Hesi T.C.
The nurse is performing a vision examination. Which of these charts is most widely used for vision examinations? A) Snellen B) Shetllen C) Smoollen D) Schwellon
A) Snellen
After the health history has been obtained, and before beginning the physical examination, the nurse should ask the patient to first: A) empty the bladder. B) completely disrobe. C) lie on the examination table. D) walk around the room.
A) empty the bladder.
During a complete health assessment, how would the nurse test the patient's hearing? A) By observing how the patient participates in normal conversation B) Using the whispered voice test C) Using the Weber and Rinne tests D) Testing with an audiometer
B) Using the whispered voice test
An 85-year-old man has come in for a physical examination, and the nurse notices that he uses a cane. When documenting general appearance, the nurse should document this information under the section that covers: A) posture. B) mobility. C) mood and affect. D) physical deformity.
B) mobility.
A 29-year-old male client informs the nurse that he came to the clinic to see if, "Maybe I have lung cancer or something," and wants to get checked out since, "I can't seem to get rid of this body-wracking dry cough that has been hanging around for the last six weeks." Which computer documentation of this client's concerns should the nurse enter? A. Expresses concern of "lung cancer" symptoms for last 6 weeks. B. Presents with a hacking non-productive cough of 6 weeks duration. C. Describes having a "body-wracking dry cough" of 6 weeks duration. D. Young adult male presents with fears that he has "lung cancer".
C. Describes having a "body-wracking dry cough" of 6 weeks duration.
During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question? a) "How do you feel today?" b) "Would you please repeat the following words?" c) "Have these medications had any effect on your pain?" d) "Has this pain affected your ability to get dressed by yourself?"
a) "How do you feel today?"
A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination? a) Auscultate the lungs and heart while the infant is still sleeping. b) Examine the infant's hips because this procedure is uncomfortable. c) Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach. d) Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems.
a) Auscultate the lungs and heart while the infant is still sleeping.
The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs would reveal: a) Dullness b) Tympany c) Resonance d) Hyperresonance
a) Dullness
The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? a) Dullness b) Tympany c) Resonance d) Hyperresonance
a) Dullness
The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of which movement(s)? a) Flexion and extension b) Supination and pronation c) Circumduction d) Inversion and eversion
a) Flexion and extension
An Asian-American woman is experiencing diarrhea, which is felt to be "cold" or "yin." The nurse expects that the woman is likely to try to treat it with: a) Foods that are "hot" or "yang" b) Readings and Eastern medicine meditations c) High doses of medicines thought to be "cold" d) No treatment at all because diarrhea is an expected part of life
a) Foods that are "hot" or "yang"
Illness is seen as a part of life's rhythmic course and as an outward sign of disharmony within. This statement most accurately reflects the views about illness from the _____ theory. a) Naturalistic b) Biomedical c) Reductionist d) Magicoreligious
a) Naturalistic
In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking? a) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors. b) Note-taking allows the patient to continue at his or her own pace as the nurse records what is said. c) Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level. d) Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort.
a) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors.
A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient's speech is dysarthric and that she is lethargic. The nurse's best approach regarding this examination is to: a) Plan to defer the rest of the mental status examination b) Skip the language portion of the examination and go on to assess mood and affect c) Do an in-depth speech evaluation and defer the mental status examination to another time d) Go ahead and assess for suicidal thoughts because dysarthria is often accompanied by severe depression
a) Plan to defer the rest of the mental status examination
The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is ____ comparison. a) Side-to-side b) Top-to-bottom c) Posterior-to-anterior d) Interspace-by-interspace
a) Side-to-side
A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse's best course of action? a) The nurse should plan to perform a complete mental status examination. b) The nurse should refer him to a psychometrician. c) The nurse should plan to integrate the mental status examination into the history and physical examination. d) The nurse should reassure his wife that memory loss after a physical shock is normal and will subside soon.
a) The nurse should plan to perform a complete mental status examination.
A man is at the clinic for a physical examination. He states that he is "very anxious" about the physical exam. What steps can the examiner take to make him more comfortable? a. Appear unhurried and confident when examining him. b. Stay in the room when he undresses in case he needs assistance. c. Ask him to change into an examining gown and take off his undergarments.
a. Appear unhurried and confident when examining him.
A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the examiner do first? a. Auscultate the lungs and heart while the infant is still sleeping. b. Examine the infant's hips because this procedure is uncomfortable. c. Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach. d. Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems.
a. Auscultate the lungs and heart while the infant is still sleeping.
1. When percussing over the ribs of a patient, the nurse notes a dull sound. The nurse would: a. Consider this a normal finding. b. Palpate this area for an underlying mass. c. Reposition the hands and attempt to percuss in this area again. d. Consider this an abnormal finding and refer the patient for additional treatment.
a. Consider this a normal finding.
The nurse is performing a cranial nerve exam on an 87-year-old client. The nurse notes that the client has a reduced upward gaze, a decreased corneal reflex, a high frequency hearing loss, and a reduced gag reflex. What action should the nurse take next? a. Continue the assessment of the next pairs of cranial nerves. b. Assess the spinal reflexes for demyelination symptoms. c. Implement neuro vital signs every 2 hours to detect Cushing's Triad. d. Review past history for any episodes of a cerebral cortex lesion.
a. Continue the assessment of the next pairs of cranial nerves.
While completing an admission assessment for a client with rectal bleeding, the nurse observes dried, dark red blood on the surface of a purple, shiny tissue mass that extrudes from the anal opening. When documenting in client's electronic medical record, which finding should the nurse enter in the client's physical assessment? a. Dried dark red blood on swollen external hemorrhoids. b. Serosanguineous and purulent exudate from anus. c. Anal mucosa prolapse and loose sphincter tone. d. Tears of the anal mucosa with old blood around anus.
a. Dried dark red blood on swollen external hemorrhoids.
When preparing to perform a physical examination on an infant, the examiner should: a. Have the parent remove all clothing except the diaper on a boy. b. Instruct the parent to feed the infant immediately before the exam. c. Encourage the infant to suck on a pacifier during the abdominal exam. d. Ask the parent to briefly leave the room when assessing the infant's vital signs.
a. Have the parent remove all clothing except the diaper on a boy.
1. During an abdominal assessment, a client with a temperature of 103F (39.4C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement? a. Nothing by mouth. b. Complete bed rest. c. Monitor urinary output. d. Electrocardiogram.
a. Nothing by mouth.
Which of the following techniques uses the sense of touch when assessing a patient? a. Palpation. b. Inspection. c. Percussion. d. Auscultation.
a. Palpation.
Which technique of assessment is used to determine the presence of crepitus, swelling, and pulsations? a. Palpation. b. Inspection. c. Percussion. d. Auscultation.
a. Palpation.
Which statement is true regarding the diaphragm of the stethoscope? a. Use the diaphragm to listen for high-pitched sounds. b. Use the diaphragm to listen for low-pitched sounds. c. Hold the diaphragm lightly against the person's skin to block out low-pitched sounds. d. Hold the diaphragm lightly against the person's skin to listen for extra heart sounds and murmurs.
a. Use the diaphragm to listen for high-pitched sounds.
What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation? a. Maternal blood pressure. b. Level of pain sensation. c. Station of presenting part. d. Variability of fetal heart rate.
a. maternal blood pressure
The nurse observes that a client is experiencing melena. What serum laboratory test should the nurse monitor in response to this finding? a. White blood cell count (WBC). b. Blood urea nitrogen (BUN). c. Glucose. d. Hematocrit.
a. white blood cell count (WBC)
During an interview the patient states, "I can feel this bump on the top of both of my shoulders—it doesn't hurt but I am curious about what it might be." The nurse should tell the patient: a) "That is your subacromial bursa." b) "That is your acromion process." c) "That is your glenohumeral joint." d) "That is the greater tubercle of your humerus."
b) "That is your acromion process."
The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination? a) When the infant is sleeping b) At the end of the examination c) Before auscultation of the thorax d) Halfway through the examination
b) At the end of the examination
The nurse keeps in mind that the most important reason to share information and offer brief teaching while performing the physical examination is to help: a) The examiner feel more comfortable and gain control of the situation b) Build rapport and increase the patient's confidence in the examiner c) The patient understand his or her disease process and treatment modalities d) The patient identify questions about his or her disease and potential areas of patient education
b) Build rapport and increase the patient's confidence in the examiner
An imaginary line connecting the highest point on each iliac crest would cross the _____ vertebra. a) First sacral b) Fourth lumbar c) Seventh cervical d) Twelfth thoracic
b) Fourth lumbar
In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 and slightly irregular; split S2. Which of these findings can be explained by expected hemodynamic changes related to age? a) Increase in resting heart rate b) Increase in systolic blood pressure c) Decrease in diastolic blood pressure d) Increase in diastolic blood pressure
b) Increase in systolic blood pressure
The review of systems provides the nurse with: a) Physical findings related to each system b) Information regarding health promotion practices c) An opportunity to teach the patient medical terms d) Information necessary for the nurse to diagnose the patient's medical problem
b) Information regarding health promotion practices
In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would: a) Palpate the artery in the upper one third of the neck b) Listen with the bell of the stethoscope to assess for bruits c) Palpate both arteries simultaneously to compare amplitude d) Instruct patient to take slow deep breaths during auscultation
b) Listen with the bell of the stethoscope to assess for bruits
When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination? a) There is no need to wash one's hands after removing gloves, as long as the gloves are still intact. b) Wash hands before and after every physical patient encounter. c) Wash hands between the examination of each body system to prevent the spread of bacteria from one part of the body to another. d) Wear gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.
b) Wash hands before and after every physical patient encounter.
With which of the following patients would it be most appropriate to use games during the assessment, such as, having the patient "blow out" the light on the penlight? a. An infant. b. A preschool child. c. A school-age child. d. An adolescent.
b. A preschool child.
In infants, the nurse knows to elicit the Moro reflex: a. When the infant is sleeping. b. At the end of the examination. c. Before auscultation of the thorax. d. Halfway through the examination.
b. At the end of the examination.
The most important reason to share information and offer brief teaching while performing the physical examination is to help: a. The examiner feel more comfortable and gain control of the situation. b. Build rapport and increase the patient's confidence in the examiner. c. The patient understands his or her disease process and treatment modalities. d. The patient identify questions about his or her disease and potential areas of patient education.
b. Build rapport and increase the patient's confidence in the examiner.
The nurse is preparing to examine a 4-year-old child. Which action is appropriate first? a. Explain procedures in detail to alleviate the child's anxiety. b. Give the child feedback and reassurance during the examination. c. Do not ask the child to remove his clothes because children at this age are usually very private. d. Perform an examination of the ear, nose, and throat first and then examine the thorax and abdomen.
b. Give the child feedback and reassurance during the examination.
When performing a physical assessment, the technique the nurse will always use first is: a. Palpation. b. Inspection c. Percussion. d. Auscultation
b. Inspection
The nurse would use bimanual palpation technique in which situation? a. Palpating the thorax of an infant. b. Palpating the kidneys and uterus. c. Assessing pulsations and vibrations. d. Assessing the presence of tenderness and pain.
b. Palpating the kidneys and uterus.
A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. Which of the following is the best action for the nurse to take? a. Count the respirations and put a call in to the physician. b. Percuss the thorax bilaterally, noting any differences in percussion tones. c. Call for a chest x-ray and wait for the results before beginning an assessment. d. Inspect the thorax for any new masses and bleeding associated with respirations.
b. Percuss the thorax bilaterally, noting any differences in percussion tones.
A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds? a. Have the client lay flat while listening to the anterior surface of the chest. b. Press the stethoscope's diaphragm firmly on the skin over each lung field. c. Shave all chest hair that may distort sounds heard through the diaphragm. d. Use the bell of the stethoscope to listen to the lung fields over lower lobes.
b. Press the stethoscope's diaphragm firmly on the skin over each lung field.
The nurse is reviewing the health history of a client who has osteoarthritis. During the physical assessment, the nurse identifies the presence of Heberden's nodes. Which finding should the nurse document in the client's medical record? a. A firm ganglion mass that is fluid filled over the dorsum of the wrist. b. Swollen nodes at the middle proximal interphalangeal joints. c. Palpable nodes at the distal interphalangeal joints with joint deviation. d. Weakness of hand muscle strength and poor grip when picking up a cup.
b. Swollen nodes at the middle proximal interphalangeal joints.
The inspection phase of the physical assessment: a. Yields little information. b. Takes time and reveals a surprising amount of information. c. May be somewhat uncomfortable for the expert practitioner. d. Requires a quick glance at the patient's body systems before proceeding on with palpation.
b. Takes time and reveals a surprising amount of information.
Which of the following statements is true regarding the stethoscope and its use? a. The slope of the earpieces should point posteriorly (toward the occiput). b. The stethoscope does not magnify sound but does block out extraneous room noise. c. The fit and quality of the stethoscope are not as important as its ability to magnify sound. d. The ideal tubing length should be 22 inches long to dampen distortion of sound.
b. The stethoscope does not magnify sound but does block out extraneous room noise.
The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best assess the patient's skin temperature? a. Use the fingertips because they're more sensitive to small changes in temperature. b. Use the dorsal surface of the hand because the skin is thinner than on the palms. c. Use the ulnar portion of the hand because there is increased blood supply that enhances temperature sensitivity. d. Use the palmar surface of the hand because it is most sensitive to temperature variations because of increased nerve supply in this area.
b. Use the dorsal surface of the hand because the skin is thinner than on the palms.
The nurse is preparing to percuss the thorax of an adult. Which technique is correct? a. Use the direct percussion technique. b. Use the indirect percussion technique. c. Use the ulnar surface of the hand to percuss the thorax. d. Use the dorsal surface of the hand to percuss the thorax.
b. Use the indirect percussion technique.
When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of the following statements describes the most appropriate actions the examiner should take when performing a physical examination? a. There is no need to wash one's hands after removing gloves, as long as the gloves are still intact. b. Wash hands at the beginning of the examination and any time that one leaves and re-enters the room. c. Wash hands between the examination of each body system to prevent the spread of bacteria from one part of the body to another. d. Wear gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.
b. Wash hands at the beginning of the examination and any time that one leaves and re-enters the room.
A 45-year-old man is in the clinic for a routine physical. During the history the patient states that he's been having difficulty sleeping. "I'll be sleeping great and then I wake up and feel like I can't get my breath." The nurse's best response to this would be: a) "When was your last electrocardiogram?" b) "It's probably because it's been so hot at night." c) "Do you have any history of problems with your heart?" d) "Have you had a recent sinus infection or upper respiratory infection?"
c) "Do you have any history of problems with your heart?"
A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data? a) "Mr. Y., at your age, surely you have been hospitalized before!" b) "Mr. Y., I just need permission to get your medical records from County Medical." c) "Mr. Y., you mentioned that you have been hospitalized on several occasions. Would you tell me more about that?" d) "Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?"
c) "Mr. Y., you mentioned that you have been hospitalized on several occasions. Would you tell me more about that?"
The nurse is conducting a patient interview. Which statement made by the patient should the nurse explore more fully during the interview? The patient states that he: a) "Sleeps like a baby" b) Has no health problems c) "Never did too good in school" d) Currently is not taking any medication
c) "Never did too good in school"
The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? a) "Tactile fremitus is caused by moisture in the alveoli." b) "Tactile fremitus indicates that there is air in the subcutaneous tissues." c) "Tactile fremitus is caused by sounds generated from the larynx." d) "Tactile fremitus reflects the blood flow through the pulmonary arteries."
c) "Tactile fremitus is caused by sounds generated from the larynx."
A 2-year-old child has been brought to the clinic for a well-child check-up. The best way for the nurse to begin the assessment is reflected by which statement? a) Ask the parent to place the child on the examining table. b) Have the parent remove all of the child's clothing before the examination. c) Allow the child to keep a security object such as a toy or blanket during the examination. d) Initially focus interactions on the child, essentially "ignoring" the parent, until the child's trust has been obtained.
c) Allow the child to keep a security object such as a toy or blanket during the examination.
Which of these statements represents subjective data the nurse obtained from the patient regarding the patient's skin? a) Skin appears dry. b) No obvious lesions. c) Denies color change. d) Lesion noted lateral aspect right arm.
c) Denies color change.
A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has: a) Aphasia b) Dysphasia c) Dysphagia d) Anorexia
c) Dysphagia
The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to: a) Administer the FACT test. b) Ask him to describe his first job. c) Give him the Four Unrelated Words test. d) Ask him to describe what television show he was watching before coming to the clinic.
c) Give him the Four Unrelated Words test.
The nurse is taking a family history. Important diseases or problems to ask the patient about specifically include: a) Emphysema b) Head trauma c) Mental illness d) Fractured bones
c) Mental illness
A patient is visiting the clinic for an evaluation of a swollen, painful knuckle. The nurse notices that the knuckle above his ring on the left hand is swollen and that he is unable to remove his wedding ring. This joint is called the _____ joint. a) Interphalangeal b) Tarsometatarsal c) Metacarpophalangeal d) Tibiotalar
c) Metacarpophalangeal
In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history? a) Family history, hypertension, stress, age b) Personality type, high cholesterol, diabetes, smoking c) Smoking, hypertension, obesity, diabetes, high cholesterol d) Alcohol consumption, obesity, diabetes, stress, high cholesterol
c) Smoking, hypertension, obesity, diabetes, high cholesterol
The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: a) Auscultate over the area with a fetoscope b) Use a goniometer to measure the pulsations c) Use a Doppler device to check for pulsations over the area d) Check for the presence of pulsations with a stethoscope
c) Use a Doppler device to check for pulsations over the area
The nurse is auscultating the chest in an adult. Which technique is correct? a) Instruct the patient to take deep, rapid breaths. b) Instruct the patient to breathe in and out through his or her nose. c) Use the diaphragm of the stethoscope held firmly against the chest. d) Use the bell of the stethoscope held lightly against the chest to avoid friction.
c) Use the diaphragm of the stethoscope held firmly against the chest.
When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are: a) Sounds normally auscultated over the trachea b) Bronchial breath sounds and are normal in that location c) Vesicular breath sounds and are normal in that location d) Bronchovesicular breath sounds and are normal in that location
c) Vesicular breath sounds and are normal in that location
The nurse is examining a patient's lower leg and notices a draining ulceration. Which of these actions is most appropriate in this situation? a) Wash hands and contact the physician. b) Continue to examine the ulceration and then wash hands. c) Wash hands, put on gloves, and continue with the examination of the ulceration. d) Wash hands, proceed with rest of the physical examination, and then continue with the examination of the leg ulceration.
c) Wash hands, put on gloves, and continue with the examination of the ulceration.
A patient has been in the intensive care unit for 10 days. He has just been moved to the medical surgical unit, and the admitting nurse is planning to perform a mental status examination on him. During the tests of cognitive function the nurse would expect that he: a) May display some disruption in thought content b) Will state, "I am so relieved to be out of intensive care" c) Will be oriented to place and person but may not be certain of the date d) May show evidence of some clouding of his level of consciousness
c) Will be oriented to place and person but may not be certain of the date
During the examination, it is often appropriate to offer some brief teaching about the patient's body or one's findings. Which of the following statements by the nurse is most appropriate? a. "Your hypertension is under control." b. "You have pitting edema and mild varicosities." c. "Your pulse is 80 beats per minute. This is within the normal range." d. "I'm using my stethoscope to listen for any crackles, wheezes, or rubs."
c. "Your pulse is 80 beats per minute. This is within the normal range."
A 2-year-old child has been brought to the clinic for a well-child check-up. How should the examiner proceed with the assessment? a. Ask the parent to place the child on the examining table. b. Have the parent remove all the child's clothing before the examination. c. Allow the child to keep a security object such as a toy or blanket during the examination. d. Initially focus interactions on the child, essentially "ignoring" the parent, until the child's trust has been obtained.
c. Allow the child to keep a security object such as a toy or blanket during the examination.
The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next? a. Ask the patient to take deep breaths to relax the abdominal musculature. b. Consider this a normal finding and proceed with the abdominal assessment. c. Increase the amount of strength used when attempting to percuss over the abdomen. d. Decrease the amount of strength used when attempting to percuss over the abdomen.
c. Increase the amount of strength used when attempting to percuss over the abdomen.
The nurse assesses a male client who is brought to the Emergency Department by his family who believe he is having a heart attack. Which finding is the best indicator that a client is experiencing an acute coronary syndrome (ACS)? ? I think? Couldn't find definite answer online a. Chest pain that intensifies upon chest excursion. b. Localized sternal border pain intensified by palpation. c. Pain in the neck, jaw, or medial side of the left arm. d. Anterior thorax pain that radiates between the scapulae.
c. Pain in the neck, jaw, or medial side of the left arm.
The nurse is preparing to percuss to assess the underlying: a. Tissue turgor. b. Tissue texture. c. Tissue density. d. Tissue consistency.
c. Tissue density.
The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: a. Auscultate over the area with a fetoscope. b. Use a goniometer to measure the pulsations. c. Use a Doppler device to check for pulsations over the area. d. Check for the presence of pulsations with a stethoscope.
c. Use a Doppler device to check for pulsations over the area.
The nurse is examining a patient's lower leg and notes a draining ulceration. Which of the following actions is most appropriate in this situation? a. Wash hands and contact the physician. b. Continue to examine the ulceration and then wash hands. c. Wash hands, put on gloves, and continue with the examination of the ulceration. d. Wash hands, proceed with rest of the physical examination, and then continue with the examination of the leg ulceration.
c. Wash hands, put on gloves, and continue with the examination of the ulceration.
A 29-year-old woman tells the nurse that she has "excruciating pain" in her back. Which would be an appropriate response by the nurse to the woman's statement? a) "How does your family react to your pain?" b) "That must be terrible. You probably pinched a nerve." c) "I've had back pain myself, and it can be excruciating." d) "How would you say the pain affects your ability to do your daily activities?"
d) "How would you say the pain affects your ability to do your daily activities?"
A woman has just entered the emergency department after being battered by her husband. The nurse needs to get some information from her to begin treatment. What is the best choice for an opening with this patient? a) "Hello, Nancy, my name is Mrs. C." b) "Hello, Mrs. H., my name is Mrs. C. It sure is cold today!" c) "Mrs. H., my name is Mrs. C. How are you?" d) "Mrs. H., my name is Mrs. C. I'll need to ask you a few questions about what happened."
d) "Mrs. H., my name is Mrs. C. I'll need to ask you a few questions about what happened."
A patient tells the nurse that he is allergic to penicillin. What would be the nurse's best response tothis information? a) "Are you allergic to any other drugs?" b) "How often have you received penicillin?" c) "I'll write your allergy on your chart so you won't receive any penicillin." d) "Please describe what happens to you when you take penicillin."
d) "Please describe what happens to you when you take penicillin."
The nurse is examining a 2-year-old child and asks, "May I listen to your heart now?" Which critique of the nurse's technique is most accurate? a) Asking questions enhances the child's autonomy. b) Asking the child for permission helps to develop a sense of trust. c) This is an appropriate statement because children at this age like to have choices. d) Children at this age like to say "No." The examiner should not offer a choice when there is none
d) Children at this age like to say "No." The examiner should not offer a choice when there is none
The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is: a) Increased salivation b) Increased liver size c) Increased esophageal emptying d) Decreased gastric acid secretion
d) Decreased gastric acid secretion
The nurse is explaining to a patient that there are "shock absorbers" in his back to cushion the spine and to help it move. The nurse is referring to his: a) Vertebral column b) Nucleus pulposus c) Vertebral foramen d) Intervertebral disks
d) Intervertebral disks
During an interview, the nurse states, "You mentioned shortness of breath. Tell me more about that." Which verbal skill is used with this statement? a) Reflection b) Facilitation c) Direct question d) Open-ended question
d) Open-ended question
The nurse asks, "I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here." This question is found at the _____ phase of the interview process. a) Summary b) Closing c) Body d) Opening or introduction
d) Opening or introduction
In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate? a) Patient denies usual childhood illnesses. b) Patient states he was a "very healthy" child. c) Patient states sister had measles, but he didn't. d) Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
d) Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? a) Percuss and palpate in the lumbar region. b) Inspect and palpate in the epigastric region. c) Auscultate and percuss in the inguinal region. d) Percuss and palpate the midline area above the suprapubic bone.
d) Percuss and palpate the midline area above the suprapubic bone.
The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short amount of time, hungry again. What other information would the nurse want to have? a) The infant's sleeping position b) Sibling history of eating disorders c) Amount of background noise when eating d) Presence of dyspnea or diaphoresis when sucking
d) Presence of dyspnea or diaphoresis when sucking
An examiner is using an ophthalmoscope to examine a patient's eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being performed correctly? a) Using the large full circle of light when assessing pupils that are not dilated b) Rotating the lens selector dial to the black numbers to compensate for astigmatism c) Using the grid on the lens aperture dial to visualize the external structures of the eye d) Rotating the lens selector dial to bring the object into focus
d) Rotating the lens selector dial to bring the object into focus
Which structure is located in the left lower quadrant of the abdomen? a) Liver b) Duodenum c) Gallbladder d) Sigmoid colon
d) Sigmoid colon
A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes: a) She probably doesn't have any problems at all. b) She is just trying to shock people and her dress should be ignored. c) She has manic syndrome because of her abnormal dress and grooming. d) That more information should be gathered to decide whether her dress is appropriate.
d) That more information should be gathered to decide whether her dress is appropriate.
The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? a) The nurse performs the examination from the left side of the bed. b) The nurse examines tender or painful areas first to help relieve the patient's anxiety. c) The nurse follows the same examination sequence regardless of the patient's age or condition. d) The nurse organizes the assessment so that the patient does not change positions too often.
d) The nurse organizes the assessment so that the patient does not change positions too often.
A client who recently underwent a routine surgical procedure made a clinic appointment. To elicit the most information, which question is best for the nurse to ask this client? a. "When did your surgery take place?" b. "What type of surgery did you have?" c. "Are you having any pain?" d. "What brought you to the clinic?"
d. "What brought you to the clinic?"
When examining the aging adult, the nurse should: a. Avoid touching the patient too much. b. Attempt to perform the entire physical during one visit. c. Speak loudly and slowly because most aging adults have hearing deficits. d. Arrange the sequence to allow as few position changes as possible.
d. Arrange the sequence to allow as few position changes as possible.
The nurse is examining a 2-year-old child and asks, "May I listen to your heart now?" Which critique of her technique is most accurate? a. Asking questions enhances the child's autonomy. b. Asking the child for permission helps to develop a sense of trust. c. This is an appropriate statement because children at this age like to have choices. d. Children at this age like to say "No." The examiner should not offer a choice when there is none.
d. Children at this age like to say "No." The examiner should not offer a choice when there is none.
The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first? a. Ask the client if he took any pain medication at home. b. Observe for nonverbal signs to measure pain intensity. c. Use a standard pain assessment questionnaire and scale. d. Collect a urine sample and strain for granules or calculi.
d. Collect a urine sample and strain for granules or calculi.
The nurse hears bilateral louder, longer, and lower tones when percussing over the lungs of a 4-year-old child. What should the nurse do next? a. Palpate over the area for increased pain and tenderness. b. Ask the child to take shallow breaths and percuss over the area again. c. Refer the child immediately because of an increased amount of air in the lungs. d. Consider this a normal finding for a child this age and proceed with the examination.
d. Consider this a normal finding for a child this age and proceed with the examination.
The nurse enters a client's room and notes that the formerly alert client is now lethargic and only utters incomprehensible sounds. In gathering additional data related to these findings, which tool should the nurse use? a. SBAR format. b. Braden scale. c. Mini-mental status exam. d. Glasgow coma scale.
d. Glasgow coma scale.
When performing the physical assessment, the examiner should: a. Perform the examination from the left side of the bed. b. Examine tender or painful areas first to help relieve the patient's anxiety. c. Follow the same examination sequence regardless of the patient's age or condition. d. Organize the assessment so that the patient does not change positions too often.
d. Organize the assessment so that the patient does not change positions too often.
When examining a 16-year-old male teenager, the examiner should: a. Discuss health teaching with the parent because the teen is unlikely to be interested in promoting wellness. b. Ask his parent to stay in the room during the history and physical examination to answer any questions and alleviate his anxiety. c. Talk to him the same as one would talk would a younger child because a teen's level of understanding may not match his or her speech. d. Provide feedback that his body is developing normally and discuss the wide variation among teenagers on the rate of growth and development.
d. Provide feedback that his body is developing normally and discuss the wide variation among teenagers on the rate of growth and development.
An examiner is using an ophthalmoscope to examine a patient's eyes. The patient has astigmatism and is nearsighted. Which of the following techniques would indicate the examination is being performed correctly? a. Using the large full circle of light when assessing pupils that are not dilated. b. Rotating the lens selector dial to the black numbers to compensate for astigmatism. c. Using the grid on the lens aperture dial to visualize the external structures of the eye. d. Rotating the lens selector dial to the red numbers to compensate for nearsightedness.
d. Rotating the lens selector dial to the red numbers to compensate for nearsightedness.
The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed? a. Avoid palpation of reported "tender" areas because this may cause the patient pain. b. Quickly palpate the area to avoid any discomfort that they patient may experience. c. Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths. d. Start with light palpation to detect surface characteristics and to accustom the patient to being touched.
d. Start with light palpation to detect surface characteristics and to accustom the patient to being touched.
Which of the following statements is true regarding the otoscope? a. The otoscope is often used to direct light onto the sinuses. b. The otoscope uses a short broad speculum to visualize the ear. c. The otoscope is used to examine the structures of the internal ear. d. The otoscope directs light into the ear canal and onto the tympanic membrane.
d. The otoscope directs light into the ear canal and onto the tympanic membrane.
A patient states, "Whenever I open my mouth real wide, I feel this popping sensation in front of my ears." To further examine this, the nurse would: A) place the stethoscope over the temporomandibular joint and listen for bruits. B) place the hands over his ears and ask him to open his mouth "really wide." C) place one hand on his forehead and the other on his jaw and ask him to try to open his mouth. D) place a finger on his temporomandibular joint and ask him to open and close his mouth.
place a finger on his temporomandibular joint and ask him to open and close his mouth.