Health Assessment Final Exam

Front 1

While auscultating heart sounds, the nurse hears a murmur What should be used to assess it?

Back 1

The bell of the stethoscope

Front 2

The nurse is testing a pt's visual accommodation, which refers to:

Back 2

Pupillary constriction when looking at a near object

Front 3

In using the ophtalmoscope to assess a pt's eyes the nurse notes a red glow in the pupils. What does the nurse do?

Back 3

Consider it a normal reflection of the light off the inner retina

Front 4

Preparing to do an otoscopic exam on a 2 yr old. What is correct procedure?

Back 4

Pull pinna down

Front 5

When using otoscope to assess the nasal cavity, what does the nurse need to do?

Back 5

Avoid touching the nasal septum w/ the speculum

Front 6

During assessment of a 20 yr old pt w/ 3-day history of N/V, nurse notes dry mucosa, deep fissures on tongue. Reflective of:

Back 6

Dehydration

Front 7

When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are:

Back 7

Aortic & pulmonic

Front 8

Assessmt of 70 yr old - swelling in ankles, jugular venous pulsations. This indicates?

Back 8

Increased pressure in the right side of his heart

Front 9

During assessmt of healthy adult, where would you palpate the apical pulse?

Back 9

Fifth left intercostal space MCL

Front 10

While counting apical pulse on 16 yr old, nurse notes irregular rhythm - speeds up on inspiration, slows on exhalation - What is the nurse's response?

Back 10

NO response - normal!

Front 11

If a mother hides a block under her baby's blanket & baby looks for it, the nurse knows that the baby has begun what concept?

Back 11

Object permanence

Front 12

The nurse is checking ROM in pts knee & knows the knee is capable of what movements?

Back 12

Flexion and extension

Front 13

A pt's annual phx exam reveals lateral curvature of thoracic & lumbar segments of spine. Dissapears when forward bending. This is called:

Back 13

Functional scoliosis

Front 14

When examining the face, what 2 prs of salivary glands are accessible to exam?

Back 14

Parotid & submandibular

Front 15

Pts lab data reveal an elevated thyroxine level. What needs examination?

Back 15

Thyroid

Front 16

A non cancerous thyroid nodule is a lump that:

Back 16

Is mobile and not hard

Front 17

Four areas of the body where lymph nodes are accessible:

Back 17

Head & neck, arms, inguinal area, axillae

Front 18

Severe HA in frontotemporal area, throbbing & somewhat relieved when lying down. Mother also had these HA's. What type?

Back 18

Migraine

Front 19

Hyperthyroidism - thyroxine & T3 levels are elevated, what finding would be likely on examination?

Back 19

Tachycardia

Front 20

What is a bruit?

Back 20

Soft, whooshing, pulsatile sound best heard w/ bell of stethoscope

Front 21

What is a characteristic of culture?

Back 21

Adapts to specific environmental factors & available natural resources

Front 22

Describe culturally competent care

Back 22

The caregiver understands & attends to the total contxt of the pts situation

Front 23

15 mo old son - mother at a loss for answers about behavior & appetite. What does the nurse do?

Back 23

Determine whether she is primary caregiver for her son

Front 24

If an American Indian comes to the clinic for care the nurse can expect that:

Back 24

She may also be seeking assistance of shaman or medicine man

Front 25

After completing initial assessmt nurse charts resp are eupnic & pulse is 58. This type of data would be:

Back 25

objective

Front 26

Pt tells nurse he is very nervous and that he "feels hot". This type of data would be:

Back 26

Subjective

Front 27

An example of objective info obtained during the phx assessmt would be: hx of allergy, use of meds, LMP, scar

Back 27

2X5cm scar on rt lower forearm

Front 28

Which technique uses sense of touch? Palpation, inspection, percussion, auscultation?

Back 28

Palpation

Front 29

What does an otoscope do?

Back 29

Directs light into the ear canal & onto the tympanic membrane

Front 30

What is an important fact about the epidermis?

Back 30

Replaced every 4 weeks

Front 31

What is an important fact about the dermis?

Back 31

Contains sensory receptors

Front 32

Pt says "I sweat a lot but it doesn't have odor." This could be related to:

Back 32

Eccrine glands

Front 33

80 yr old man w/ skin that is thin, lax, wrinkled and dry. Related to:

Back 33

Increased loss of elastin & decrease in subcutanous fat in the elderly

Front 34

Pt has excess dryness of the skin - described as:

Back 34

Xerosis

Front 35

65 yr old w/ emphysema & bronchitis, what is expected on examination of skin:

Back 35

Clubbing of the nails

Front 36

Pt w/ "terrible itch" for seceral mos that he has been scratching continuously. Nurse might expect to find:

Back 36

Lichenification

Front 37

Purpura would be seen as:

Back 37

Confluent & extensive patch of petechiae & ecchymosis

Front 38

What is the vertebra prominens?

Back 38

Spinous process of C7

Front 39

Costal angle of 90*. This characteristic is:

Back 39

Normal finding in a healthy adult

Front 40

Normal to feel tactile fremitus most intensely over which location?

Back 40

3rd intercostal space MCL

Front 41

Trachea bifurcates anteriorly at the:

Back 41

Sternal angle

Front 42

The primary muscles of respiration are the:

Back 42

Diaphragm and intercostals

Front 43

The most important technique when auscultating on the thorax is:

Back 43

Side-to side comparison

Front 44

When auscultating the chest in an adult, the nurse would:

Back 44

Use the diaphragm of the stethoscope held firmly against the chest

Front 45

Percussion over an area of atelectsis in the lungs would reveal:

Back 45

Dullness

Front 46

A normal finding when assessing the resp system of elderly adult is decreased:

Back 46

mobility of the thorax

Front 47

When inspecting the anterior chest of an adult, the nurse should assess for:

Back 47

The shape & configuration of the chest wall

Front 48

Unequal chest expansion occurs when:

Back 48

Part of the lung is obstructed or collapsed

Front 49

Pt has long hx of COPD. During assessmt nurse most likely observes:

Back 49

An anteroposterior-to-transverse diameter ratio of 1:1

Front 50

During auscultation of breath sounds, the nurse will use the stethoscope correctly as follows:

Back 50

Listen to at least one full resp in each location

Front 51

Nurse suspects injured spleen. What is true regarding assessmt of spleen in this situation?

Back 51

An enlarged spleen should not be palpated because it can rupture easily

Front 52

Abdominal pulsations between the xiphoid & umbilicus aer:

Back 52

Normal abdominal aortic pulsations

Front 53

The main reason auscultation precedes percussion & palpation of the abdomen is to:

Back 53

Prevent distortion of bowel sounds that might occur after percussion & palpation

Front 54

What is true of bowel sounds?

Back 54

They are usually high-pitched, gurgling, irregular sounds

Front 55

Tenderness along the costovertebral angles is most often indicative of:

Back 55

Kidney inflammation

Front 56

A nurse notes pt has ascites, which indicates that which of the following is present? Fluid, feces, flatus, fibroid tumors

Back 56

Fluid

Front 57

Pt has black tarry stool. Possible cause would be:

Back 57

GI bleeding

Front 58

Tenderness on light palpation in RLQ could indicate a disorder of what structure?

Back 58

Appendix

Front 59

Pt asks nurse to explain what a hernia is. What action by nurse is appropriate?

Back 59

Explain that hernia is loop of bowel protruding through weak spot in abdominal muscles

Front 60

18 month old w/ rounded "pot belly" abdomen, marked lordosis, short slightly bowed legs, & large head. Nurse concludes:

Back 60

Child is built like a normal toddler

Front 61

Erikson believes toilet training to be representative of which of his stages?

Back 61

Autonomy v. Shame & Doubt

Front 62

Developmental crisis of generativity versus stagnation could be resolved by:

Back 62

Having and raising a family

Front 63

How would you best describe tasks of late adulthood?

Back 63

Older adults must accept that they cannot change the past & make peace w/ their lives

Front 64

24 month old - mother describes as a child who falls apart if she changes even the smallest thing in his environment. This behavior:

Back 64

Can be expected from a toddler. They typically experience ritualism & global thinking

Front 65

What is an appropriate health & safety issue to teach the parent of an 8 month old?

Back 65

Stair guards or gates are important to use at this stage

Front 66

75 yr old man, during the mental status portion of the exam the nurse can expect:

Back 66

He may take a little longer to respond, but his general knowledge & abilities should not have declined

Front 67

What is the first thing to be assessed with aging adults before making judgements about mental status?

Back 67

Their sensory-perceptive abilities

Front 68

Pt admitted to unit after MVA, during mental exam pts speech is dysarthric & she is lethargic. Best approach to this exam?

Back 68

Plan to defer the rest of the mental status exam

Front 69

Pt in ICU x 10 days. Just been moved to med-surg. During tests of cognitive function the nurse would expect that he:

Back 69

Will be oriented to place & person but may not be certain of the date

Front 70

When evaluating a pt's pain, the nurse knows example of acute pain would be: arthritis, fibromyalgia, kidney stones, low back pain.

Back 70

Kidney stones

Front 71

4 year old points to stomach and says "it hurts so bad". Which pain assessment tool would be the best choice?

Back 71

Wong-Baker Scale (Faces)

Front 72

What is the most reliable indicator of pain?

Back 72

The subjective report

Front 73

When assessing the quality of pt's pain the nurse should ask which question?

Back 73

What does your pain feel like?

Front 74

What is true regarding the internal structures of the breast? (What is it composed of?)

Back 74

Composed of fibrous, glandular, and adipose tissue

Front 75

9 yr old girl says "Am I normal? I don't need a bra yet but my friends do." What is the nurse's best response?

Back 75

I understand it is hard to feel different from your friends, breasts usually develop btw 8-10 yrs old

Front 76

Pt describes unilateral enlargement of rt breast w/ associated tenderness in 10 yr old daughter. What is nurse's best response?

Back 76

Tell mother: exam would rule out a problem, it is most likely normal breast development

Front 77

What are some things the nurse should teach a newly pregnant woman about her breasts?

Back 77

She can expect areolae to become larger & darker in color.

Front 78

Pt states she has noticed pain in left breast. What is nurse's most appropriate response?

Back 78

I would like some more information about the pain in your left breast.

Front 79

43 states she doesn't perform monthly breast self-exams. Tell the nurse mammmograms are better. Nurse should explain:

Back 79

Mammography may not detect all palpable lumps

Front 80

During exam nurse notices left breast is larger than right. What should she do?

Back 80

Finding is not unusual, but nurse should verify that this change is not new

Front 81

What position is most likely to make significant lumps more distinct during breast palpation?

Back 81

Supine w/ arms raised over head

Front 82

Pt states she noticed a lump in her left breast near the axilla. The nurse should plan to:

Back 82

Palpate the unaffected breast first

Front 83

What is the purpose of a functional assessment?

Back 83

With the elderly, it helps to determine how they are managing day-to-day activities

Front 84

Nurse suspects pt may be deficient in iron. What lab studies should be anticipated?

Back 84

Hemoglobin and hematocrit

Front 85

To assess the dorsalis pedis artery the nurse would palpate:

Back 85

Lateral to the extensor tendon of the great toe

Front 86

The documentation of a pt pulse states: radial pulses "2+". This indicates what type of pulse?

Back 86

Normal