Quiz 56: Health Assessment Perry et al.: Clinical Nursing Skills & Techniques, 9th Edition

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Quiz 56: Health Assessment
Perry et al.: Clinical Nursing Skills & Techniques, 9th Edition

Questions 45
Instructor Verified Answers Included
WarofGrades Guaranteed A+ Graded Tutorial

MULTIPLE CHOICE

1. The nurse is visiting the patient for the first time this shift. She introduces herself and asks the patient several questions related to his condition. While doing so, and without being obvious, she is looking at the color of his eyes and is assessing his ears and nose for discharge and the symmetry of his mouth. Which assessment technique is the nurse using?
a. Palpation
b. Percussion
c. Inspection
d. Auscultation

2. The patient is admitted with fever and acute lower abdominal pain. He has taken Tylenol but says he still feels feverish. Before taking the patient’s temperature, the nurse may:
a. touch the patient’s skin with the dorsum of her hand.
b. touch the patient’s skin with the pads of her fingers.
c. palpate the skin using the bimanual method.
d. tap the patient’s skin using the fingertips.

3. What should the nurse do when preparing to complete an assessment for a 16-year-old patient?
a. Focus on illness behaviors.
b. Plan for a diminished energy level.
c. Treat the patient as an individual.
d. Have the parents present throughout.

4. In providing a physical assessment of an 88-year-old patient, the nurse should:
a. do it as quickly as possible to prevent fatigue.
b. assume that the patient will have disabilities.
c. prepare to perform a mental status examination.
d. always do the exam in the small exam room to prevent chills.

5. The general survey begins with a review of the patient’s primary health problems and an evaluation of the patient’s vital signs, height and weight, general behavior, and appearance. It also provides information about the patient’s illness, hygiene, skin condition, body image, and emotional state. Which of the following cannot be delegated to nursing assistive personnel?
a. Reporting subjective signs and symptoms
b. Measuring the patient’s height and weight
c. Monitoring I&O
d. Obtaining initial vital signs

6. Petechiae are noted on the patient as a result of the nurse finding:
a. bluish-black patches.
b. tenting.
c. pinpoint-sized red dots.
d. large areas of raised, irritated skin.

7. The nurse is assessing the patient by grasping a fold of skin on his forearm. She notices that the skin remains suspended for a longer than normal period. What could this indicate?
a. Stage 1 pressure ulcer
b. Increased blood flow to the area
c. Localized vasodilation
d. Dehydration

8. The nurse is preparing to examine a patient who has chronic lung disease. She realizes that the patient most likely will need to be in which position for the examination?
a. Sitting upright
b. Supine
c. Side-lying
d. Prone

9. Which of the following may a nursing assistive personnel (NAP) be responsible for determining?
a. Vital signs
b. Cranial nerve function
c. Neck vein distention
d. Auscultation of bowel sounds

10. The nurse is caring for a patient who is recovering from an acute myocardial infarction. While providing cardiac education, the nurse realizes that the patient needs more education when he:
a. describes changes in his behavior that may improve cardiovascular function.
b. describes the schedule, dosage, and purpose of his medication.
c. states that he will take his medication when he has chest pain or when his heart rate is greater than 100.
d. describes the benefits of taking his medication regularly.

11. Which of the following is an expected outcome for a patient after cardiac assessment?
a. Apical pulse rate equals 58 beats per minute
b. Carotid bruits present
c. PMI palpable at left fifth intercostal space at midclavicular line
d. Jugular veins distended with patient in sitting position

12. Where is the pulmonic area for auscultation found?
a. Second intercostal space on the right side
b. Second intercostal space on the left side
c. Third intercostal space (Erb’s point)
d. Fourth intercostal space along the sternum

13. While performing a cardiovascular assessment on a patient with suspected left-sided congestive heart failure, the nurse is unable to palpate the PMI with the patient lying supine. What might her next step be?
a. Have the patient turn onto his left side.
b. Have the patient lean forward.
c. Have the patient move to a sitting position.
d. Palpate the PMI to the right of the midclavicular line.

14. Which is the best position in which to place the patient to hear low-pitched cardiovascular sounds?
a. Supine
b. Sitting up
c. Dorsal recumbent
d. Left lateral recumbent

15. What technique should the nurse implement for assessment of the carotid artery?
a. Massaging the arteries briskly
b. Using the diaphragm of the stethoscope
c. Palpating each carotid artery separately
d. Placing the patient in a supine position

16. Which of the following is an unexpected finding after a cardiac assessment?
a. A pulse rate of 72 beats per minute
b. Jugular vein pulsation with the patient supine
c. PMI found at the midclavicular line
d. A sustained swishing sound during systole or diastole

17. Which technique is most appropriate for a nurse to implement during the assessment of the abdomen?
a. Assessing painful areas first
b. Auscultating for 5 minutes over each quadrant
c. Positioning the patient in a supine position with the arms behind or over the head
d. Palpating painful masses or organ enlargement deeply and firmly

18. How should the nurse document an exaggeration of the posterior curvature of the thoracic spine found during the assessment of a 90-year-old patient?
a. Lordosis
b. Osteoporosis
c. Scoliosis
d. Kyphosis

19. The patient is diagnosed with Bell’s palsy. The nurse assesses the patient and notices drooping of the patient’s right eye and the right side of his mouth. When the functions of the following nerves are compared, the most likely cause of these symptoms would be a dysfunction of the:
a. facial nerve (CN VII).
b. trigeminal nerve (CN V).
c. oculomotor nerve (CN III).
d. glossopharyngeal nerve (CN IX).

20. Measurement of the patient’s ability to differentiate between sharp and dull sensations over the forehead tests which cranial nerve?
a. Abducens
b. Facial
c. Trigeminal
d. Oculomotor

21. The nurse is assessing the neurological status of a patient. She uses the handle end of a reflex hammer to stroke the lateral aspect of the sole of the foot. She notes that the great toe dorsiflexes and the other toes spread out like a fan. What does this indicate?
a. A positive Romberg’s test
b. A negative Babinski’s reflex
c. A hyperactive patellar tendon reflex
d. A normal reflex in a child younger than age 2

22. How does a nurse appropriately measure intake and output?
a. Recording 50% of ice chip consumption
b. Checking urinary output every 24 hours
c. Emptying the chest tube drainage every 2 hours
d. Subtracting liquid medications from the total intake

23. Which skin condition would cause a nurse to suspect chickenpox?
a. Wheals
b. Nodules
c. Pustules
d. Vesicles

24. Which patient position maximizes the nurse’s ability to assess the patient’s body for symmetry?
a. Sitting
b. Supine
c. Prone
d. Dorsal recumbent

25. During assessment of a patient with anemia, a nurse is alert for the presence of:
a. pallor.
b. jaundice.
c. cyanosis.
d. erythema.

26. A nurse is documenting a patient’s breath sounds. Crackles are heard as:
a. loud, low-pitched, coarse sounds.
b. high-pitched, musical squeaks.
c. dry, grating sounds on inspiration.
d. high-pitched, fine sounds at the end of inspiration.

27. A student nurse is working with a patient who has asthma. The primary nurse tells the student that wheezes can be heard on auscultation. The student expects to hear:
a. coarse crackles and bubbling.
b. high-pitched musical sounds.
c. dry, grating noises.
d. loud, low-pitched rumbling.

28. A nurse is documenting a patient’s breath sounds. Rhonchi are heard as:
a. loud, low-pitched, coarse sounds.
b. high-pitched, musical squeaks.
c. dry, grating sounds on inspiration.
d. high-pitched, fine sounds at the end of inspiration.

MULTIPLE RESPONSE

1. The purpose of the physical assessment is to: (Select all that apply.)
a. compare the patient’s status with previous findings.
b. help the nurse gather additional data.
c. help select the best nursing measures.
d. teach patients about better health promotion.

2. The nurse is preparing to examine a comatose patient on a ventilator. Before beginning the procedures, she: (Select all that apply.)
a. speaks to the patient to minimize anxiety.
b. drapes the body parts not being examined.
c. encourages the patient to ask questions.
d. uses medical terms to let the patient know that she is professional.

3. The patient has come to the clinic complaining of bleeding from what she calls a “mole” on her neck. She states that her mother died from skin cancer at a fairly early age because she was fair-skinned and had a lot of exposure to the sun. Because of this, the patient has been going for tanning sessions regularly for several years to keep her dark and to protect her from the sun. The nurse prepares to examine the “mole” while being especially watchful for: (Select all that apply.)
a. uneven shape of the mole (asymmetry).
b. ragged or blurred edges of the mole border.
c. pigmentation that is not uniform.
d. size of the mole.

4. While performing a physical examination, the nurse incorporates health promotion by teaching the patient about how to reduce the risk of lung cancer. The nurse explains that besides cigarette smoking, exposure to other substances may lead to this disease. Some of these substances are: (Select all that apply.)
a. arsenic.
b. asbestos.
c. radiation.
d. air pollution.

5. In teaching the patient about prevention of cervical cancer, the nurse teaches the patient about the risk factors for cervical cancer. Risk factors for cervical cancer include which of the following? (Select all that apply.)
a. History of human papillomavirus (HPV) infection
b. Multiple sex partners
c. Smoking
d. Multiple pregnancies

COMPLETION

1. The patient is 3 days post abdominal surgery. The nurse uses her stethoscope to listen for bowel sounds. This assessment technique is known as _________________.

2. The female nurse is preparing to assess and possibly change a scrotal dressing on a 34-year-old patient. Before changing the dressing, she should ______________.

3. The nurse is providing health education to a group of adolescent females. The topic is “Preventing Skin Cancer.” As part of the health promotion education, the nurse recommends that they avoid tanning under direct sun at midday and avoid _________________.

4. ________________ is a major cause of lung cancer, cerebrovascular disease, heart disease, and chronic lung disease.

5. When performing an assessment of the cardiovascular system, the nurse evaluates the skin and nails of the patient. Inadequate tissue perfusion is known as ______________.

6. The patient has been immobile at home after having had leg trauma in an automobile accident and is now being admitted with calf pain and localized swelling of the calf muscle. One test that is contraindicated in assessment of this patient is testing for _____________.

7. The patient has been in the ICU following an acute myocardial infarction 3 days earlier. During an initial assessment of the patient, the nurse detects a heart murmur that the patient did not have previously. The nurse should __________________.

8. The patient is noted to have difficulty swallowing. The nurse realizes that the most probable cause of this difficulty is damage to cranial nerve ______.

9. When breast self-examination is done, it should be done once a month. For women who menstruate, the best time is ______________.

10. Increased visibility of oxyhemoglobin caused by dilation or increased blood flow is known as ________________.

11. A late sign of decreased oxygen levels may cause a change in skin color known as _________.

12. ____________ is a yellow-orange skin color seen with increased deposit of bilirubin in tissues.

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