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Stack #1258608
| Question | Answer |
|---|---|
| decrease in power of accommodation with aging | presbyopia |
| A patient has been in the ICU for 10 days. He has just been moved to the med-surg unit, and the admitting nurse is planning to perform a mental status examination on him. During the tests of cognitive function the nurse would expect that he: | will be oriented to place and person but may not be certain of the date. |
| A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying and laughs loudly at the content. This behavior is a display of: | inappropriate affect |
| affect clearly discordant with the content of the person's speech | inappropriate affect |
| The nurse is preparing to assess an older adult and discovers that the older adult is in severe pain. Which statement about pain and the older adult is true? | Alleviating pain should be a priority over other aspects of the assessment. |
| the confrontation test assesses | visual fields |
| Functional ability refers to | one's ability to perform activities necessarry to live in modern society |
| functional ability can include | driving, using the telephone, or performing personal tasks such as bathing and toileting |
| cranial nerve responsible for facial symmetry. | VII (7) |
| paroxysmal nocturnal dyspnea occurs when | the patient awakens from sleep with shortness of breath and needs to be upright to achieve comfort. |
| cranial nerve that enable the patient to shrug their shoulders against resistance. | XI (11) |
| complete physical examination: the head and neck should be examined in the sitting position to best palpate the | thyroid and lymph nodes |
| during examination of the genitalia, the male patient should | stand |
| How would the nurse test that patient's hearing during a complete health assessment? | Using the whispered voice test |
| lesion with color change, flat and circumscribed, and less than 1 cm. | macule |
| macules are also known as | freckles |
| patient drifts to sleep when not being stimulated, but can be aroused easily when calling her name. She remains drowsy during the conversation. What is this patient's level of consciousness? | lethargic (somnolent) |
| very loud splash auscultated over the upper abdomen when an infant is rocked side to side. | succussion splash |
| succusion splash indicates | increased air and fluid in the stomach |
| succussion splach may be indicative of | pyloric obstruction or large hiatus hernia |
| cranial nerve that enables a person to stick out their tongue | XII (12) |
| the nurse should test the cerebellar function of the upper extemeties by using the | finger-to-nose test or rapid-alternating-movements test. |
| the nurse should test cerebellar function of the lower extremities by asking the patient to | run each heel down the opposite shin |
| during inspection of the posterior chest, the nurse should assess for: | symmetry of shoulders and muscles |
| during inspection of the posterior chest, the nurse should inspect for | symmetry of shoulders and muscles, configuration of the thoracic cage, and skin characteristics. |
| stron persistent, irrational fear of an object or situation; the person feels driven to avoid it. | phobia |
| gravida refers to | number of pregnancies |
| para refers to | the number of children |
| gravida of 1, and para of 3 = | 1 pregnancy with triplets. |
| young children should not be asked to rate pain using | numbers |
| pain rating scales can be introduced to children at the age of | 4-5 years |
| ____ indicates pathology or injury and should never be considered something that an elderly person should expect or tolerate. | PAIN |
| people who experience chronic pain for years may _____ to it | adapt |
| persons with chronic pain typically try to give little indication that they are in | pain |
| persons with chronic pain may, over time, | adapt to the pain |
| persons with chronic pain that have adapted to pain are typically at risk for | underdetection |
| before beginning the physical examination, the nurse should ask the patient to first: | empty the bladder |
| responses to poorly controlled acute pain include | tachycardia, elevated blood pressure, and hypoventilation |
| the aging process leaves the parameters of mental status mostly: | intact |
| The nurse is assessing a 75 yr old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient: | may take a little longer to respond, but his general knowledge and abilities should not have declined. |
| Most reliable indicator of pain: | subjective report |
| extraocular muscles are innervated by cranial nerves | III, IV, and VI (3, 4, and 6) |
| bucket hat guy exhibits | flight of ideas |
| during an examination, the nurse notes that a patient is exhibiting flight of ideas. which statment by the patient is and example of flight of ideas. | "take this pill? The pill is red. i see red. red velvet is soft, soft as a baby's bottom." |
| which of these statements is true regarding the recording of data from the history and physical examination? | record the data as soon as possible after the interview and physical examination. |
| data from the history and physical examination should be recorded when? | as soon after the event as possible |
| the nurse should test for hip stability in the neonate by testing for the | Ortolani's sign |
| a procedure that induces pain in adults will also induce pain in the: | infant |
| the nurse should wear gloves when palpating the | mouth and tongue |
| the nurse is preparing to perform a functional assessment of an older patient and knows that a good approach would be to: | observe the patient's ability to perform the tasks |
| The nurse should wear gloves for which of these examinations? | Palpation of the mouth and tongue |
| The nurse is preparing to perform a functional assessment of an older patient and knows that a good approach would be to: | observe the patient’s ability to perform the tasks. |
| Which of these actions is most appropriate to perform on a 9-month-old infant at a well-child checkup? | Testing for Ortolani’s sign |
| While recording in a patient’s medical record, the nurse notices that a patient’s Hematest results are positive. This means that there: | is occult blood in his stool. |
| During an examination, the patient tells the nurse that she sometimes feels as if objects are spinning around her. The nurse would document that she occasionally experiences: | vertigo. |
| An 85-year-old man has come in for a physical examination, and the nurse notices that he uses a cane. When documenting general appearance, the nurse should document this information under the section that covers: | mobility. |
| A 5-year old child is in the clinic for a checkup. The nurse would expect him to: | be able to sit on the examination table. |
| The nurse should use which location for eliciting deep tendon reflexes? | Achilles |
| The nurse is performing the Denver II screening test on a 12-month-old infant during a routine well-child visit. The nurse should tell the infant’s parents that the Denver II: | is a screening instrument designed to detect children who are slow in development. |
| When assessing the quality of a patient’s pain, the nurse should ask which question? | what does your pain feel like?” |
| During report, the nurse hears that a patient is experiencing hallucinations. Which is an example of a hallucination? | A man believes that his dead wife is talking to him. |
| The nurse notices that a patient has ulcerations on the tips of the toes and on the lateral aspect of the ankles. This finding indicates: | arterial insufficiency. |
| A patient’s uvula rises midline when she says “ahh” and she has a positive gag reflex. The nurse has just tested which cranial nerves? | IX, X |
| A mother brings her 2-month-old daughter in for an examination and says, “My daughter rolled over against the wall and now I have noticed that she has this spot that is soft on the top of her head. Is there something terribly wrong?” The nurse’s response | “That ‘soft spot’ is normal, and actually allows for growth of the brain during the first year of your baby’s life.” |
| When examining the face, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the _____ glands. | parotid and submandibular |
| A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to cranial nerve (CN) _____ and proceeds with the examination by _____. | XI; asking the patient to shrug her shoulders against resistance |
| The nurse is aware that the four areas in the body where lymph nodes are accessible are the: | head and neck, arms, inguinal area, and axillae. |
| A mother brings her newborn in for an assessment and asks, “Is there something wrong with my baby? His head seems so big.” The nurse recognizes that which statement is true regarding the relative proportions of the head and trunk of the newborn? | Head circumference should be greater than chest circumference at birth. |
| When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is: | a normal finding in a healthy adult. |
| When assessing a patient’s lungs, the nurse recalls that the left lung: | consists of two lobes. |
| During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of: | muffled voice sounds and symmetrical tactile fremitus. |
| During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from: | increased density of lung tissue. |
| The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is ____ comparison. | side-to-side |
| When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are: | vesicular breath sounds and are normal in that location. |
| The nurse is auscultating the chest in an adult. Which technique is correct? | Use the diaphragm of the stethoscope held firmly against the chest. |
| The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs would reveal: | dullness. |
| The nurse notes hyperresonant percussion tones when percussing the thorax of an infant. The nurse’s best action would be to: | consider this a normal finding. |
| The nurse knows that a normal finding when assessing the respiratory system of an elderly adult is: | decreased mobility of the thorax. |
| When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. | recognize that these are serious signs and contact the physician. |
| When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect? | The presence of bronchovesicular breath sounds in the peripheral lung fields |
| When inspecting the anterior chest of an adult, the nurse should include which assessment? | The shape and configuration of the chest wall |
| When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are: | aortic and pulmonic. |
| The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates: | elevated pressure related to heart failure. |
| A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous exam, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. | This is the result of peripheral vasodilatation and is an expected change. |
| A 45-year-old man is in the clinic for a routine physical. During the history the patient states he’s been having difficulty sleeping. “I’ll be sleeping great and then I wake up and feel like I can’t get my breath.” | “Do you have any history of problems with your heart?” |
| In assessing a patient’s major risk factors for heart disease, which would the nurse want to include when taking a history? | Smoking, hypertension, obesity, diabetes, high cholesterol |
| During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate: | blood flow turbulence. |
| During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse? | Fifth left intercostal space at the midclavicular line |
| ____ 73. While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse’s response? | No further response is needed because this is normal. |
| When listening to heart sounds, the nurse knows that S1: | coincides with the carotid artery pulse. |
| While auscultating heart sounds on a 7-year-old child for a routine physical, the nurse hears an S3, a soft murmur at left midsternal border, and a venous hum when the child is standing. Which of these would be a correct interpretation of these findings? | These can all be normal findings in a child. |
| When performing a genital examination on a 25-year-old man, the nurse notices deeply pigmented, wrinkled scrotal skin with large sebaceous follicles. On the basis of this information the nurse would: | consider this a normal finding and proceed with the examination. |
| The mother of a 10-year-old boy asks the nurse to discuss the recognition of puberty. The nurse should reply by saying: | “The first sign of puberty is enlargement of the testes.” |
| During an examination of an aging male, the nurse recognizes that normal changes to expect would be: | decreased penis size. |
| A 59-year-old patient has been diagnosed with prostatitis and is being seen at the clinic for complaints of burning and pain during urination. He is experiencing: | dysuria. |
| A 45-year-old mother of two children is seen at the clinic for complaints of “losing my urine when I sneeze.” The nurse documents that she is experiencing: | stress incontinence. |
| When the nurse is conducting sexual history from a male adolescent, which statement would be most appropriate to use at the beginning of the interview? | “Often boys your age have questions about sexual activity.” |
| Which of these statements is most appropriate when the nurse is obtaining a genitourinary history from an elderly man? | “Do you need to get up at night to urinate?” |
| A patient is being assessed for range of joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called: | adduction. |
| The nurse notices that a woman in an exercise class is unable to jump rope. The nurse knows that to jump rope, one’s shoulder has to be capable of: | circumduction. |
| The nurse is checking the range of motion in a patient’s knee and knows that the knee is capable of which movement(s)? | Flexion and extension |
| This shift in posture during pregnancy is known as: | lordosis. |
| An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because: | of the shortening of the vertebral column. |
| The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen’s test. To perform this test, the nurse should instruct the patient to: | hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. |
| 3 month old: The nurse does not notice any “clunking” sounds and is confident to record a: | negative Ortolani’s sign. |
| The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? | Dullness |
| Which structure is located in the left lower quadrant of the abdomen? | Sigmoid colon |
| A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has: | dysphagia. |
| The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? | Percuss and palpate the midline area above the suprapubic bone. |
| The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is: | decreased gastric acid secretion. |
| man falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation? | An enlarged spleen should not be palpated because it can rupture easily. |
| A patient’s abdomen is bulging and stretched in appearance. The nurse should describe this finding as: | protuberant. |
| A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: | peritonitis. |
| During an admission assessment of a patient with dementia, the nurse assesses for pain because the patient has recently had several falls. Which of these are appropriate for the nurse to assess in a patient with dementia? | Assess the patient’s breathing independent of vocalization./ Note whether the patient is calling out, groaning, or crying./Observe the patient’s body language for pacing and agitation. |
| During assessment of a patient’s pain, the nurse keeps in mind that certain nonverbal behaviors are associated with chronic pain. Which of these behaviors are associated with chronic pain? | Sleeping/Bracing/Rubbing |
| For the abdominal assessment, place these assessment techniques in the correct order, with A being performed first and E being performed last. | inspect, auscultate, percuss, light, deep |
Created by:
rynime1