Nursing 224 Health Assessment (Final Exam Review; Jarvis 6th Ed.)

Nursing 224 Health Assessment (Final Exam Review; Jarvis 6th Ed.) 1. A 45-year-old mother of two children is seen at the clinic for complaints of "losing my urine when I sneeze." The nurse documents that she is experiencing: A. enuresis. B. stress incontinence. C. urinary frequency. D. urge incontinence. 2. A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says he "can't always tell where the sound is coming from" and the words often sound "mixed up." What might the nurse suspect as the cause for this change? A. Cilia becoming coarse and stiff B. Nerve degeneration in the inner ear C. Scarring of the tympanic membrane D. Atrophy of the apocrine glands 3. A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting she gets "really dizzy" and feels like she is going to fall over. The nurse's best response would be: A. "I'll refer you for a complete neurologic examination." B. "Have you been extremely tired lately?" C. "You need to get up slowly when you've been lying or sitting." D. "You probably just need to drink more liquids." 4. A nurse notices that a patient has ascites, which indicates the presence of: A. flatus. B. feces. C. fibroid tumors. D. fluid. 5. A patient has been admitted to the hospital with vertebral fractures related to osteoporosis. She is in extreme pain. This type of pain would be classified as: A. deep somatic. B. visceral. C. cutaneous. D. referred. 6. A patient has had three pregnancies and two live births. The nurse would record this information as gravida , para , AB . A. 3; 2; 1 B. 2; 2; 1 C. 3; 2; 0 D. 3; 3; 1 7. A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: A. scleroderma. B. Bell's palsy. C. damage to the trigeminal nerve. D. frostbite with resultant paresthesia to the cheeks. 8. A 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 these assessment findings indicates an acute pain response to poorly controlled pain? A. Increased blood pressure and pulse B. Confusion C. Hyperventilation D. Depression 9. A patient with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the patient that the middle ear functions to: A. interpret sounds as they enter the ear. B. conduct vibrations of sounds to the inner ear. C. maintain balance. D. increase amplitude of sound for the inner ear to function. 10. A patient with lack of oxygen to his heart will have pain in his chest and possibly the shoulder, arms, or jaw. The nurse knows that the statement that best explains why this occurs is which of these? A. The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing pain. B. There is a lesion in the dorsal root that is preventing the sensation from being transmitted normally. C. The sensory cortex does not have the ability to localize pain in the heart, so the pain is felt elsewhere. D. There is a problem with the sensory cortex and its ability to discriminate the location. 11. A patient's laboratory data reveal an elevated thyroxine level. The nurse would proceed with an examination of the gland. A. adrenal B. parotid C. parathyroid D. thyroid 12. A woman states that 2 weeks ago she had a urinary tract infection that was treated with an antibiotic. As a part of the interview, the nurse should ask, "Have you noticed: A. a change in your urination patterns?" B. any changes in your desire for intercourse?" C. any excessive vaginal bleeding?" D. any unusual vaginal discharge or itching?" 13. After completing an assessment of a 60-year-old man with a family history of colon cancer, the nurse discusses with him early detection measures for colon cancer. The nurse should mention the need for a(n): A. annual proctoscopy. B. colonoscopy every 10 years. C. fecal test for blood every 6 months. D. digital rectal examinations every 2 years. 14. An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because: A. there is a significant loss of subcutaneous fat. B. there is a thickening of the intervertebral disks. C. of the shortening of the vertebral column. D. long bones tend to shorten with age. 15. During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse's most appropriate response to this would be: A. "I would like some more information about the pain in your left breast." B. "Don't worry about the pain; breast cancer is not painful." C. "Breast pain is almost always the result of benign breast disease." D. "Oh, I had pain like that after my son was born; it turned out to be a blocked milk duct." 16. During an examination the nurse observes a female patient's vestibule and expects to see the: A. paraurethral (Skene) and vestibular (Bartholin) glands. B. urethral meatus and vaginal orifice. C. vaginal orifice and vestibular (Bartholin) glands. D. urethral meatus and paraurethral (Skene) glands. 17. During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is: A. decreased in the elderly. B. stimulated by cranial nerves I and II. C. stimulated by cranial nerves III, IV, and VI. D. impaired in a patient with cataracts. 18. Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called: A. tendons. B. ligaments. C. bursa. D. cartilage. 19. In assessing the tonsils of a 30-year-old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is correct response to these findings? A. Nothing, because this is the appearance of normal tonsils. B. Obtain a throat culture on the patient for possible strep infection. C. Refer the patient to a throat specialist. D. Continue with assessment looking for any o