Health Assessment Lecture

Mark is a contractor who recently injured his back. He was told he had a "bulging disc" to account for the burning pain down his right leg and slight foot drop. The vertebral bodies of the spine involve which type of joint?

B) Cartilaginous

Which of the following statement(s) is/are true concerning the diagnosis and management of epigastric hernias?

b. At the time of surgical repair, a careful search for other defects should be performed

A 58-year-old man comes to your office complaining of Pain, swelling, loss of both active and passive motion, locking, and deformity would be consistent with which of the following?

A) Articular joint pain

An 85-year-old retired housewife comes with her daughter to establish care. Her daughter is concerned because her mother has started to fall more. As part of her physical examination, you ask her to walk across the examination room. Which of the following is not part of the stance phase of gait?

A) Foot arched

Mrs. Fletcher complains of numbness of her right hand. On examination, sensation of the volar aspect of the web of the thumb and index finger and the 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

A 38-year-old woman comes to you and has multiple small joints involved with pain, swelling, and stiffness. Which of the following is the most likely explanation?

A) Rheumatoid arthritis

You are assessing a patient with joint pain and are trying to decide whether it is inflammatory or noninflammatory in nature. Which one of the following symptoms is consistent with an inflammatory process?

A) Tenderness

The symptoms occurring with lactose intolerance include:

A) bloating and flatulence.

Older adults have:

A) decreased salivation leading to dry mouth.

Which of the following values is considered normal for ICP?

A. 0 to 15 mm Hg

The nurse is planning to assess the abdomen of an adult male. What should be done first?

A. Ask client to empty bladder

After completing a health assessment, the nurse documents the findings on a flow sheet with checkmarks and short notations. The type of documentation this nurse is using is most likely:

A. Charting by exception

After completing the health history, the nurse begins to ask more detailed questions to clarify points and follow up on concerns expressed by the client during the interview. This portion of the health assessment is:

A. Focused interview

The nurse is assessing a client's smoking behavior. During the interview, the nurse learns that the client wants to stop smoking but needs help with this behavior change. Which nursing theory would best support the care this client needs?

A. Health promotion model

After conducting the health interview, the nurse begins to measure the client's vital signs. The nurse is collecting:

A. Objective data

Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene?

A. Placing the client on the back with a small pillow under the head.

The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure?

A. Side-lying, with legs pulled up and head bent down onto the chest.

The following statements about the repair of inguinal hernias are true except:

A. The conjoined tendon is sutured to Cooper's ligament in the Bassini hernia repair.

A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment?

A. Time of onset of current stroke

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective?

A. Urine output increases.

The human nervous system comprises

A. the central nervous system and the peripheral nervous system

Broca's area is located in

A. the frontal lobe

Severe acute abdominal pain and a silent abdomen suggests which of the following?

A.Peritonitis

Ray works a physical job and notes pain when he attempts to lift his arm over his head. When you move the shoulder passively, he has full range of motion without pain and there is no gross swelling or tenderness. What type of joint disease does this most likely represent?

B) Extra-articular

A high school football player injured his wrist in a game. He is tender between the two tendons at the base of the thumb. Which of the following should be considered?

B) Scaphoid fracture

A 32-year-old warehouse worker presents for evaluation of low back pain. He notes a sudden onset of pain after lifting a set of boxes that were heavier than usual. He also states that he has numbness and tingling in the left leg. He wants to know if he needs to be off of work. What test should you perform to assess for a herniated disc?

B) Straight-leg raise

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits:

B. A positive Brudzinski's sign.

Based on the interview and physical examination of Ms. Wong, which of the following NANDAs would be the priority NANDA for this client?

B. Fluid volume, the deficient risk for related to vomiting and diarrhea

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising?

B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances?

B. Intracranial pressure (ICP) is increased.

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?

B. Pupil size and pupillary response

The somatic nervous system is part of the

B. peripheral nervous system -C central nervous system

Which of the following is NOT a function of cerebrospinal fluid:

B. to improve conduction of nerve signals between different brain regions

High-pitched peristalsis or borborygmi in rushes in a patient with acute abdominal pain and distention suggests which of the following?

B.Bowel obstruction

A 50-year-old realtor comes to your office for evaluation of neck pain. She was in a motor vehicle collision 2 days ago and was assessed by the emergency medical technicians on site, but she didn't think that she needed to go to the emergency room at that time. Now, she has severe pain and stiffness in her neck. On physical examination, you note pain and spasm over the paraspinous muscles on the left side of the neck, and pain when you make the patient do active range of motion of the cervical spine. What is the most likely cause of this neck pain?

C) Cervical sprain

You are assessing a patient with diffuse joint pains and want to make sure that only the joints are the problem, and that the pain is not related to other diseases. Which of the following is a systemic cause of joint pain?

C) Lupus

A 33-year-old construction worker comes for evaluation and treatment of acute onset of low back pain. He notes that the pain is an aching located in the lumbosacral area. It has been present intermittently for several years; there is no known trauma or injury. He points to the left lower back. The pain does not radiate and there is no numbness or tingling in the legs or incontinence. He was moving furniture for a friend over the weekend. On physical examination, you note muscle spasm, with normal deep tendon reflexes and muscle strength. What is the most likely cause of this patient's low back pain?

C) Mechanical low back pain

Pyloric stenosis is a(n):

C) congenital narrowing of the pyloric sphincter.

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?

C. A blood pressure of 220/120 mmHg.

The staff on a rehabilitation unit is attending an During a health interview, the client states that she becomes increasingly short of breath when sitting in city traffic. The nurse views this information as:

C. An external environmental factor

The nurse assessing an older client who has lost 5 ounds since her last visit 1 year ao. The client tells the nurse her husband died 2 months ago. The nurse should assess for

C. Appetite changes

During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client's:

C. Blood pressure

A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to:

C. Escape the source of pain.

During the health interview, the client mentioned that she is "very stressed about her home situation." The nurse sees this information as impacting the client's level of pain control. Which approach is the nurse using during the health interview?

C. Holistic

The nurse begins to document approximately three hours after completing the health, and physical assessment of a client admitted with acute right lower quadrant abdominal pain. Which of the following might be true about this documentation?

C. It may not be as detailed due to the time that has elapsed since the assessment.

During the interview with Ms. Wong, she complains of nausea, vomiting, diarrhea, and fever. Which of Ms. Wong's symptoms needs to be assessed first?

C. Nausea

Which of the following signs and symptoms of increased ICP after head trauma would appear first?

C. Restlessness and confusion

To palpate tenderness of an adult's appendix, where should you begin?

C. Right lower quadrant

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority?

C. Schedule for A STAT computer tomography (CT) scan of the head.

The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?

C. The assistant places her hand under the client's right axilla to help him/her move up in bed.

Abdominal pain that causes the patient to writhe around trying to get comfortable suggests which of the following?

C.Renal colic

A 45 year old man presented to the emergency department with colicky abdominal pain, vomiting, and a painful groin lump. On examination he had a pulse of 110 beats/min and temperature of 37.8°C. There was marked abdominal distension, high pitched bowel sounds, and an erythematous, tender mass in the left groin above and medial to the pubic tubercle (fig 1). A plain abdominal radiograph was taken in the emergency department. What is the next step in management?

D. Nil by mouth, nasogastric tube, and intravenous drip

If assessing a client for kidney tenderness, where would you begin?

D Costovertebral angle

An obese 55-year-old woman went through menarche at age 16 and menopause 2 years ago. She is concerned because an aunt had severe osteoporosis. Which of the following is a risk factor for osteoporosis?

D) Delayed menarche

bilateral back pain that now awakens him at night. This has been steadily increasing for the past 2 months. Which one of the following is the most reassuring in this patient with back pain?

D) Pain that is bilateral

A high school soccer player "blew out his knee" when the opposing goalie's head and shoulder struck his flexed knee while the goalie was diving for the ball. All of the following structures were involved in some way in his injury, but which of the following is actually an extra-articular structure?

D) Tendons

Ascites is defined as:

D) an abnormal accumulation of serous fluid within the peritoneal cavity.

Methods to enhance abdominal wall relaxation during examination include:

D) positioning the patient with the knees bent.

The nurse is documenting the findings from a health assessment. Which of the following demonstrates the documentation of subjective information?

D. "It hurts when I put weight on my leg."

educational session to review the newest treatment options for clients with knee injuries. This program is most likely being presented by:

D. A clinical nurse specialist

The nurse is phoning the physical therapy department to alter a client's scheduled therapy appointment. Afterward, the nurse coordinates the time for the same client's morning care and afternoon radiology appointment. This nurse is functioning as:

D. A manager

During the health assessment, the nurse reviews the client's laboratory data. This is an example of:

D. A secondary source of information

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?

D. An oral anticoagulant medication

The nurse is looking at the information collected during the health interview in an effort to cluster or group the data together. The nurse is demonstrating which phase of the nursing process?

D. Diagnosis

The nurse is preparing to assess the abdomen of a hospitalized client 2 days after abdominal surgery. The nurse should first

D. Inspect the abdominal area

During the interview process and physical assessment of Ms. Wong, which of the following would alert the nurse of a possible fluid volume deficit?

D. Lips and mucous membranes dry

The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain?

D. Nail bed pressure

Problems with memory and learning would relate to which of the following lobes?

D. Temporal

The three main anatomical neural planes are

D. sagittal, coronal and horizontal