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Review questions HA
Review questions HA 7, 9, 10, 11, 15, & 16
| Question | Answer |
|---|---|
| CH. 7 The nurse is using the CAGE screening tool, which stands for Cut down, Annoyed, Guilty, and Eye Opener. This tool is used to screen for which disorder? Drug use Alcohol use Altered mental status Depression | Alcohol use |
| CH. 7 Which part of the cerebrum is responsible for emotions, effect, awareness of self? Frontal lobes Temporal lobes Parietal lobes Occipital lobes | Frontal lobes |
| CH. 7 The nurse is caring for a patient who has a diagnosis of depression. This disorders associated with pathology in which part of the central nervous system? Hypothalamus Thalamus Neurotransmitters Central spinal fluid | Neurotransmitters |
| CH. 7 An insufficient amount of the neurotransmitter gamma aminobutyric acid (GABA) may result in Hallucinations Anxiety Depression Delusions | Anxiety |
| CH. 7 At what point does data collection for mental health assessment begins? When the nurse First sees the patient Begins the examination Begins history Obtains biographic data | First sees the patient |
| CH. 7 A 24 year old male patient tells the nurse he has no energy for 2 weeks. He has trouble falling asleep. He states that he has no appetite and no friends. The nurse Associates these manifestations with which mental health disorder? Anxiety disorder Schizophrenia Bipolar disorder Depression | Depression |
| CH. 7 Which patient may be experiencing severe anxiety? A man who tells the nurse he feels worthless as always tired A man who phones the nurse five times asking for instructions about how to take his new medication A woman who reports is sleeping very lightly each night because her child has an ear infection A woman the nurse used terrified of cats | A man who feels a nurse five times asking for instructions about how to take his new medication |
| CH. 7 A patient in the waiting room appears anxious and moves around the room cleaning services with a disinfected cloth. His behaviors consistent with which disorder? Schizophrenia Bipolar disorder Obsessive compulsive disorder Delirium | Obsessive compulsive disorder |
| CH. 7 Nurse taking a health history suspects the patient has altered mental status. Which questions below are appropriate to ask when assessing mental status? (Select all ) Do you know where you are? What does this phrase mean: a rolling stone gathers no Moss? Are there times when you wanted to escape? What would you do if a fire started in your home? If you brought a hat first $5.75 and gave the sales person $10 how much change would you expect back? Do you have difficulty making decisions? | Do you know where you are? What does this phrase mean: a rolling stone gathers no Moss? What would you do if a fire started in your home? If you brought a hat first $5.75 and gave the sales person $10 how much change would you expect back? |
| CH. 7 The nurse is obtaining the mental health history of a new patient. What should the nurse include in this mental health history? (Select all that apply.) Medications be patient is taking A past health history The patient's concept of self Cultural rituals commonly performed Spiritual beliefs | Medications be patient is taking A past health history The patient's concept of self |
| CH. 9 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 dermis The subcutaneous tissue The epidermis The hypodermis | The dermis |
| CH. 9 What findings does a nurse expect when inspecting and palpating a patient’s nails? Transverse depression running across the nails. A nail base angle of not more than 90 degrees. Nail surface is smooth and rounded. Whitish to clear nails in darker-skinned patients. | Nail surface is smooth and rounded. |
| CH. 9 A 49-year-old woman tells the nurse she is distressed by the presence of dark, coarse hair on her face that has recently developed. What is the nurse’s most appropriate response to this patient? “This is unusual, female hair distribution should be limited to arms, legs, and pubis.” “Some women in your cultural group normally have dark hair on their faces. “Coarse dark hair could result from hormonal changes such as from menopause.” | Coarse dark hair could result from hormonal changes such as from menopause |
| CH. 9 The nurse is assessing an African-American patient for cyanosis. Cyanosis in dark pigmented skin appears as a(n) deeper tone of brown or purple. ashen gray color to the skin. yellowish-green skin. cluster of dark spots over the skin surface. | ashen gray color to the skin. |
| CH. 9 The nurse is assessing a patient with chronic cardiopulmonary disease 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 |
| CH. 9 In assessing a patient’s skin lesion, which finding by the nurse indicates a need for further investigation? The lesion bleeds easily when it is touched. The lesion has been present for 20 years. The lesion is dark brown. The lesion is slightly raised and circumscribed. | The lesion bleeds easily when it is touched. |
| CH. 9 While inspecting the skin, a nurse notes that a lesion on the patient’s upper right arm. What is the best way to document the size of this lesion? Compare its size to the size of a coin. Trace the lesion onto a piece of paper. Use a centimeter ruler to measure the lesion. Estimate its size to the nearest inch. | Use a centimeter ruler to measure the lesion |
| CH. 9 During a health fair, which recommendation is appropriate as a primary prevention measure to reduce the risk for skin cancer? Perform self-examination of skin monthly. Use sunscreen with a sun protection except on overcast days. Wear protective clothing while in the sun. Use a tanning booth instead of sunning outside if a tan is desired. | Wear protective clothing while in the sun. |
| CH. 9 How does a nurse assess a patient’s skin turgor? By pinching the skin and watching the skin return to place. pressing on the skin and observing the depression. stretching the skin and observing for a degree of flexibility. inspecting the skin for a yellow-green discoloration. | pinching the skin and watching the skin return to place. |
| CH. 9 Which questions would be appropriate to ask a patient when performing a symptom analysis for a rash? (Select all that apply.) Select all that apply. “What makes the rash worse?” “What do you do to make your rash better?” “When did the rash first start?” “Describe what the rash looked like initially.” “Describe the sensation from the rash, dose it burn or itch?” “Do you have a family history of rashes?” | "What makes the rash worse?” “What do you do to make your rash better?” “When did the rash first start?” “Describe what the rash looked like initially.” “Describe the sensation from the rash, dose it burn or itch?” |
| CH. 10 During symptom analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates vertigo? “I was afraid that I was going to lose consciousness.” “I felt faint, like I was going to pass out.” “It seemed that the room was spinning around.” “I just could not keep my balance when I sat up.” | “It seemed that the room was spinning around.” |
| CH. 10 To assess jaw movement of an adult patient, the nurses uses which technique? Asking the patient to open the mouth and then passively moving the patient’s open jaw from side to side Using the pads of all fingers to feel along the mandible for tenderness and nodules Placing two fingers in front of each ear and asking the patient to slowly open and close the mouth Asking the patient to open the mouth and to resist the nurse’s attempt to close the mouth | Placing two fingers in front of each ear and asking the patient to slowly open and close the mouth |
| CH. 10 Which patient in the eye clinic should the nurse assess first? The patient who complains of poor night vision The patient who reports a gradual clouding of vision The patient who complains of sudden loss of vision The patient who complains of double vision | The patient who complains of sudden loss of vision |
| CH. 10 A patient complains of right ear pain. What findings does the nurse anticipate on inspecting of patient’s ears? Increased cerumen in the right ear canal Bulging and red tympanic membrane in the right ear Redness and edema of the pinna of the right ear Report of pain when the nurse manipulates the right ear | Bulging and red tympanic membrane in the right ear |
| CH. 10 What technique does a nurse use when palpating the right lobe of a patient’s thyroid gland using the anterior approach? Manipulates the thyroid between the thumb and index finger. Moves the sternocleidomastoid muscle to the right with the left thumb. Pushes the cricoid process to the left with the right thumb. Displaces the trachea to the right with the left thumb. | Pushes the cricoid process to the left with the right thumb. |
| CH. 10 The nurse is assessing a patient for recurring nosebleed. What could be a possible cause of the nosebleeds? Inflamed cilia Snorting cocaine Allergic rhinitis Tobacco use | Snorting cocaine |
| CH. 10 What is the purpose of assessing a patient’s vision confrontation? To assess for visual acuity. peripheral vision. red reflex. extraocular muscle movement. | peripheral vision. |
| CH. 10 When performing an ophthalmoscopic examination, the nurse examines the patient’s right eye with the nurse’s right eye and the patient’s left eye with the nurse’s left eye. with the nurse’s left eye, and the patient’s left eye with the nurse’s right eye. | h the nurse’s right eye and the patient’s left eye with the nurse’s left eye. |
| CH. 10 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) Facial nerve (CN VII) Vagus nerve (CN X) Trigeminal nerve (CN V) | Hypoglossal nerve (CN XII) |
| CH. 10 What findings does the nurse expect when assessing the ears of a healthy adult? (Select all that apply.) Select all that apply. Ratio of air conduction to bone conduction 2:1 Pinna located below the external corner of the eye Cone of light located in the 5 o’clock position in the left ear Tympanic membrane pearly gray Whispered words repeated accurately Cerumen noted in the outer ear canal | Ratio of air conduction to bone conduction 2:1 Tympanic membrane pearly gray Whispered words repeated accurately Cerumen noted in the outer ear canal |
| CH. 10 Which findings does the nurse expect when assessing the mouth of a healthy adult? (Select all that apply.) Select all that apply. Mucous membranes are dry and intact. Exposed tooth neck and brown spots between teeth Slight roughness on the dorsum of the tongue Lips appear pink, smooth, moist and symmetric. Teeth are white, yellow, or gray, with smooth edges. Hard palate appears smooth, red, and movable. | Slight roughness on the dorsum of the tongue Lips appear pink, smooth, moist and symmetric. Teeth are white, yellow, or gray, with smooth edges. |
| CH. 11 The student nurse is reviewing the pathophysiology of inspiration. The primary muscles of inspiration are the diaphragm and the ____________. pectoral muscles abdominal muscles external intercostal muscles scalene muscles | external intercostal muscles |
| CH. 11 A patient complains to the nurse of coughing up green phlegm and is having difficulty breathing at rest. The nurse suspects bacterial pneumonia. a viral infection. tuberculosis. pulmonary edema. | bacterial pneumonia. |
| CH. 11 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 Atelectasis Pneumothorax Pneumonia | Chronic obstructive pulmonary disease |
| CH. 11 The nurse auscultates prolonged expiration with expiratory wheezing and diminished breath sounds while assessing a patient. What disorder does the nurse suspect? Tuberculosis Croup Pneumonia Asthma | Asthma |
| CH. 11 What is the purpose of palpating a patient’s chest wall? Identification of lung sounds Determination of oxygenation Assessment of equal chest expansion Approximation of lung size | Assessment of equal chest expansion |
| CH. 11 The nurse percusses a patient’s chest and feels dullness. The nurse suspects which diagnosis? Pneumonia Chronic obstructive pulmonary disease (COPD) Bronchiectasis Emphysema | Pneumonia |
| CH. 11 A nurse hears inspiratory and expiratory wheezes bilaterally. What is the meaning of this finding? Consolidation in alveoli Fluid in the alveoli Narrowed airways Sputum in the bronchi | Narrowed airways |
| CH. 11 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. |
| CH. 11 The nurse 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 pneumothorax. The patient may have a pleural effusion. | The patient may have a pleural effusion. |
| CH. 11 What findings does the nurse expect when auscultating the chest of a healthy adult? (Select all that apply.) Select all that apply. Symmetric chest Expansion muffled voice sounds Adventitious sounds and limited chest expansion Absent voice sounds and hyperresonant percussion tones Increased tactile fremitus and dull percussion tones Resonant percussion tones Muffled voice sounds and symmetric tactile fremitus | Symmetric chest Absent voice sounds and hyperresonant percussion tones Increased tactile fremitus and dull percussion tones Resonant percussion tones |
| CH. 15 The nurse is preparing to assess a patient’s peripheral nervous sensory function. Which assessment test would the nurse use? Romberg Two-point discrimination Light touch sensation Rinne | Light touch sensation |
| CH. 15 The nurse assesses the glossopharyngeal nerve (CN IX) by testing which reflex? Gag reflex Blink reflex Corneal reflex Cough reflex | Gag reflex |
| CH. 15 Which statement regarding variations in neurologic functioning is true? The function of the neurologic system is consistent across racial lines. 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. |
| CH. 15 The nurse assesses an active reflex response. Which score should be documented? 3+ 2+ 4+ 1+ | 2+ |
| CH. 15 While obtaining a symptom analysis from a patient who had a transient ischemic attack, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates dizziness? “It felt like I was on a merry-go-round.” “My body felt like it was revolving and could not stop.” “The room seemed to be spinning around.” “I felt light-headed when I stood up.” | “I felt light-headed when I stood up.” |
| CH. 15 The nurse notices that a patient is able to understand what is said but has trouble formulating a response. The nurse suspects receptive aphasia. Parkinson disease. Guillain-Barré syndrome. expressive aphasia. | expressive aphasia. |
| CH. 15 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 an intact spinal accessory nerve. has appropriate kinesthetic sensation. has appropriate cerebellar function. | has appropriate cerebellar function. |
| CH. 15 A 52-year-old obese male who smokes and has diabetes has risk factors for Guillain-Barré syndrome. cerebrovascular accident. multiple sclerosis. seizures. | cerebrovascular accident. |
| CH. 15 The nurse is assessing the olfactory nerve. Which instructions should the nurse give to the patient before assessment? “Breathe through your mouth.” “Close both of your nostrils.” “Lie down on your back.” “Close your eyes.” | “Close your eyes.” |
| CH. 15 To complete a symptom analysis, the nurse asks which questions of a patient who recently had a seizure for the first time? (Select all that apply.) Select all that apply. “Did you lose consciousness during the seizure?” “Did the room seem to be spinning around before the seizure?” “What did you hear while you were seizing?” “Did you have any warning signs before the seizure started?” “Did you urinate during the seizure?” “How did you feel after the seizure?” | “Did you lose consciousness during the seizure?” “Did you have any warning signs before the seizure started?” “Did you urinate during the seizure?” “How did you feel after the seizure?” |
| CH. 16 The nurse is reinforcing the need to perform breast self-examinations. Which statement regarding breast self-examination (BSE) is true? BSE is more sensitive than a mammogram in detection of a breast mass. BSE is useful for breast awareness to learn how breasts normally look and feel. BSE reduces mortality rates associated with breast cancer. BSE is an effective method to prevent breast cancer. | BSE is useful for breast awareness to learn how breasts normally look and feel. |
| CH. 16 The nurse is teaching patient BSE and emphasizes the need to check ________, where tumors are commonly found. in the upper and lower inner (medial) quadrants around the nipple and areola in the upper outer quadrant and the tail of Spence in the lower third of the breast | in the upper outer quadrant and the tail of Spence |
| CH. 16 The nurse assesses small raised bumps observed on the nipples of a patient. These are known as lymph nodes. Cooper’s ligaments. lactiferous ducts. Montgomery’s tubercles. | Montgomery’s tubercles. |
| CH. 16 The nurse assesses that an older male has gynecomastia. The nurse suspects which cause? Lymphatic engorgement An increase in lactiferous duct glands A decrease in testosterone A decrease in physical activity | A decrease in testosterone |
| CH. 16 The nurse observes a supernumerary nipple on a female patient. What is the significance of this finding? This woman has a significant risk for breast cancer. This woman may not be able to breast feed her infants. This is considered a normal variation. This woman may have infertility problems later in life. | s considered a normal variation. |
| CH. 16 Which position does the nurse recommend to the patient before palpating the axilla? Sitting with her arms at her sides Supine with her arms on her hips Lateral with her arms at her sides Sitting with her hands over her head | Sitting with her arms at her sides |
| CH. 16 Which statement is true regarding a patient who had a right-sided mastectomy 2 years ago? Inspect the mastectomy scar, but do not palpate it because of pain. There is no need to examine the right breast at all. Swelling and small lumps at the mastectomy site are normal findings. If a malignancy recurs, it may occur in the scar. | If a malignancy recurs, it may occur in the scar. |
| CH. 16 A nurse performing a breast exam on a female patient places the patient in a supine position, places a pillow under the right shoulder, and asks the patient to place her right lower arm above her head. What is the reason for this position? Flatten the breast tissue evenly over the chest wall. Reveal lumps deep in the breast more easily. Help the patient to relax and feel more comfortable. Expose any drainage from the nipples. | Flatten the breast tissue evenly over the chest wall. |
| CH. 16 What type of nipple discharge would make the nurse suspect that the patient has an infection in the breast? A purulent discharge A watery discharge A bloody discharge A milky discharge | A purulent discharge |
| CH. 16 The nurse knows that these are risk factors for breast cancer. (Select all that apply.) Select all that apply. Giving birth to a first child at age 38 A first-degree relative with breast cancer Menarche at age 14 Menopause after age 55 | Giving birth to a first child at age 38 A first-degree relative with breast cancer Menopause after age 55 |
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nursingmvc25