Health Assessment Final Exam: Review Questions

Health Assessment Final Exam: Review Questions An elderly patient is admitted to the hospital. While performing a skin assessment, the nurse discovers bruises in various stages of healing all over the patient's body. Why is it important for the nurse to promptly document and report these findings? a.The patient may have been abused. b.The patient is elderly. c.The patient may have peripheral vascular disease. d.The patient may have a cognitive deficit. Ans- a. The patient may have been abused When the nurse observes the patient for general characteristics including age, gender, and level of alertness, what aspect of assessment are you performing? a.Inspecting b.Interviewing c.Palpating d.Ausculating Ans- a. Inspecting The four areas to consider during the general survey include: a. Dress, medical history, nonverbal behavior, and mobility. b.Ethnicity, gender, age, and socioeconomic status. c.Physical appearance, gender, ethnicity, and medical history. d.Physical appearance, body structure, mobility, and behavior. Ans- d. Physical appearance, body structure, mobility, and behavior. When reading the patient's medical record, the nurse sees the following notation: Patient states, "I have had a cold for about a week, and I am having difficulty breathing." This is an example of: a.A past health history. b.A review of systems. c.A functioning assessment. d.A chief compliant. Ans- d.A chief compliant. Normal cervical lymph nodes are: a.Smaller than 1 cm b.Warm and red c.Fixed d.Firm Ans- a.Smaller than 1 cm The first step to cultural competency by a nurse is to: a.Identify the meaning of health to the patient. b.Understand their own heritage and its basis in cultural values. c.Develop a frame of reference to traditional health care practices. d.Understand how a health care delivery system works. Ans- b.Understand their own heritage and its basis in cultural values. The nurse is conducting a physical assessment of a new patient. What data does the nurse collect that are measurable? a.Objective b.Effective c.Subjective d.Affective Ans- a.Objective While assessing a patient, the nurse is asking questions that help the nurse perceive and communicate an understanding of what the patient is feeling. What is this called? a.Caring b.Therapeutic communication c.Sympathy d.Empathy Ans- d.Empathy Checking for skin temperature is best accomplished by using: a.The palms of the hands. b.The back of the hands c.The fingertips. d.The ventral surfaces of the hands. Ans- b.The back of the hands The nurse is conducting a patient interview and responds to the patient in a way that encourages the patient to more completely describe his or her problems. What is this called? a.Guided questioning b.Focusing c.Clarification d.Restatement Ans- a.Guided questioning A risk factor for melanoma is: a.Brown eyes b.Darkly pigmented skin c.Use of sunscreen products d.Skin that freckles or burns before tanning Ans- d.Skin that freckles or burns before tanning What is the nurse assessing when asking the patient, "What things seem to make it better?" a.Relieving/exacerbating factors b.Functional goal c.Pain goal d.Duration Ans- a.Relieving/exacerbating factors The nurse examines the nail beds of a patient. Which findings indicates a normal angle? a.160 degrees b.100 degrees c.60 degrees d.180 degrees Ans- a.160 degrees The nurse notes the appearance of freckles while assessing a patient's skin. What is the appropriate term to use when documenting this finding? a.Macules b.Vesicles c.Bulla d.Patches Ans- a.Macules To assess for early jaundiced, the nurse should assess: a.The lips b.The sclera and hard palate c.All visible skin surfaces d.The nail beds Ans- b.The sclera and hard palate While assessing a patient for allergies, the patient states being allergic to penicillin. Which response is best? a."Please describe what happens to you when you take penicillin?" b."How often have you received penicillin? c."I'll write your allergy on your chart so you will not receive any." d."Are you allergic to any other drugs?" Ans- a."Please describe what happens to you when you take penicillin?" A patient comes to the Emergency department (ED) complaining of chest pain. This would be considered: a.Secondary data b.Objective data c.Subjective data d.Tertiary data Ans- c.Subjective data The nurse is conducting an interview in the room of a newly admitted patient. Because the nurse is expecting a phone call, the nurse stands near the door. Which would have been a more appropriate approach? a.Use this approach given the circumstances. b.Arrange for a time free of interruptions after the initial physical examination is complete. c.Have someone else answer the phone so their full attention was focused on the patient. d.Arrange to have someone notify them when the call came, thus allowing the nurse to sit on the side of the bed. Ans- c.Have someone else answer the phone so their full attention was focused on the patient. While interviewing a patient, the nurse asks, "What happens when you have low blood glucose?" This type of response to the patient is used for what purpose? a.To promote objectivity. b.To summarize the conversion. c.To clarify. d.To restate what the patient has said. Ans- c.To clarify. The nurse performs a head and neck assessment on an adult patient and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action? a.Refer the patient to their primary care provider. b.Position the patient supine and reattempt palpation. c.Perform a focused endocrine exam. d.Document this as an expected assessment finding. Ans- d.Document this as an expected assessment finding. The nurse is admitting a 27 year old patient to the hospital's medical unit. While performing the admission assessment, the patient tells the nurse that she is being abused by her spouse. Which of the following is the nurse's best action? a. Make a referral to the social worker. b. Make a referral to the hospital chaplin. c. Report the abuse to the hospital CEO. d. Call 911 immediately. Ans- a. Make a referral to the social worker. While completing a neurological assessment, a nurse is assessing a patient for abnormalities of gait. The nurse is concerned that the patient is at increased risk for a fall. Which instruction should the nurse give the patient first? a."Walk heel to toe." b."Hop on one foot." c."Walk across the room and back." d."Walk on your toes then on your heels." Ans- c."Walk across the room and back." The nurse is preparing to complete an assessment of a patient's posterior thorax. Which of the following should be included in this examination? a.Auscultation of lung sounds b.Auscultation of the apical impulse c.Palpation of the subclavicular lymph nodes. d.Perform the Romberg test Ans- a.Auscultation of lung sounds A patient with a recent head injury is admitted to the emergency department. The patient appears to be dazed. The nurse asks the patient, "Do you know where you are?" Which of the following parameters is the nurse assessing? a.Attention b.Memory c.Orientation d.Mood and affect Ans- c.Orientation To elicit the plantar response (Babinski response), the nurse should: a.Present a noxious odor to the person and ask to identify the scent. b.Observe the person walking heel to toe. c.Stroke the lateral aspect of the sole of the foot, starting with heel and then across the ball. d.Gently tap the Achilles tendon with the thicker part of the reflex hammer. Ans- c.Stroke the lateral aspect of the sole of the foot, starting with heel and then across the ball. The nurse is examining the movements of a patient's eyes through each of the 6 cardinal gazes. Which crainal nerves are being assessed by the nurse? a.Abducens nerve b.Facial nerve c. Hypoglossal nerve d.Oculomotor nerve e.Trochlear nerve Ans- a.Abducens nerve d.Oculomotor nerve e.Trochlear nerve Your patient has a productive cough and is expectorating yellow mucous at times. Which breath sound would the nurse expect to auscultate due to the presence of mucous in this patient's respiratory tract? a.Absent b.Crackles c.Stridor d.Rhonchi Ans- d.Rhonchi When the nurse is assessing the motor function of cranial nerve VII as part of the neurological examination, what should the nurse instruct the patient to do? a.Clench the teeth b.Smell coffee beans c.Smile d.Cover one eye Ans- c.Smile A patient's patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding? a.Right knee+4; Left knee +3 b.Right knee +1; Left knee 0 c.Right knee +2; Left knee +1 d.Right knee +3; Left knee +2 Ans- c.Right knee +2; Left knee +1 The nurse is completing a neurological assessment on a patient. To test for stereognosis the nurse would: a.Have the person close his or her eyes and then raise the patient's arm and ask them to describe its location. b.Touch the patient with a cold objec