Nurs 351L Assessment
A nurse is assessing a child who is able to dress herself, jump rope, identify colors, and follow rules when playing games. These are expected developmental achievements of a child of what age? 4 years old 5 years old 6 years old 3 years old
5 years old
The majority of adults can understand written education materials written at _____ grade or below. 10th 8th 5th 3rd
5th
Where is mitral pulse?
5th LMCL
The nurse is performing an assessment on an older patient. Which change that occurs with aging explains why an older adult may be unaware of an infection or injury to the eye? Decreased corneal sensitivity Diminished tearing Reduced visual acuity Increased density of the lens
A
The nurse is preparing to assess a female patient's genitalia. In which position should the nurse instruct the patient to be? Lithotomy Supine Semi-Fowler's Trendelenburg
A
The Rinne and Weber tests measure which of the following? A. Air and bone conduction B. Movement of the tympanic membrane C. Tenderness of the mastoid area D. Nodules in the auricles
A
The nurse believes a male patient has a sexually transmitted disease. Which symptom is commonly associated with STDs? Penile discharge Difficulty maintaining an erection Difficulty initiating a urine stream A heavy feeling in the scrotum
A
The nurse is assessing a patient in the 8 month of pregnancy. The nurse would expect to find: the position of the heart changes slightly. the lower legs have 3+ edema. her blood pressure is 150/118 mm Hg. auscultation of the heart reveals an S4 heart sound
A
The nurse is assessing a patient using a goniometer. What is this instrument used for? Range of motion Muscle strength Joint symmetry Length of extremity
A
The nurse is assessing a patient who has pain with a sudden onset and a limited duration and that subsides as healing occurs. Which type of pain would this be considered? Acute pain Chronic pain Cancer pain Nonmalignant pain
A
The nurse is assessing a patient who presents to the emergency department. Which question should the nurse ask and initially document? "Why did you come to the emergency room today?" "When did your symptoms start?" "What did you do to relieve your symptoms?" "Are there any spiritual or religious considerations?"
A
The nurse is assessing a patient's muscle strength of the trapezius muscle. The nurse will apply resisting force while the patient: shrugs her shoulders. moves her jaw laterally. flexes her elbow. extends her knee.
A
The nurse is assessing an 88-year-old woman who has a blood pressure reading of 160/90 mm Hg. This blood pressure reading indicates: high blood pressure. prehypertension. hypertension. a normal value for an older adult.
A
The nurse is assessing an infant. The nurse takes a toy and moves it from the infant's sight. The nurse is assessing for which of the following? Object permanence Advancement in manual skills Social adaptive behavior Fluid intelligence
A
The nurse is explaining the prostate exam to a male patient. The nurse explains that the ______________________ surface is palpated during the examination. anterior rectal surface anorectal junction anterior prostate surface deep external sphincter surface
A
The nurse is inspecting a patient's face and notices that one side of the face droops. The nurse suspects during inspection of a patient's face, the nurse notices that the facial _________________cranial nerve may be affected? VII I X II
A
The nurse is palpating a patient's pericardium. What may be detected by palpating the pericardium? An inflammation of the heart An increased heart size An increase in cardiac output A thrill
A
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. The stomach is flask-shaped. The stomach secretes digestive enzymes. The stomach is a muscular organ.
A
The nurse is percussing the heart. Percussion of the heart could be performed to: estimate the heart's size and borders. determine fluid levels in the heart. locate the presence of a murmur. identify congenital heart defects.
A
The nurse is preparing to assess a patient's peripheral nervous sensory function. Which assessment test would the nurse use? Light touch sensation Two-point discrimination Romberg Rinne
A
The nurse is reading a report from the patient's chart and sees a note stating the prostate is hard and irregular. The nurse suspects: prostate cancer. benign prostate hypertrophy (BPH). prostatitis. rectal cancer.
A
An adult patient is being assessed in the outpatient clinic secondary to a recent weight loss. Why is the weight of an adult patient measured routinely during a physical assessment? It allows assessment of body fat content. A change in body weight can be indicative of health problems. Fat deposits in specific locations can be identified. It identifies patients who exercise and those who do not exercise.
A change in body weight can be indicative of health problems.
The nurse is assessing a newborn and hears a click when the Barlow-Ortolani maneuver is performed. What would this finding indicate? An indication of Erb's palsy A possible indication of spina bifida An indication of congenital hip dislocation A normal finding in the newborn
C
The nurse auscultates the abdomen to gain information regarding: the metabolic activity of the liver. the production of erythrocytes by the spleen. the peristaltic activity of the intestinal tract. the perfusion of the mesentery.
C
What are we inspecting the anterior chest wall for?
Contour, pulsations, lifts, heaves, retractions
A male patient indicates that he has sex with multiple partners and that he does not use protection. The most appropriate response is: "Are your partners using birth control?" "You should avoid sex until you are married." "How well do you know your partners?" "Many men use condoms to protect themselves from disease and pregnancy."
D
The nurse includes questions about chest pain as part of an abdominal history because myocardial pain can be: associated with ulcer disease. caused by esophageal herniation or rupture. perceived as esophageal and stomach pain. related to congenital abdominal defects.
C
The nurse is assessing a 72-year-old patient who was diagnosed with osteoporosis at age 65. The nurse detects the patient has kyphosis on exam. The nurse suspects: kyphosis is related to previous injury and should be monitored. kyphosis will require the patient to be in a wheelchair. kyphosis is a normal finding for this age group because of osteoporosis. kyphosis is not normal and must be evaluated further.
C
The nurse is assessing a 72-year-old's spinal column. Which spinal finding would be considered normal for a 72-year-old patient? Meningocele Myelomeningocele Kyphosis Scoliosis
C
The nurse has assessed the client's shoulder strength and finds that the client has full range of motion. The nurse should document this finding with which of the following ratings? 5 2 3 4
5
The nurse is assessing a patient for confrontation. The confrontation test assesses: visual acuity. peripheral vision. extraocular muscle movement. red reflex.
peripheral vision. ]
The nurse is assessing a patient's skin turgor. Skin turgor is assessed by: auscultating the skin to note the presence of motility sounds. pressing on the skin and observing the depression. stretching the skin and observing for a degree of flexibility. pinching the skin and watching the skin return to place.
pinching the skin and watching the skin return to place.
What is milia?
small, raised, pearly white or yellowish bumps on the skin
What is SB?
sternal border
what is SB?
sternal border
The nurse is conducting an interview. During an interview, the primary type of data being collected is: subjective data. objective data. secondary data. recent data.
subjective data. Correct
What is onset of pain?
when does pain occur? did it happen suddenly or gradually? what do you think is causing it?
A patient tells the nurse that he is allergic to penicillin (PCN). How would the nurse document this information? "Patient allergic to PCN, Sulfa, and adhesive tape" "Patient cannot have PCN" "Patient states allergy to PCN" "Patient allergic to PCN, reaction = Hives"
D
An insufficient amount of the neurotransmitter GABA may result in _________. depression hallucinations delusions anxiety
D
The nurse is performing a skin assessment and finds that the patient has milia. In which age group would this be an expected finding? Newborns Young children Adolescents Older adults
Newborns
Is pain an expected part of aging?
No
Is there a correlation b/w amount of tissue damage and degree/intensity of pain?
No
What are we looking for in a healed bottom?
Perineum: intact, laceration or episiotomy Cesarean incision: lower abdomen REEDA acronym for any skin impairment: redness edema, ecchymosis, discharge, and approx.
How do you assess psychosocial status?
Person status: feelings about self family and social relationships diet and nutrition functional ability mental health personal habits health promotion activities environment
The nurse is using the CAGE screening tool. This tool is used to screen for what? Sexual activity Depression Problem alcohol use Decreased mental status
Problem alcohol use
What is passive immunity?
Protection induced by antibodies produced in an animal or human are transferred to another person: unborn baby via placenta, transfer from another person/animal using immune globulin
What reflexes do we check on newborns?
Protective reflexes (blink, gag, cough), feeding reflexes (root, suck, and swallow), upper extremities (palmar grasp, startle), and lower extremities (plantar grasp, Babinski)
An adolescent patient appears reluctant to discuss sensitive issues with her parents present. What is the nurse's most appropriate intervention? Provide time when the adolescent is alone with the nurse. Tell the patient that it is very important to be honest and specific. Ask the parents to answer the questions if the patient is not willing to answer. Reassure the patient that anything said in the interview is considered confidential.
Provide time when the adolescent is alone with the nurse.
What is a variation of health history for older adults?
age-related questions: childhood immunizations/develop a genogram are not important, check symptoms, conditions, medications
What is affect?
emotional tone
What is hyperthyroidism and what are clinical findings?
excessive producation and secretion of thyroid hormone most body systems affected, increased metabolism, increased size of thyroid gland/expothalmos
The student nurse is reviewing the pathophysiology of inspiration. The primary muscles of inspiration are the diaphragm and the ____________. pectoral muscles external intercostal muscles abdominal muscles scalene muscles
external intercostal muscles Correct
The pregnant patient tells the nurse that she has had three pregnancies and two live births to date. How does the nurse record this in the patient's history? Gravida 2, para 3 Gravida 3, para 2 Gravida 2, para 2 Gravida 3, para 3
Gravida 3, para 2
What do we learn about history of pregnancies?
Gravida: # of pregnancies conceived to date Para: # of pregnancies went past viability
What are examples of Bacterial vaccines?
Haemophilius influenzae type B, pneumococcal, DTaP, TDap, meningococcal
The nurse is aware that the greatest physical variation of ears among individuals of different races is: the size of the ear. hearing acuity. consistency and color of cerumen. the length of the auditory canal.
consistency and color of cerumen.
A patient at 20 weeks of gestation is concerned about a discharge from her nipples. What is the nurse's appropriate response to this patient? "I suggest you decrease your fluid intake for several days to see if this makes a difference." "After the first trimester a thin, yellow fluid called colostrum may be secreted from the nipples." "A nipple discharge is unusual. I advise you to consult your obstetrician." "That is expected. It is milk production that begins at the onset of pregnancy."
"After the first trimester a thin, yellow fluid called colostrum may be secreted from the nipples."
A nurse is asking questions about the present health status of a young woman who has lost weight recently. Which question is most appropriate when inquiring about present health status? What concerns have you had in the past regarding your weight?" "Do you have anorexia?" "Describe the recent changes in your weight." "Do you have a family history of eating disorders?"
"Describe the recent changes in your weight."
In taking a history from an adolescent girl about diet and nutrition, a nurse specifically asks which question. "How frequently do you eat fast food or junk food?" "Do you have any food restrictions or diet routines?" "Which carbonated drinks do you drink most often?" "What are your favorite fruits and vegetables?"
"Do you have any food restrictions or diet routines?"
A patient reports a change in the usual pattern of urination. What question does the nurse ask to determine if incontinence is the reason for these symptoms? "Do you have the feeling that you cannot wait to urinate?" "Have you noticed any swelling in your ankles at the end of the day?" "Has the color of your urine changed lately?" "Are you urinating a large amount each time you go to the bathroom?"
"Do you have the feeling that you cannot wait to urinate?"
During an assessment for abdominal pain, a patient reports a colicky abdominal pain and pain in the right shoulder that gets worse after eating fried foods. What question does the nurse ask to confirm the suspicion of cholelithiasis? "Have you vomited up any blood in the last 24 hours?" "Have you noticed a change in the color of urine or stools?" "Have you experienced fever, chills, or sweating?" "Have you noticed any swelling in your ankles or feet at he end of the day?"
"Have you noticed a change in the color of urine or stools?"
The nurse suspects that a female patient is having trouble with the thyroid when the patient answers yes to which question? "How much alcohol do you drink?" "Have you noticed a change in your level of energy?" "Do you have headaches?" "Are you currently menstruating?"
"Have you noticed a change in your level of energy?"
To document the palpation of a pulse, the nurse is correct in making which notation about the rhythm? "Rhythm noted at +2" "Rhythm 100 beats/min" "Irregular rhythm" "Bounding rhythm"
"Irregular rhythm"
A patient is concerned because the dermatologist diagnosed macules all over the skin. The patient asks the nurse what could be causing this? The nurse's best response is: "Macules need to be watched closely for signs of skin cancer." "Macules are warts and should be removed." "Macules are freckles are considered normal on the skin." "You have an infection and will need an antibiotic."
"Macules are freckles are considered normal on the skin."
During a sports physical for a 16-year-old girl, the nurse asks which question to collect data about drug use? "Your high school has a reputation for drug use. Do you use drugs?" "Do most of your friends drink alcohol or do street drugs?" "Tell me which street drugs your friends have offered to you?" "Many teenagers have tried street drugs. Have you tried these drugs?"
"Many teenagers have tried street drugs. Have you tried these drugs?"
Where is tricuspid pulse?
4th LICS
The nurse needs to assess an adolescent patient's risk for sexually transmitted diseases. What technique shows the most sensitivity? "Statistics show that teens between the ages of 14 and 20 are at high risk for sexually transmitted diseases. Would you more like information?" "What do you rate your risk of sexually transmitted disease?" Ask the parent, "Have you talked to your teen about sexually transmitted diseases?" "Many young people have questions regarding sexually transmitted diseases. What questions do you have?"
"Many young people have questions regarding sexually transmitted diseases. What questions do you have?" Correct
A patient asks the nurse if it is possible to grow new skin. What is the nurse's most appropriate response? "The outer layer of skin remains the same over the lifetime except for repairing injuries." "The avascular epidermis sheds slowly and is replaced completely every 4 weeks." "Epidermal regeneration is impossible because it is avascular." "Even if new skin growth is required, the melanocytes do not regenerate."
"The avascular epidermis sheds slowly and is replaced completely every 4 weeks."
The nurse is assessing a patient's activity level. Which question or comment best facilitates discussion with the patient regarding his or her level of activity? "Do you exercise during the week?" "Do you keep in shape?" "Tell me what form of exercise you do on a daily basis?" "What do you do to get exercise?"
"What do you do to get exercise?"
While assessing edema on a male patient's lower leg, the nurse notices that there is a slight imprint of his fingers where he palpated the patient's leg. How does the nurse document this finding? +1 edema +2 edema No edema +3 edema
+1 edema
What is Cataracts and what are clinical findings of it?
- Opacity of crystalline lens from denaturation of lens protein caused by aging and may be congenital or caused by trauma. -Cloudy/blurred vision, poor night vision, frequent changing of prescription, cloudy lens can be observed on inspection, red reflex is absent because light cannot penetrate opacity of lens
What do we do to help newborn assessment?
-0-6 months-on table if baby is comfortable, 6+ months on parents lap -6 months+ on parent's lap -babies like smiling faces and noise makers. -Do quiet things first: fontanels, heart/lungs, abdomen/pulses then head to toe -take advantage of opportunities
What are major milestones for children?
-4-6 months: good head control and rolling over -Crawling, stranger anxiety, says mama/dada: 8-10 months -Stands alone, walks holding furniture: 10-12 months (walking independently by 15 months) -Runs/climbs, more stranger anxiety: 1-2 years -Speech: 2 years old, 2 word sentences, 75% understandable
What mental health assessment should be taken with geriatric patients?
-Ability to cope with stress, recent stresses? -Medications? Yesavage geriatric depression scale -environmental safety: hazards in home/neighborhood
What is cephalocaudal development?
-Development that occurs from the head down -infants gain control of head & neck prior to the trunk & limbs as well as crawling before walking
When doing mental health assessment, what do you inspect?
-Appropriate dress? -mood and affect seem appropriate? -Patient body posture? -Tone of voice? -Conversation logical? ■ 1.Appearance ● General appearance, motor activity, demeanor ■ 2.Speech ■ 3.Orientation and Alertness ■ 4.Mood and Affect ■ 5.Cognition: Acute or chronic??? ● a)Information Processing ● b)Thought processes SYNONYMS ● c)Cognitive processes ■ Appearance, speech, orientation, alertness, mood and affect are reflections of cognition.
What is APGAR?
-Assess transition to extrauterine life -performed at 1 and 5 minutes of age -5 categories with 2 points each: breathing effort, HR, skin color, position/movement, and reflex irritability -7-10 points is WNL
What is sensorineural hearing loss and what are clinical findings of it?
-Caused by structural changes, disorders of inner ear, auditory nerve: SNHL accounts for more than 90% of hearing loss, presbycusis caused by atrophy and deterioration of cells in cochlea -usually manifests as gradual and progressive bilateral deafness with a loss of high-pitched tones -patiens have difficults filtering background noise
Why are developmental stages important for nurses to know?
-Early identification of developmental delays -Nurses educate parents and are myth busters who can relieve parental anxiety about erroneous information -understanding normal childhood development is vital to keep children comfortable during assessment
When do you ask for family history for geriatric assessment?
-Family history can be questionable -genogram is not routinely asked
What are complications that can occur with pregnancy?
-Hemorrhage: monitor for vaginal bleeding (placenta previa-no pain, abruption-pain) -HTN: monitor BP and proteinuria -Infection: preterm labor or rupture of membranes -Birth defects: ask about nutrition and vitamins (alcohol, smoking, and drug use)
How do you obtain a pediatric health history?
-Identifying data: patient name, age, sex, informatn -Chief complaint: reason child is seeking medical care and duration of symptom -History of present illness: describe the course of the patient's illness (OLD CARTS) -past medical history: medical problems, hospitalizations, surgeries
How do you examine hair?
-Inspect and palpate scalp and hair for surface characteristics, hair distribution, texture, quantity, and color, should be shiny and soft
What does social-adaptive in developmental assessment refer to?
-Interactions of infant or child with other persons -ability to organize stimuli -perceive relationships b/w objects -dissect a whole into its component parts -Reintegrate these parts in a meaningful fashion -Solving practical problems -ex: smiling at other persons and learning to feed self
How do we check pregnancy growth?
-Maternal weight gain -Funal height: top of uterus -Fetal heart rate (110-160 b/m) -fetal movement (mother starts feeling movement b/w 16-20 weeks
What do you ask for with a personal and psychosocial history with geriatrics?
-Personal status: ask patient for general statemtn of feelings about self, explore work/retirement concerns, reduced/fixed income, moving/selling home, living alone, and role changes -Functional ability focuses on ability to perform self-care activities or basic activities of daily living, and instrumental activities of daily living(BADLs-dressing , eating, ambulating, etc and IADLs-function independently)
What is systole?
-S1 heart sound -Ventricles contract creating pressure that closes AV valves, preventing backflow of blood into atria -Ventricular pressure also forces semilunar valves to open, resulting in ejection of blood into aorta from left ventricle and pulmonary arteries from right ventricles -As blood is ejected ventricular pressure decreases, causing semilunar valves to close -Ventricles relax to begin diastole
What is diastole?
-S2 heart sound -Ventricles relax and fill with blood from left and right atria -movement of blood from atria to ventricles is accomplished when pressure of blood in atria becomes higher than pressure in ventricles -About 80% of blood from atria flows into relaxed ventricles, remaining 20% is called atrial kick -At the end of diastole, ventricles are filled with blood
What are the stages of pressure ulcers?
-Stage 1: prolonged redness with unbroken skin -Stage 2: Partial-thickness skin loss appears as a shallow, open ulcer with pink wound bed -Stage 3: full thickness skin loss with damage to subcutaneous tissue -Stage 4: full thickness skin loss with exposed bone, muscle, or tendon -Unstagable=Eschar or slough may cover the entire wound bed
Tell me about pneumococcal vaccine
-any infection caused by strep pneumoniae bacteria -2 types: Pneumococcal conjugate, pneumococcal polysaccharide
What do you ask about with sleep assessment in geriatrics?
-any problems? -As person ages, proportion of time spent in deep sleep decreases and light sleep increases, less efficient -problems can be secondary to chronic problems -inquire about daytime napping and increase in number or length of naps during the day
How do you obtain perinatal history of patients?
-gestational age at birth, obstetrical compliations, type of delivery, birth weight, apgar scores, complications, length of hospital stay, medications, nutrition, developmental history (age attaining major milestones, relationships, behavior problems), immunizations, allergies, family history
What are abnormal heart sounds?
-murmurs -clicks-abnormal valvular sounds -rubs-associated with pericarditis, scratchy best heard at apex -S3-ventricular overload -S4: decreased LV complance
What are general rules of immunizations?
-the more similar a vaccine is to natural disease, the better the immune response -antibody has greater effect of live attenuated vaccs than inactivated vaccs -All vaccs can be administered at the same visit as other vaccines -live attenuated vaccs produce long lasting immunity w/ 1-2 doses. -intervals between doses does not diminish effect of vaccine. decreasing the interval may interfere with antibody response of protection -adverse rxns following live attenuated vaccs are similar to mild form of natural disease. with inactivated vaccs, rxns are local and can occur with or without fever -Only 3 permanent contraindications to vaccinations: sever allergic reaction, encephalopathy occurring wi/in 7 days of dose of pertussis containing vaccing, rotavirus vacc in infants disease with severe combined immunodeficiency disease
According to the 2003 National Assessment of Adult Literacy, the percentage of adults who are proficient in health literacy is: 75% 50% 12% 25%
12%
A patient's pre-pregnant weight was 131 lb., within the desirable range for her height. What is the expected weight for this pregnant patient? 140 lb. at the end of the first trimester 131 lb. at 1 week postpartum 176 lb. at the beginning of the third trimester 145 lb. at the end of the second trimester
145 lb. at the end of the second trimester
How long does birth trauma recovery take?
2-4 weeks
Which tool is the best choice for a nurse to use as a quick screening tool to assess a patient's dietary intake? Food diary 24-hour recall Comprehensive diet history Calorie count
24-hour recall
Where do you find pulmonic pulse?
2nd LICS
Where do you find aortic pulse?
2nd RICS
Where do you find Erb's point?
3rd LICS, where S2 is heard best
The patient with a respiratory rate that is within normal limits is the _____ whose respiratory rate is _____ breaths/min. 6-year-old; 20 16-month-old; 46 40-year-old; 10 14-year-old; 26
6-year-old; 20
A nurse is caring for a patient who has just had major abdominal surgery to resect a portion of his colon. What is the most reliable sign that the patient has significant postoperative pain? A. The patient rates his pain a 7 on a scale of 0 to 10. B. The patient winces and guards the area as the nurse gently palpates the abdomen. C. The patient is having trouble sleeping and has become irritable. D. The patient is moaning softly and frowning, with a pinched expression on his face.
A
A patient reports leg and foot pain with activity that resolves with rest. With what type of problem is this consistent? Arterial insufficiency Leg edema Venous thrombosis Hypertension
A
A patient reports shortness of breath with a gradual onset. The nurse suspects: heart failure. dysrhythmia. deep vein thrombosis. myocardial infarction.
A
In which patient would a pulsation within the epigastric area be considered a normal finding during inspection? A very thin patient An obese patient A patient with ascites An elderly patient
A
The nurse is reviewing risk factors for respiratory infection with an older adult patient. Which physiologic change that occurs with aging predisposes the older adult to respiratory infections? Mucous membranes become drier and more difficult to clear. Calcification occurs at the rib articulation points. The alveoli become less elastic and more fibrous. There is a reduction of interalveolar folds.
A
The student nurse is studying the liver. The primary function of the liver is to: metabolize nutrients. store vitamin C. produce red blood cells for circulation. absorb most nutrients.
A
What will the nurse instruct nursing assistive personnel (NAP) to do regarding the management of a patient's pain? A. "Let me know at least 30 minutes before you transport her so I can administer her pain medication." B. "Be sure to keep the room temperature high and the TV on at all times." C. "Be sure to tell me if you notice grimacing, guarding, or any unusual behavior." D. "I've given her some medication; please report to me whether it seems to have relieved her pain within an hour or so."
A
You are the nurse who is preparing to perform a physical assessment on a patient in the outpatient setting. When would the nurse begin the assessment? As soon as you meet the patient After the vital signs are taken After you explain to the patient everything you are going to do After the patient has put on a gown
A
_________ pain is associated with feeling pain when a limb has been amputated. Phantom Psychotic Chronic Invisible
A
In assessing a patients deep tendon reflexes, a nurse finds a patient has a 4+ triceps response. How does the nurse interpret this finding? A hyperactive response A diminished response An absent response An expected response
A hyperactive response
After the nurse has completed the interview, a symptom analysis is performed to derive appropriate interventions. What is the best description of symptom analysis? A way to document a comprehensive interview A method of collecting data about a patient's past medical history A systematic collection of subjective data related to the patient's chief complaint Interview data collected through the use of an interpreter
A systematic collection of subjective data related to the patient's chief complaint Correct
The nurse is caring for a patient who presents to the clinic for her first prenatal visit. What priorities will the nurse focus the assessment on? (Select all that apply.) Healthy eating Teaching about body changes Establishment of baseline data Parenting skills Taking prenatal vitamins Breastfeeding benefits
A, B, C, E
The nurse is assessing an older patient's ability to perform IADLs. What is included in this assessment? (Select all that apply.) Proper use of medications Cooking dinner Using public transportation Walking Bathing Writing checks
A, B, C, F
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.
A, B, D, E
Which concepts are included in the developmental assessment of a family? (Select all that apply.) Families undergo change as family members age. Individuals struggle with ego integrity versus despair. There are multiple and complex interrelationships within some families. Individuals often struggle with being members of more than one family. Individuals struggle with generativity versus stagnation.
A, C, D
A patient is complaining of chest pain. The nurse assessing the patient would ask and document the following questions: (Select all that apply.) "Where is the pain?" "Did you have these pains before?" "On a scale of 1 to 10, how bad is the pain?" "How often does the pain occur?" "What makes the chest pain feel better?" "Do you have any family history of heart disease?"
A, C, D, E
The student nurse is trying to learn how to perform a complete health assessment. Which actions will promote success? (Select all that apply.) Develop a routine. Learn to focus on a variety of problems. Visualize what you need to do. Put yourself in the patient's place. Adapt your technique to the setting in which you are. Practice before you perform the exam.
A, C, D, F
The nurse is compelled to address and manage a patient's pain level by which ethical principles? (Select all that apply.) Beneficence Liberty Autonomy Nonmaleficence Justice
A, D
The nurse is trying to assess a patient's risk of osteoporosis. The nurse knows that the following groups have the highest incidence of osteoporosis. (Select all that apply.) Asian females White males American Indian males African-American males Postmenopausal women Patients who had fractures in the past
A, E, F
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
A,B, C, E
The nurse is assessing a patient's spiritual beliefs and practices. Which questions should be considered part of the assessment? (Select all that apply.) What type of spiritual/religious support do you desire? What is the name of your clergy, ministers, chaplains, pastor, rabbi? What does pain mean to you? What does dying mean to you? What are your educational goals? Do you use prayer in your life?
A,B,D,F
The nurse assesses a pulse at 3+ amplitude. Which word best describes a pulse with 3+ amplitude? Diminished Normal Full volume Bounding
C
A patient is sitting slightly forward bracing his arms on his knees in a tripod position. This position is associated with which symptom? Back pain Abdominal pain Spinal deformity Breathing difficulty
Breathing difficulty
While assessing a man during a physical examination for work, the nurse suspects alcohol use. Which assessment tool is appropriate in this situation? HITS screening tool Rapid eye test AUDIT screening tool Mental status examination
AUDIT screening tool
The nurse is planning to teach a group of patients stress reduction exercises to reduce the risk of depression. Which population group is at highest risk for depression? Males School-age children Adolescents Individuals starting new careers
Adolescents
Tips for successful oral education include Limiting the message to 3-5 chunks per session Giving only "need to know" information. Use shorter words and sentences. All of the above
All of the above
Which of the following is NOT a component of the definition of health literacy? Making decisions based on health information. Understanding health information. Accessing health information. All of these are components of the definition.
All of these are components of the definition.
What are diseases from family you always want to know about?
Alzheimer's Cancer Diabetes (which type) CAD (MI) HTN stroke seizure disorders mental illness (depression, bipolar, schizophrenia) alcoholism endocrine diseases kidney disease
The nurse is assessing for objective findings are associated with the patient's pain level. Which findings are commonly associated with acute pain? (Select all that apply.) The patient is crying An elevated blood pressure An elevated heart rate Diaphoresis The patient states a pain level of 8 out of 10 on pain scale Vital signs stable
An elevated blood pressure An elevated heart rate Diaphoresis
What is the difference between Arterial and venous PVD?
Arterial: Intermittent/claudication pain, no edema, no pulse or weak pulse, no drainage, round smooth sores, black eschar, sores will be on toes/feet Venous: Dull, achy pain, lower leg edema, pulse present drainage, sores with irregular borders, yellow slough or ruddy skin, sores will be on ankles
The nurse is assessing an African-American patient for cyanosis. Cyanosis in dark pigmented skin appears as a(n): yellowish-green skin. deeper tone of brown or purple. Ashen gray color to the skin. cluster of dark spots over the skin surface.
Ashen gray color to the skin.
What signs of cyanosis does a nurse inspect for in a dark-skinned patient? Blue-gray color in the ear lobes and lips Ashen-gray color of the oral mucous membranes Blue color in the nail beds Ashen-blue color in the palms and soles
Ashen-gray color of the oral mucous membranes
How do we approach toddlers/preschoolers?
Assess on parent's lap, leave most invasive parts to last, expect resistance, do not ask permission (favorite word is often no), playful approach, use parents, dolls, etc to demonstrate procedures
How does a nurse assess perfusion to the foot when a patient has a cast from the left middle calf to the toes? Palpate the popliteal pulse of the left leg. Palpate the posterior tibial pulse of the left leg. Assess movement and sensation of the left toes. Assess the capillary refill of the left toes.
Assess the capillary refill of the left toes.
What is included in the history of present illness?
Brief statement regarding purpose of visit recorded in direct quotes from patient list and proritize Include symptomology: onset, location/duration, related and alleviating factors, attempts at self-treatment
The nurse is palpating a patient's chest wall. What can be accomplished with palpation of the chest? Approximation of lung size Determination of oxygenation Assessment of equal chest expansion Identification of lung sounds
Assessment of equal chest expansion Correct
Which is a common mistake made by health care professionals when collecting data about ethnic and cultural considerations of a patient? Acknowledging the practice of folk or herbal remedies Adapting health care concepts to meet the needs of individuals of other cultures Assuming data about the patient based on skin color or ethnic group Overestimating the ability of individuals from diverse cultures to understand health care concepts
Assuming data about the patient based on skin color or ethnic group
The nurse auscultates prolonged expiration with expiratory wheezing and diminished breath sounds while assessing a patient. What does the nurse suspect? Tuberculosis Pneumonia Croup Asthma
Asthma
A nurse is assessing a patient's neck. Which of the following is considered an expected finding? A. Jugular vein distention B. Midline trachea C. Carotid artery prominence D. Thyroid enlargement
B
A patient complains of chest pain. Which report made by a patient would suggest to the nurse that the chest pain is cardiac in origin? "My chest hurts every time I cough." "My chest feels really tight and heavy." "I have sharp pains in my chest when I eat raw vegetables." "I fell on some ice yesterday. Today, my chest hurts when I breathe."
B
A patient complains of pain and clicking in the jaw with movement. These symptoms are consistent with: gout in the jaw. temporomandibular joint syndrome. rheumatoid arthritis of the jaw. bursitis of the temporomandibular joint.
B
A patient has 3+ pitting edema in her feet and ankles. The nurse suspects: the patient has a heart murmur. the patient has excess fluid in the interstitial space. the patient is having a myocardial infarction. the patient has elevated cholesterol levels.
B
A pregnant patient in her sixth month asks the nurse why her breasts are getting so big. The nurse's best response is, "The breasts enlarge during pregnancy because of": increased fat deposits within the breast tissue. an increase in the size and number of lactiferous ducts and breast alveoli. engorgement of blood vessels as a result of increased vascularization. increased pigmentation of the areolae and protrusion of the nipple.
B
A school nurse is developing a health seminar for the tenth grade student assembly. When planning learning activities, the nurse should consider which developmental task of the adolescent population? Becoming an active and cooperative member of a family Developing mature peer relationships and accepting physical changes Planning direction in one's life and developing love relationships Allocating resources for security in future years
B
A woman in her seventh month of pregnancy reports that her gums bleed easily. What is the significance of this data? This is a common finding and is caused by elevated estrogen levels. This is a common finding and is caused by increased vascularity and proliferation of the gums. This is an abnormal finding and indicates a risk of hemorrhage. This is an abnormal finding and indicates gum atrophy.
B
During vocalization, the soft palate: A. Lowers symmetrically B. Raises symmetrically C. Vibrates D. Has a gag reflex
B
The daughter of an elderly patient is concerned because her mother has been falling lately. The nurse performs a head-to-toe assessment. Which finding indicates a need for further evaluation? The patient is 60 years old. The patient appears agitated. The patient is not taking medications. The patient relies on her daughter for transportation.
B
The nurse assesses an active reflex response. Which score should be documented? 1+ 2+ 3+ 4+
B
The nurse explains that a Pap test involves the provider taking a sample of: vaginal discharge. endocervical cells. cervical tissue. uterine tissue.
B
The nurse has completed a well visit for a 65-year-old patient. Which immunization would be recommended for this patient? Tetanus diphtheria (Td) every 5 years Influenza annually Measles, mumps, rubella (MMR) annually Oral polio vaccine (OPV)
B
The nurse is assessing a patient who recently was diagnosed with a stroke. The patient is very emotional. In what part of the brain did the stroke most likely occur? Brain stem Limbic system Prefrontal lobe Cerebellum
B
The nurse is assessing a patient's dorsalis pedis pulse. What is the primary reason for this assessment? The patient's heart rate Perfusion to the foot Sensation to the foot Reflexes within the foot
B
The nurse is assessing an older adult's neurologic status. The nurse should be aware that the neurologic responses of older adults: should be the same as those of younger adults. may be slower than those of younger adults. are present but difficult to evaluate. are enhanced as a result of irritability. 6.
B
The nurse is assessing the degree of pain or discomfort a patient is feeling. The nurse knows that this will be dependent primarily on: ability to explain the pain or discomfort. perception of the pain or discomfort. age of the individual. type of painful stimulus.
B
The nurse is assessing the olfactory nerve. Which instructions should the nurse give to the patient before assessment? "Lie down on your back." "Close your eyes." "Close both of your nostrils." "Breathe through your mouth."
B
The nurse is documenting a patient's response to, "What brings you here today?" Which of these statements would be correct? The nurse should: paraphrase the patient's words and document. put the patient's words in quotes and document exactly what is stated. ask the patient what is wrong and summarize the reason for seeking care in the chart. document wherever there is room on the chart.
B
The nurse is documenting the reproductive system in the review of systems section of the chart for a female patient. What should be included in this documentation? Describes urine as yellow and clear; voiding frequency four to five times daily; denies problems with voiding, changes in urinary pattern, or pain Last menstrual period 8 years ago No tenderness; denies lumps, masses, or nipple discharge Denies headache, vertigo, syncope
B
The nurse is documenting the review of systems. Which information will be helpful to the nurse? Physical findings related to each system Information regarding health promotion practices An opportunity to teach the patient about the diagnosis Information necessary for the nurse to diagnose the patient's medical problem
B
The nurse is examining a 4-year-old child who is having difficulty breathing. Which area should the nurse consider examining last? Abdomen Ears Respiratory system Skin
B
The nurse is performing a complete health assessment on a patient in the hospital setting. Which test would the nurse use to assess hearing for this patient? By observing how the patient participates in normal conversation Using the whispered voice test Using the Snellen exam Testing with an audiometer
B
The nurse is performing a developmental assessment on a child in the outpatient setting. The primary purpose focus of this assessment will be to: identify children at risk for physical impairments. identify children below the normal developmental level for their age group. predict adult behavior. predict achievement in school.
B
The nurse is preparing to assess an older patient's ability to perform IADLs. Which statement about IADLs is true? The nurse uses direct observation to implement this tool. They are designed as a self-report measure of performance rather than ability. They are not useful in the acute hospital setting. They are best used for those residing in an institutional setting.
B
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
B
The nurse notes that the patient is able to touch each finger to his thumb in rapid sequence. This finding indicates that the patient: has intact trochlear and abducens cranial nerves. has appropriate cerebellar function. has an intact spinal accessory nerve. has appropriate kinesthetic sensation.
B
The patient tells the nurse that she has clay-colored stools. Stool of this color results from: intestinal tract bleeding. lack of bile pigment. excessive dietary beef. insufficient fluid intake.
B
The student nurse is studying how to perform a physical exam. Which statement regarding the physical examination is true? The nurse should always do a head-to-toe examination. The nurse should develop a consistent approach for examination. The nurse should always conduct the examination in the order presented in the document used. The nurse should conduct the examination in the order presented in the textbook.
B
The student nurse is studying the changes a woman goes through during pregnancy. The student nurse knows that which body system undergoes the most dramatic physiologic changes during pregnancy? The skin The cardiovascular system The urinary system The gastrointestinal system
B
The student nurse is studying the difference between middle-age adults and older adults. The student nurse should be aware that the neurologic responses of older adults: should be the same as those of younger adults. may be slower than those of younger adults. are present but difficult to evaluate. are enhanced as a result of irritability.
B
Which observation indicates that a patient's pain medication has been effective in managing pain that she rated a 6 out of 10 on a pain rating scale before the intervention? A. The patient is seen quietly reading a magazine. B. The patient rates her current pain as 3 out of 10 on the pain rating scale. C. The patient is overheard telling her family that she is "feeling better today." D. The patient is observed sleeping, with a respiratory rate assessed at 18/minute, compared with 22/minute before the intervention.
B
Which statement regarding the comparison of the circumference between the right and left extremities is true? Measurements between the right and left sides should be identical. Measurement differences are less than 1 cm. Measurement differences are within 2 cm. Measurement differences are within 2 inches.
B
The nurse is assessing a patient's neurologic status. What assessment should the nurse perform? (Select all that apply.) Romberg test Glasgow Coma Scale Tonic neck Corneal reflex Mini-Mental State Exam Recall test
B, D, E, F
The nurse is assessing a newborn and notices the child has a cleft palate. What are the risks associated with this finding? (Select all that apply.) A vaginal breech delivery Speech impairments A birth weight of 1900 g Exposure to music while in utero Hearing impairment Failure to thrive Premature birth
B, E, F, G
During a symptom analysis, a patient describes his productive cough and states his sputum is thick and yellow. Based on these data, the nurse suspects which factor as the cause of these symptoms? Bacteria: Allergy Fungus Virus
Bacteria
Tell me about meningococcal vaccine:
Bacteria: meningitis or infection of blood close lengthy contact death and disability
What is the upper part of the heart?
Base
What are we auscultating for with abdominal examination?
Before palpation, systematic, diaphragm, bowel sounds
What is the S2 heart sound?
Beginning of diastole, closure of aortic and pulmonary valves, and heard loudest at base
What is S1 heart sound?
Beginning of systole, closure of mitral and tricuspid valve, heard loudest at apex, and synchronous with carotid
How do we approach adolescents?
Best to include parent for part of assessment then have them leave, be aware of modesty/privacy, confidentiality issues
A patient complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what findings will suggest that the cause of this patient's dyspnea is due to heart disease rather than respiratory disease? Increased anteroposterior diameter Clubbing of the fingers Bilateral peripheral edema Increased tactile fremitus
Bilateral peripheral edema
A patient complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what findings will suggest that the cause of this patient's dyspnea is due to heart disease rather than respiratory disease? Increased anteroposterior diameter Increased tactile fremitus Bilateral peripheral edema Clubbing of the fingers
Bilateral peripheral edema
What are the components of the comprehensive health history?
Biographic data-initial visit Reason for seeking care Present health status past medical history family history personal/psychosocial history review of all body systems
A pregnant woman who drinks alcoholic beverages while pregnant increases the risk for which disorder? Abruptio placentae Low infant birth weight Gestational diabetes mellitus Birth defects
Birth defects
The nurse knows that the _______ blood vessels should be used to assess an adult's blood pressure. carotid artery brachial vein brachial artery radial artery
Brachial artery
What is the assessment of the 3 B's?
Breasts: how is she feeding baby? Belly: how is her uterus recovering (fundus and lochia-vaginal discharge)? Bottom: how is her birth canal recovering: perineal area or abdominal incision?
A 50-year-old woman tells the nurse that in the last year she has been very active in her community and is working with troubled youths. The nurse assesses the patient at which developmental stage? Ego integrity versus despair Identity versus role confusion Generativity versus stagnation Initiative versus guilt
C
A patient reports that he has intermittent chest pain. Which is the most appropriate question to ask next? "Do you work in a stressful environment?" "Have you told your physician about the chest pain?" "What other symptoms do you have when the chest pain occurs?" "Do you have high cholesterol levels?"
C
A pregnant patient in her first trimester is complaining of nausea. The patient asks why she feels so sick. The nurse explains that anorexia and nausea are common to the first trimester of pregnancy because of which of the following? Low iron levels Nocturia Elevated levels of human chorionic gonadotropin Heartburn and constipation
C
Sensory neurologic testing cannot realistically be performed with children until they are: at least 6 months old. toddlers. kindergarten age. middle school age.
C
The nurse is assessing a patient's internal rotation of the shoulder joint. How should the nurse direct the patient? "Place your right hand behind the left side of your head." "Elevate your right arm over your head." "Place your right hand against the small of your back." "Rotate the palm of your hand up and down."
C
The nurse is assessing the patient's general appearance. Which of these is included in assessment of general appearance? Height Weight Skin color Vital signs
C
The nurse is assessing the risks of colorectal cancer for a group of patients. Which patient has a known risk factor for colorectal cancer? Steven, a 21-year-old college student who is a vegetarian Marie, a 22-year-old mother who has multiple hemorrhoids Susan, a 38-year-old female with a 15-year history of ulcerative colitis Jack, a 40-year-old man with frequent constipation
C
The nurse is caring for an 85-year-old patient. A developmental task for this age group is: adjusting to slower physical and intellectual responses. finding meaning in life and keeping active. combining new dependency needs with a continued need for independence. developing competencies that maintain family functioning during crises.
C
The nurse is counseling an adolescent on preventing sexually transmitted diseases (STDs). The patient understands this when he states, "The most common STD in the United States is___________________." gonorrhea syphilis chlamydia trichomoniasis
C
The nurse is listening to a patient's heart and hears an S2 sound. The S2 heart sound is caused by which of the following? Opening of the aortic and pulmonic valves Opening of the mitral and tricuspid valves Closing of the aortic and pulmonic valves Closing of the mitral and tricuspid valves
C
The nurse is palpating the fundal height of a pregnant patient. The nurse knows that to determine fundal height, one needs to measure from the___________________ to the top of the fundus. umbilicus perineum symphysis pubis xiphoid process
C
The nurse is performing a pain assessment of a 4-year-old toddler. Which pain assessment scale would be best for this patient? Visual Analog Scale Numeric Pain Intensity Scale Wong/Baker Faces Rating Scale Pain Intensity Scale
C
The nurse is preparing to perform an abdominal assessment. In which position should the patient be placed for abdominal assessment? Sitting upright on the examination table In a high-Fowler's position Supine In a left lateral position
C
The nurse is taking a family history. What questions and responses will the nurse document in this part of the chart? Immunizations Smoking status Relatives with cancer History of fractures
C
The nurse notes that a child is having a great deal of difficulty adjusting to the new school year. According to Erickson's theory, personality development depends on: making choices appropriate for each stage mastering behavior over conflict resolving conflict successfully within each stage developing conflict in each of eight stages
C
The nurse notices that his patient has none of the signs and symptoms normally associated with pain, such as diaphoresis, tachycardia, and hypertension. The patient does, however, seem moody and a bit uncooperative. What conclusion does the nurse draw? A. It is likely the patient is a drug seeker and has little or no pain. B. The patient's problem is more mental than physical. C. The absence of physiological signs and symptoms is associated with chronic pain. D. The patient's pain cannot be accurately assessed until the patient has been treated for anxiety.
C
The nurse should auscultate the abdomen for at least __________________ before documenting an absence of bowel sounds. 5 to 15 seconds 30 seconds several minutes 1 hour
C
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
C
The nurse suspects that a male patient has syphilis. Which finding suggests this diagnosis? A syphilis lesion on the skin in the pubic hair A syphilis lesion on the shaft of the penis near the base A syphilis lesion on the glans penis A syphilis lesion on the underside of the scrotal sac
C
Which findings by the nurse would produce the most accurate assessment of the severity level of a patient's pain? The nurse's experience The cause of the pain The patient's subjective data The patient's objective findings
C
During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of what? (Select all that apply.) Adventitious sounds and limited chest expansion Increased tactile fremitus and dull percussion tones Muffled voice sounds and symmetric tactile fremitus Absent voice sounds and hyperresonant percussion tones Symmetric chest Resonant percussion tones Expansion muffled voice sounds
C E F G
The nurse is attending an in-service on pain management for postoperative patients. Which statement regarding pain is true? (Select all that apply.) An individual's pain response is predictable based on his or her culture or ethnicity. Individuals from all cultures respond to pain similarly. The pain response may be influenced by one's culture. Individuals may express pain differently. Pain management may vary depending on the source of pain.
C, D, E
Which risks are associated with testicular cancer? (Select all that apply.) Multiple sex partners Men age 60 and over Men age 20 to 34 Family history of testicular cancer Cryptorchidism Caucasian men
C, D, E, F
What are the divisions of the brain?
CNS: brain and spinal cord PNS: cranial and spinal nerves ANS: symp and parasympathetic
What are the parts of the brain?
Cerebellum: muscles, voluntary movement, equilibrium and balance Brainstem: involuntary autonomic: life support: hearing, speech, swallowing Spinal cordL sensory tracts, motor path, upper/lower motor neurons
How do you assess labor progression?
Cervical dilation: opening of the cervix Cervical effacement: shortening/thinning
What does past health assessment focus on?
Childhood illnesses (fluidity and need to see importance), surgeries, hospitalizations, accidents/injuries, immunizations, ob history, las examinations
A nurse inspects a patient's hands and notices clubbing of the fingers. The nurse correlates this finding with what condition? Pulmonary infection Chronic hypoxemia Allergic reaction Trauma to the thorax
Chronic hypoxemia
The nurse assesses a patient who has a costal angle greater than 90 degrees. What is the most likely cause of this finding? Chronic obstructive pulmonary disease Pneumothorax Infant respiratory distress syndrome Atelectasis
Chronic obstructive pulmonary disease Correct
What are we inspecting for abdominal examination?
Color, surface characteristics/movement, contour
What is erythema toxicum?
Common skin rash in health newborns?
Tell me about HPV vaccine:
Common virus, 1/4 people are infected. Most never develop symptoms, most infection go away w/in 2 years, can cause cancers
The nurse is teaching a parent about risk factors associated with the skin for their school-age child. What would the nurse include as the most common cause of skin lesions for this age group? Communicable disease and bacterial infection Changes in skin turgor and skin tone Maturation of melanocytes, causing changes in skin color Skin inflammation from sebaceous gland activity
Communicable disease and bacterial infection
What are the functions of the upper airways? Select all that apply. Conduct air to lower airway. Provide area for gas exchange. Prevent foreign matter from entering respiratory system. Warm, humidify, and filter air entering lungs. Provide transportation of oxygen and carbon dioxide between alveoli and cells.
Conduct air to lower airway. Prevent foreign matter from entering respiratory system. Warm, humidify, and filter air entering lungs.
What are routine techniques for skin assessment?
Consistency over body, whitish pink to olive tones, sun-exposed skin is darker, not color/pigmnetation/vascularity/systematically inspect, provide adequate lighting. look for localized variations in color, normal localized variations
What is an example of chief complaint & HPI?
Cough x 3 weeks. cough is loose and productive, sputum yellow. gets worse with exertion. Has tried OTC cough medications which do not help. also with nasal congestion & sore throat. no fevers. siblings are sick with similar symptoms
The nurse is performing a cultural assessment for an immigrant from Mexico. The patient is having difficulty adapting to the American health system. What is the most likely explanation for this problem? Culture shock Cultural taboos Cultural unfamiliarity Culture disorientation
Culture shock
A 52-year-old obese male who smokes and has diabetes has risk factors for: seizures. Guillain-Barré syndrome. multiple sclerosis. cerebrovascular accident.
D
A 59-year-old patient tells the nurse that he has Crohn disease. He has been having black stools for the last 24 hours. How should the nurse best document the patient's reason for seeking care? "The patient is a 59-year-old male who has Crohn disease." "The patient came into the clinic complaining of black stools for the past 24 hours." "The patient is a 59-year-old male, states he has Crohn disease and wants it checked." "The patient is a 59-year-old male who has had black stools for the past 24 hours."
D
The nurse assesses that a woman in her eighth month of pregnancy has a wide thoracic cage. What best explains this finding? She may have a lung disease such as emphysema. She may be hypoxic and may require oxygen. This is a finding seen only in women carrying multiple fetuses. This is considered a normal finding with advanced pregnancy.
D
The nurse has completed a social history on a hospitalized patient. Where would the nurse document the findings? Under past medical history With the biographic information Directly after reason for seeking care Directly after family history
D
The nurse is assessing a 5-month-old infant to determine if the infant is meeting typical milestones. Which observation should be considered an expected finding for a 5-month-old infant? Stands while holding onto furniture Sits alone Head lags when pulled to sitting position Rolls over independently
D
The nurse is assessing a 72-year-old patient in the clinic. Which statement made by a 72-year-old patient describes a normal process of aging? "My tongue feels swollen." "My tonsils are large and sore." "I have a black spot on my gums." "Food does not taste the same as it used to."
D
The nurse is assessing a patient who may have cerebellar dysfunction. Which assessment should the nurse perform? Phalen test Tinel test Cranial nerve VIII test Romberg test 3.
D
The nurse is assessing a patient's abdomen and suspects ascites. Which technique is used to confirm the presence of abdominal ascites? Auscultation of fluid movement within the abdominal cavity Palpation of rebound tenderness Palpation of pitting edema of the abdomen Percussion of dullness over dependent areas of the abdomen
D
The nurse is assessing a patient's deep tendon reflexes. In which location will the nurse elicit a response? Abdomen Femoral Scapular Bicep
D
The nurse is developing a teaching plan for a pregnant patient. One of the interventions in the plan of care is to wear sunscreen and avoid the sun. What is the rationale for the recommendation? Decreased blood flow to the hands and feet causes occasional cyanosis. A decreased number of sebaceous glands cause conservation of body heat. Thickness of the skin decreases. Pigmentation of the skin increases.
D
The nurse is performing a skin check on a patient. In which age group is seborrheic keratosis an expected finding? Newborns Young children Adolescents Older adults
D
The nurse is performing an assessment on a newborn infant. The nurse will assess the infant's weight, length, and ____________ as part of this routine assessment. chest circumference hip-to-toe length forearm length head circumference
D
The nurse notes a black umbilicus on a 5-day-old infant. What does this finding indicate? The infant may have a feeding problem. The umbilicus is infected. The infant has hepatitis. This is a normal finding.
D
The nurse notices that a patient is able to understand what is said but has trouble formulating a response. The nurse suspects: Parkinson disease. Guillain-Barré syndrome. receptive aphasia. expressive aphasia.
D
The nurse records the childhood illnesses of a patient who denies having had any. Which note by the nurse would be most accurate? Patient denies usual childhood illnesses. Patient states "he was a very healthy" child. Patient states sister had measles, but he did not. Patient denies having had measles, mumps, rubella, chickenpox, pertussis, and strep throat.
D
The nurse that is examining a patient with normal muscle strength would document Grade _____. 0 1 3 5
D
When assessing the quality of a patient's pain, the nurse should ask which of the following question? "When did the pain start?" "Is the pain a stabbing pain?" "Is it a sharp pain or dull pain?" "What does your pain feel like?"
D
Which patient condition increases the risk of osteomyelitis? Severe gout Rheumatoid arthritis (RA) Severe osteoporosis An open fracture of the radius
D
Which statement regarding variations in neurologic functioning is true? African-American adults have an enhanced reflex response. American Indian children tend to develop early motor skills more rapidly than other children. Asians have a greater sensation than do whites. The function of the neurologic system is consistent across racial lines.
D
The nurse is preparing to assess an older patient's basic activities of daily living (BADLs). What should be included in this assessment? (Select all that apply.) Shopping Food preparation Driving Walking Bathing Dressing
D, E, F
What is hypothyroidism and what are clinical findings?
Decreased production of thyroid hormone -decreased metabolism, depressed effect, goiter
The nurse asks the patient to hold the arms straight out, perpendicular to the floor, and the nurse tries to push the patient's arms down. This procedure tests the strength of which muscles? Biceps Trapezius Deltoid Triceps
Deltoid
What is proximodistal development?
Development that occurs from center of body out -Children gain control of their hangs before fingers, they can grab and hold things with the hand before being able to pick up with just fingers
What is delirium and what are clinical findings of it?
Disturbance of consciousness and rapidly developing change in cognition. Manifestations are 1+ weeks, reversible with treatment. Altered LOC, impaired memory, fluctuating attention span, may have hallucinations or delusions, sundowning may occur, speech may be rapid/inappropriate/rambling
__________ refers to differences in gender, age, culture, race, ethnicity, religion, sexual orientation, physical or mental disabilities, and social and economic status. Discrimination Spirituality Culture sensitivity Diversity
Diversity
What is an example of documentation for HEENT?
Documenting Expected Findings Head is normocephalic. Scalp clean, intact with female hair distribution pattern. Facial features symmetrical. Reported distance vision 20/20 with glasses. (No obvious far or near sighted vision problems). Eyebrows symmetric, with lashes evenly distributed. Conjunctiva pink, sclera is white & clear, no discharge. PERRLA, consensual reaction present. Hearing present w/ conversation. Ears symmetric, no cerumen visible. Nose is smooth & symmetric, nares clear. No problems w/ smell reported. Breath without odor. Lips symmetric, moist, smooth. Teeth intact w/ no visible decay. Mucous membranes moist, pink. Uvula midline. Trachea midline. No palpable lymph nodes. Full, active neck ROM.
The nurse suspects altered thought processes. Which findings might suggest an altered thought process? (Select all that apply.) Dress or appearance Socioeconomic issues Cultural differences Problems articulating words Tone of voice
Dress or appearance, problems articulating words, tone of voice
How do you assess uterine contractions?
Duration: how long one contraction lasts Frequency: from beginning to beginning Intensity: mild, moderate, or strong
Tell me about influenza vaccine
Every flu season is different, everyone 6 months of age and older should get a vaccine every season
During inspection of the mouth of an older adult, a nurse notices which finding as an expected change associated with aging? Leukoplakia of the dorsal and ventral tongue Collection of debris at the gingival margins Exposed root surfaces of teeth Aphthous ulcers of the mucosa
Exposed root surfaces of teeth
Tell me about HepB vaccine
First dose should be admin before discharge from hospital
Before educating a patient, the nurse should use the Test of Functional Health Literacy to determine the patient's health literacy level, and target education accordingly.
False
How do you obtain a social history of peds?
Family situation, alcohol, smoking, drugs, sexual activity, childcare/school/friends, parental level of education/occupation, safety-child car seats, smoke detectors, bicycle helmets, firearms in home
If first day of last menstraul period was May 14th, when is expected due date?
Feb 21st
The nurse is conducting an interview with a patient who is mentally challenged. The nurse knows that ____________ assessment is the preferred method for this interview. comprehensive focused family health risk
Focused
What does postpartum mean?
mom after birth
he nurse is focusing the interview for a patient who complains of headaches and nausea. Which interview format is based on body function as opposed to body system? Review of systems Functional health patterns Health perception database Nursing process
Functional health patterns
What is the cerebellum function?
Gait/station, normal walk, neg romberg test, finger to nose, heel shin movement, finger to finger, rapid hand movement
What do you examine for respiratory?
General appearance, posture, breathing effort Respirations: rate/quality, pattern, expansion Inspect nails, skin, and lips Inspect thorax Auscultate
What do you need to identify with family history?
Genetic, familia, and environmental factors that might affect current/future health status
In collecting a history from an older adult, which information does the nurse consider least essential for a patient of this age? Past health history Mental health Genogram Functional abilities
Genogram
A patient reports having abdominal distention. The nurse observes that the patient's sclera are yellow. Which abnormal finding does the nurse anticipate on examination of this patient's abdomen? Glistening or taut skin of the abdomen Decreased bowel sounds in all quadrants Bulge in the abdomen when coughing Bruit around the umbilicus
Glistening or taut skin of the abdomen
What does the physical exam for HEENT include?
Head: Inspect head & facial structures Vision: general assessment 1st Eyes: Inspect external structures Sclera, cornea, iris: Pupils: size, shape reaction to light, accommodation, consensual Ears: Hearing - conversation Inspect external structures Nose: Inspect Mouth: Inspect lips, teeth, gums, tongue, buccal mucosa, uvula, tonsils Neck: Inspect, Palpate lymph nodes
What are common problems related to HEENT?
Headache Dizziness Difficulty with vision Hearing loss Ringing in ears Earache Nasal discharge Sore throat Oral lesions
A nurse is auscultating the lungs of a healthy male patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding? Ask the patient not to talk while the nurse is listening to the lungs. Change the patient's position to ensure accurate sounds. Hold stethoscope firmly to prevent movement when placed over chest hair. Make sure the bell of the stethoscope is used, rather than the diaphragm.
Hold stethoscope firmly to prevent movement when placed over chest hair.
How does the nurse accurately assess bowel sounds? Press the bell of the stethoscope firmly against the abdomen in each quadrant. Press the bell of the stethoscope lightly against the abdomen in each quadrant. Press the diaphragm of the stethoscope firmly against the abdomen in each quadrant. Hold the diaphragm of the stethoscope lightly against the abdomen in each quadrant.
Hold the diaphragm of the stethoscope lightly against the abdomen in each quadrant.
The nurse is assessing the patient's stressors. Which tool can be used to identify the degree of stressors a patient may be experiencing? CAGE Holmes Social Readjustment Inventory Scale AUDIT Mini-Mental State
Holmes Social Readjustment Inventory Scale Correct
The nurse is asking the patient to stick out his tongue and move it back and forth. Which cranial nerve is the nurse testing? Hypoglossal nerve (CN XII) Vagus nerve (CN X) Facial nerve (CN VII) Olfactory nerve (CN I)
Hypoglossal nerve (CN XII)
What are Erikson's stages of developmet?
Infancy (0-2): Trust vs Mistrust Early childhood (2-4 yrs): Autonomy vs Shame and Doubt Preschool (4-5 yrs): Initiative vs. Guilt School Age (5-12 yrs): industry vs. inferiority Adolescence (13-19 yrs): identity vs. role confusion
What do you examine for posterior thorax?
Inspect for shape, symmetry and muscle development. Ausculate posterior and lateral thorax for breath sounds
How do you inspect nails?
Inspect nails for shape (edges should be smooth and rounded), contour (should be flat and slightly rounded), color (pink, blanched, yellow, brown), consistency (should note grooves, depressions, pitting, and ridges), thickness, and cleanliness
How does the nurse recognize jaundice in a dark-skinned patient? Inspect the palms and soles for yellowish-green color. Inspect the conjunctiva for ashen-gray color. Inspect the oral mucous membrane for yellow color. Inspect the nail beds for a deeper brown or purple skin tone.
Inspect the palms and soles for yellowish-green color.
What is the order of physical exam?
Inspect, Palpate, ausculate
What do you assess for musculoskeletal?
Inspect, palpate, ROM, extremity strength
What are we examining for in cardiovascular?
Inspect/palpate lower extremities for symmetry, skin integrity, color/temp, hair distribution, cap refill, color/angle of nail beds, tenderness, superficial veins Palpate lower extremities for femoral, popliteal, posterior tibial pulses and dorsalis pedis pulses for amplitude
The nurse is interviewing a patient for the first time. The nurse can expect the interview to be conducted in which type of order? Introduction, discussion, and summary Assessment, planning, intervention, and evaluation Discussion, introduction, and summary Assessment, evaluation, planning, and reevaluation
Introduction, discussion, and summary Correct
Tell me about polio vaccine
Invades/infects brain and spinal cord, causing paralysis
How do you check for general health history for family history?
Is there a history of cancer in your family? Which of the family members and what kind of cancer was diagnosed? Does anyone in your family have conditions impacting hearing, vision, or thyroid? Cataracts Glaucoma Sensorineural hearing loss Ménière's disease Hyperthyroidism
What is oral cancer and what are clinical findings of it?
Lesions can occur within the oral cavity that are subtle and asymptomatc, red/white patches, nonhealing ulcers, enlarged-hard, non-tender cervical chain or submental lymph nodes.
What are inactivated vaccines?
Kills microorganisms. whole/pieces of dead microbes are in the vaccines. They cannot replicated. multiple doses may be needed. Examples: DTAP/TDap, Flu type B, Hep B/A, HPV, Meningococcal, influenza, pneumococcal, polio
Where do you find the apical pulse?
LNCL, 5ICS
Tell me about HIB vaccine
Leading cause of bacteria meningitis in children younger than 5, can cause death or permanent neuro damage or deafness
What is LMCL?
Left midclavicular line
What are examples of viral vaccines?
MMR, Hep B and A, Varicella, influenza, HPV, polio
The nurse knows that the single most important factor in conducting an interview is the communication process. Which factors will most likely affect a positive interview process and therapeutic communication? (Select all that apply.) Obtaining the patient's history Maintaining privacy Asking open-ended questions Conducting a fast, efficient interview Obtaining answer to questions in advance Asking closed-ended questions Asking how the patient is feeling today
Maintaining privacy Asking open-ended questions Asking how the patient is feeling today
0 out of 10 points The nurse asks the patient to stand with feet together, arms resting at the sides, with eyes open and then with the eyes closed. Which response by the patient indicates a problem in the cerebellum? Is unable to stand upright after turning around in a circle once Steps sideways when standing with feet together and eyes closed Maintains balance when eyes are open, but loses balance with eyes closed Sways slightly and maintains upright posture with feet together
Maintains balance when eyes are open, but loses balance with eyes closed
How do you assess pain in infants/children?
Neonate: increased HR, HTN, pallor, seating, decreased O2 sat young children can describe pain and location usually
What are you assessing during neuro assessment?
Mental status (LOC, orientation, memory) cranial nerves (smell, see, blinking, eyes move, symmetric face, hearing, swallowing, shrugs/turns head, enunciates words)
Tell me about rotavirus vaccine
Min age is 6 weeks, dose 1 should not be given after15 weeks, max age for any does is 8 months
What is live attenuated vaccine and examples?
Modifying disease causing orgs, they are still alive but weakened. Can replicate but doesn't cause illness. Ex: MMR and Varicella
A woman who is 16 weeks pregnant with her first child is concerned because she has not felt the fetus move. What is the most appropriate explanation for a nurse to give this patient? Movement of a fetus in the first pregnancy often does not occur until the twenty-eighth week of pregnancy. Movement of the fetus is related to fundal height; the greater the fundal height, the sooner the fetal movement. Movement of the fetus is not expected until the nineteenth week of pregnancy. A referral to an obstetrician should be made for further evaluation of this finding.
Movement of the fetus is not expected until the nineteenth week of pregnancy.
A nurse hears inspiratory and expiratory wheezes bilaterally. What is the meaning of this finding? Consolidation in alveoli Narrowed airways Sputum in the bronchi Fluid in the alveoli
Narrowed airways Correct
Where does a nurse expect to hear bronchovesicular lung sounds in a healthy adult? Near the sternal border In the apices of the lungs In the lower lobes Over the trachea
Near the sternal border
The nurse is documenting in the chart. For documentation purposes, which term is used to describe a head that is of average size and shape? Normocephalic Microcephalic Macrocephalic Hydrocephalic
Normocephalic
How do you assess pruritus?
OLDCARTS
A patient reports having difficulty swallowing. Based on this information, how does the nurse assess the cranial nerve related to swallowing? Observe the rising of the soft palate when the patient says "Ahh." Observe the symmetry of the face when the patient talks. Ask the patient about feeling the blunt end of a paper clip along the jaw line. Assess taste on the anterior part of the tongue.
Observe the rising of the soft palate when the patient says "Ahh."
The nurse is obtaining a pulse oximeter reading on an adult patient. Where is the probe of a pulse oximeter placed? In the mouth or under the arm On the ear' On the tip of a finger or toe or on an ear lobe In the rectum
On the tip of a finger or toe or on an ear lobe Correct
What is mood?
Overall life situation and current feeling by patient report
A nurse suspects appendicitis in a patient with abdominal pain. Which findings are suggestive of appendicitis? Select all that apply. Pain around the umbilicus. Right lower quadrant pain. Pain relieved by lying still. Pain radiating to the right shoulder.
Pain around the umbilicus. Right lower quadrant pain. Pain relieved by lying still.
What is referred pain?
Pain felt in a location away from the injury. Often visceral pain, as many abdominal organs have no pain receptors
What does the join commission assert regarding pain?
Pain is assessed in all patients, initial/regular assessment takes cultural/spiritual/ethnic beliefs into account, education of all relevant proviers in pain assessment and management, and education of patients and families regarding roles in managing pain and potential limitation and side effects of pain treatments.
How do you review each system?
Past and present health (once symptom is identified, explore that), conduct symptom analysis, define medical terms
What does the present history consist of?
Patient's acute and chronic conditions like current health conditions, medication reconcilliation, allergies
While the nurse is performing an admission assessment on a newly admitted client, the client states, "I am very unsteady on my feet." What assessment would the nurse perform to evaluate the client's statement? Test ocular fields to see if there is a visual problem causing unsteadiness Test the client's intellectual functioning by asking the client to remember several sequences of numbers. Assess the client for two-point discrimination Perform assessments to evaluate cerebellar function
Perform assessments to evaluate cerebellar function
What assessment do we compare to gestational age?
Physical: ear (cartilage), hair (lanugo), skin (thickness and wrinkles), breasts (buds), genitals (development), neuromuscular (mostly extremity flexion)
What does the nurse teach to parents to prevent sudden infant death syndrome (SIDS)? Place the baby on back to sleep. Place the baby on side to sleep. Not to feed the baby for 3 hours before sleep. Place the baby on her stomach to sleep.
Place the baby on back to sleep.
Which complication of pregnancy does a nurse suspect when the patient reports painless vaginal bleeding at 32 weeks of gestation? Abruptio placentae Placenta previa Premature rupture of membranes Eclampsia
Placenta previa
The nurse percusses a patient's chest and feels dullness. The nurse suspects which diagnosis? Emphysema Pneumonia Bronchiectasis Chronic obstructive pulmonary disease (COPD)
Pneumonia
How does a nurse document a large, flat bluish capillary area on a neonate's cheek? Strawberry hemangioma Stork bite (telangiectasis) Mongolian spot Port-wine stain (nevus flammeus)
Port-wine stain (nevus flammeus)
When do you reassess for pain?
Post medication: 30 min after parenteral, 60 min after oral observe behavioral changes, self-reports
How do you check present health status for HEENT?
Present health status: Have you noticed any changes to your eyes, ears, nose, or mouth? Do you have any chronic conditions that affect eyes, ears, nose, mouth, head, or neck? Examples: Cataracts, glaucoma, migraine headaches, hearing loss, oral cancer, and hypothyroidism. Other chronic conditions include: Hypertension, human immunodeficiency virus (HIV) infection, diabetes mellitus, and autoimmune disorders. Chronic diseases often impact clinical findings. Medications: What, and how often? Side effects of medications are common and may explain symptoms or clinical findings associated with head and neck regions. Headaches, dizziness, changes in vision, ringing in ears, and dry mouth are all examples of medication side effects.
What are common issues with skin problems?
Pruritus is most commonly reported symptom of skin disease Rashes Pain/discomfort lesions wounds changes in skin color or texture, hair, or nails
When the patient's chart includes a notation that petechiae are present, what finding does a nurse expect during inspection? Generalized reddish discoloration of an area of skin Purplish-red pinpoint lesions Small raised fluid-filled pinkish nodules Deep purplish or red patches of skin
Purplish-red pinpoint lesions
Tell me about TDap vaccine?
REcommended for >11 yrs, one time booster. children 7-10, reccomended for pregnant women -Children 7-10 should recieve single dose if not fully vaccinated against pertussis (fewer than 4 doses, no contraindication)
What vital signs do we assess for newborns?
RR for 1 minute, HR apical for 1 minute, temp: axillary route, BP (prn) tiny cuff
_________ is genetic in origin and includes physical characteristics such as skin color, bone structure, eye color, and hair color. Culture Religion Spirituality Race
Race
What are we ausculating S1 and S2 sounds for?
Rate, rhythm, pitch splitting
What does the left side of the heart do?
Receives blood from pulmonary veins and pumps blood through aorta into systemic circulation to perfuse the body
What does the right side of the heart do?
Receives de-oxygenated blood from superior and inferior venae cavae and pumps blood through pulmonary arteries to pulmonary circulation to be oxygenized
A health literate health care organization: Puts the responsibility for ensuring health information is understood entirely on the nurse. Reduces barriers to patients receiving health information and services. Uses health literacy strategies only for written communication. Tests all patients' health literacy levels.
Reduces barriers to patients receiving health information and services.
The nurse is reviewing concepts related to one's heritage and beliefs. The belief in a divine or superhuman power or powers to be obeyed and worshipped as the creator(s) and ruler(s) of the universe is known as: culture. religion. ethnicity. spirituality.
Religion
Correct The nurse performs teach back after instructing a patient how to take her medication. The patient is not able to accurately tell the nurse how she will take the medications. The nurse's next step is to: Repeat the information using different terminology. Ask the provider to teach the patient about the medication instead. Give the patient a written handout instead. Repeat the information using the exact same words.
Repeat the information using different terminology.
When performing a skin assessment of an adult patient, the nurse expects what finding? Flaking or scaling of the skin Reddened area does not blanch when gentle pressure is applied Indentation of the finger remains in the skin after palpation Return of skin to its original position when pinched up slightly
Return of skin to its original position when pinched up slightly
What findings does the nurse expect when assessing the cardiovascular system of a healthy adult? Select all that apply. Capillary refill greater than 3 seconds S1 & S2 present with regular rate & rhythm Pulse of smooth contour with +2 amplitude Warm, elastic turgor Blood pressure 141/90 Heart rate of 102 beats per minute
S1 & S2 present with regular rate & rhythm Pulse of smooth contour with +2 amplitude Warm, elastic turgo
A patient reports that he has coronary artery disease with ventricular hypertrophy. Based on these data, what finding should the nurse expect during assessment? Splitting of the S1 heart sound Pericardial friction rub S4 heart sound Clubbing of fingers
S4 heart sound
How do we approach school age children?
School age children love to help, explain what you are doing, teach about health, usually appropriate to use head-to-toe approach on bed/exam table
The nurse knows that the functions of the skin include which of the following? (Select all that apply.) Sensory input Protection Production of vitamin D Temperature regulation Production of vitamin C Sensory output
Sensory input Correct Protection Correct Production of vitamin D Correct Temperature regulation Correct
What is the routine exam for skin, hair and nails?
Skin: inspect color, palpate texture, temperature, moisture, mobility, turgor Hair: inspect, palpate scalp and body hair Nails: inspect and palpate
The student nurse is learning how to obtain blood pressures and is studying what factors can affect blood pressure. What should the student nurse include as factors that affect blood pressure? (Select all that apply.) What the person ate Smoking Mobility Race Gender Weight Pain
Smoking, race, gender, weight, pain
The nurse is treating a patient for a nosebleed. The patient complains of frequent nosebleeds. What could be a possible cause of the nosebleeds? Excessive cilia Tobacco use Snorting cocaine Hypotension
Snorting cocaine \
What are the 3 stages of when the baby will be born?
Stage 1: uterine fundus contracts regularly, uterine cervix shortens and opens Stage 2: mother pushes with contractions, fetus descends and is born stage 3: placenta separates and is expelled
The nurse states, "All homosexuals have HIV infection." This statement is an example of: sexism prejudice stereotyping racism
Stereotyping
When examining lymph nodes in a 7-year-old child, the nurse records which finding as abnormal? "Shotty" nodes in the cervical areas Tender, fixed nodes greater than 1 cm Nodes that are tender 1 week after a tetanus vaccination Palpable submandibular nodes
Tender, fixed nodes greater than 1 cm
What are we palpating for with abdominal examination?
Tenderness, muscle tone, surface characteristics
What standards or guidelines exist to help eliminate racial and ethnic health disparities and to improve the health of all people who live in the United States? Each ethnic group has its own written standards for competent cultural care. There are no standards or guidelines for giving competent cultural care. The U.S. Office of Minority Health published standards to ensure culturally appropriate health care services. The American Society of Cultural Competence has guidelines containing the health beliefs and practices of major cultural groups.
The U.S. Office of Minority Health published standards to ensure culturally appropriate health care services. \
The nurse is assessing a patient for nail clubbing. Where should the nurse focus the exam? The width of the nail base The color of the nail The thickness of the nail The angle of the nail base
The angle of the nail base
What does the S2 heart sound represent? The beginning of systole. The closure of the aortic and pulmonic valves. A split heard sound on exhalation The closure of the tricuspid and mitral valves
The closure of the aortic and pulmonic valves.
The nurse is performing a skin assessment on a patient in pain. Which skin layer contains sensory fibers that react to touch, pain, and temperature? The epidermis The dermis The hypodermis The subcutaneous tissue
The dermis
What is pain considered?
The fifth vital sign
A patient comes to the clinic for a skin check. Which finding by the nurse indicates a need to further investigate a lesion? The lesion is dark brown. The lesion has been present for 20 years. The lesion bleeds easily when it is touched. The lesion is slightly raised and circumscribed.
The lesion bleeds easily when it is touched.
The nurse is auscultating the lungs to listen for breath sounds. What sounds will indicate that the nurse is auscultating correctly? The nurse will hear the diffusion of air and carbon dioxide. The nurse will hear the air move in and out of the lungs. The nurse will hear a lub/dub sound. The nurse will hear gurgling noises.
The nurse will hear the air move in and out of the lungs.
The nurse is assessing a patient's optic disc. What instrument would be best for this assessment? The optic disc is viewed with an ophthalmoscope. The optic disc is viewed with a stethoscope. The optic disc is viewed with an otoscope. The optic disc is viewed by the naked eye
The optic disc is viewed with an ophthalmoscope.
A patient is complaining of difficulty hearing. Which structure of the ear stimulates the acoustic nerve? The tympanic membrane The ossicle The organ of Corti The tragus
The ossicle
The nurse is reviewing the pathophysiology of pain. Where does the perception of pain actually occur? The dorsal horn of the spinal cord The parietal lobe of the cerebral cortex The afferent (sensory) nerves The visceral and somatic free nerve endings (nociceptors)
The parietal lobe of the cerebral cortex
The examiner notes a diaphragmatic excursion of 4 cm on the right side and 8 cm on the left side. What do these findings mean? The patient may have a pleural effusion. The patient may have a pneumothorax. Asymmetric findings are common in well-conditioned adults. This is a normal finding because the right lung is larger than the left lung.
The patient may have a pleural effusion. Correct
To assess the triceps and biceps muscle strength, the nurse applies resistance to the patient's arm. What should be done to ensure the appropriate muscle is being assessed? -The patient pushes up against the nurse's hand to abduct the biceps muscle and pushes down against the nurse's hand to adduct the triceps muscle. -The patient pushes up against the nurse's hand to abduct the triceps muscle and pushes down against the nurse's hand to adduct the biceps muscle. -The patient pulls backward against the nurse's hand to flex the triceps muscle and pushes forward against the nurse's hand to extend the biceps muscle. -The patient pushes forward against the nurse's hand to extend the triceps muscle and pulls backward against the nurse's hand to flex the biceps muscle.
The patient pushes forward against the nurse's hand to extend the triceps muscle and pulls backward against the nurse's hand to flex the biceps muscle.
A nurse uses the Glasgow Coma Scale to assess which patient? The patient who has tonic-clinic seizures The patient who has a new onset of quadriplegia The patient who has dementia The patient who requires stimuli for responses
The patient who requires stimuli for responses
The nurse is obtaining the mental health history of a new patient. What should the nurse include in the mental health history? (Select all that apply.) The patient's description of self A past medical history The current medications the patient is taking Cultural beliefs Spiritual beliefs
The patient's description of self A past medical history The current medications the patient is taking
How do you assess skin texture changes?
Thinning, fragile, excessive dryness? Excessive dry (xerosis) or oily (seborrhea) skin: seasonal, intermittent, continous, self treatment?
Which valve does a nurse auscultate when the stethoscope is placed on the fourth intercostal space at the left of the sternal border? Aortic Tricuspid Mitral Pulmonic
Tricuspid
The use of teach back can help reduce hospital readmissions.
True
Using a combination of oral instruction with written material is more effective than either strategy alone.
True
Using appropriate pictures or graphics on a written handout can improve understanding of the material presented.
True
The nurse is assessing the temperature of a toddler. Which method is best for this patient? A thermometer is inserted into the patient: defer temperature for this age group oral rectal tympanic
Tympanic
The nurse is obtaining a patient's blood pressure and suspects that the reading is a false-high reading. What leads the nurse to confirm this suspicion? Using a cuff that is too narrow Having the examiner's eyes looking down at the meniscus Deflating the cuff too rapidly Positioning patient's arm below the level of the heart
Using a cuff that is too narrow
A 4-year-old child has had a tonsillectomy and the nurse is preparing to ask him about his pain. Which technique is the most appropriate method for pain assessment for this patient? Asking him to rate the pain on a scale of 0 to 10 Using the visual analog scale to rate the pain Using the Wong/Baker FACES rating scale Asking him if the pain hurts "a little or a lot"
Using the Wong/Baker FACES rating scale
What are we looking for in lochia?
Uterine lining sloughs off: -color: rubra (red), serosa (pink), alba (white), gradually over days and then weeks -Amounts: scant, light, moderate, or heavy -Consistency: liquid or small clots
The nurse is counting an infant's respirations. Which technique is correct? Watch the chest rise and fall. Watch the abdomen for movement. Place a hand across the infant's chest. Use a stethoscope to listen to the breath sounds.
Watch the abdomen for movement. Correct
How do you assess rash?
When did it start? Does it itch or burn? do you have any known allergies? does anyone else in your family have a similar rash?
How do you check personal/psychosocial history for HEENT?
When were your last routine examinations? Do you use corrective devices? Describe your daily practice to maintain health. Are there any occupational or recreational risks for injury to your eyes, ears, or mouth? Do you use nicotine products or drink alcohol?
How do you assess skin lesions?
Where? When did you first notice it? Do you have any symptoms associated with lesions such as pain, discomfort, pruritus, or drainage? Changes: color, shape, texture, tenderness, bleeding, itching?
When do you begin feeding baby?
Within 1 hour of age
A nurse assessing a patient with liver disease expects to find which manifestation during the examination? Very pale skin on the palms Yellow pigmentation in the sclera Yellowish color in the axilla and groin Ashen-gray color in the oral mucous membranes
Yellow pigmentation in the sclera
The nurse is assessing a 13-month-old. The nurse notes which reflexes as normal for this age group? The infant's toes fan when the lateral surface of the sole is stroked. The infant demonstrates a positive Moro reflex when startled. The infant grasps a finger that is touched against ulnar side of his or her hand. The infant turns his or her head in response to brushing the infant's cheek.
a
A nurse hears bronchovesicular sounds in the posterior chest on either side of the spine. This finding indicates: a normal finding pneumonia lung cancer pleural effusion
a normal finding Correct
The nurse is assessing a patient's mandible. The area between the sternocleidomastoid muscles and the mandible is anatomically known as the: anterior neck. thyroid. anterior triangle. cervical lymph nodes of the neck.
anterior triangle.
What is nocioceptive pain?
arises from somatic structures such as bone, joint, or muscle. results from activation of normal neural systems.
What cognitive factors play a role on pain perception?
attention people give to the pain, expectation or anticipation of pain, appraisal or expression of pain
What are the positions for baby, breast and latch?
baby: cradle, football, side-lying breast: mother cups with a c hold latch: rooting, then most of areola
A patient complains to the nurse of coughing up green phlegm and is having difficulty breathing at rest. The nurse suspects: a viral infection. tuberculosis. pulmonary edema. bacterial pneumonia.
bacterial pneumonia. Correct
The nurse is assessing a 1-year-old and suspects respiratory distress. Which finding indicates this? A respiratory rate of 30 breaths/minute An irregular respiratory pattern Observation of sternal and supraclavicular retractions with breathing Auscultation of bronchovesicular sounds throughout the lung field 5.
c
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
c
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.
c
The nurse notices that a patient has difficulty separating relevant from irrelevant information during a conversation. This patient is having difficulty with: circumstantiality. neologism. blocking. flight of ideas.
circumstantiality.
What are the 4 different breath sounds?
crackles, wheezes, rhonchi, pleural friction rub
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." 9.
d
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
d
The student nurse is learning how to use the ophthalmoscope. When performing an ophthalmoscopic examination, examine the patient's right: eye with your right eye and the patient's left eye with your left eye. eye with your left eye, and the patient's left eye with your right eye. and left eyes with your dominant eye. and left eyes with your nondominant eye.
eye with your right eye and the patient's left eye with your left eye.
The nurse is performing a mental health assessment. Data collection for mental health assessment begins when the nurse: first sees the patient. obtains biographic data. begins the history. ends the examination.
first sees the patient.
In the introduction phase of the interview, the nurse asks why the patient came into the clinic. This is known as the __________________________.' history of present illness biographic data present health status review of symptoms
history of present illness
What is duration of pain?
how long do you feel pain? constant or intermittent? often does it occur? how long does it last?
What is the order of abdomincal exam?
inspect, ausculate, palpate
What is the definition of mental status?
intellectual, emotional, psychological, personality
What is ICS?
intercostal space
What does intrapartum mean?
labor and birth
What is LICS?
left intercostal space
What is LSB?
left sternal border
What cultural factors play a role on pain perception?
may affect how pain is communicated
What is chronic pain?
may be intermittent or continuous pain lasting 6+ months. Often reports signs of irritability, depression, withdrawl, or insomnia
what is MCL?
midclavicular line
The nurse is caring for a patient in the mental health facility who has a diagnosis of bipolar disorder. The nurse knows that this is because mental health is directly affected by the: cerebral spinal fluid. neurotransmitters. thickness of the dura mater. the pia mater.
neurotransmitters.
How do you examine pain?
observe patient for posture/behavior that helps relieve pain, observe facial expressions, listen for sounds made by patient, inspect skin for color/temp/moisture, measure BP/HR, assess respiratory rate/pattern, observe pupillary size/rxn to light
What is neuropathic pain?
occurs because of abnormal processing of sensory input
What is OLDCARTS?
onset, location, duration, character, aggravating/alleviating factors, radiation, timing, severity
What are we looking for healed belly consistency?
should always be firm
What is phantom pain?
pain felt in an amputated extremity
The nurse is checking a patient's heart rate. An appropriate technique for an adult patient is to: use the pulse oximeter device to obtain heart rate. use the automatic blood pressure cuff to obtain heart rate. palpate the carotid artery for 1 full minute. palpate the radial artery for 15 seconds and multiply by 4 to obtain heart rate.
palpate the radial artery for 15 seconds and multiply by 4 to obtain heart rate.
What are related factors of pain?
palpitations, shortness of breath, sweating, rapid/irregular heart beat, nausea/vomiting
What does antepartum mean?
pregnancy: conception through end of pregnancy, fetus is legally viable at 20 weeks gestation, ideally lasts 40 weeks
What is active immunity?
produced by immune system in response to antigens. can come from natural infection or vaccination. body makes antibodies
What is acute pain?
recent onset, results from tissue damage. usually self-limiting and ends when tissue heals. may cause physiologic signs associated with pain
An elderly African-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally sensitive nurse should: perform a physical examination. recognize and accept different beliefs about health. identify high-risk patients for various diseases. apply statistical trends of various ethnic and cultural groups.
recognize and accept different beliefs about health. Correct
What things happen when pain is present?
reduces mobility, impairs sleep, contributes to loss of appetite
What is the sign for healed uterus?
returns to prepregnant size, fundus is initially at the umbilicus then decreases 1 cm/daily
What is RICS?
right intercostal space
What is RMCL?
right midclavicular line
What is RSB?
right sternal border
What is characteristics of pain?
sharp, achy, crampy, etc
How do you palpate skin?
texture, temperature, moisture, mobility, turgor, and thickness
What is the lower part of the heart?
the apex
What is colostrum?
thick, yellowish, then mild
How does pain move through the body?
transduction from site of stimulation of peripheral receptors to spinal cord, perception at cerebral cortex, and modulation back down spinal cord
The nurse is taking a patient's oral temperature. How should the nurse perform the procedure? The thermometer should be placed: under the tongue next to the frenulum of the lower lip . under the tongue in the posterior sublingual pocket. between the tongue and the hard palate. along the outer aspect of the lower molars and against the cheek.
under the tongue in the posterior sublingual pocket.
Examples of providing culturally competent care are: (Select all that apply.) understands people from cultures other than his or her own. speaks at least one foreign language. seeks knowledge of the health beliefs and practice of all the cultures. has visited a foreign country. incorporates foods from home into the diet. allows for complementary interventions for pain relief.
understands people from cultures other than his or her own. seeks knowledge of the health beliefs and practice of all the cultures. incorporates foods from home into the diet. allows for complementary interventions for pain relief.
What are language developmental assessments for kids?
visible and audible forms like facial expressions, gestures, postural movements, vocalizations of words, phrases, or sentences
What measurements do we take of newborns?
weight, length, head circumference (above ears), and chest circumference (nipple line)
When do the transitions to world for baby happen?
within the first 4 hours
How do you assess change in skin color?
yellowish tone, paleness? Localized changes in skin color? Vitiligo (is loss of pigmentation in skin)?
What is the peripheral pulse amplitude scale?
■ 0: absent ■ 1+: weak ■ 2+: normal ■ 3+: full volume ■ 4+: bounding
What is the Edema scale of pitting?
■ 1+ 2mm: barely perceptible ■ 2+ 4mm: rebounds in a few secs ■ 3+ 6 mm: rebounds 10-20 secs ■ 4+ 8mm: rebounds >30 secs
What are things to consider about babies?
■ Anterior fontanel palpable until 18 months, posterior fontanel until 2-3 months ■ Infants are obligate nasal breathers ■ Tongue large relative to nasal/oral airway ■ Short, narrow trachea < age 5 (susceptible to FBO) ■ Increased RR, fewer and smaller alveoli, less lung volume. Diaphragm primary breathing muscle until age 4-5 years. Ribs more flexible/compliant (higher % cartilage) ■ Body surface area large for weight ■ Susceptible to hypothermia in infancy ■ Proportion of body weight in water larger until later school age ■ Daily water exchange rate higher ■ Head proportionately larger, all brain cells present at birth, but myelination/development nerve fibers continue through 1st year ■ Cardiac output rate dependent, increase HR, blood volume weight dependent ■ Until 12-18 months of age kidneys do not compensate urine effectively ■ Susceptibility to trauma of liver and spleen due to poor protection of abdomen ■ Bones soft, more easily bent/fractured, decreased muscle tone, power, coordination in infancy
What is generalized edema scale?
■ Dependent ■ Absent ■ 1+ trace ■ 2+ mild ■ 3+ moderate ■ 4+ severe
What are procedures to inspect musculoskeletal?
■ Inspect axial skel and extremities for alignment, contour, symmetry, size and gross deformities. ■ Inspect muscles for size and symmetry. ■ Palpate bones, joints ans muscles for tenderness, heat, edema, tone. ■ Observe ROM ■ Test muscle strength and compare sides.
What is the strength grade of muscles?
○ 5: active motion against full resistance ○ 4: active motion against some resistance ○ 3: active against gravity ○ 2: passive ROM ○ 1: Slight Flicker of Contraction ○ 0: no muscular contraction
What is the scale used to test musculoskeletal stuff?
● 5: 100% normal; complete ROM against gravity w/ full resistance ● 4: 75% normal; complete ROM against gravity w/ some resistance ● 3: 50%; complete ROM w/ gravity ● 2: 25%; complete ROM w/ gravity eliminated ● 1: 10%; evidence of slight contractility ● 0: 0% no evidence of contractility.
What are examples of affect descriptors?
● Bright ● Blunt ● Flat: absence of affect, even less intense than blunted ● Labile: fluctuates ● Full range ● Congruous or not (with mood or situation)
TF: ■ Children learn to talk at their own pace, some kids are just "late bloomers" like Albert Einstein who didn't start talking until age 5.
● FALSE: Early intervention can reverse or even prevent some common communication disorders.
■ There is no need to talk to infants, they can't understand what you are saying anyway.
● FALSE: Talking to infants teaches them new words and demonstrates the patterns and rhythms of language. Taking turns "talking" to infants and responding to their babbles encourages them to speak more.
■ Toddlers throw tantrums because they can express more language than they understand.
● FALSE: The opposite is actually true. Toddler tantrums are normal because toddlers understand more than they can express their own needs and ideas.
■ "Standing" babies causes them to be bow legged.
● False: Infants are learning how to bear weight on their legs and find their center of gravity, so letting them stand or bounce is both fun and developmentally stimulating.
■ Walkers help babies learn to walk sooner.
● False: Walkers can lead to dangerous accidents and the AAP has actually supported a ban on walkers. The toddler's body is also not aligned properly in these devices and can delay walking if used too often.
■ Language development starts at birth.
● TRUE: Infants first learn how to communicate through crying, cooing & smiling. Listening and forming sounds/words develops skills later used for reading & writing.
■ Toddlers learn how to walk best when barefoot.
● True: By allowing the feet to feel the floor or ground, going shoeless actually helps toddlers develop their balance, strength, and coordination.
■ Tummy Time helps infants develop the single most important requirement for walking.
● True: Strong back muscles!
What is sensory function?
● sharp/dull, light touch, vibration, position sense, tactile discrimination.