Health Assessment Final

Disorders of the urinary tract may also cause kidney pain. Which of the following facts are true related to this finding? Select all that apply. A. Kidney pain is also reported as flank pain B. Kidney pain is often assessed at or below the posterior costal margin near the costovertebral angle. C. Kidney pain can radiate to the mid-axillary line D. Kidney pain is a visceral pain E. Ureteral pain is the same as kidney pain

A, B, D

Which of the following statements are true related to breast self exam. Select all that apply A. A high proportion of breast masses are detected by women examining their own breasts B. Prophylactic bilateral mastectomy is advised in women at very high genetic risk for breast cancer. C. On examination the finding of an extra nipple is a significant pathologic finding. D. After menopause there is a decrease in number of lobules in the breast. E. After menopause, glandular tissue grows and replaces fat in the breast tissue

A, B, D

Causes of polyuria include (select all that apply) A. Psychogenic polydipsia B. Poorly controlled diabetes C. Increased secretion of Antidiuretic hormone (ADH) D. Increase renal sensitivity to ADH E. Diabetes insipidus

A, B, E

A nursing student is preparing to demonstrate how to test the range of motion for the elbow. Which of the following would the student include? Select all that apply. A. Flexion B. Abduction C. Extension D. Rotation E. Supination F. Circumduction

A- Flexion C- Extension E- Supination

When visualizing the structures of the abdominal cavity, which of the following would the nurse expect to be in the right upper quadrant? A. Right kidney, ascending colon, and liver B. Right ovary, pancreas, and sigmoid colon C. Right ovary, descending colon, and spleen D. Right kidney, transverse colon, and inguinal ligament

A- Right kidney, ascending colon, and liver

When the nurse moves a client's leg upward, the nurse is performing A. supination. B. external rotation. C. eversion. D. Internal rotation

A- Supination

The nurse is caring for a patient with a diagnosis of degenerative disease of the cervical spine. What might the nurse find on inspection of this patient? A. Torticollis B. Hypotonicity C. Atrophy D. Hypertonicity

A- Torticollis

A 27-year-old woman comes to the emergency department reporting severe right lower quadrant pain. Her temperature is 101.5°F (38.6°C), BP 122/80 mm Hg, pulse 95 beats/min, and respirations 22 breaths/min. What might the nurse suspect the patient has A. Acute appendicitis B. Chronic gall bladder disease C. Hepatitis A D. Gastric cancer

A- acute appendicitis

After completing the musculoskeletal health history, the nurse determines that a client is at risk for osteoporosis. Which of the following risk factors were most likely identified in this client?(Select all that apply.) A. Age 65 B. Current smoker C. Sedentary lifestyle D. Weight 180 pounds E. Alcohol intake four drinks per day

A- age 65 B- current smoker c- sedentary lifestyle E- alcohol intake four drinks per day

Mrs. Philips complains of numbness of her right hand. On examination, sensation of the volar aspect of the web of the thumb and index finger and pulp of the middle finger are normal. The pulp of the index finger has decreased sensation. Which of the following is affected? A. Median nerve B. Ulnar nerve C. Radial nerve

A- median nerve

Which action by a nurse is a correct method for performing the Tinel's test to determine the presence of carpel tunnel syndrome? A. Percuss lightly on the inner aspect of the wrist. B. Palpate the hollow area on the back of the wrist. C. Ask the client to bend the wrist down and back. D. Perform wrist movements against resistance.

A- percuss lightly on the inner aspect of the wrist

A nurse assesses a client's ability to open jars due to report of weakness in the hands. Which tests should be conducted to determine if nerve compression is causing the weakness? Select all that apply. A. Phalen's sign B. Tinel's sign C. test flexion D. Crossover test E. Weak thumb abduction

A- phalens sign B- tinel's sign E- Weak thumb abduction

As part of an abdominal assessment, the nurse must palpate a client's liver. In which quadrant is this organ located? A. Right upper quadrant B. Right lower quadrant C. Left upper quadrant D. Left lower quadrant

A- right upper quadrant

The nurse is providing community education on osteoporosis. What risk factors for osteoporosis need to be included in the teaching? Select all that apply. A. Smoking B. Hormones C. Alcohol consumption D. low salt intake E. Weight-bearing activities

A- smoking B- hormones C- alcohol consumption

While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is enlarged and everted. The nurse should refer the client to a physician for possible A. umbilical hernia. B. ascites. C. intra-abdominal bleeding. D. pancreatitis.

A- umbilical hernia

During assessment, the nurse notes the client has limited movement of his lower extremities and sways when standing with feet together. The nurse identifies that the client is at risk for what? A. Falls B. Stroke C. Impaired mobility D. Pressure ulcers

A. Falls

What task should a nurse ask a client to perform to assess the function of cranial nerve XI? A. shrug shoulders against resistance B. move tongue side to side C. swallow water D. walk in heel-to-toe fashion

A. Shrug shoulders against resistance, CN XI Accessory- spinal

When the nurse is assessing the motor function of cranial nerve VII as part of the neurological examination, what should the nurse instruct the client to do? A. Smile. B. Clench the teeth. C. Cover one eyed. D. Clench the teeth

A. Smile- VII Facial Nerve

The nurse is performing the Romberg test as part of a client's focused neurological assessment. What finding would constitute a positive Romberg test? A. The client moves her feet apart to prevent herself from falling. B. The client is unable to consistently touch her finger to her nose while her eyes are close. C. The client experiences pain during neck flexion and extension. D. The client experiences pain when clenching her teeth.

A. The client moves her feet apart to prevent falling

The nurse is planning to assess a client for graphesthesia. How will the nurse perform this phase of assessment? A. The client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object. B. The client is asked to identify the number of points felt when the nurse touches the client with the ends of two applicators at the same time. C. The nurse will simultaneously touch the client in the same area on both sides of the body, and the client will identify where the touch occurred. D. Have the client close the eyes. The nurse will then gently touch the client, and the client will identify where the touch occurred.

A. The client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object.

The nurse plans to test which cranial nerve when testing an elderly patient's hearing status? A. VIII B. VII C. VI D. V

A. VIII-8 Vestibulococchlear

Which of these medications should a nurse ask a client if they are taking when assessing the risk for osteoporosis? Select all that apply. A. Corticosteroids B. Antihypertensives C. Estrogen replacement therapy D. Thyroid replacement drugs E. Rescue inhaler for asthma

A: Corticosteroids D: Thyroid replacement drugs

A nurse tells a client that the next step in the musculoskeletal assessment is to perform range of motion of the thoracic and lumbar spine. The nurse should demonstrate which movements for the client to facilitate the examination? Select all that apply. A. Flexion B. Lateral bending C. Rotation D. Circumduction E. Extension

A: Flexion B: Lateral Bending C: Rotation

A nurse is instructing a client with gouty arthritis on foods to avoid that trigger this condition. Which of the following should the nurse mention? A. Liver B. Whole milk C. Sardines D. Orange juice E. Coffee F. Alcohol

A: Liver C: Sardines

Blood in the urine is a cause for concern. Which of the following facts are true regarding this assessment? Select all that apply. A. Blood that is assessed as microscopic hematuria is not a cause for concern. B. The ongoing assessment should include questions regarding ingestion of beets C. Before you settle on a diagnosis of hematuria it is recommended that you test the urine with a dipstick and utilize a microscopic examination D. When blood is visible to the naked eye it is called gross hamaturia

B,C,D

During the nursing history of a newly admitted client, the nurse is reviewing a client's current medication regimen. What medication category creates a risk for decreased bone density? A. Beta-adrenergic blockers B. Corticosteroids C. Nonsteroidal anti-inflammatories (NSAIDs) D. Calcium channel blockers

B- Corticosteroids

A client complains of a burning sensation in the esophagus after eating. Which associated condition should the nurse most suspect? A. Pancreatic cancer B. Acid reflux C. Gastric ulcer D. Acute pancreatitis

B- acid reflux

___________arises from an imbalance of estrogens and androgens and sometimes may be drug related. A. Mastitis B. Gynecomastia C. Fibroadenoma D. Mastectomy

B- gynecomastia

Bones in synovial joints are joined together by A. cartilage. B. ligaments. C. tendons. D. periosteal tissue.

B- ligaments

When assessing for appendicitis, what signs might the nurse look for? (Select all that apply.) A. Murphy sign B. Psoas sign C. Obfuscator sign D. Rovsing sign E. Romberg

B- psoas sign D- Rovsing sign

The client tells the nurse that he has joint stiffness that is worse in the morning but improves as the day progresses. The nurse should assess the client for what musculoskeletal disorder? A. Gouty arthritis B. Rheumatoid arthritis C. Osteoarthritis D. Osteoporosis

B- rheumatoid arthritis

A client is experiencing parietal abdominal pain. The nurse would expect the client to describe the pain as which type of sensation? A. Dull B. Steady C. Cramping D. Burning

B- steady

A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. What would the nurse do? A. Use a Snellen chart to test visual acuity. B. Ask a client to identify scents. C. Test extraocular eye movements. D. Perform the Weber test.

B. Ask a client to identify scents

A client is concerned about tripping when walking and feeling uncoordinated. Which part of the brain might be causing this client's symptoms? A. brainstem B. cerebellum C. frontal lobe D. parietal lobe

B. Cerebellum

Upon reviewing the client's medical record, the nurse finds the client has left ptosis. The nurse would assess the client for what? A. Drooping of the left side of the mouth B. Drooping of the left eye C. Swelling of the optic nerve D. Loss of visual fields on the left

B. Drooping of left eye

How many pairs of cranial nerves exit from the brain? A. 10 B. 12 C. 14 D. 16

B: 12

The nurse suspects that a client has carpal tunnel syndrome of the right wrist. What did the nurse assess to make this clinical determination? A. strong hand grasp B. numb index finger C. weak extension of the wrist D. wrists held in flexion for 90 seconds

B: Numb index finger

Upon assessing the client's jaw, the nurse finds decreased range of motion and notes crepitus. What would the nurse suspect? A. Arthritis B. Temporomandibular Joint (TMJ) C. Facial fractures D. Myofascial pain syndrome

B: Temporomandibular joint

A nurse inspects a client's abdomen and notices that a bulge is present in the right lower quadrant. How should the nurse further assess this finding using inspection? A. Palpate to measure the diameter of the mass B. Percuss to determine if the mass is fluid filled C. Ask the client to raise the head off the bed D. Have the client cough forcefully a few times

C- Ask the client to raise the head off the bed

A previously healthy 64-year-old man has been recently diagnosed with osteoarthritis. The client is motivated to maintain his quality of life and slow the progression of his new health problem. What advice can the nurse provide for the client in his efforts to minimize the effects and progression of osteoarthritis? A. "Because this is generally an unavoidable aspect of the aging process, there is little you can do to affect how quickly or slowly it progresses." B. "Increasing the amount of calcium that you get in your diet has been shown to have a real effect." C. "It's important for you to maintain a healthy body weight." D. "It is helpful for you to make sure that you get enough vitamin D in your diet or to take supplements."

C- It's important for you to maintain a healthy body weight

A client has suffered a suspected rotator cuff tear. Which finding would the nurse expect during assessment? A. Limitation of all shoulder motion B. Chronic pain C. Limited abduction D. Sharp catches of pain with movement

C- Limited abduction

An emergency department nurse is caring for a teenage client who has severe pain in the umbilical area. Documentation shows that the client exhibits "Rovsing's sign." What might this client's medical diagnosis be? A. Gastroenteritis B. Liver disease C. Appendicitis D. Enlarged spleen

C- appendicitis

A group of students is preparing for their clinical experience, for which they are required to demonstrate the techniques for examining the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order? A. Palpate, percuss, inspect, auscultate B. Auscultate, inspect, palpate, percuss C. Inspect, auscultate, percuss, palpate D. Percuss, inspect, auscultate, palpate

C- inspect, auscultate, percuss, palpate

A 21-year-old receptionist comes to the clinic reporting frequent diarrhea. She states that the stools are very loose and there is some cramping beforehand. She states this has occurred on and off since she was in high school. She denies any nausea, vomiting, or blood in her stool. Occasionally she has periods of constipation but that is rare. She thinks the diarrhea is much worse when she is nervous. Her past medical history is not significant. She is single and a university student majoring in accounting. She smokes when she drinks alcohol but denies any illegal drugs. Both of her parents are healthy. Her entire physical examination is unremarkable. What cause of diarrhea is the most likely etiology? A. Secretory infections B. Inflammatory infections C. Irritable bowel syndrome D. Malabsorption syndrome

C- irritable bowel syndrome

After teaching a group of students about the important organs to be assessed during an abdominal assessment, the instructor determines that the teaching was successful when the students identify which organ as the largest solid organ in the body? A. Pancreas B. Spleen C. Liver D. Kidney

C- liver

A client complains of abdominal pain that is worsened with alcohol ingestion. The nurse should suspect which of the following as the underlying cause? A. Crohn's disease B. Gastric ulcer C. Pancreatitis D. Gastroesophageal reflux

C- pancreatitis

To promote relaxation of the abdominal muscles, which of the following would be most appropriate for the nurse to do? A. Encourage the client to hold his or her breath. B. Cover the client in a warm blanket. C. Place a pillow under both of the client's knees. D. Assure the client that painful areas will not be examined.

C- place a pillow under both client's knees

The nurse is assessing a 51-year-old morbidly obese client who is seeking care for the recent loss of sensation in his feet and toes. The client also complains of intermittent burning and tingling in his feet that radiate up his legs. For which of the following health problems should the nurse first assess? A. Lead poisoning B. Multiple sclerosis C. Diabetic peripheral neuropathy D. Alcohol abuse

C. Diabetic peripheral neuropathy

Which of the following would the nurse most likely expect to find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident? A. Inability to hear high-pitched sounds B. Loss of tactile sensation C. Difficulty speaking D. Blurred vision

C. Difficulty speaking

A client who was injured by a fall at a construction site has been admitted to the hospital. He has suffered nerve damage such that his gag reflex is no longer intact, requiring him to receive intravenous total parenteral nutrition. Which nerve should the nurse suspect to be involved in this client's injury? A. Vagus (X) B. Spinal accessory (XI) C. Glossopharyngeal (IX) D. Hypoglossal (XII)

C. Glossopharyngeal- CN IX

The nurse is preparing to perform the Romberg test on an adult male client. The nurse should instruct the client to A. squat down as far as he is able to do so. B. keep his eyes open while he bends at the knees. C. stand erect with arms at the sides and feet together D. touch the tip of his nose with his finger.

C. stand erect with arms at the sides and feet together

Which of the following synovial joints would be an example of a condylar joint? A. Hip B. Interphalangeal joints of the hand C. Temporomandibular joint D. Intervertebral joint

C: Temporomandibular joint

The nurse is preparing to assess the abdomen of a hospitalized client 2 days after abdominal surgery. The nurse should first A. palpate the incision site. B. auscultate for bowel sounds. C. percuss for tympany. D. inspect the abdominal area.

D- inspect the abdominal area

While conducting the physical examination, which of the following assessments would require the nurse to auscultate the abdomen? A. To identify the edges of abdominal organs B. To identify abdominal tenderness C. To identify the distribution of gas in the abdomen D. To identify bowel sounds

D- to identify bowel sounds

A nurse is preparing to assess a client's cerebellar function. What aspect of neurological function should the nurse address? A. Remote memory B. Sensation C. Mental status exam D. Balance

D. Balance

The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the A. vagus. B. hypoglossal. C. trigeminal. D. glossopharyngeal.

D. Glossopharyngeal

When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding? A. Stationary soft palate on phonation B. Deviation of uvula when client says "ah" C. Asymmetrical soft palate D. Uvula and soft palate rising bilaterally

D. Uvula and soft palate rising bilaterally

Which tests are appropriate for a nurse to perform to test cranial nerve VIII? A. Gag reflex, rise of the uvula, and ability to swallow B. Clench the teeth, light touch, and sharp/dull discrimination C. Smile, frown, show teeth, and puff out cheeks D. Whisper, Rinne, and Weber tests

D. Whisper, rinne, weber tests

The nurse is assessing the client to assist in diagnosing which musculoskeletal condition a client is suffering from. Which signs and symptoms are most suggestive of osteoarthritis? (Select all that apply.) A. Upper extremity pain B. Significant stiffness in the mornings C. Significant pain in the great toes D. Onset at age 57 E. Tender joints in lower extremities

D: Onset at age 57 E: Tender joints in lower extremities

During an admission assessment, the nurse notes that the client has diabetes with peripheral neuropathy. What finding would the nurse expect to find? A. Decreased sensation in the feet B. Severe pain in legs C. Open sores on legs D. Bluish discoloration

Decreased sensation in the feet

Sequence the steps of the physical examination of the abdomen in the order the nurse should follow. All options must be used. a. Drape the client. b. Ask the client about pain. c. Warm hands and membrane of stethoscope. d. Stand at the client's right side. e. Begin palpation, auscultation, and percussion. A. 1b, 2a, 3d, 4c, 5e B. 1d, 2b, 3a, 4c, 5e C. 1b, 2d, 3a, 4c, 5e D. 1a, 2d, 3b, 4c, 5e E. 1a, 2b, 3c, 4d, 5e

E- A, B, C, D, E

What task should a nurse ask a client to perform to assess the function of cranial nerve XII? A. Shrug shoulders against resistance B. Move the tongue from side to side C. Swallow water D. Water in heel-to-toe fashion

Move tongue from side to side - hypoglossal

Which cranial nerve controls pupillary constriction? A. Optic B. Oculomotor C. Trochlear D. trigeminal

Occulomotor

Polyuria refers to a significant increase in 24 hour urine volume defined as 3 liters or more. TRUE FALSE

True

Which action by a nurse demonstrates the correct technique to use the reflex hammer? A. Strike the tendon then palpate for a response B. Instruct the client to tense the muscles before striking C. Tap the tendon gently to avoid pain and tingling D. Use rapid wrist movement and strike the tendon

Use rapid wrist movement and strike the tendon

When testing sensory function of the trigeminal nerve (CN V), which of the following sensations would the nurse assess? A. Pain and light touch B. Dull touch and vibration C. Vibration and stereognosis D. Proprioception and extinction

pain and light touch