Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
NURS 6512 - Midterm
Advanced Health Assessment
| Question | Answer |
|---|---|
| What is the goal of using a screening tool during a patient health history interview? 1 | To determine if the patient has a problem related to the issue |
| Select the data included in a sexual history. 1 | Sexual partners Sexual practices Methods used to prevent pregnancy Past history of sexual transmitted infections Protection used against sexual transmitted infections |
| Research findings show that a family history for which conditions increases the risk to develop diabetes type 2 and cardiovascular disease? 1 | Obesity Dyslipidemia |
| A patient is curt, avoids eye contact, and states that he does not know why he bothered to seek medical attention. How should the nurse address this behavior? 1 | Tell the patient he seems angry and ask him to state his concerns |
| How does a nurse convey courtesy to a patient during an appointment? 1 | Knocking on the door before entering |
| A patient must wait 45 minutes after the scheduled appointment time because the office is running late. Select the best way the nurse should address the issue. 1 | Thank the patient for his patience. |
| Which communication technique is most appropriate to use while conducting an interview with a patient? 1 | Use active listening techniques, including clarification and reflection. |
| Health care professionals discuss that a patient obtains secondary gain from an illness. What is meant by secondary gain from an illness? 1 | Attention and caring from others because of the illness |
| From a questionnaire the patient completed, the nurse learns that the patient uses illicit drugs. What technique is appropriate to explore this health concern during the interview? 1 | Reassure the patient that all information will be kept confidential. |
| A patient tells the nurse that his wife, who is the patient’s caregiver, becomes irritable when more assistance is needed. How should the nurse respond to the patient initially? 1 | Ask the patient how he feels when his wife becomes irritated. |
| Which is good practice when the nurse communicates with patients from other cultures? 2 | Allowing time for greeting exchange at the beginning and end of encounters. |
| A patient belonging to a specific ethnic group tells the nurse that she has been eating cold foods since developing a respiratory infection last month. What does the patient mean? 2 | An infection is a hot disease, so treatment includes foods that are cold. |
| An ethnic minority client comes to the health clinic. The client does not speak or understand the language of the health care provider. What should the health care provider do? 2 | Obtain the services of a trained translator to be present during the examination. |
| Which of the characteristics are considered to be components of a patient’s cultural identity? 2 | Gender Religion Sexual Orientation |
| Which is the best method to determine what culture a patient identifies with? 2 | Ask the patient if there is an ethnic group he or she identifies with. |
| Which is the best way a health care provider can become culturally competent? 2 | Be respectful and open to understanding the ways of all patients. |
| Select the best way a nurse demonstrates cultural competence in communication during a health examination. 2 | Listening and allowing time to understand and be understood. |
| A patient who eats traditional Hispanic foods is prescribed a diet that is low in saturated fat and low in sodium. How should the nurse intervene to assist the patient? 2 | Include the person who prepares meals in teaching. Refer and inform the dietician of patient's ethnicity and new diet. Discuss how traditional foods can be modified to lower fat and sodium. |
| A patient from an ethnic minority culture comes to a clinic appointment accompanied by two other persons of the same ethnicity. How should the nurse approach the people with the patient? 2 | Introduce oneself, greet them and the patient, and find out their relationship. |
| Select the best manner to address the use of home remedies by a patient. 2 | Tell me how you have been treating this and how it has been working. |
| A nurse uses an electronic sphygmomanometer during an examination. Further assessment is needed to obtain which data? 3 | Pulse rhythm |
| Which part of the hand is most sensitive and used in performing palpation? 3 | finger pads |
| A nurse is performing percussion while examining a patient. Over which body organ would the examiner expect to hear tympany? 3 | Stomach |
| What is the purpose of using a monofilament during a physical examination? 3 | Determine the ability to perceive stimulation in the feet. |
| Which position is commonly used to conduct a pelvic examination of a female patient? 3 | Lithotomy Positioning for pelvic exams |
| A nurse is testing the deep tendon reflexes of a preschool-aged child. What is the appropriate instrument to use to check the patellar reflex? 3 | Examiner's finger |
| When does the nurse use inspection during a health assessment? 3 | When the examiner sees the patient and continuously throughout the examination. |
| A nurse is having difficulty hearing differences while percussing over lung fields. What should the nurse do? 3 | Increase pressure on the finger in contact with the patient's skin. |
| The nurse plans to test the client’s tympanic membrane for compliance. Which piece of equipment is required to perform this task? 3 | Otoscope with a pheumatic attachment |
| Which component of the vital signs of this adult patient is within the normal range? 4 | Pulse: 88 beats/min |
| Which technique is the correct manner to locate the radial pulse rate? 4 | Place the finger pads of the second and third fingers over the wrist bone below the thumb. |
| Select the reasons why elderly persons may be reluctant to report pain. 4 | Elderly persons do not want to bother others. Elderly persons are reluctant to take pain medications. Elderly persons believe pain is a part of the aging process. Elderly persons may fear being hospitalized because of pain. |
| Select the best method to determine the respiratory rate. 4 | After counting the pulse, proceed to counting breaths for 30 seconds and multiply by 2. |
| Identify the physiological components that comprise the systolic blood pressure. 4 | Cardiac output Compliance of arteries Circulating blood volume |
| Which characteristic is correct in describing pain related to nerve damage? 4 | Burning and shocklike. |
| The nurse applies a BP cuff to a patient’s arm and finds the radial pulse. The BP cuff is pumped up 20 mm Hg higher than the point when the pulse was obliterated. The air is let out, and the pulse is felt again at 110 mm Hg. What is the sig. of the 110? 4 | Systolic BP |
| Which is the best intervention to assess a patient’s level of pain? 4 | Ask the patient to compare present pain to past pain and rate it on a pain scale. |
| Damage to which part of the brain may result in pyrexia? 4 | Hypothalamus |
| The nurse has difficulty taking a blood pressure because the patient’s upper arm is too large for the blood cuff. What should the nurse do? 4 | Place the cuff on the forearm and palpate the radial pulse to obtain the SBP. |
| Research shows that undernutrition of a fetus during the second and third trimesters of pregnancy increases the risk for which type of health problems? 6 | Cardiovascular |
| Which condition affecting growth is always caused by a genetic disorder? 6 | Turner Syndrome |
| An 18-month-old child is seen in a clinic for a routine examination. What measurements should be obtained? 6 | Head circumference Chest circumference Length while supine Weight on an infant scale |
| Growth patterns in individuals older than age 60 years include a decrease in which component? 6 | Weight Height Physical Stature Skeletal muscle mass |
| Which symptom is likely to suggest precocious puberty? 6 | Adult-sized penis in a 6-year-old boy |
| At what age should an infant have tripled his or her birth weight? 6 | 12 months |
| Which term correctly describes an infant born at 36 weeks of gestation? 6 | Preterm |
| The nurse notes from the records of an 8-month-old infant that head growth has slowed down significantly. What condition does this finding suggest? 6 | Microcephaly |
| Failure to thrive is diagnosed at what growth percentile? 6 | Below the 3rd to 5th |
| What is the main purpose for plotting an infant’s or child’s height and weight on a growth chart? 6 | Monitor the child's growth on a percentile growth curve over time. |
| The formula for waist-to-hip ratio is Waist circumference/Hip circumference. Calculate the waist-to-hip ratio for a woman with a waist circumference of 28 inches and a hip circumference of 40 inches.__ 7 | 0.7 |
| Which condition is associated with decreased serum hemoglobin, hematocrit, and transferrin saturation levels? 7 | Iron-deficiency anemia |
| Which body organ depends on carbohydrates as its only energy supply? 7 | Brain |
| Which common breakfast food increases the bioavailability of medications such as simvastatin and may increase the incidence of adverse effects? 7 | Grapefruit |
| Which recommendation is correct? 7 | Caloric intake is mainly from complex carbohydrates. |
| Which intervention will lower serum total cholesterol and improve HDL and LDL levels? 7 | Increase physical activity |
| What is the significance of body mass index (BMI)? 7 | Indicator of obesity |
| A patient is following a vegan vegetarian diet. Which nutrients are likely to be deficient in this diet? 7 | Protein Calcium |
| Which group of patients is most appropriate to have the triceps skinfold testing to estimate body fat stores? 7 | Nonobese adults |
| Which food source contains the most calories per gram? 7 | Fats |
| Hormonal changes that occur with puberty cause adolescents to be at risk for which condition? 8 | Acne |
| What changes are expected in the skin as a person ages? 8 | Increased incidence of bruising |
| A patient is being treated for Lyme disease based on what assessment finding? 8 | Red macular rash with appearance of a bull's eye |
| Select the correct statement regarding skin turgor. 8 | It reflects the elasticity of the skin. |
| Which finding while assessing the skin in children is suggestive of physical abuse? 8 | Human bite marks Injuries covered by clothing Bruising with fingertip grab marks Burns consistent with immersion of buttocks |
| Which skin lesion in the elderly patient requires further observation? 8 | Actinic keratosis (Precancerous due to sun exposure) |
| Which description is correct about intertriginous surfaces of skin? 8 | Areas where skin surfaces meet |
| Which lesion is suspicious for basal cell cancer? 8 | Crusty sore that does not heal |
| What are the risk factors for melanoma? 8 | Inability to tan Familial history Fair skin and light eye color |
| Upon inspecting the hands, the nurse observes that the patient has a black discoloration of one fingernail. The patient states the nail is painful. What is this finding? 8 | Subungual hematoma |
| The nurse reviews the history of a child who was diagnosed with positional plagiocephaly as an infant. What is the cause of this condition? 10 | Positioning the child to sleep in a supine position. |
| Which condition could lead to tracheal deviation? 10 | Tension pneumothorax |
| While assessing the neck, the nurse displaces the thyroid cartilage to the left side and is able to feel a pulsation. This sign could be associated with which condition? 10 | Aortic arch aneurysm |
| A patient with Bell palsy is at risk for which complication? 10 | Corneal abrasion (because they cannot fully close the eye) |
| Which is the expected assessment finding when palpating the thyroid in an adult? 10 | The thyroid is slightly palpable |
| While assessing a patient, the nurse palpates the thyroid gland and finds that it is enlarged. What should the nurse do next? 10 | Listen to the area with a stethoscope (listen to thyroid area for bruit) |
| At what age should the anterior fontanel be closed? 10 | 12 to 15 months (Posterior closed at 2-3 months) |
| Which assessment finding is consistent with hypothyroid function? 10 | Constipation Periorbital puffiness Coarse, scaly, dry skin |
| Where does the parotid duct open? 10 | Buccal mucosa near the second molar tooth (AKA: Stensen duct) |
| What should the nurse ask the patient to do while inspecting the thyroid? 10 | Swallow water Slightly extend neck |
| Which finding during an ophthalmoscopic examination suggests the patient has hypertension? 11 | Narrowed retinal arteries |
| What is the common cause of a hordeolum? 11 | Infection d/t S.aureus (hordeolum = stye) |
| Which finding on the assessment of a patient’s eye suggests hyperthyroidism? 11 | Positive eyelid lag assessment findings Fine tremor noted when patient shuts eyes |
| Which condition of the eye is associated with impaired vision? 11 | Corneal scar |
| The nurse begins the eye exam using an ophthalmoscope. What is observed? 11 | Red Reflex (Video: Examining the Retina 1) |
| Which patient concern suggests the development of a cataract? 11 | Poor night vision |
| Which instruction is given to a patient for the Snellen test? 11 | Testing will be done with and without corrective lens |
| Which test assesses a patient’s peripheral vision? 11 | Confrontation test |
| The nurse asks the patient to close his eyes and gently palpates the eyes simultaneously. This is a screening test for which condition? 11 | Open-angle glaucoma |
| An increased number of drusen in the macular area are noted on ophthalmoscopic examination. What action should follow? 11 | Ask the patient to self-test using the Amsler grid |
| Which description is correct regarding the use of the otoscope on an adult? 12 | Use the largest speculum that fits comfortably in the patient's ear. |
| Which finding is associated with Meniere disease? 12 | Vertigo Tinnitus Hearing loss |
| Which finding upon inspection of the external ear is considered normal? 12 | Darwin tubercle |
| Using a nasal speculum, the nurse observes the nasal mucosa to be blue-gray in color. With what is this finding associated? 12 | Allergy |
| Chronic insufflation of cocaine is associated with which assessment finding? 12 | Perforated nasal septum |
| The nurse palpates the areas of the skull behind the ears and is able to identify the mastoid processes, which are nontender. What is the significance? 12 | This is a normal finding |
| Which sinuses are accessible to palpation during physical examination? 12 | Frontal Maxillary |
| Which is the most exact testing of hearing acuity? 12 | Pure tone audiometry |
| What condition of the oral mucous membranes is characterized by thickened white patches that cannot be wiped away? 12 | Leukoplakia (precancerous lesion of mouth that is white and thickened and cannot be wiped away) |
| Which finding is considered normal when visualizing the tympanic membrane? 12 | Visible handle of malleus |
| The nurse observes a bluish discoloration around the umbilicus in a patient (Cullen sign). What is this sign associated with? 17 | Intraabdominal bleeding |
| Under which circumstance is it appropriate to use direct or indirect percussion with a closed fist during assessment? 17 | To test tenderness of the kidney |
| The nurse assesses hypoactive and absent bowel sounds in the four quadrants of the abdomen in a female patient. Which finding from the patient history is likely the cause? 17 | Takes diuretic medication daily Takes narcotic analgesics for recent shoulder injury |
| What is the purpose of the liver scratch test? 17 | Determine liver span when abdomen is distended |
| How does a nurse assess for pain related to peritonitis? 17 | Assess for rebound tenderness |
| An infant develops severe abdominal pain, keeps his legs pulled to his abdomen, and has light red mucous stools. What condition do these symptoms suggest? 17 | Intussusception |
| Which intervention should the nurse do first in assessing the abdomen? 17 | Ask the patient to empty the bladder. |
| Which type of incontinence is caused by dementia in patients? 17 | Functional |
| Which condition is associated with episodes of bloating, abdominal pain, and constipation alternating with diarrhea? 17 | Inflammatory Bowel Disease |
| Which method should the nurse use to determine if a patient has ascites? 17 | Test for a fluid wave in the abdomen. Test for shifting dullness in the abdomen. |
| What documentation is missing from the patient’s chief concern: “elephant standing on my chest, horrible pressure”? 26 | Duration |
| Which is objective data? 26 | Pretibial edema bilateral 3+ pitting |
| Which is included in the patient’s chief concern? 26 | Presenting problem and its duration |
| Which is subjective data? 26 | Sore throat for 1 week |
| Select the example of correct documentation. 26 | Incontinent of scant urine that is clear, brown, and non-odorous. Nodule in left breast is hard, round, nontender, 1 cm in diameter, movable, and located at 3 o'clock, 2 cm from the areola, no induration. |
| Which datum is included in the history of present illness (HPI). 26 | Onset of symptoms Aggrevating factors Quality of symptoms Location of symptoms |
| Documentation: “Left lower leg medial incision drainage: thick, purulent, cream-colored drainage with foul odor.” What is missing from the documentation? 26 | Amount |
| Where in the problem-oriented medical record (POMR) should the nurse record the patient’s chief concern? 26 | History |
| What modification is made to documentation of the history of older adults? 26 | Include family support system |
| What should the nurse do after discovering the previous documentation the nurse included in an assessment erroneously stated an enlarged cervical lymph node was on the left side instead of the right side? 26 | Document an addendum noting the error and include correction. |
Created by:
rstacey1