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HA Test #2 Q's
Test on March 31
| Question | Answer |
|---|---|
| Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system? | Neuropathic pain |
| Which of the following conditions is an example of visceral pain? | Cholecystitis |
| Which question would best assess the quality of the patient’s pain? | What does your pain feel like? |
| Which statement indicates that the health care giver understands the pain experience in the elderly? | “Pain indicates pathology or injury and is not a normal process of aging.” |
| A 4-year-old is brought to the emergency department by his mother. She says he points to his stomach and says, “It hurts so bad.” Which pain assessment tool would be the best choice when assessing this child’s pain? | The Wong-Baker FACES Scale |
| A patient has arthritic pain in her hips for several years. She is able to move around in her room and has not had any complaints this morning. But when asked, she states that her pain is “bad” and rates it an 8 on a 1-10 scale. What do you suspect? | She has experienced chronic pain for years and has adapted to it. |
| Which of the following is considered the most reliable indicator of pain? | The subjective report |
| Which of the following is an example of acute pain? | Kidney stones |
| A 60-year-old female has developed reflexive sympathetic dystrophy following arthroscopic repair of her shoulder. A key feature of this condition is that: | the slightest touch, such as a sleeve brushing against her arm, causes severe, intense pain. |
| Your patient states that the pain medication is “not working” and rates his postoperative pain at a 10 on a 1 to 10 scale. Which of the following assessment findings indicates an acute pain response to poorly controlled pain? | Increased blood pressure and pulse |
| Your patient has been shown to have a sensorineural hearing loss. During your assessment, it would be important to: | ask the patient what medications he is currently taking. |
| Your 70-year-old patient tells you he's noticed that he is having trouble hearing, especially in large groups. He can’t “always tell where the sound is coming from” and the words often sound “mixed up.” What might you suspect as the cause for this change? | Nerve degeneration in the inner ear |
| You are performing an assessment on a 65 yr old male. He reports a crusty nodule behind the pinna. It bleeds intermittently and has not healed over the past 6 months. You note an ulcerated crusted nodule with an indurated base. You analyze that this is: | could be a potential carcinoma and should be referred. |
| A 31-year-old patient tells you he has noticed a progressive loss in his hearing. It does seem to help when people speak louder or he turns up the volume. The most likely cause of his hearing loss is: | Otosclerosis |
| Which of the following statements is true concerning air conduction? | It is the most efficient pathway for hearing. |
| A pt states she is unable to hear well with her left ear. The Weber test shows lateralization to the right ear. Rinne has AC greater than BC with ratio of 2:1 in both ears, left-AC 10 sec and BC 5 sec, right-AC 30 sec and BC 15 sec. What do you interpret? | The patient may have sensorineural loss. |
| In performing an examination of a 3-year-old with a suspected ear infection, you would: | perform the otoscopic examination at the end of the assessment. |
| In taking the history of a patient whom you suspect may have perforated an eardrum, what would be an important question? | “Was there any relation between the ear pain and the discharge you mentioned?” |
| In performing a voice test to assess hearing, which of the following would you do? | Whisper two-syllable words and ask the patient to repeat them. |
| You are assessing a 16-year-old patient with head injuries from a recent motor vehicle accident. Which of the following statements indicates the most important reason for assessing for any drainage from the canal? | Bloody or clear watery drainage can indicate a basal skull fracture. |
| While obtaining a history from the mother of a 1-year-old, you notice that the baby has had a bottle in his mouth the entire time. The mother states, “it makes a great pacifier.” Your response might be: | “Prolonged use of a bottle can increase the risk for tooth decay and ear infections.” |
| In your assessment of an 80-year-old male, you would expect to find: | a decreased ability to identify odors |
| During your oral assessment of a healthy 30-year-old black male, you note bluish lips as well as a dark line along the gingival margin. What would you do in response to this finding? | Proceed with assessment, knowing this is a normal finding |
| During a check-up, a 22-year-old woman tells you that she uses an over-the-counter nasal spray because of her allergies. She also notes that it does not work as well as it used to when she started using it. You tell her: | “Using these nasal medications irritates the lining of the nose and may cause rebound swelling.” |
| In an assessment of a 26 yr old at the clinic for “a spot on my lip I think is cancer” you note a group of clear vesicles with an erythematous base around them at the lip-skin border. She just returned from Hawaii. What's the most appropriate response? | Tell the patient this is herpes simplex I and will heal in 4 to 10 days. |
| You are assessing a 3 yr old who is here for “drainage from the nose.” There is purulent drainage from the left nares & has a very foul odor to it. The child has no drainage from the right nares and is afebrile w/ no other symptoms. What is your response? | Perform an examination of the left nares with an otoscope |
| In assessing the tonsils of a 30-year-old, you note they are involuted, granular in appearance, and appear to have deep crypts. What would be your response to these findings? | Nothing, this is the appearance of normal tonsils. |
| A 92-year-old patient has suffered a stroke. The right side of his face is droopy. You might also suspect which of the following: | Dysphagia |
| You are assessing a patient in the hospital who has received numerous antibiotics. You note that his tongue appears to be black and hairy. In response to his concern, what would you say? | “This is a fungal infection caused by all the antibiotics you’ve received.” |
| Which of the following assessment findings would you be most concerned about? | An ulceration under the tongue lasting longer than 2 weeks |
| When auscultating the lungs of an adult patient, you note that over the posterior lower lobes you hear low-pitched, soft breath sounds, with inspiration being longer than expiration. You know that these are: | vesicular breath sounds and are normal in that location. |
| A 26-week pregnant woman states that she is “not really short of breath,” but feels that she is aware of her breathing and the need to breathe. What is your best reply? | “It is normal to experience an increased awareness of the need to breathe. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong.” |
| A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. This may indicate: | Postnasal drip or sinusitis |
| A mother brings her 3 month old to your clinic for evaluation of a cold. She tells you he had had “a runny nose for a week.” When performing the physical assessment you note that the child has nasal flaring and sternal and intercostal retractions. You: | recognize that these are serious signs and refer the child immediately. |
| A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. Which of the following are assessment findings related to this condition? | Chest pain that is worse on deep inspiration, dyspnea. |
| You note hyperresonant percussion tones when percussing the thorax of an infant. You would: | consider this a normal finding |
| A 35 yr old Asian immigrant, is seen in the clinic for a cough with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. Your preliminary analysis, based on this history, is that Mr. H. may be suffering from: | Tuberculosis |
| A patient with allergies comes to the clinic with wheezing & difficulty in breathing. Your findings are tachypnea, use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, expiratory wheezes. You suspect: | Asthma |
| A 65-year-old patient with a history of heart failure comes to the clinic with complaints of “being awakened from sleep with shortness of breath.” You: | suspect that the patient is experiencing paroxysmal nocturnal dyspnea. |
| A teenage pt comes to ER with inability to “breathe and a sharp pain in left chest.” Findings are cyanosis, tachypnea, tracheal deviation to right, decreased tactile fremitus on left, hyperresonance on left, decreased breath sounds on left. You suspect: | Pneumothorax |
| The findings from your assessment of a 70-year old male with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when he is elevated 45 degrees. This would indicate: | increased pressure in right side of heart |
| A pregnant 25 year old in her fifth month has a blood pressure of 100/70. In reviewing her previous exam, you note that her blood pressure in her second month was 124/80. In evaluating this change what do you know to be true? | This is the result of peripheral vasodilation and is an expected change. |
| In assessing a 65 year old male, you find the following: BP 140/100, HR 104 and slightly irregular; split S2; increased cardiac output. Which of these findings can be explained by expected hemodynamic changes related to age? | Increase in systolic blood pressure. |
| The mother of a 3 month old states that her daughter has not been gaining weight. With further questioning you find that the infant falls asleep after nursing and wakes up after a short time hungry. what other information would you want to have? | Presence of dyspnea or diaphoresis when sucking |
| In your assessment of a 68-year-old male with recent onset of right-sided weakness, you hear a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This would indicate: | Blood flow turbulence |
| While counting the apical pulse on a 16-year-old patient, you note an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be your response? | No further response needed, as this is normal. |
| During the cardiac auscultation you hear a sound occurring immediately after S2 at the second left intercostal space. To further assess this sound, what would you do? | Watch patient’s respirations while listening for effect on the sound. |
| While auscultating heart sounds on a 7-year-old for “routine physical” you hear the following: an S3, a soft murmur at left midsternal border, and a venous hum when standing. Which of the following would be true regarding the findings? | These can all be normal findings in a child. |
| During assessment on adult male for “chest pain,” you find jugular vein pulsations 4 cm above sternal angle when he's elevated @ 45 degrees, BP 98/60, HR 130; pale gray, cool, moist skin; difficulty breathing when supine; S3 on auscultation. You suspect? | Fluid overload |
| 30 yr old w/ history of mitral valve states she's been very tired. She's waking up @ night her heart is pounding. You palpate a thrill & lift @ 5th left intercostal space midclavicular line & auscultate blowing/swishing sound right after S1. You suspect? | Mitral Regurgitation |
| A 65-year-old male is experiencing pain in his left calf when he exercises, which disappears after resting for a few minutes. This description is most consistent with: | ischemia due to partial blockage of an artery supplying the left leg. |
| A 70-year-old male is scheduled for open-heart surgery. The physicians plan to use the great saphenous vein for the coronary bypass grafts. The patient asks you, “What happens to my circulation when the veins are removed?” You reply: | “As long as the deeper veins in your leg are in good condition, this vein can be removed without harming your circulation.” |
| Which of the following situations best describes a person at risk for developing venous disease? | A person who has been on bedrest for 3 days |
| A 67-year-old patient states that he recently began to develop pain in his left calf when climbing 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes then he's able to resume his activities. This patient is experiencing: | Claudication |
| You are performing a well-child assessment on a 3-year-old child. The child’s vital signs are normal. Capillary refill time is 5 seconds. You would: | consider this a delayed capillary refill time and investigate further. |
| When performing a peripheral vascular assessment on a patient, you are unable to palpate the ulnar pulses. The patient’s skin is warm and capillary refill time is normal. You would: | consider this a normal finding and proceed with the peripheral vascular evaluation. |
| A pt complains of leg pain that wakes him at night. He “has been having problems” with his legs. He gets pain in his legs when they're elevated & disappears when he dangles them. He noticed “a sore” on the inner aspect of the right ankle. You suspect: | problems related to arterial insufficiency |
| When assessing a patient you document the left femoral pulse as 0/0-4+. Which of the following findings would you expect at the dorsalis pedis pulse? | 0/0-4+ |
| You are performing a peripheral vascular assessment on a bedridden patient. You note the following findings in the right leg: increased warmth, swelling, redness, tenderness to palpation, and a positive Homan’s sign. You would: | seek emergent referral due to the risk of pulmonary embolism. |
| When assessing a pts pulse, the amplitude is weaker during inspiration, and stronger during expiration. When you measure the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing: | Pulsus paradoxus |
| The labyrinth of the inner ear is responsible for maintaining the body's | Equilibrium |
| The Weber test is generally performed on an individual who complains of | Hearing better in one ear than the other |
| Which of the following pairs of sinuses is absent at birth, fairly well developed between 7 and 8 years of age and is fully developed after puberty? | Frontal |
| The external structure of the ear is identified as the | Auricle |
| Inspection of the nasal mucosa of an individual with rhinitis would demonstrate mucosa that is | Bright red and swollen |
| Which of the following questions would you ask to determine whether an individual has epistaxis? | "Do you experience nose bleeds?" |
| Under normal conditions, transillumination of the sinuses would produce | Diffuse red glow |
| The parotid gland's duct that opens into the mouth opposite the second molar is: | Stenson's duct |
| One of the purposes of the paranasal sinuses is to | Lighten the weight of the skull bones |
| Risk reduction for acute otitis media includes | Eliminating smoking in the house and car |
| The nurse is planning to percuss the chest of an adult male client for diaphragmatic excursion. The nurse should begin the assessment by: | Asking the client to exhale forcefully and hold his breath |
| While assessing the thoracic area of an adult client, the nurse plans to auscultate for voice sounds. To assess bronchophony, the nurse should ask the client to: | Repeat the phrase "ninety-nine" |
| You are assessing your patient's lungs over the manubrium and you hear a medium pitched sound with equal inspiratory and expiratory phases. The sound most likely is: | Bronchovesicular sound |
| You are assessing your patient's lungs. While listening over the trachea, you hear a high pitched, loud sound with inspiratory phase shorter than the expiratory phase. The sound most likely is: | Bronchial sound |
| What area is best for assessing color changes in dark skinned people? | Conjunctiva |
| The vertebra prominens is: | The spinous process at C7 |
| When performing a respiratory assessment on your patient, you note a costal angle of approximately 90 degrees. This is | A normal finding in a healthy adult |
| The trachea bifurcates anteriorly at the | Sterna angle |
| Expected assessment findings in the normal adult lung include the presence of: | Muffled voice sounds and symmetrical tactile fremitus |
| The primary muscles of respiration include the | Diaphragm and intercostals |
Created by:
heatherodom12