tolerate high light intensity. It may occur due to the overstimulation of the photoreceptors, corneal abrasion, or allergic conjunctivitis.

The patient reports having a sudden stabbing pain below the sternum, in the upper back, and in the neck. During the assessment, the nurse also finds that the patient has a fever, joint pains, and a dry cough. What condition is most consistent with these findings?

Sudden pain in the substernal region that radiates to the trapezius muscle and is present in the upper back is a sign of pericarditis. Pericarditis refers to the inflammation of the pericardium. Fever, dry cough, and joint pains are subjective symptoms of pericarditis. The patient with angina pectoris feels pressure such as discomfort behind the sternum or in the retrosternal region. Nausea, vomiting, dyspnea, and diaphoresis are the subjective symptoms of angina pectoris. The patient with a myocardial infarction feels heaviness in the chest region. The pain associated with myocardial infarction does not radiate to the trapezius muscle. Nausea, vomiting, dizziness, palpitations, and dyspnea are the symptoms of myocardial infarction. The patient with pulmonary hypertension experiences pain in the chest region, and may have dyspnea, lower-extremity edema, and fatigue.

After assessing pain in a 2-year-old child, the nurse documents the score as five using the FLACC scale. How does the nurse interpret this score?

The FLACC scale is an objective assessment of pain in young children less than 3 years of age. The tool assesses five behaviors of pain: facial expression, leg movement, activity level, cry, and consolability. A score range of 4 to 6 indicates that the child has moderate pain. As the documented score falls within this range, the nurse interprets that the patient may have moderate pain. The score of 0 indicates that the child is relaxed and comfortable and is not experiencing any pain. The score range of 1 to 3 indicates that the child has mild pain. The score range of 7 to 10 indicates that the child has severe pain.

Which pain assessment tool is most useful to evaluate the intensity of pain in children?

The Faces pain rating scale is a pain assessment tool that can be used to evaluate the intensity of pain in children. It consists of drawings of six faces with different facial expressions. Each face depicts a different level of pain intensity, from no pain to a lot of pain. The children are asked to select one picture that matches their facial expression while experiencing pain. In the numeric rating scale, the patients are asked to rate the intensity of the pain they are experiencing. The visual analogue scale consists of a 10 cm horizontal line with markings for "no pain" to "worst imaginable pain." While using the verbal descriptor scale, the nurse asks the patient to describe the pain. As cognition and communication skills are not well developed in children, the numeric rating scale, visual analogue scale, and verbal descriptor scale are not useful for assessing pain in these patients.

The nurse uses the Mini-Cog instrument to test the cognitive ability of a patient and declares that the patient has dementia. How many words did the patient recall?

The Mini-Cog test is used to screen whether a patient has cognitive impairment. In the test, the nurse tells the patient three words and asks the patient to repeat them. If the patient cannot repeat even a single word, it indicates dementia. If the patient repeats one or two words, it indicates that the patient has the possibility of developing dementia. If the patient repeats three words, it indicates that the patient has no cognitive impairment.

What is the maximum score of the Short Michigan Alcoholism Screening Test- Geriatric Version (SMAST-G)?

The Short Michigan Alcoholism Screening Test- Geriatric Version (SMAST-G) includes 10 questions with a maximum score of 10. The Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) includes only the first three questions of the Alcohol Use Disorder Identification Test (AUDIT), which focuses on alcohol consumption. The maximum score of the AUDIT-C is 12. The AUDIT questionnaire includes 10 questions that determine the presence of alcohol problems and dependence disorders, with a maximum score of 40. A maximum score of 67 appears in the Clinical Institute Withdrawal Assessment (CIWA).

Which is the best questionnaire to assess "at-risk" drinking of alcohol in a pregnant patient?

The Tolerance, Worry, Eye-opener, Amnesia, and Kut down (TWEAK) questionnaire is especially designed for pregnant women and helps to identify at-risk drinking in women. If the total score of this questionnaire is more than 2 points, it indicates that the patient has a drinking problem. The Cut down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire is less effective in detecting low-risk drinking problems and is not very effective for women, because most are at low risk. The Alcohol Use Disorders Identification Test (AUDIT) questionnaire is a set of 10 questions designed for all alcoholics to assess to what extent they are addicted to alcohol. The Short Michigan Alcoholism Screening Test—Geriatric Version (SMAST-G) questionnaire is designed to assess "at-risk" alcoholism in older patients, not pregnant women.

The nurse avoids using the average-sized cuff while measuring the blood pressure of a 20-year-old patient who has cone-shaped, obese arms. What is the rationale behind avoiding the average-sized cuff?

The average-sized cuff may create extra pressure on the artery for compression and result in falsely high blood pressure in an obese patient. Therefore, the nurse avoids the average-sized cuff for the measurement of blood pressure in the obese patient. The patient's age is not an appropriate criterion for the selection of cuff; instead, the patient's arm size and shape are considered for the selection of a cuff for blood pressure measurement. The tapered cuff is usually suitable to measure the blood pressure in the patient with cone-shaped, obese arms. The width of the rubber bladder should be equal to 40% of the arm circumference to obtain accurate blood pressure measurement in the patient.

The nurse assesses the eye movements of a patient using the diagnostic positions test and finds that the patient is unable to turn his or her eyes in three cardinal positions of gaze—up and nasal, straight nasal, and down and temporal positions. Based on these findings, which cranial nerve paralysis could the patient have?

The diagnostic positions test helps to detect the paralysis of eye muscles. In this test, the nurse assesses the eye movements of a patient through six cardinal positions of gaze. The patient with cranial nerve III or oculomotor nerve paralysis may not be able to turn the eyes in the straight nasal, up and nasal, and down and temporal positions. The oculomotor nerve innervates the muscles of the eye. The patient with cranial nerve IV or trochlear nerve paralysis may not be able to turn the eyes in down and nasal cardinal position of gaze. Paralysis of the abducens nerve or the cranial nerve VI may not allow the patient to move the eyes in a straight temporal position. The trigeminal nerve or the cranial nerve V carries the afferent sensory impulses to the brain. This nerve does not influence the functioning of the eye muscles.

Which part of the ear connects the middle ear to the nasopharynx?

The eustachian tube connects the middle ear to the back of the nose and the upper part of the throat. The semicircular canals are the three tubes present in the inner ear. The tympanic membrane is also called the eardrum. It separates the external and the middle ear. The external auditory canal is a long tube that leads to the tympanic membrane.

what is the function of the inner ear?

The inner ear contains the bony labyrinth, which comprises the parts that aid in hearing and maintaining body balance. The external auditory canal is part of the external ear and consists of wax glands that secrete cerumen to promote the lubrication of the ear. Cerumen acts as a sticky barrier that traps foreign bodies and prevents them from reaching the tympanic membrane. The eustachian tube is part of the middle ear and it equalizes air pressure on both the sides of the eardrum.

The nurse is assisting the health care provider in performing a vaginal, pelvic, and rectal examination of a patient. Which intervention does the nurse perform in this situation?

The lithotomy position is used for the assessment of vaginal, pelvic, and rectal examinations. In this position, the patient is instructed to slide the buttocks all the way down to the edge of the examination table. The nurse assists the patient to assume the prone position while examining the back and extension of the hip joint. The nurse assists the patient to assume sitting position while examining the lower extremities. The nurse assists the patient to assume the supine position while examining the head, chest, and abdomen.

Which structures will the nurse assess when looking at the mediastinum? Select all that apply.

The mediastinum is in the middle section of the thoracic cavity. The nurse, while assessing the mediastinum, will actually be assessing the heart, trachea, and the esophagus along with the great vessels. The lungs are contained in the right and left pleural cavities on either side of the mediastinum and are not examined with the mediastinum.

apgar scales?

The newborn's heart rate is above 100, so the score is 2. The respiratory effort is good, so the score is 2. The score is 1 each for muscle tone, reflex irritability, and color. The total score is 2 + 2 + 1 + 1 + 1, which is equal to 7.

During a vital sign assessment of an adult patient, the nurse observes that the rectal temperature is 99.3° F (37.4° C). What should the nurse conclude from the finding?

The normal temperature range of a rectal thermometer is higher than an oral thermometer. The normal oral temperature in a resting person is taken as 98.4° F (36.9° C). The range for a rectal thermometer is 0.7° F to 1° F higher than that of an oral thermometer. Therefore, a reading of 99.3° F (37.4° C) indicates normal body temperature. If the patient has a rectal temperature higher than 99.6° F (37.6° C), then the patient is suffering from fever. Hypothermia is temperature lower than the normal temperature. A reading of 99.3° F (37.4° C) in arectal thermometer does not indicate hypothermia. Rectal temperature of 99.3° F (37.4° C) is considered as normal body temperature, so the thermometer is giving a correct reading. If the thermometer is giving a reading less than 97° F (36.1° C), it is an indication that the rectal thermometer is not giving a correct reading.

The nurse is assisting with a neurologic examination in a pregnant patient and sees that the deep tendon reflex is greater than 2+. The patient also presents with an elevated blood pressure and headaches. What does this finding indicate?

The nurse documents the brisk deep tendon reflexes with the grades greater than 2+. Brisk tendon reflexes may occur in the pregnant patient who has cerebral edema associated with preeclampsia. The patient with preeclampsia will also have an elevated blood pressure and headaches. Condyloma refers to infection of the genitals. The patient with condyloma will not have brisk tendon reflexes. The patient with valvular disease may have an alteration in the systolic murmur, but not brisk tendon reflexes. Deep venous thrombosis does not lead to cerebral edema; therefore, the patient would not have brisk tendon reflexes.

Which part of the body should the nurse examine to assess cranial nerve VII?

The nurse examines the face of the patient to assess cranial nerve VII. The facial expression and symmetry of the face indicate normal functioning of cranial nerve VII. The nurse examines the eyes to test the visual fields and assess the functioning of cranial nerve II. The patient is asked to stick out the tongue during an examination of the mouth to assess cranial nerve XII. The nurse examines the throat to assess the mobility of the uvula and the gag reflex to assess cranial nerves IX and X.

he nurse is assessing the patient's posture. What distance should the nurse maintain from the patient during this assessment?

The nurse is assessing the patient's posture. In this case, the nurse would maintain a personal distance, which is about 1.5 to 4 ft. The nurse needs to maintain a distance of 1 foot while assessing the breath and body odors of the patient. The distance of 4 to 12 feet indicates social distance. The nurse maintains social distance while interviewing the patient. Therefore, the nurse should not maintain a distance of 5 to 7 feet while performing the physical assessment.

The patient enters the examination room for a physical assessment. The nurse switches on all the lights and stares at the patient for a few minutes before starting any procedure. What is the reason for this behavior by the nurse?

The nurse is inspecting the patient carefully. Inspection involves close, careful scrutiny, first of the patient as a whole and then of each body system. The procedure requires intense concentration and involves staring at the patient. For proper and minute observation, the place where the patient is inspected must be brightly lit. Auscultation is listening to the sounds produced by the body such as the heart, blood vessels, lungs, and abdomen. The process of palpation applies the nurse's sense of touch to assess factors such as swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or pain. Percussion involves tapping the patient's skin with short, sharp strokes to assess the underlying structures.

What should the nurse expect to feel while palpating a patient's chest wall after undergoing thoracic surgery?

The nurse is likely to feel crepitus, which is a coarse, crackling sensation palpable over the skin surface. Crepitus occurs when air escapes from the lung and enters the subcutaneous tissue after open thoracic surgery. Rhonchal fremitus is palpable with thick bronchial secretions. Decreased fremitus occurs with obstructed bronchus, pleural effusion, or thickening. Pleural friction fremitus is palpable with the inflammation of the pleura.

The nurse is reviewing the characteristics of percussion notes of four different patients. Which patient has tympanic percussion notes?

The nurse obtains a percussion note that has a loud intensity, high pitch, and a drum-like musical quality which sustains for a long duration while examining patient A. This is referred to as a tympanic percussion note. The nurse obtains a percussion sound that has a loud intensity with a low-pitched booming quality and sustains for a long duration while assessing patient B. This note is referred to as a hyperresonant note. The nurse obtains a percussion sound that has a short duration, soft intensity, high pitch, and muffled thud quality while examining patient C. These are the characteristics of a dull percussion note. The nurse obtains a percussion sound that lasts for a very short duration, is of very short intensity, and is high-pitched while examining patient D. These are the characteristics of a flat percussion note.

The nurse is assessing a patient's mental status during the review of systems. Which question should the nurse ask the patient?

The nurse should ask the patient about mood changes while assessing the patient's mental status. Memory-related questions are asked to evaluate the patient's cognitive status. Regular sleeping cycles can be assessed to determine sleep disorders due to stress; sleep/rest is a functional assessment. The patient who has tics or tremors may have problems with motor function.

The nurse is preparing a patient for cardiac assessment. Which interventions should the nurse follow while assessing?

The nurse should ask the patient to sit during the carotid artery assessment because the seated position allows proper exposure of the neck. The nurse places the patient in the supine position while auscultating the precordium to obtain accurate jugular venous pressure. The nurse needs to maintain a warm room temperature during the cardiac assessment because a cold room may make the patient uncomfortable, and shivering interferes with auscultating heart sounds. The nurse should not compress the carotid artery during the assessment, because it can cause vagal stimulation and the patient may develop bradycardia. The nurse should start observations from the periphery and move in toward the heart. Hence, the nurse should assess the pulse and blood pressure, not the neck, first.

A patient in the hospital experiences epistaxis. What should the nurse instruct the patient to do to stop the bleeding?

The nurse should ask the patient to sit up with the head tilted forward. The patient should pinch the nose between the thumb and forefinger for 5 to 15 minutes to stop bleeding. The patient must not lie down with the head tilted back, because it may cause the blood to go into the mouth or throat, which is a potential choking hazard. A gauze pad may help absorb the blood but does little to actually stop the nosebleed.

Which intervention does the nurse follow while examining the external genitalia of a male patient?

The nurse should check for an inguinal hernia while examining the genitalia of a male patient. The nurse should check for the Romberg sign while assessing the vision, proprioception, and vestibular sense of the patient. The nurse should palpate the epitrochlear nodes while assessing the upper extremities. The nurse should percuss the costovertebral angle while assessing the posterior and lateral sides of the chest.

The nurse in a primary health care setting documents a patient's complete health history. In which order should the nurse arrange the sections of this patient's health history?

The nurse should document the complete health history of the patient in a standard sequence as determined by the health care setting. The nurse should first record the biographic data, which include the patient's personal information such as occupation, ethnicity, and health practices. This is followed by the reason for seeking care, in which the nurse documents the signs and symptoms and the purpose of the patient's visit. Next, the nurse should document the history of the present illness; it includes the location, character, onset, and frequency of the symptoms. Then the nurse should document the patient's past history, which includes childhood illnesses, accidents, hospitalizations, and operations. Finally, the nurse should document a comparative list of current medications with a previous one; this is called medication reconciliation.

A nurse is preparing for a patient interview. What tasks does the nurse complete before the interview begins: select all that applyEnsure direct, bright light in the room. = Turn off the television and radio in the room. = Ask the patient to change into a hospital gown. = Ask the accompanying family member to step out. = Request other staff not to interrupt the discussion

The nurse should ensure that the physical settings are optimal for a patient interview. The television and radio in the room should be turned off to prevent distractions. Asking the accompanying family members to step out during an interview helps provide privacy for the patient. Other staff members should be informed in advance about the interview so that they do not interrupt the discussion. The room should be well lit, but should not have direct or bright light, because it can cause squinting. A hospital gown may make the patient feel exposed and uncomfortable.

The student nurse interviews an adolescent patient. After the interview, the patient reports to the nurse that the student nurse seemed to be aloof and not concerned. Which behavior of the student nurse may have led the patient to have this opinion?

The nurse should maintain a distance of 4 to 5 feet while conducting an interview. If the nurse stands farther than 5 feet, then the patient may feel that the nurse is not concerned and is not interested in gathering any information from the patient. Standing during the interview indicates that the nurse is assuming superiority or is in a hurry to complete the interview. Asking open-ended questions encourages the patient to give more elaborate information to the patient. Calling the patient by the first name indicates that the nurse is being disrespectful to the patient.

What habits may be helpful to a nurse when preparing educational materials for a patient

The nurse should present the written information clearly to enable understanding in the patient. Bullets help the patient identify the key points. A 12-point font helps the readers read the information clearly. Headings and subheadings help the patient scan the information and identify the important points mentioned in the document. Poor readers may not understand inanimate pictures and may become confused; therefore, the nurse should use the simple pictures in the materials. Using all capital letters may decelerate the speed of reading; hence, it should be avoided.

e nurse is teaching a mother about preventing baby bottle tooth decay. Which statement by the nurse is appropriate?

The nurse should teach the mother not to put the baby to bed with a bottle of milk, because it causes destruction of the deciduous teeth. Liquid pools in the upper front teeth when the baby is put to bed with a bottle of milk or juice. Bacteria in the mouth act on the carbohydrates in the liquid to form metabolic acids. These acids break down the tooth enamel and destroy its protein. The baby should not be bottle-fed past the age of one year to prevent the risk of losing deciduous teeth. Bottle-feeding does not delay the arrival of permanent teeth.

The nurse is examining the throat of a patient. What does the nurse document as a normal finding?

The oval, rough-surfaced tonsils lie behind the anterior tonsillar pillar. It is normal to find the rough surface peppered with indentations, or crypts. The tonsils are normally the same pink in color as found on the oral mucosa. Bright red and swollen tonsils indicate acute infection. A white membrane may cover the tonsils if the patient has infectious mononucleosis, leukemia, or diphtheria. During an acute infection, the tonsil may have large white spots or exudates.

A patient tells the nurse, "Something is stuck in my eye, and I can't see anything." On examination, no foreign body is seen. The patient also reports tearing and sensitivity to light. What condition would the nurse suspect?

The patient feels pain, foreign body sensation, tearing, and photophobia. The symptoms indicate corneal abrasion. A corneal abrasion occurs due to damage to the cornea caused by injury, blunt trauma, scratches, or poorly fitting contact lens. Because the area has several nerve endings, the person feels excruciating pain. In aged adults, the cornea may look cloudy. A gray-white arc or circle caused by lipid deposition around the limbus can be noticed. This is called arcus senilis. Dacryocystitis is infection and blockage of lacrimal sac and duct. It is characterized by pain, warmth, redness, and swelling that occurs below the inner canthus toward the nose. Cataract formation is clouding of the crystalline lens from the clumping of proteins. It is caused by thickening of the transparent fibers of the lens.

While assessing a pregnant patient, the nurse observes that the patient is short of breath. Upon further examination, the nurse auscultates the lungs and hears wheezing. What should the nurse infer from these findings?

The patient who has asthma may present with shortness of breath and wheezing while breathing. Shortness of breath occurs because of increased pressure on the diaphragm by the fetus and is considered normal during pregnancy. However, wheezing while breathing is not normal at any time, let alone during pregnancy. Preeclampsia is a pregnancy disorder associated with increased blood pressure and proteinuria. Therefore, the symptoms of the patient do not indicate preeclampsia. A congested cough and crackles noted when auscultating the lungs are associated with pulmonary infection.

What is the best goal for a patient who is learning self-breast examination techniques?

The patient who is learning self-breast examination techniques will have to learn the correct sequence. Improving knowledge related to breast cancer is not helpful for the patient, because the focus is on learning the technique. Making monthly breast self-examination a habit would be an effective goal for a patient who has learned the technique. The patient will be able to identify a lump only after learning the technique.

While assessing a patient with an acute myocardial infarction, the nurse finds that the patient has hypotension. What is the most likely reason for this finding in the patient?

The patient with acute myocardial infarction may have arrhythmias such as ventricular tachycardia. These may cause ineffective pumping of the blood from the heart throughout the body and, therefore, decrease cardiac output in the patient. This decreased cardiac output causes hypotension. A decrease in blood cholesterol levels is called "hypocholesterolemia," which does not cause hypotension. However, high cholesterol levels may be the cause of myocardial infarction. Increased peripheral vascular resistance increases pressure in the vascular system; therefore, it results in hypertension, not hypotension. An increase in total blood volume, in the absence of other factors, will cause hypertension, not hypotension, in the patient.

Which assessment finding in a patient may indicate breast cancer?

The presence of a unilateral, dense, irregular mass may indicate breast cancer. A cancerous mass has poorly delineated borders and grows constantly. A fibroadenoma or benign tumor is generally well defined. It may be oval in shape and freely movable on palpation. It easily slides through the tissue because it is a firm, rubbery, and elastic mass. An inframammary ridge is a normal finding in the lower quadrant of the breast. It thickens with age, and must not be confused with an abnormal lump.

After performing the otoscopic examination of a patient, the nurse concludes that the patient has an infection. Which findings enabled the nurse to reach this conclusion?

The presence of a yellow/amber-colored tympanic membrane indicates otitis media with effusion, which is a middle ear infection. The normal tympanic membrane is shiny, translucent, and pearl gray in color. Usually, the annulus appears white in color and denser at the periphery. Therefore, it does not indicate that the patient has an infection. In a healthy individual, the malleus is visible through the tympanic membrane.

The nurse is assessing a patient who reports feeling nodules in the breast. Further assessment reveals that the patient is in the midcycle of menstruation. What is the best intervention by the nurse?

The presence of pain and nodules in the breast is a common finding in most patients in the midcycle of menstruation. Therefore, the nurse asks the patient to return for a follow-up examination a week after menstruation, on day 4 to 7 of the cycle. During this time the hormone levels will be lower, and normal edema will be absent. The nurse need not refer the patient for further investigation until a repeat examination confirms the presence of a lump. At this stage, the nurse need not report the finding to the health care provider or inform the patient of the need for a biopsy at this stage.

What does the nurse assess during the review of systems?

The review of systems refers to the act of evaluating each body system which would include the skin (e.g., a history of skin disease) and gastrointestinal system (e.g., appetite and food intolerances). The nurse evaluates the patient's sociologic system to understand the patient's interpersonal relationships, family support, and role in the family. The review of systems is not used to record the physical assessment findings; it is used to understand the patient's body systems. Usual daily activities are part of the functional assessment not the review of systems.

A patient experiencing alcohol withdrawal has normal levels of serum protein gamma glutamyl transferase (GGT). During the follow-up visit a month later, however, the GGT levels are increased. What could be the reason for this?

The serum protein gamma glutamyl transferase (GGT) is a biomarker for alcohol. It is helpful in detecting relapses of alcohol dependency in patients who stop consuming alcohol. Elevated levels of GGT after a period of normal levels indicate that alcoholism has relapsed in the patient. They also indicate that the patient may have nonalcoholic liver disease, which is unrelated to alcohol consumption. Alcohol abstinence for 15 days normalizes the levels of carbohydrate-deficient transferrin (CDT); it does not increase them. Alcohol abstinence for 4 to 5 weeks normalizes, but does not increase, the levels of GGT. Drinking alcohol occasionally does not increase the levels of GGT, but chronic drinking for months will.

The nurse instructs a student nurse to assess the patency of the anus in a 1-day-old neonate. How should the student nurse determine this?

The student nurse should check for the passage of meconium in a neonate within 24 to 48 hours in order to assess the patency of the anus. The Ortolani sign helps to determine if there is hip dislocation in an infant. It does not help to assess the gastrointestinal functioning and patency of the anus in the newborn. The dorsalis pedis pulse is assessed to determine blood supply to the lower limbs but not the rectum. Therefore, the nurse would palpate the dorsalis pedis pulse to determine lower limb abnormalities but not to determine the patency of the anus. The nurse should palpate the inguinal lymph nodes in order to determine the functioning of the lymphatic system in the neonate.

The nurse takes special care while checking a patient's tail of Spence. What is the reason for this intervention?

The tail of Spence is a cone-shaped breast tissue that projects up into the axilla. It is located at the upper quadrant of the breast. The upper quadrant is a common site of breast cancer. Paget's disease starts with a small crust on the nipple apex and spreads to the areola. It is also associated with abnormal nipple discharge. A supernumerary nipple is a congenital variation. It is an extra nipple along the embryonic "milk line" on the thorax or abdomen and is a congenital finding. To observe skin retraction, the patient is asked to push her hands onto her hips.

While assessing a bedridden patient, the nurse finds that the patient has a pressure ulcer. Upon further assessment, the nurse finds that the bones are visible through the ulcer, and there is black necrotic tissue around the wound. How would the nurse stage this pressure ulcer?

The term pressure ulcer refers to a localized injury caused by complete or partial obstruction of blood flow to the soft tissue at the site of an injury. Immobility increases the pressure on the bones, which are in contact with the bed, and may result in the development of the pressure ulcer. Based on the extent of the damage caused to the tissues, pressure ulcers are classified into four types. In the stage IV pressure ulcer, all skin layers are damaged and the wound extends into supporting tissue. Thus, the nurse can see the bone and the black necrotic tissue around it. A stage I pressure ulcer is characterized by localized redness. A stage II pressure ulcer is characterized by loss of epidermis and dermis. A stage III pressure ulcer is associated with damage to the subcutaneous tissues. In this stage, the nurse can visualize subcutaneous fat from the wound, but not the bone.

What changes occur in the respiratory system during pregnancy that the nurse would tell a pregnant patient about? Select all that apply.

The total circumference of the chest cage increases by 6 cm. The transverse diameter of the chest cage increases by 2 cm and the costal angle widens. Although the diaphragm is elevated, it is not fixed. The enlarging uterus elevates the diaphragm by 4 cm, leading to a decrease in the vertical diameter of the thoracic cage. Physiologic dyspnea may occur in early pregnancy, leading to an increased awareness of the need to breathe. An increase in estrogen levels during pregnancy relaxes the chest cage ligaments, allowing the chest cage to increase in the horizontal diameter. Although the diaphragm is elevated, it moves with breathing even more during pregnancy. This movement results in a 40% increase in tidal volume.

While examining a newborn, the nurse inspects the trunk incurvation reflex. What body part is the nurse assessing by doing this?

The trunk incurvation reflex assesses the spinal column. In order to assess the development of the lower limbs, the nurse would note the range of motion and muscle tone and test for the presence of the Ortolani sign in the newborn. The nurse would inspect the genital organs of the newborn in order to determine genital development. The nurse would count the fingers and palmar creases and check for the presence of the grasp reflex and scarf sign in the newborn in order to check development of the upper limbs. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same as or similar in nature to those in one or two of the options.

How does the normal tympanic membrane appear during an otoscopic examination?

The tympanic membrane is concave with a pearly gray color. A prominent cone of light is seen in the anteroinferior quadrant, which is the reflection of the otoscope light. This structure is obliquely placed and is not straight. The tympanic membrane is not convex or opaque; it is concave and translucent. The normal tympanic membrane is pearly gray, and is not pink, white, or red in color.

While examining the eyes, the nurse finds that the patient has 20/20 vision, symmetric corneal reflex, and white sclera. The patient's pupil size is 3 mm while resting and 2 mm while constricting. What does the nurse infer from these findings?

The visual acuity of 20/20, symmetric corneal reflex, white sclera, pupil size of 3 mm resting and 2 mm constricted are normal findings. Therefore, the patient has normal vision. Ptosis is the drooping of the upper eyelid, which blocks the vision. Strabismus is a condition in which the patient is not able to direct both eyes toward the same object. A patient with strabismus will have visual acuity of 20/40 and asymmetric corneal reflexes. Nystagmus refers to the involuntary eye movement that is caused by damage to the brain.

When reviewing the ultrasound report of a 55-year-old female patient, the nurse finds that a rapidly growing single nodule is seen in the thyroid gland. What does such a report signify?

Thyroid nodules are palpable in 1% to 5% of ambulatory care patients. They can be identified in 50% of ultrasound studies. More than 95% of these are benign tumors, especially when the patient is a female. Males between 15 years and 45 years are at higher risk of malignant tumors. However, the risk reduces with age. Multiple nodules usually indicate inflammation. Cancerous nodules are usually hard and fixed to the surrounding structures. In case of goiter, more than one nodule is found in the thyroid gland.

The nurse is examining the hearing of an elderly patient using the whisper voice test. Which intervention would the nurse follow to properly administer this test?

To perform the whisper voice test, the nurse would stand 2 feet behind the patient and whisper a set of three random numbers and letters while the patient holds one ear closed. Then the nurse asks the patient to repeat the numbers and letters. This helps the nurse to assess the hearing ability of the patient and provide appropriate treatment. If the nurse stands in front of the patient and whispers the numbers, the patient may be able to understand them by lip reading. The nurse might thus make an inaccurate assessment that the patient has normal hearing. If the nurse stands 10 feet away and whispers the numbers and letters, even an individual with normal hearing would not be able to hear them. Therefore, the nurse needs to stand closer to the patient. The patient may not be able to hear if both ears are closed so the nurse should inform the patient to close only the ear that is not being assessed.

Which assessment technique should the nurse use to determine the body temperature of a patient?

Touching the patient's skin with the dorsal side of the hands and fingers helps in determining the body temperature of the patient. This is because the skin is thinner on the dorsal surface of the hands and fingers than over the palm, and is more sensitive to changes in temperature. The grasping action of the fingers and thumb is used to determine the position, shape, and consistency of an organ. Bimanual palpation is used to envelop or capture certain body parts or organs such as the kidneys, uterus, or adnexa for more precise delimitation. The base of the fingers is used for fine tactile discrimination.

A patient presents with complaints of chest pain. The nurse identifies a heart murmur in the patient. Which pathologic conditions can cause heart murmurs? Select all that apply.

Turbulent blood flow and collision currents can cause heart murmurs. A murmur is a gentle blowing swooshing sound that can be heard in the chest wall. Structural defects in the valves such as regurgitant valves can cause heart murmurs. Similarly, septal defects such as unusual openings in the heart chambers may produce heart murmurs. Flow murmurs may occur when the velocity of the blood increases due to exercise or thyrotoxicosis. Decreased myocardial contraction may result in ischemic heart disease. The right bundle branch block causes a wide split in the second heart sound.

The nurse is interviewing a pregnant patient. The patient tells the nurse, "I cannot think of being on bed rest now because I have kids at home and I'm worried about them." Which statement by the nurse indicates that the nurse has given a reflection type of verbal response?

Verbal response plays an important role with communication. Reflection is a type of verbal response in which the nurse repeats the patient's words. This type of verbal response enables the patient to elaborate about his or her problem. The statement "You feel worried and anxious about your children" indicates that the nurse has given a reflection type of verbal response. "It must be hard to stay away from the children" is a verbal response that indicates empathy. "You feel worried about your children because you love them a lot" is an interpretation type of verbal response. "You have to control your emotions because it may affect your health" is an explanation type of verbal response.

Which signs and symptoms does the nurse expect to find in a patient with vitamin B6 deficiency?

Vitamin B6, or pyridoxine, helps in amino acid, glucose, and lipid metabolism, neurotransmitter synthesis, and hemoglobin synthesis. Deficiency of vitamin B6 affects the synthesis of hemoglobin, resulting in pale conjunctivae. Vitamin B6 helps to regulate the sensory function of the peripheral nerves; therefore, deficiency of vitamin B6 may cause peripheral neuropathy in the patient. Deficiency of niacin and riboflavin may cause cheilosis in the patient. Disorientation may occur due to the deficiency of vitamin B12. Deficiency of riboflavin may cause red discoloration of the conjunctival layer in the patient.

The nurse is assessing a patient who is devoid of melanin pigment in patchy areas of the skin on the face, neck, hands, feet, and body folds, and around orifices. What term would the nurse use to describe this condition?

Vitiligo is an acquired condition characterized by a lack of melanin pigment in patchy areas of the skin on the face, neck, hands, feet, and body folds and around orifices. Dark-skinned people are more susceptible to this condition. Freckles are tiny, flat macules of brown melanin pigment that occur on skin that is frequently exposed to the sun. A clump of melanocytes that are flat or raised and that are brown or tan are called moles. A birthmark is a tan or brown mark that exists from birth.

When would a nurse establish a complete database of a patient?

While assessing a patient during an initial home visit, in a primary health care setting, and in a community health care setting, the nurse would review the patient's medical history and laboratory and diagnostic reports. Along with this information, the nurse would evaluate the patient's coping skills, support system, and lifestyle modifications. This information would help the nurse to establish a complete database. This is an elaborate and time-consuming procedure. In an emergency department or an operating room, the patient may develop serious complications suddenly and require immediate and effective treatment. Therefore, while caring for such patients, the nurse would establish an emergency database.

After conducting a cardiac examination, the nurse concludes that the patient has normal cardiopulmonary functioning. Which findings enabled the nurse to reach this conclusion? Select all that apply.

While conducting a cardiac examination, the nurse should evaluate the heart sounds; this helps to determine the cardiac functioning. Cardiac murmur is caused by abnormal blood flow. Therefore, the absence of cardiac murmur indicates that the patient has intact cardiac valves. The first heart sound (S1) and second heart sound (S2) are heart sounds that are produced by the opening or closing of the heart valves; it is normal for S2 to be louder when auscultating at the base of the heart. The presence of a loud or accentuated S1 heart sound indicates a prolapsed mitral valve. A diminished S2 heart sound indicates that the patient may have aortic stenosis. The absence of bilateral breath sounds indicates that the patient may have a pulmonary disorder and is not a normal finding.

The nurse is performing an otoscopic examination in an adult patient. What would the nurse do to straighten the patient's ear canal during the test?

While performing the otoscopic examination in an adult patient, the nurse should pull the patient's ear up and back, which helps straighten the S-shaped ear canal. Pulling the ear straight out or leaving it undisturbed does not straighten the ear canal, and could hinder the examination. Pulling the patient's pinna down and back is only effective on children under the age of three, because their ear canals are much shorter.

While performing chest percussion on a patient, the nurse obtains a loud sound. Under which percussion note characteristic does the nurse document this finding?

loudness or softness of sounds indicates the intensity or amplitude of the sound. Pitch or frequency indicates the number of vibrations per second. The pitch could be low or high. Quality refers to the subjective difference caused by the distinctive overtones of a sound. Duration refers to the length of time of the produced sound.

what causes S1 sounds?

mitral and tricupsid valve closure

The nurse is assessing a patient's breasts. Which finding does the nurse identify as abnormal?

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After assessing a patient who has undergone an appendectomy, the nurse documents the presence of a keloid. Which finding enabled the nurse to reach this conclusion?

the presence of excessive fibrous tissue over the skin at the site of the injury or surgery indicates that the patient has a keloid scar. The presence of depressed skin at the site of the surgery indicates that the patient has an atopic scar. It is caused by the loss of tissue. Crusts are the thick dried exudates left after the bursting of vesicles. The presence of tightly packed papules at the site of the surgery indicates that the patient has lichenification. It is caused by prolonged or intense scratching.