NUR 220 EXAM 2 ELIMINATION
The nurse is interviewing a patient with a history of flank pain, fever, chills, and pain radiating to the groin. Which examination technique is most appropriate for this patient? 1. Percussion of the costovertebral angle 2. Deep palpation of the lower abdomen 3. Inspection of a urine specimen 4. Auscultation of the lower quadrants of the abdomen
1.
The nurse is teaching a patient how to evaluate the percentage of fat in a serving of food. She explains that the label on a package of a toaster pastry states that there are 6 g of fat and 210 calories per serving. What is the percentage of fat per serving? 1. 26% 2. 35% 3. 54% 4. 72%
1.
The student nurse is studying the liver. The primary function of the liver is to: 1. metabolize nutrients. 2. store vitamin C. 3. produce red blood cells for circulation. 4. absorb most nutrients.
1.
A pathology report states that a client's urinary calculus is composed of uric acid. Which food item should the nurse instruct the client to avoid? 1 Milk 2 Liver 3 Cheese 4 Vegetables
2.
A patient states that he has experienced "a lot" of unintentional weight loss over the past 4 months. The nurse measures his height and weight (5 feet 11 inches, 170 pounds) and determines that his body mass index is 22.7. Which of the following is the most appropriate action to better evaluate his recent weight loss? 1. Calculate his desirable body weight. 2. Ask, "What is your usual body weight?" 3. Record what he ate in the last 24 hours. 4. Determine his hip-to-waist ratio.
2.
A patient with a missed menstrual period and nausea has which signs and symptoms of pregnancy? 1. Questionable 2. Presumptive 3. Probable 4. Positive
2.
The nurse suspects a foreign body in a young child's nose. Which finding is most likely to cause the nurse to suspect this? The mother states that the child plays with toys. There is purulent discharge coming from the child's nose. There is a foul-smelling odor coming from the child's nose. The child cries when lying down.
3.
The nurse suspects that a child has sensory impairment. At what age can the child undergo sensory neurologic testing? At least 6 months old Toddlers Kindergarten age Middle school age
3.
Which is an expected finding of an abdominal examination of an adult? 1. Abdomen has a rounded contour 2. Venus hum over the epigastrium 3. High-pitched gurgles every 5 to 15 seconds 4. Swishing sounds over the abdominal aorta
3.
Why does the nurse ask a patient which medications he takes as part of a nutritional assessment? 1. Medications must be taken with food to avoid irritation to the gastrointestinal system. 2. Many drugs affect nutritional intake requirements; thus adjustments to the diet must be made. 3. The absorption and bioavailability of some medications are affected by food. 4. Some medications taste bad and may interfere with the appetite.
3.
During an initial prenatal visit the nurse identifies which factor as consistent with a high-risk pregnancy? 1. Patient is 18 years old. 2. Patient height is 5 feet 4 inches. 3. Birth weight of infant with last pregnancy was 2800 g. 4. Patient smokes one-half pack of cigarettes a day.
4
What question does a nurse ask a patient with a history of pancreatitis who is complaining of abdominal pain? 1. "Which foods aggravate the pain?" 2. "Have you recently traveled outside the United States?" 3. "Have you noticed a change in your bowel habits?" 4. "How severe is the pain on a scale of 0 to 10?"
4
7 locations of vascular sounds
aorta, 2 renal, 2 iliac, 2 femoral
listen to vascular sounds using ______ side of stethoscope
bell
turbulent blood flow (swishing) outside of the heart that can lead to aneurysm
bruit
during urinary assessment one should inspect:
color, symmetry, flanks
listen to bowl sounds using __________ of stethoscope
diaphragm
normal bowel sounds are
gurgling, clicking, popping
When assessing a patient's abdomen, the nurse uses assessment techniques in which order? 1. Inspection, palpation, and auscultation 2. Inspection, auscultation, and palpation 3. Auscultation, inspection, and palpation 4. Palpation, auscultation, and inspection
2.
Which instruction should the nurse provide the client who is concerned about contracting amebic dysentery during foreign travel? 1 Apply insect repellent. 2 Drink only bottled water. 3 Avoid drinking pasteurized milk. 4 Obtain vaccine prior to foreign travel.
2.
Which technique does the nurse use to palpate a patient's abdomen? 1. Asks the patient to breath slowly though the mouth 2. Uses the heel of the hand to perform deep palpation 3. Uses the left hand to lift the rib cage away from the abdominal organs 4. Depresses the abdomen 1 cm for light palpation
4.
The nurse palpates the abdomen to gather data about which organs located in the right upper quadrant? 1. Liver and gallbladder 2. Stomach and spleen 3. Uterus, if enlarged, and right ovary 4. Right ureter and ascending colon
1
What does the nurse assess for during each prenatal visit? 1. Blood pressure 2. Hemorrhoids 3. Personal habits (smoking, alcohol consumption) 4. Visual acuity
1
The school nurse is performing a hearing screening for an adolescent. The primary focus of a history and examination for this age group would be: Select all that apply. explore exposure to loud noises, including music. perform the whisper test. examine the ear canal with an otoscope. perform screening tests for hearing loss. ask about previous antibiotic use.
1,2,4,5
A 24-hour urine test is prescribed for a client who has a tentative diagnosis of pheochromocytoma. What should the nurse do first? 1 Start the time of the test after discarding the first voiding. 2 Discard the last voiding in the 24-hour time period for the test. 3 Insert a urinary retention catheter to promote the collection of urine. 4 Strain the urine following each voiding before adding the urine to the container.
1.
A client is scheduled for a colonoscopy, and the healthcare provider prescribes a tap water enema. In which position should the nurse place the client during the enema? 1 Left Sims 2 Back lying 3 Knee chest 4 Mid-Fowler
1.
The nurse is caring for a client who had a hip replacement 2 days prior. After removing a bedpan from under the client, what is a priority nursing intervention? 1 Provide perineal care. 2 Turn and position the client. 3 Give a complete bed bath. 4 Document the bowel movement
1.
Which finding is considered abnormal during late pregnancy? 1. Watery vaginal discharge 2. Hemorrhoids 3. Lordosis 4. Abdominal striae
1.
A 50-year-old patient asks how he can reduce his risk of colon cancer. What is the most appropriate response by the nurse? 1. "A diet high in animal protein reduces the risk." 2. "Regular exercise to reduce body fat helps prevent colon cancer." 3. "Taking antacids for heartburn can help prevent colon cancer." 4. "Taking vitamin C daily helps reduce the risk."
2.
A man weighs 265 pounds and is 6 feet 4 inches tall. Based on these data, how does the nurse classify his weight? 1. Overweight 2. Class I obesity 3. Class II obesity 4. Class III obesity
2.
A 9-year-old child with chronic kidney disease is undergoing peritoneal dialysis. For which associated complication should the nurse monitor the child? 1 Petechiae 2 Abdominal bruit 3 Cloudy return dialysate 4 Increased blood glucose level
3.
A nurse performing an abdominal examination on a 37-year-old woman would document which finding as abnormal? 1. No aortic pulsations to light or deep palpation 2. Bowel sounds every 15 seconds in the lower quadrants 3. Bulges observed when coughing 4. Silver-white striae and a faint vascular network
3.
normal amount of urine output per hour
30-60ml/hr
After several episodes of intermittent abdominal pain and vomiting, a 5-month-old infant is admitted to the pediatric unit. A diagnosis of intussusception is made. What is the priority nursing assessment that will help confirm the diagnosis? 1 Auscultating for bowel sounds 2 Listening for high-pitched crying 3 Measuring fluid intake and output 4 Observing characteristics of stools
4
The nurse is performing an eye exam on a child. The nurse knows that the child will have the visual acuity of an adult at which age? 2 years 3 years 6 years 10 years
6 years
Wavy motion or pulsations
ABNORMAL
Laminar blood flow is characterized by A. Parabolin velocity profile B. Murmurs C. Turbulence D. Eddy currents
D. eddy currents
assessment of hernia
Have patient cough, observe umbilicus for bulging
order of abdominal assessment
Inspection Auscultation Palpation Percussion
diastisis recti
Separation of the longitudinal muscles of the abdomen
The nurse is percussing a patient's abdomen and hears tympany. Which anatomic features explain the finding of tympany with stomach percussion?
The stomach is hollow.
In which patient would a pulsation within the epigastric area be considered a normal finding during inspection? a. A very thin patient b. An obese patient c. A patient with ascites d. An elderly patient
a very thin patient
The nurse is performing an abdominal assessment. What assessment techniques should be included in the assessment? Select all that apply. Inspection Percussion Palpation Illumination Auscultation Mirror check
1,2,3,5
The nurse is caring for a client with burns and reviews the client's laboratory results: blood urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL (184 mcmol/L); serum potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; Po 2, 90 mm Hg; and hemoglobin (Hgb), 7.4 g/dL (74 mmol/L). Which condition does the nurse suspect the client has based upon these findings? 1 Azotemia 2 Hypokalemia 3 Metabolic alkalosis 4 Respiratory alkalosis
1.
The nurse notes that a 2-year-old child has a cough that sounds like a bark. What other findings should the nurse anticipate? Wheezing and coarse rhonchi bilaterally Labored breathing and fever Hyperresonance with percussion Productive, blood-tinged sputum
2.
A patient reports a gnawing, burning pain in the midepigastric area that is aggravated by bending over or lying down. Which additional question does the nurse ask for the symptom analysis? 1. "Do you have a family history of this type of pain?" 2. "How long ago did you eat?" 3. "Do you have any symptoms such as nausea with this pain?" 4. "Have you noticed any yellow coloring in your eyes or on your skin?"
3.
A patient reports having abdominal distention and having vomited several times yesterday and today. What question is appropriate for the nurse to ask in response to this information? 1. "Has there been a change in the amount of the distention?" 2. "Did you have heartburn before the vomiting?" 3. "What did the vomitus look like?" 4. "Have you noticed a change in the color of your urine or stools?"
3.
The nurse auscultates the abdomen to gain information regarding: 1. the metabolic activity of the liver. 2. the production of erythrocytes by the spleen. 3. the peristaltic activity of the intestinal tract. 4. the perfusion of the mesentery.
3.
The nurse includes questions about chest pain as part of an abdominal history because myocardial pain can be: a. associated with ulcer disease. b. caused by esophageal herniation or rupture. c. perceived as esophageal and stomach pain. d. related to congenital abdominal defects.
3.
The nurse is preparing to perform an abdominal assessment. In which position should the patient be placed for abdominal assessment? 1. Sitting upright on the examination table 2. In a high-Fowler's position 3. Supine 4. In a left lateral position
3.
An older woman is 5 feet 2 inches tall and weighs 100 pounds. To best understand her dietary intake, which question is most appropriate? 1. "Who prepares your meals on a daily basis?" 2. "What are your favorite foods?" 3. "How do you get to the grocery store each week?" 4. "Could you describe what you eat on a typical day?"
4.
The mother of a child tells the nurse that she is concerned that her child may be having trouble hearing. Which statement made by a parent suggests a possible hearing impairment in the child? "My 5-month-old baby is babbling but not saying any words." "My 3-year-old son does not listen to me." "I have a hard time understanding my 15-month-old baby." "My 4-month-old baby does not respond to loud noise."
4.
The nurse is assessing a patient's abdomen and suspects ascites. Which technique is used to confirm the presence of abdominal ascites? a. Auscultation of fluid movement within the abdominal cavity b. Palpation of rebound tenderness c. Palpation of pitting edema of the abdomen d. Percussion of dullness over dependent areas of the abdomen
4.
What is the nurse assessing when measuring from the patient's symphysis pubis to the top of the fundus? 1. Fetal development 2. Fetal lie and position 3. Attitude of the fetus 4. Gestational age
4.
Which drug prescribed to a client with a urinary tract infection (UTI) turns urine reddish-orange in color? 1. Amoxicillin 2 Ciprofloxacin 3 Nitrofurantoin 4 Phenazopyridine
4.
turbulent blood flow INSIDE the heart
murmur
The nurse notes a black umbilicus on a 5-day-old infant. What does this finding indicate? a. The infant may have a feeding problem. b. The umbilicus is infected. c. The infant has hepatitis. d This is a normal finding.
normal finding
The nurse should auscultate the abdomen for at least __ before documenting an absence of bowel sounds. 1. 5 to 15 seconds 2. 30 seconds 3. several minutes 4. 1 hour
several minutes
The nurse suspects an infant has fetal alcohol syndrome. Which assessment finding is consistent for an infant with fetal alcohol syndrome? Malformation of the ear "Moon face" Torticollis Thin upper lip
thin upper lip
