Fundamentals Ch 1-40 Updated Questions With Complete
Solutions
Why does the nurse utilize a head-to-toe approach when
performing physical examinations of patients?
a. The head-to-toe format excludes unnecessary body systems.
b. It is a methodical way to include all body systems.
c. It reduces time by allowing examination of only one side.
d. It requires that painful procedures be done first.
B
The nurse is assessing a patient with suspicious bruises. Which
action is most appropriate to facilitate an accurate account of the
patient's injuries?
a. Ask the patient's family member to wait outside in the waiting
room.
b. Ignore the bruises because the patient has provided an
explanation.
c. Realize that the patient may be abused, but that is a family
issue.
d. Provide referrals for health counseling once the assessment is
complete.
A
The mother of a small infant is surprised when the clinic scale
indicates a 1-pound weight gain from the scale used that
morning at
home. What is the appropriate response of the nurse?
,a. "Babies have significantly different weights throughout the
day."
b. "Variations occur because of the weight of the baby's
clothing."
c. "Weight variation of 1 to 2 pounds is common for most
scales."
d. "Weight measurements can vary with different scales."
D
How can the nurse most accurately assess the skin tone for an
older adult African American patient with deeply pigmented
skin?
a. Utilize fluorescent lighting.
b. Turn up the heat in the room.
c. Utilize natural sunlight.
d. Turn down the temperature in the room.
C
The patient is brought in after collapsing outside on a very hot
day. Which assessment finding will the nurse expect to note
during
physical examination of the patient?
a. Pallor of the patient's extremities
b. Cyanosis of the patient's nail beds and lips
c. Dry mucus membranes and poor skin turgor
d. Lower extremity edema and a generalized itchy rash
C
,The nurse is caring for a patient who has a dangerously low
platelet count. Which assessment finding will the nurse expect to
note
during physical examination of the patient?
a. Bright yellow jaundice in the sclera of the patient's eyes
b. Pinpoint red spots on the skin of the patient's torso
c. Dry, flaky skin with evidence of frequent scratching
d. Thick indurated skin across the patient's back
B
Which assessment finding will the nurse expect to note during
physical examination of the patient with a cast on the lower left
leg?
a. The patient's left foot has a musty, fetid smell
b. The patient's left foot has 3+ pitting edema and pallor.
c. The temperature of the left foot is the same as the right foot.
d. The patient's left foot is cool with thin, shiny skin.
C
The nurse is caring for a dehydrated, confused patient whose
breath smells like fruity bubble gum. What is the priority action
of the
nurse based on these assessment findings?
a. Check the patient's pulse oximetry.
b. Check the patient's oral mucosa for thrush.
c. Check the patient's blood sugar.
d. Check the patient's sclerae for jaundice.
C
, The nurse notes that the patient has bilateral entropion. What
will the nurse plan to do as a result of this assessment finding?
a. Instruct the patient to rinse the mouth gently with warm saline
solution.
b. Clean the patient's eyelids gently and apply antibiotic
ointment.
c. Place a wedge pillow between the patient's legs to prevent
crossing at the hip.
d. Elevate the head of the patient's bed and administer
supplemental oxygen.
B
The patient has red, itchy eyes with thick yellow drainage. What
will the nurse plan to do as a result of this assessment finding?
a. Apply antibiotic eyedrops and use alcohol-based hand
sanitizer before and after caring for the patient.
b. Assess the patient's visual fields and compare results from
each of the patient's eyes.
c. Ask the patient about any history of hyperthyroid disease,
hypertension, or Addison's disease.
d. Instruct the patient not to pluck or wax the eyebrows until the
eye infection symptoms have resolved completely.
A
Which assessment finding will the nurse expect to note during
physical examination of the patient with a history of
uncontrolled
hyperthyroid disease?
a. Exophthalmos
Solutions
Why does the nurse utilize a head-to-toe approach when
performing physical examinations of patients?
a. The head-to-toe format excludes unnecessary body systems.
b. It is a methodical way to include all body systems.
c. It reduces time by allowing examination of only one side.
d. It requires that painful procedures be done first.
B
The nurse is assessing a patient with suspicious bruises. Which
action is most appropriate to facilitate an accurate account of the
patient's injuries?
a. Ask the patient's family member to wait outside in the waiting
room.
b. Ignore the bruises because the patient has provided an
explanation.
c. Realize that the patient may be abused, but that is a family
issue.
d. Provide referrals for health counseling once the assessment is
complete.
A
The mother of a small infant is surprised when the clinic scale
indicates a 1-pound weight gain from the scale used that
morning at
home. What is the appropriate response of the nurse?
,a. "Babies have significantly different weights throughout the
day."
b. "Variations occur because of the weight of the baby's
clothing."
c. "Weight variation of 1 to 2 pounds is common for most
scales."
d. "Weight measurements can vary with different scales."
D
How can the nurse most accurately assess the skin tone for an
older adult African American patient with deeply pigmented
skin?
a. Utilize fluorescent lighting.
b. Turn up the heat in the room.
c. Utilize natural sunlight.
d. Turn down the temperature in the room.
C
The patient is brought in after collapsing outside on a very hot
day. Which assessment finding will the nurse expect to note
during
physical examination of the patient?
a. Pallor of the patient's extremities
b. Cyanosis of the patient's nail beds and lips
c. Dry mucus membranes and poor skin turgor
d. Lower extremity edema and a generalized itchy rash
C
,The nurse is caring for a patient who has a dangerously low
platelet count. Which assessment finding will the nurse expect to
note
during physical examination of the patient?
a. Bright yellow jaundice in the sclera of the patient's eyes
b. Pinpoint red spots on the skin of the patient's torso
c. Dry, flaky skin with evidence of frequent scratching
d. Thick indurated skin across the patient's back
B
Which assessment finding will the nurse expect to note during
physical examination of the patient with a cast on the lower left
leg?
a. The patient's left foot has a musty, fetid smell
b. The patient's left foot has 3+ pitting edema and pallor.
c. The temperature of the left foot is the same as the right foot.
d. The patient's left foot is cool with thin, shiny skin.
C
The nurse is caring for a dehydrated, confused patient whose
breath smells like fruity bubble gum. What is the priority action
of the
nurse based on these assessment findings?
a. Check the patient's pulse oximetry.
b. Check the patient's oral mucosa for thrush.
c. Check the patient's blood sugar.
d. Check the patient's sclerae for jaundice.
C
, The nurse notes that the patient has bilateral entropion. What
will the nurse plan to do as a result of this assessment finding?
a. Instruct the patient to rinse the mouth gently with warm saline
solution.
b. Clean the patient's eyelids gently and apply antibiotic
ointment.
c. Place a wedge pillow between the patient's legs to prevent
crossing at the hip.
d. Elevate the head of the patient's bed and administer
supplemental oxygen.
B
The patient has red, itchy eyes with thick yellow drainage. What
will the nurse plan to do as a result of this assessment finding?
a. Apply antibiotic eyedrops and use alcohol-based hand
sanitizer before and after caring for the patient.
b. Assess the patient's visual fields and compare results from
each of the patient's eyes.
c. Ask the patient about any history of hyperthyroid disease,
hypertension, or Addison's disease.
d. Instruct the patient not to pluck or wax the eyebrows until the
eye infection symptoms have resolved completely.
A
Which assessment finding will the nurse expect to note during
physical examination of the patient with a history of
uncontrolled
hyperthyroid disease?
a. Exophthalmos
