NR 302 Health Assessment Final Exam with 100% Correct Answers

The retinal structures viewed through the ophthalmoscope are: - Correct answer-optic disc, vessels, macula, background "Positive consensual light reflex" means... - Correct answer-simultaneous constriction The thickening and yellowing of the lens due to aging is described as: - Correct answer- cataract Eye emergency - Correct answer-sudden change in vision Visual acuity is assessed with: - Correct answer-Snellen eye chart The cover test is used to assess for: - Correct answer-muscle weakness When using the ophthalmoscope, you would: - Correct answer-remove your own glasses and approach the patient's left eye with your left eye The 6 eye muscles that control eye movement are innervated by cranial nerves: - Correct answer-III, IV, VI Conjunctivitis - Correct answer-redness of the conjunctiva normal peripheral vision would see finger at - Correct answer-90 degrees patient blind in left eye, what happens when light in right - Correct answer-both constrict interruption of red reflex happens when - Correct answer-there is opacity of cornea or lens One cause of visual impairment in aging adults is: - Correct answer-glaucoma PERRLA - Correct answer-pupils equal, round, reactive to light and accommodation cause of red reflex - Correct answer-light reflecting from the retina color of tympanic membrane - Correct answer-pearly gray sensioneural hearing loss - Correct answer-related to gradual nerve degeneration Before ear exam, palate - Correct answer-pinna, tragus, and mastoid process NR 302 Health Assessment Final Exam with 100% Correct Answers Ear exam of 3 year old - Correct answer-pull pinna down ear exam of adult - Correct answer-pull pinna up and back darwin tubercle - Correct answer-a congenital, painless nodule at the helix when assessing patients ear - Correct answer-tilt head away from examiner The hearing receptors are located in the - Correct answer-cochlea The sensation of vertigo may indicate: - Correct answer-pathology in the semicircular canals common cause of conductive hearing loss - Correct answer-impacted cerumen Signs of ear infection - Correct answer-absent light reflex, red and bulging drum Reducing risk of ear infection - Correct answer-dont smoke in house or car assessing hearing in babies - Correct answer-watch for head turn when you call their name patient w head injury has clear watery drainage from ear - Correct answer-consider possible basal skull fracture, refer immediately common site of nose bleeds - Correct answer-kiesselbach plexus Which sinuses can you assess through examination? - Correct answer-frontal and maxillary the frenulum is the - Correct answer-midline fold of tissue that connects the tongue to the floor of the mouth The largest salivary gland is located: - Correct answer-within the cheeks in front of the ear old woman with dry mouth - Correct answer-medication find a deviated septum, what next - Correct answer-document in case it needs suction Oral malignancies are most likely to develop: - Correct answer-in the mucosal "gutter" under the tongue tonsils 3+ - Correct answer-tonsils touch the uvula function of nasal turbinates - Correct answer-warm the inhaled air Opening of adult's parotid gland is opposite what? - Correct answer-upper 2nd molar A nasal polyp is distinguished from the nasal turbinates by 3 things - Correct answer- moveable, pale/gray, nontender The examiner notes small, round, white, shiny papules on the hard palate and gums of a 2-month-old infant. What is the significance of this finding? - Correct answer-epstein pearls, normal when assessing tongue - Correct answer-palpate u shaped area under tongue expected finding of 75 year old oral cavity - Correct answer-decreased ability to identify odors african american with flat, 3cm, nontender, gray/white lesion on bucal mucosa - Correct answer-leukodema, normal The manubriosternal angle is - Correct answer-the articulation of the manubrium and the body of the sternum description of left lung - Correct answer-narrower than the right lung with two lobes Documentation of cough - Correct answer-productive cough for at least 3 months throughout the year, happens last two years Confirm symmetric chest expansion - Correct answer--Place hands on posterior chest wall thumbs at T9 or T10 slide medially pinch up skin between thumbs Auscultation of breath sounds - Correct answer-Hold the diaphragm of the stethoscope against the chest wall; listen to one full respiration in each location, being sure to do side to side comparisons Bronchiovesicular breath sounds - Correct answer-medium-pitched, moderately loud sounds heard over the mainstem bronchi; inspiration = expiration Fever, increased respiratory rate, chest expansion decresed on left side, dull to percussion over left low lobe, loud breath sounds w crackles on low left lobe - Correct answer-lobar pneumonia angle of nail is less than 160 and spongy, indicates- - Correct answer-congenital heart disease and COPD Coarse and low pitched sound heard on inspiration and expiration and accompanied by pain with breathing. - Correct answer-Pleural friction rub egophony test - Correct answer-patient says "eeee" when diaphragm moved Examine for tactile fremitus - Correct answer-palpate chest symmetrically pulse oximetry measure - Correct answer-arterial oxygen saturation of hemoglobin pleural friction rub best detected by - Correct answer-auscultation A barrel-shaped chest is characterized by: - Correct answer-equal anteroposterior transverse diameter and ribs being horizontal Apex - Correct answer-3 to 4cm above inner third of clavicles base - Correct answer-rests on diaphragm Lateral left - Correct answer-6th rib, midclavicular line lateral right - Correct answer-fifth intercostal posterior apex - Correct answer-C7 normal chest - Correct answer-Elliptic shape with an anteroposterior to transverse diameter in the ratio of 1:2 barrel chest - Correct answer-anteroposterior = transverse diameter pectus excavatum - Correct answer-sunken sternum and adjacent cartilages pectus carinatum - Correct answer-forward protrusion of the sternum Scoliosis - Correct answer-abnormal lateral curvature of the spine kyphosis - Correct answer-excessive outward curvature of the spine, causing hunching of the back. the precordium is - Correct answer-the area on the anterior chest overlying the heart and great vessels Description of Tricuspid Valve - Correct answer-right atrioventricular valve function of pulmonic valve - Correct answer-protect the orifice between the right ventricle and the pulmonary artery atrial systoles occurs during - Correct answer-ventricular diastole second heart sound is result of - Correct answer-closing of the aortic and pulmonic valves Abnormal finding of jugular venous pressure - Correct answer-patient elevated to 45 degrees , Internal jugular vein pulsation at 4 cm above sternal angle normal sized apical impulse - Correct answer-1 x 2 cm Auscultation of Pulmonic Area - Correct answer-2nd intercostal space what differentiates a split s2 from s3 - Correct answer-S3 is lower pitched and is heard at the apex assessment to rule out pericardial friction rub - Correct answer-listen with diaphragm, patient sitting up and leaning forward, holding breath in expiration First step in auscultating the heart - Correct answer-identify S1 and S2 You will hear a split S2 most clearly in which area? - Correct answer-pulmonic bell should be pressed lightly against skin so that - Correct answer-is does not act as a diaphragm A murmur heard after S1 and before S2 is classified as: - Correct answer-systolic, possibly benign Assessment of carotid artery - Correct answer-palpate medial to sternomastoid muscle, one side at a time S1 is best heard at the of the heart, whereas S2 is loudest at the of the heart. S1 coincides with the pulse in the and coincides with the wave if the patient is on an ECG monitor. - Correct answer-S1 heard at apex, S2 at base, S1 pulse coinsides with carotid artery and R wave tough, fibrous, double-walled sac that surrounds and protects the heart - Correct answer-pericardium thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves - Correct answer-endocardium reservoir for holding blood - Correct answer-atrium ensures smooth, friction-free movement of the heart muscle - Correct answer- pericardial fluid Muscular pumping chamber - Correct answer-ventricle muscular wall of heart - Correct answer-myocardium Biomedical model - Correct answer-the Western European/North American tradition that views health as the absence of disease The concept of health and healing has evolved in recent years. Which is the best description of health? - Correct answer-Health depends on an interaction of mind, body, and spirit within the environment What would be included in a database for a new patient admission to surgical unit? - Correct answer-All subjective and objective data, data gathered from patient, and results of any labs or imagine You are reviewing assessment data of a 45 year old male patient and note pain of 8/10, labored breathing and pale. This documentation is an example of - Correct answer-data cluster A patient is in the emergency department with nausea and vomiting. Which would you include in the database? - Correct answer-A diet and GI history A patient has recently received health insurance and would like to know how often to see his provider. How do you respond? - Correct answer-Your visits may very, depending on your level of wellness You are reviewing concepts related to steps in the nursing process for determining prioritization and developing patient outcomes. To what are these actions attributed? - Correct answer-planning Which best describes evidence based practice? - Correct answer-Combining clinical expertise with the use of nursing research to provide the best care for patients while considering the patient's values and circumstances What can be determined when the nurse clusters data as part of the critical-thinking process? - Correct answer-The nurse recognizes relevant information among the data A patient says she is very nervous and nauseated, and she feels as if she will vomit. This is what type of data? - Correct answer-Subjective The expert nurse differs from the novice nurse by acting without consciously thinking about the actions. This is referred to as - Correct answer-intuition Which would be considered a risk diagnosis? - Correct answer-Identifying potential problems the individual may develop