Health Assessment
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| During an assessment of a patient who has been homeless for several years, the nurse notices that his tongue is magenta in color. This is an indication of: | riboflavin deficiency.
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| The patient complains of pain just below the xiphoid process. The RN documents this as the: | epigastric area.
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| The nurse is listening to bowel sounds. Which of the following is true of bowel sounds? | They are usually high-pitched, gurgling, irregular sounds.
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| A 59-year-old has been diagnosed with prostatitis and is being seen at the clinic for complaints of burning and pain during urination. He is experiencing: | dysuria
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| Why is it important to ask a patient what medications they are taking when doing a nutritional assessment? | Certain drugs can affect the metabolism of nutrients.
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| A patient tells the nurse that his food just doesn't have any taste anymore. The nurse's best response would be: | "When did you first notice this change?"
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| The physician comments that a patient has abdominal "borborygmi". The nurse knows that this term refers to: | hyperactive bowel sounds.
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| The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? | The nurse should examine the tender area last.
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| After completing a diet assessment on a 30-year-old woman, the nurse suspects that she may have an iron deficiency. Laboratory studies obtained to verify this condition would be: | hemoglobin and hematocrit
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| You suspect that a patient is suffering from appendicitis. Which of the following procedures would be helpful in assessing for appendicitis? | Rebound tenderness
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| Which of the following factors is most likely to affect the nutritional status of an 82-year-old male? | Living alone on a fixed income
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| All of the following diagnoses place an individual at nutritional risk EXCEPT: | urinary retention.
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| A patient is having difficulty in swallowing her medications and her food. In your charting, you would say that she is experiencing: | dysphagia
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| BMI stands for: | body mass index.
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| You are palpating the abdomen of a 20-year-old female patient who is complaining of fatigue. You note the presence of tenderness in the left upper quadrant with deep palpation. Which of the following structures is most likely to be involved? | Spleen
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| Which of the following statements is most appropriate when the nurse is obtaining a genitourinary history form an elderly man? | "Do you need to get up at night to urinate?"
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| To the horizontal plane, a scaphoid contour of the abdomen depicts: | a concave profile.
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| Which of the following tests is most specific for renal function? | serum creatinine
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| The main reason auscultation precedes percussion and palpation of the abdomen is: | to prevent stimulating peristalsis which might occur after percussion and palpation.
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| The nurse is assessing a patient for possible peptic ulcer disease and knows that which condition often caused this problem? | Frequent use of nonsteroidal anti-inflammatory drugs
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| The nurse is providing care for a 68-year-old woman who is complaining of constipation. What concern exists regarding her nutritional status? | The absorption of nutrients may be impaired.
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| Which of the following statements is true concerning the admission nutrition screening tool assessment? | It identifies patients who are at risk of malnutrition.
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| Which of the following urine specific gravity values would indicate to the nurse that the patient is receiving excessive IV fluid therapy? | 1.002
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| During a health history, a patient tells the nurse that he has trouble in starting his urine stream. This problem is known as: | hesitancy
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| Which of the following is the cause of ascites? | Fluid
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| Which of the following may be the cause of black, tarry stools? | Gastrointestinal bleeding
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| Tenderness on palpation in the right upper quadrant (RUQ) could indicate a disorder of which of the following structures? | Gallbladder
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| A patient is described as being cachetic. The RN understands this to mean: | fat and muscle wasting.
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| Which of the following labs is indicative of protein status? | Albumin
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| A 40-year-old man states that his doctor told him that he has a hernia. He asks the nurse to explain what a hernia is. Which action by the nurse is appropriate? | Explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal nuscles.
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| During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "absent bowel sounds" the nurse should listen for at least: | 5 minutes.
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| During an assessment the nurse notes that a patient's umbilicus is enlarged and everted. It is midline and there is no change in skin color. The nurse recongizes that the patient may have which condition? | Umbilical hernia
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| A 52-year-old patient states that when she sneezes or coughs she "wets herself a little." She is very concerned that something may be wrong with her. The nurse knows that the problem is: | stress incontinence and is usually due to muscle weakness.
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| Referred pain is: | when the pain's location is not directly over the involved organ.
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| The nutritional needs of a patient with trauma or major surgery: | may be two to three times greater than normal.
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| The patient's lab results indicate an albumin of 2.8 g/dl. The student nurse understands this to represent: | severe protein depletion.
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| The RN notes the presence of silvery white, linear, jagged-edged marks across a patient's lower abdomen. This is documented as: | striae
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| Which of the following diagnoses places a patient at nutritional risk according to the Admission Nutrition Screening Tool? | Nonhealing wounds
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| The patient record indicates that the patient has hematemesis. The RN knows this to mean: | vomitus is bloody.
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| Select the sequence of techniques used during an examination of the abdomen: | Inspection, auscultation, percussion, palpation
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| You are performing a nutritional assessment on an 80-year-old male. You know that physiologic changes that directly affect the nutritional status of the elderly include: | slowed gastrointestinal motility.
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| A patient is found to have a BMI of 23. This is interpreted as: | normal weight.
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| RLQ stands for: | right lower quadrant.
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| The patient's abdomen is found to be distended. The RN is unsure if it is due to gas distention or ascites. The RN can differentiate the two with which of the following tests? | Test for a fluid wave.
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| The term hepatomegaly refers to: | enlarged liver.
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| Deep palpation is used to determine: | enlarged organs.
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| In performing an assessment on a 49-year-old woman who has imbalanced nutrition as a result of dysphagia, which of the following data would the nurse expect to find? | Inadequate food intake.
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| Which of the following is a cause of hypoactive bowel sounds? | Paralytic ileus
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| Optimal nutritional status is best defined as: | sufficient nutrients to provide for daily body requirements as well as for increased metabolic demands.
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| A 22 yr old male comes to clinic for examination after falling off his motorcycle & landing on his left side on handlebars. You suspect that he may have injured his spleen. Which of following is true regarding assessment of his spleen in this situation? | An enlarged spleen should not be palpated because it can rupture easily.
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