Health Assessment Jarvis Final Updated & Combined 2022 (Answered)

Health Assessment Jarvis Final Updated & Combined 2022 (Answered) 1. A hospitalized patient does not require a full neurologic examination during every shift assessment. What is a method of assessing the neurologic status of a patient without performing a full neurological examination? a. Palpate the carotid pulse. b. Offer the patient a glass of water. c. Look at the significant other throughout the examination. d. Assign the nursing assistant to ask the patient questions and report the findings. b A physician tells the nurse that a patient's vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is: a.Just above the diaphragm. b.Just lateral to the knee cap. c.At the level of the C7 vertebra. d.At the level of the T11 vertebra. C The C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable when the head is flexed. 1. The nurse is assessing an older adult's functional ability. Which definition correctly describes one's functional ability? a. It denotes an older person's cognitive level. b. It is the measure of the expected changes of aging that one is experiencing. c. It describes the individual's motivation to live independently. d. It refers to one's ability to perform activities necessary to live in modern society. d After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be: a. Objective. b. Reflective. c. Subjective. d. Introspective. A The nurse is reviewing the development of culture. Which statement is correct regarding the development of one's culture? Culture is: a. Genetically determined on the basis of racial background. b. Learned through language acquisition and socialization. c. A nonspecific phenomenon and is adaptive but unnecessary. d. Biologically determined on the basis of physical characteristics. B The nurse is conducting an interview with a woman who has recently learned that she is pregnant and has come to the clinic today to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs loudly. Considering the concept of communication, the nurse knows that which statement is most accurate? The woman: 1. is excited about her pregnancy but nervous about labor. 2. is exhibiting verbal and nonverbal behavior that does not match. 3. is excited about her pregnancy but her husband is not and this is upsetting to her. 4. is not excited about her pregnancy but believes the nurse will respond negatively to her if she states this. ANS: 2 Communication is all behavior, conscious and unconscious, verbal and nonverbal. All behavior has meaning. The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history? a.To provide an opportunity for interaction between the patient and the nurse b.To provide a form for obtaining the patient's biographic information c.To document the normal and abnormal findings of a physical assessment d.To provide a database of subjective information about the patient's past and current health D During an examination, the nurse can assess mental status by which activity? a. Examining the patients electroencephalogram b. Observing the patient as he or she performs an intelligence quotient (IQ) test c. Observing the patient and inferring health or dysfunction d. Examining the patients response to a specific set of questions C 1. A woman has come to the clinic to seek help with a substance abuse problem. She admits to using cocaine just before arriving. Which of these assessment findings would the nurse expect to find when examining this woman? a. Dilated pupils, pacing, and psychomotor agitation b. Dilated pupils, unsteady gait, and aggressiveness c. Pupil constriction, lethargy, apathy, and dysphoria d. Constricted pupils, euphoria, and decreased temperature ANS: A A cocaine users appearance includes pupillary dilation, tachycardia or bradycardia, elevated or lowered blood pressure, sweating, chills, nausea, vomiting, and weight loss. The persons behavior includes euphoria, talkativeness, hypervigilance, pacing, psychomotor agitation, impaired social or occupational functioning, fighting, grandiosity, and visual or tactile hallucinations. When performing a physical assessment, the first technique the nurse will always use is: a. Palpation. b. Inspection. c. Percussion. d. Auscultation. B The nurse is performing a general survey. Which action is a component of the general survey? A) Observing the patient's body stature and nutritional status B) Interpreting the subjective information the patient has reported C) Measuring the patient's temperature, pulse, respirations, and blood pressure D) Observing specific body systems while performing the physical assessment A Which of these statements is true regarding the vertebra prominens? The vertebra prominens is: the spinous process of C7 1. At the beginning of rounds, when the nurse enters the room, what should the nurse do first? A. Check the intravenous infusion site for swelling or redness. B. Check the infusion pump settings for accuracy. C. Make eye contact with the patient and introduce himself or herself as the patient's nurse. D. Offer the patient something to drink ANS: C As a mandatory reporter of elder abuse, which of these must be present before a nurse notifies the authorities? ANS: Suspicion of elder abuse and/or neglect Many health care workers are under the erroneous assumption that proof is required before notification of suspected abuse can occur. Only a suspicion of elder abuse or neglect is necessary. The sac that surrounds and protects the heart is called the: a. Pericardium. b. Myocardium. c. Endocardium. d. Pleural space. ANS: pericardium. The pericardium is a tough fibrous double-walled sac that surrounds and protects the heart. It has two layers that contain a few milliliters of serous pericardial fluid. The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the: a. Auricle. b. Concha. c. Outer meatus. d. Mastoid process. A. auricle The external ear is called the auricle or pinna and consists of movable cartilage and skin. The nurse recognizes which of these persons is at greatest risk for undernutrition? a. 5-month-old infant b. 50-year-old woman c. 20-year-old college student d. 30-year-old hospital administrator A Which of these statements about the anal canal is true? The anal canal: A) is about 2 cm long in the adult. B) slants backward toward the sacrum. C) contains hair and sebaceous glands. D) is the outlet for the gastrointestinal tract. ANS: D The anal canal is the outlet for the gastrointestinal tract, and it is about 3.8 cm long in the adult. It is lined with a modified skin that does not contain hair or sebaceous glands, and it slants forward toward the umbilicus. During a health history, a 22-year old woman asks, "Can I get that vaccine for HPV? I have genital warts and I'd like them to go away!" What is the nurse's best response? A) "The HPV vaccine is for girls and women ages 9 to 26, so we can start that today." B) "This vaccine is only for girls who have not started to have intercourse yet." C) "Let's check with the physician to see if you are a candidate for this vaccine." D) "The vaccine cannot protect you if you already have an HPV infection." ANS: D The HPV (human papillomavirus) vaccine is appropriate for girls and women age 9 to 26 and is given to prevent cervical cancer by preventing HPV infections before girls become sexually active. However, it cannot protect the woman if an HPV infection is already present. Statement by the patient would indicate a need for further teaching? A. "The best time to check my breasts is a week before my cycle." B. "I will check my breasts in the shower one week after my cycle." C. "I will exam my breast in a clock-like sequence so that I don't miss any surface area." D. "I will be sure to check my arm pits." A The week before a woman's cycle is not the best time to check for lumps because the breasts become sore and tender and may also be "lumpy" a week prior to the cycle. Answer 2 is incorrect because the week after a woman's cycle is the best time to do the examination, and the shower allows for ease of palpation. Answer 3 in incorrect because a clock-like sequence is the proper way to perform a BSE. Answer 4 is incorrect because under the arms houses lymph nodes and the axillary tail of Spence, which is a common site for breast cancer. When examining the eye, the nurse notices that the patient's eyelid margins approximate completely. The nurse recognizes that this assessment finding: a. Is expected. b. May indicate a problem with extraocular muscles. c. May result in problems with tearing. d. Indicates increased intraocular pressure. A is expected The palpebral fissure is the elliptical open space between the eyelids, and, when closed, the lid margins approximate completely, which is a normal finding. The external male genital structures include the: ANS: scrotum. The external male genital structures include the penis and scrotum. The testis, epididymis, and vas deferens are internal structures. The primary purpose of the ciliated mucous membrane in the nose is to: a.Warm the inhaled air. b.Filter out dust and bacteria. c.Filter coarse particles from inhaled air. d.Facilitate the movement of air through the nares. B. filter out dust and bacteria Because hair for humans is no longer needed for protection from cold or trauma, it is called: vestigial. Hair is vestigial for humans. It no longer is needed for protection from cold or trauma. The two parts of the nervous system are the: a. Motor and sensory. b. Central and peripheral. c. Peripheral and autonomic. d. Hypothalamus and cerebral. B A patient is being assessed for range of joint movement, The nurse asks him to move his arm in toward the center of his body. This movement is called: Adduction 1. The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? A) Dullness B) Tympany C) Resonance D) Hyperresonance ANS: A The liver is located in the right upper quadrant and would elicit a dull percussion note During a home visit, the nurse notices that an elderly woman is caring for her bedridden husband. The woman states that this is her duty, she does the best she can, and her children come to help when they are in town. Her husband is unable to care for himself, and she appears thin, weak, and exhausted. The nurse notices that several of his prescription medication bottles are empty. This situation is best described by the term: ANS: unintentional physical neglect. Unintentional physical neglect may occur despite good intentions. It is the failure of the family member or caregiver to provide basic goods or services. Physical abuse is defined as violent acts that result or could result in injury, pain, impairment, or disease. Financial neglect is failure to use the assets of the elderly person to provide services needed by the elderly person. Psychological abuse is defined as behaviors that result in mental anguish. 2. During an assessment, the nurse is unable to palpate pulses in the left lower leg. What should the nurse do next? A. Document that the pulses are not palpable. B. Reassess the pulses in 1 hour. C. Have the patient turn to the side and then palpate for the pulses again. D. Use a Doppler device to assess the pulses ANS: D The nurse should be prepared to assess pulses in the lower extremities by Doppler measurement if they cannot be detected by palpation. When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is: a normal finding in a healthy adult When measuring a patient's weight, the nurse keeps in mind which of these guidelines? A) Always weigh the patient with only his or her undergarments on. B) It does not matter what type of scale is used, as long as the weights are similar from day to day. C) The patient may leave on his or her jacket and shoes as long as this is documented next to the weight. D) Attempt to weigh the patient at approximately the same time of day, if a sequence of weights is necessary. D The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase: a. Usually yields little information. b. Takes time and reveals a surprising amount of information. c. May be somewhat uncomfortable for the expert practitioner. d. Requires a quick glance at the patients body systems before proceeding with palpation. B When the nurse is evaluating the reliability of a patient's responses, which of these statements would be correct? The patient: a.Has a history of drug abuse and therefore is not reliable. b.Provided consistent information and therefore is reliable. c.Smiled throughout interview and therefore is assumed reliable. d.Would not answer questions concerning stress and therefore is not reliable. B 2. The nurse is assessing a patient who has been admitted for cirrhosis of the liver, secondary to chronic alcohol use. During the physical assessment, the nurse looks for cardiac problems that are associated with chronic use of alcohol, such as: a. Hypertension. b. Ventricular fibrillation. c. Bradycardia. d. Mitral valve prolapse. ANS: A Even moderate drinking leads to hypertension and cardiomyopathy, with an increase in left ventricular mass, dilation of ventricles, and wall thinning. Ventricular fibrillation, bradycardia, and mitral valve prolapse are not associated with chronic heavy use of alcohol. The nurse is assessing the mental status of a child. Which statement about children and mental status is true? a. All aspects of mental status in children are interdependent. b. Children are highly labile and unstable until the age of 2 years. c. Children's mental status is largely a function of their parents level of functioning until the age of 7 years. d. A child's mental status is impossible to assess until the child develops the ability to concentrate. A Which statement is true regarding the arterial system? a. Arteries are large-diameter vessels. b. The arterial system is a high-pressure system. c. The walls of arteries are thinner than those of the veins. d. Arteries can greatly expand to accommodate a large blood volume increase. B Receiving is a part of the communication process. Which receiver is most likely to misinterpret a message sent by a healthcare professional? 1.A well-adjusted adolescent in for a sports physical 2.A recovering alcoholic in for a basic physical examination 3.A man whose wife has just been diagnosed with lung cancer 4.A hearing-impaired man who uses sign language to communicate and has an interpreter with him ANS: 3 The receiver attaches meaning determined by his or her past experiences, culture, self-concept, and current physical and emotional states. During a class on the aspects of culture, the nurse shares that culture has four basic characteristics. Which statement correctly reflects one of these characteristics? a. Cultures are static and unchanging, despite changes around them. b. Cultures are never specific, which makes them hard to identify. c. Culture is most clearly reflected in a person's language and behavior. d. Culture adapts to specific environmental factors and available natural resources. D A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be: a. Objective. b. Reflective. c. Subjective. d. Introspective. C A mother brings her 2-month-old daughter in for an examination and says, "My daughter rolled over against the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is something terribly wrong?" The nurse's best response would be: a."Perhaps that could be a result of your dietary intake during pregnancy." b."Your baby may have craniosynostosis, a disease of the sutures of the brain." c."That 'soft spot' may be an indication of cretinism or congenital hypothyroidism." d."That 'soft spot' is normal, and actually allows for growth of the brain during the first year of your baby's life." D Membrane-covered "soft spots" allow for growth of the brain during the first year of life. They gradually ossify; the triangular-shaped posterior fontanel is closed by 1 to 2 months, and the diamond-shaped anterior fontanel closes between 9 months and 2 years. During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is: a. Decreased in the older adult. b. Impaired in a patient with cataracts. c. Stimulated by cranial nerves (CNs) I and II. d. Stimulated by CNs III, IV, and VI. D. stimulated by CNs III, IV, and VI Movement of the extraocular muscles is stimulated by three CNs: III, IV, and VI. When assessing a patient's nutritional status, the nurse recalls that the best definition of optimal nutritional status is sufficient nutrients that: a. Are in excess of daily body requirements. b. Provide for the minimum body needs. c. Provide for daily body requirements but do not support increased metabolic demands. d. Provide for daily body requirements and support increased metabolic demands. D A pregnant woman who has breast implants asks the nurse if she can still breastfeed. What is the nurse's best response? A. "You should not have any problems breast feeding because your implants do not affect milk production." B. "When the breast implants are inserted they usually affect the milk glands, and breastfeeding is not possible." C. "This would depend on which type of implants were placed and which procedure was used by the surgeon. Check with your surgeon to see if your milk production will be affected." C Milk production may vary depending on the procedure. Many women can still breastfeed after breast augmentation. The surgeon would be able to determine this ability. Answers 1 and 2 are incorrect because they may not be true. Only the surgeon can determine if milk production will be affected. 2. Which structure is located in the left lower quadrant of the abdomen? A) Liver B) Duodenum C) Gallbladder D) Sigmoid colon ANS: D The sigmoid colon is located in the left lower quadrant of the abdomen. 1. The nurse is preparing to perform a functional assessment of an older patient. What is an appropriate approach for the nurse to take? a. Observe the patient's ability to perform the tasks. b. Ask the patient's wife how he does when performing tasks. c. Review the medical record for information on the patient's abilities. d. Ask the patient's physician for information on the patient's abilities. a An accessory glandular structure for the male genital organs is the: ANS: prostate. Glandular structures accessory to the male genital organs are the prostate, seminal vesicles, and bulbourethral glands Which of these statements about the sphincters is correct? A) The internal sphincter is under voluntary control. B) The external sphincter is under voluntary control. C) Both sphincters remain slightly relaxed at all times. D) The internal sphincter surrounds the external sphincter. ANS: B The external sphincter surrounds the internal sphincter but also has a small section overriding the tip of the internal sphincter at the opening. The external sphincter is under voluntary control. Except for the passing of feces and gas, the sphincters keep the anal canal tightly closed. During an examination the nurse observes a female patient's vestibule and expects to see the: A) urethral meatus and vaginal orifice. B) vaginal orifice and vestibular (Bartholin) glands. C) urethral meatus and paraurethral (Skene) glands. D) paraurethral (Skene) and vestibular (Bartholin) glands. ANS: A The labial structures encircle a boat-shaped space, or cleft, termed the vestibule. Within it are numerous openings. The urethral meatus and vaginal orifice are visible. The ducts of the paraurethral (Skene) glands and the vestibular (Bartholin) glands are present but not visible. 1. The examiner is assessing the extraocular muscles. Which of the following tests would be inappropriate? a. Confrontation test b. Corneal light reflex c. Six cardinal positions of gaze d. Cranial nerve III, IV, and VI testing a The projections in the nasal cavity that increase the surface area are called the: a.Meatus. b.Septum. c.Turbinates. d.Kiesselbach plexus. C. turbinates The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is: a. Contains mostly fat cells. b. Consists mostly of keratin. c. Is replaced every 4 weeks. d. Contains sensory receptors. replaced every 4 weeks. The epidermis is thin yet tough, replaced every 4 weeks, avascular, and stratified into several zones. The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the __________ lobe. a. Frontal b. Parietal c. Occipital d. Temporal A A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth she must perform which movement? Flexion The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct? a. Sticky honey-colored cerumen is a sign of infection. b. The presence of cerumen is indicative of poor hygiene. c. The purpose of cerumen is to protect and lubricate the ear. d. Cerumen is necessary for transmitting sound through the auditory canal. C. the purpose of cerumen is to protect and lubricate the ear The ear is lined with glands that secrete cerumen, which is a yellow waxy material that lubricates and protects the ear. The direction of blood flow through the heart is best described by which of these? a. Vena cava right atrium right ventricle lungs pulmonary artery left atrium left ventricle b. Right atrium right ventricle pulmonary artery lungs pulmonary vein left atrium left ventricle c. Aorta right atrium right ventricle lungs pulmonary vein left atrium left ventricle vena cava d. Right atrium right ventricle pulmonary vein lungs pulmonary artery left atrium left ventricle ANS: Right atrium right ventricle pulmonary artery lungs pulmonary vein left atrium left ventricle Returning blood from the body empties into the right atrium and flows into the right ventricle and then goes to the lungs through the pulmonary artery. The lungs oxygenate the blood and it is then returned to the left atrium by the pulmonary vein. It goes from there to the left ventricle and then out to the body through the aorta. The nurse is aware that intimate partner violence (IPV) screening should occur with which situation? ANS: As a routine part of each health care encounter Many nursing professional organizations have called for routine, universal screening for IPV to assist women in getting help for the problem. 3. During a morning assessment, the nurse notices that a patient's urine output is below the expected amount. What should the nurse do next? A. Obtain an order for a Foley catheter. B. Obtain an order for a straight catheter. C. Perform a bladder scan test. D. Refer the patient to a urologist. ANS: C If urine output is below the expected value, then the nurse should perform a bladder scan according to institutional policy to check for retention. When assessing a patient's lungs, the nurse recalls that the left lung: consists of two lobes During an examination of a child, the nurse considers that physical growth is the best index of a child's: A) general health. B) genetic makeup. C) nutritional status. D) activity and exercise patterns. A The nurse is assessing a patients skin during an office visit. What part of the hand and technique should be used to best assess the patients skin temperature? a. Fingertips; they are more sensitive to small changes in temperature. b. Dorsal surface of the hand; the skin is thinner on this surface than on the palms. c. Ulnar portion of the hand; increased blood supply in this area enhances temperature sensitivity. d. Palmar surface of the hand; this surface is the most sensitive to temperature variations because of its increased nerve supply in this area. B A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having "black stools" for the last 24 hours. How would the nurse best document his reason for seeking care? a.J.M. is a 59-year-old man seeking treatment for ulcerative colitis. b.J.M. came into the clinic complaining of having black stools for the past 24 hours. c.J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it checked. d.J.M. is a 59-year-old man who states that he has been having "black stools" for the past 24 hours. D