N224 Exam 1 QUESTIONS WITH |\ |\ |\ |\ |\
ANSWERS
When performing a physical assessment, the technique you will
|\ |\ |\ |\ |\ |\ |\ |\ |\
always use first is: - CORRECT ANSWERS ✔✔Inspection -
|\ |\ |\ |\ |\ |\ |\ |\ |\
Inspection begins the moment you first meet the person to
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
include the individual as a whole and then each body system
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
The nurse is preparing to use a stethoscope for auscultation.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
Which statement is true regarding the diaphragm of the
|\ |\ |\ |\ |\ |\ |\ |\ |\
stethoscope? The diaphragm: - CORRECT ANSWERS ✔✔is used |\ |\ |\ |\ |\ |\ |\ |\
for high pitched sounds - The diaphragm of the stethoscope is
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
best for listening to high-pitched sounds such as breath, bowel,
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
and normal heart sounds. It should be held firmly against the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
person's skin, firmly enough to leave a ring. The bell of the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
stethoscope is best for soft, low-pitched sounds such as extra |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
heart sounds or murmurs. REF: Page: 113
|\ |\ |\ |\ |\ |\
Which one of the following statements is true regarding correct
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
use of your stethoscope? - CORRECT ANSWERS ✔✔The slope of
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the earpieces should point forwards toward nose - The slope of
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the earpieces should point forward to nose that follows natural
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
curve of the ear canal. The bell of the stethoscope should be
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
lightly applied to the skin. For males with much body hair, wet
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the area to decrease confusing this with abnormal lung sounds
|\ |\ |\ |\ |\ |\ |\ |\ |\
The most important step that the nurse can take to prevent
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
transmission of microorganisms in the hospital setting is to: - |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
CORRECT ANSWERS ✔✔Wash hands before and after contact with
|\ |\ |\ |\ |\ |\ |\ |\
, each patient - The most important step to decrease the risk of
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
microorganism transmission is to wash hands promptly and |\ |\ |\ |\ |\ |\ |\ |\
thoroughly before and after physical contact with each patient.
|\ |\ |\ |\ |\ |\ |\ |\ |\
Stethoscopes should also be cleansed with an alcohol swab |\ |\ |\ |\ |\ |\ |\ |\ |\
before and after each patient contact. The best routine is to
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
combine stethoscope rubbing with hand hygiene each time hand
|\ |\ |\ |\ |\ |\ |\ |\ |\
hygiene is performed. REF: Pg 117 |\ |\ |\ |\ |\
One student nurse asked another student nurse if handwashing
|\ |\ |\ |\ |\ |\ |\ |\ |\
was required after removing gloves. Which one statement below
|\ |\ |\ |\ |\ |\ |\ |\ |\
is an incorrect response? - CORRECT ANSWERS ✔✔Not necessary
|\ |\ |\ |\ |\ |\ |\ |\ |\
if you use sterile technique - Wearing gloves is NOT a protective
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
substitute for washing hands and must always be done after
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
removing gloves. REF: Page: 117 |\ |\ |\ |\
The nurse is performing a general survey. Which action is a
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
component of the general survey? - CORRECT ANSWERS |\ |\ |\ |\ |\ |\ |\ |\
✔✔Observing the patient's body structure and nutritional status - |\ |\ |\ |\ |\ |\ |\ |\
The general survey is a study of the whole person that includes
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
observing the patient's physical appearance, body structure,
|\ |\ |\ |\ |\ |\ |\
mobility, and behavior. Interpreting subjective data is not part of
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the general survey. Measuring the patient's vital signs
|\ |\ |\ |\ |\ |\ |\ |\
(temperature, pulse, respirations, and blood pressure) and |\ |\ |\ |\ |\ |\ |\
observing specific body systems while performing a physical
|\ |\ |\ |\ |\ |\ |\ |\
assessment are part of the physical examination, not the general |\ |\ |\ |\ |\ |\ |\ |\ |\
survey. REF: Page 126
|\ |\ |\ |\
The nurse is assessing an 85-year-old male patient. Which
|\ |\ |\ |\ |\ |\ |\ |\ |\
assessment findings would be considered expected age-related |\ |\ |\ |\ |\ |\ |\
changes? - CORRECT ANSWERS ✔✔Presence of kyphosis and
|\ |\ |\ |\ |\ |\ |\ |\
flexion in bilateral knees and hips - Changes that occur in the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
aging person include postural changes of kyphosis and slight
|\ |\ |\ |\ |\ |\ |\ |\ |\
, flexion in the knees and hips. Other changes that occur with
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
aging include more prominent bony landmarks, decreased body
|\ |\ |\ |\ |\ |\ |\ |\
weight (especially in men), a decrease in subcutaneous fat from
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the face and periphery, and additional fat deposited on the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
abdomen and hips. Changes that occur in the aging person |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
include decreased body weight (especially in men), not increased
|\ |\ |\ |\ |\ |\ |\ |\
body weight; a decrease in subcutaneous fat from the face and
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
periphery, not an increase; and additional fat deposited on the |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
abdomen and hips. Change in overall body proportion does occur
|\ |\ |\ |\ |\ |\ |\ |\ |\
but includes a shorter trunk with relatively longer extremities
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
because long bones do not shorten with age rather than a longer
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
trunk and shorter extremities. REF: Page 136
|\ |\ |\ |\ |\ |\ |\
When assessing a 55-year-old patient who has asthma, the nurse
|\ |\ |\ |\ |\ |\ |\ |\ |\
notes that he assumes a tripod position, leaning forward with
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
arms braced on the chair. How should the nurse interpret these
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
findings? - CORRECT ANSWERS ✔✔Recognize that a tripod |\ |\ |\ |\ |\ |\ |\ |\
position is often used when a patient is having respiratory
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
difficulties - Assuming a tripod position—leaning forward with |\ |\ |\ |\ |\ |\ |\ |\
arms braced on chair arms—occurs with chronic pulmonary
|\ |\ |\ |\ |\ |\ |\ |\
disease. The other actions or assumptions are not correct. REF:
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
Page 128 |\
The nurse is performing a general survey of a patient. Which is
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
an optimal finding? - CORRECT ANSWERS ✔✔Body mass index
|\ |\ |\ |\ |\ |\ |\ |\ |\
(BMI) of 10 - A body mass index (BMI) of 20 is within the range of
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
a healthy weight category (normal BMI is 19-24). When standing,
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
a patient's base should be wide, and an older appearance than
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the stated age may indicate a history of a chronic illness or
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
chronic alcoholism. When performing the general survey, the
|\ |\ |\ |\ |\ |\ |\ |\
patient's arm span (fingertip to fingertip) should equal the
|\ |\ |\ |\ |\ |\ |\ |\ |\
patient's height. An arm span that is greater than the person's
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
height may indicate Marfan syndrome. REF: Pages 127, 128, 130
|\ |\ |\ |\ |\ |\ |\ |\ |\
ANSWERS
When performing a physical assessment, the technique you will
|\ |\ |\ |\ |\ |\ |\ |\ |\
always use first is: - CORRECT ANSWERS ✔✔Inspection -
|\ |\ |\ |\ |\ |\ |\ |\ |\
Inspection begins the moment you first meet the person to
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
include the individual as a whole and then each body system
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
The nurse is preparing to use a stethoscope for auscultation.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
Which statement is true regarding the diaphragm of the
|\ |\ |\ |\ |\ |\ |\ |\ |\
stethoscope? The diaphragm: - CORRECT ANSWERS ✔✔is used |\ |\ |\ |\ |\ |\ |\ |\
for high pitched sounds - The diaphragm of the stethoscope is
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
best for listening to high-pitched sounds such as breath, bowel,
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
and normal heart sounds. It should be held firmly against the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
person's skin, firmly enough to leave a ring. The bell of the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
stethoscope is best for soft, low-pitched sounds such as extra |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
heart sounds or murmurs. REF: Page: 113
|\ |\ |\ |\ |\ |\
Which one of the following statements is true regarding correct
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
use of your stethoscope? - CORRECT ANSWERS ✔✔The slope of
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the earpieces should point forwards toward nose - The slope of
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the earpieces should point forward to nose that follows natural
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
curve of the ear canal. The bell of the stethoscope should be
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
lightly applied to the skin. For males with much body hair, wet
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the area to decrease confusing this with abnormal lung sounds
|\ |\ |\ |\ |\ |\ |\ |\ |\
The most important step that the nurse can take to prevent
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
transmission of microorganisms in the hospital setting is to: - |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
CORRECT ANSWERS ✔✔Wash hands before and after contact with
|\ |\ |\ |\ |\ |\ |\ |\
, each patient - The most important step to decrease the risk of
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
microorganism transmission is to wash hands promptly and |\ |\ |\ |\ |\ |\ |\ |\
thoroughly before and after physical contact with each patient.
|\ |\ |\ |\ |\ |\ |\ |\ |\
Stethoscopes should also be cleansed with an alcohol swab |\ |\ |\ |\ |\ |\ |\ |\ |\
before and after each patient contact. The best routine is to
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
combine stethoscope rubbing with hand hygiene each time hand
|\ |\ |\ |\ |\ |\ |\ |\ |\
hygiene is performed. REF: Pg 117 |\ |\ |\ |\ |\
One student nurse asked another student nurse if handwashing
|\ |\ |\ |\ |\ |\ |\ |\ |\
was required after removing gloves. Which one statement below
|\ |\ |\ |\ |\ |\ |\ |\ |\
is an incorrect response? - CORRECT ANSWERS ✔✔Not necessary
|\ |\ |\ |\ |\ |\ |\ |\ |\
if you use sterile technique - Wearing gloves is NOT a protective
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
substitute for washing hands and must always be done after
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
removing gloves. REF: Page: 117 |\ |\ |\ |\
The nurse is performing a general survey. Which action is a
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
component of the general survey? - CORRECT ANSWERS |\ |\ |\ |\ |\ |\ |\ |\
✔✔Observing the patient's body structure and nutritional status - |\ |\ |\ |\ |\ |\ |\ |\
The general survey is a study of the whole person that includes
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
observing the patient's physical appearance, body structure,
|\ |\ |\ |\ |\ |\ |\
mobility, and behavior. Interpreting subjective data is not part of
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the general survey. Measuring the patient's vital signs
|\ |\ |\ |\ |\ |\ |\ |\
(temperature, pulse, respirations, and blood pressure) and |\ |\ |\ |\ |\ |\ |\
observing specific body systems while performing a physical
|\ |\ |\ |\ |\ |\ |\ |\
assessment are part of the physical examination, not the general |\ |\ |\ |\ |\ |\ |\ |\ |\
survey. REF: Page 126
|\ |\ |\ |\
The nurse is assessing an 85-year-old male patient. Which
|\ |\ |\ |\ |\ |\ |\ |\ |\
assessment findings would be considered expected age-related |\ |\ |\ |\ |\ |\ |\
changes? - CORRECT ANSWERS ✔✔Presence of kyphosis and
|\ |\ |\ |\ |\ |\ |\ |\
flexion in bilateral knees and hips - Changes that occur in the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
aging person include postural changes of kyphosis and slight
|\ |\ |\ |\ |\ |\ |\ |\ |\
, flexion in the knees and hips. Other changes that occur with
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
aging include more prominent bony landmarks, decreased body
|\ |\ |\ |\ |\ |\ |\ |\
weight (especially in men), a decrease in subcutaneous fat from
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the face and periphery, and additional fat deposited on the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
abdomen and hips. Changes that occur in the aging person |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
include decreased body weight (especially in men), not increased
|\ |\ |\ |\ |\ |\ |\ |\
body weight; a decrease in subcutaneous fat from the face and
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
periphery, not an increase; and additional fat deposited on the |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
abdomen and hips. Change in overall body proportion does occur
|\ |\ |\ |\ |\ |\ |\ |\ |\
but includes a shorter trunk with relatively longer extremities
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
because long bones do not shorten with age rather than a longer
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
trunk and shorter extremities. REF: Page 136
|\ |\ |\ |\ |\ |\ |\
When assessing a 55-year-old patient who has asthma, the nurse
|\ |\ |\ |\ |\ |\ |\ |\ |\
notes that he assumes a tripod position, leaning forward with
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
arms braced on the chair. How should the nurse interpret these
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
findings? - CORRECT ANSWERS ✔✔Recognize that a tripod |\ |\ |\ |\ |\ |\ |\ |\
position is often used when a patient is having respiratory
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
difficulties - Assuming a tripod position—leaning forward with |\ |\ |\ |\ |\ |\ |\ |\
arms braced on chair arms—occurs with chronic pulmonary
|\ |\ |\ |\ |\ |\ |\ |\
disease. The other actions or assumptions are not correct. REF:
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
Page 128 |\
The nurse is performing a general survey of a patient. Which is
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
an optimal finding? - CORRECT ANSWERS ✔✔Body mass index
|\ |\ |\ |\ |\ |\ |\ |\ |\
(BMI) of 10 - A body mass index (BMI) of 20 is within the range of
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
a healthy weight category (normal BMI is 19-24). When standing,
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
a patient's base should be wide, and an older appearance than
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the stated age may indicate a history of a chronic illness or
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
chronic alcoholism. When performing the general survey, the
|\ |\ |\ |\ |\ |\ |\ |\
patient's arm span (fingertip to fingertip) should equal the
|\ |\ |\ |\ |\ |\ |\ |\ |\
patient's height. An arm span that is greater than the person's
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
height may indicate Marfan syndrome. REF: Pages 127, 128, 130
|\ |\ |\ |\ |\ |\ |\ |\ |\
