HESI Prep – Health Assessment Practice Questions – Flashcards
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1. In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking? A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors. B) Note-taking allows the patient to continue at his or her own pace as the nurse records what is said. C) Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level. D) Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort.
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A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors. Page: 31 Some use of history forms and note-taking may be unavoidable. But be aware that note-taking during the interview has disadvantages. It breaks eye contact too often, and it shifts attention away from the patient, which diminishes his or her sense of importance. It also may interrupt the patient's narrative flow, and it impedes the observation of the patient's nonverbal behavior.
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2. During an interview, the nurse states, "You mentioned shortness of breath. Tell me more about that." Which verbal skill is used with this statement? A) Reflection B) Facilitation C) Direct question D) Open-ended question
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D) Open-ended question Page: 32 The open-ended question asks for narrative information. It states the topic to be discussed but only in general terms. The nurse should use it to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic.
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3. A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, "You don't smoke, drink, or take drugs, do you?" This question is an example of: A) talking too much. B) using confrontation. C) using biased or leading questions. D) using blunt language to deal with distasteful topics.
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C) using biased or leading questions. Page: 36 This is an example of using leading or biased questions. Asking, "You don't smoke, do you?" implies that one answer is "better" than another. If the person wants to please someone, he or she is either forced to answer in a way corresponding to their implied values or is made to feel guilty when admitting the other answer.
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4. During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his son's treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This would suggest that the parent is: A) just changing positions. B) more comfortable in this position. C) tired and needs a break from the interview. D) uncomfortable talking about his son's treatment.
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D) uncomfortable talking about his son's treatment. Page: 37 Note the person's position. An open position with the extension of large muscle groups shows relaxation, physical comfort, and a willingness to share information. A closed position with the arms and legs crossed tends to look defensive and anxious. Note any change in posture. If a person in a relaxed position suddenly tenses, it suggests possible discomfort with the new topic.
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5. The nurse is interviewing a patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient? A) Determine the communication method he prefers. B) Avoid using facial and hand gestures because most hearing-impaired people find this degrading. C) Request a sign language interpreter before meeting with him to help facilitate the communication. D) Speak loudly and with exaggerated facial movement when talking with him because this helps with lip reading.
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A) Determine the communication method he prefers. Pages: 40-41 The nurse should ask the deaf person the preferred way to communicate—by signing, lip reading, or writing. If the person prefers lip reading, then the nurse should be sure to face him or her squarely and have good lighting on the nurse's face. The nurse should not exaggerate lip movements because this distorts words. Similarly, shouting distorts the reception of a hearing aid the person may wear. The nurse should speak slowly and should supplement his or her voice with appropriate hand gestures or pantomime.
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6. The nurse is performing a health interview on a patient who has a language barrier, and no interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation? A) "Do you take medicine?" B) "Do you sterilize the bottles?" C) "Do you have nausea and vomiting?" D) "You have been taking your medicine, haven't you?"
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A) "Do you take medicine?" Page: 46 In a situation where there is a language barrier and no interpreter available, use simple words avoiding medical jargon. Avoid using contractions and pronouns. Use nouns repeatedly and discuss one topic at a time.
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7. A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice? A) A trained interpreter B) A male family member C) A female family member D) A volunteer college student from the foreign language studies department
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A) A trained interpreter Page: 46 whenever possible, the nurse should use a trained interpreter, preferably one who knows medical terminology. In general, an older, more mature interpreter is preferred to a younger, less experienced one, and the same gender is preferred when possible.
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8. The nurse is conducting an interview. Which of these statements is true regarding open-ended questions? Select all that apply. A) They elicit cold facts. B) They allow for self-expression. C) They build and enhance rapport. D) They leave interactions neutral. E) They call for short one- to two-word answers. F) They are used when narrative information is needed.
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B) They allow for self-expression. C) They build and enhance rapport. F) They are used when narrative information Page: 32 Open-ended questions allow for self-expression, build rapport, and obtain narrative information. These features enhance communication during an interview. The other statements are appropriate for closed or direct questions.
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9. The nurse is conducting an interview in an outpatient clinic and is using a computer to record data. Which is the best use of the computer in this situation? Select all that apply. A) Collect the patient's data in a direct, face-to-face manner. B) Enter all the data as the patient states it. C) Ask the patient to wait as the nurse enters data. D) Type the data into the computer after the narrative is fully explored. E) Allow the patient to see the monitor during typing.
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A) Collect the patient's data in a direct, face-to-face manner. D) Type the data into the computer after the narrative is fully explored. E) Allow the patient to see the monitor during typing. Page: 32 The use of a computer can become a barrier. The nurse should begin the interview as usual by greeting the patient, establishing rapport, and collecting the patient's narrative story in a direct face-to-face manner. Only after the narrative is fully explored should the nurse type data into the computer. When typing, the nurse should position the monitor so that the patient can see it.
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10. During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate? A) Ask the patient about the item and its significance. B) Ask the patient to lock the item with other valuables in the hospital's safe. C) Tell the patient that a family member should take valuables home. D) No action is necessary.
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A) Ask the patient about the item and its significance. Page: 21 The nurse should inquire about the amulet's meaning. Amulets, such as charms, are often seen as an important means of protection from "evil spirits" by some cultures.
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11. In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this is true, probably because Mexican-Americans: A) have less efficient immune systems and are often ill. B) consider these symptoms a part of normal living, not symptoms of ill health. C) come from Mexico and coughing is normal and healthy there. D) are usually in a lower socioeconomic group and are more likely to be sick.
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B) consider these symptoms a part of normal living, not symptoms of ill health. Page: 27 The nurse needs to identify the meaning of health to the patient, remembering that concepts are derived, in part, from the way in which members of the cultural group define health.
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12. Among many Asians there is a belief in the yin/yang theory, rooted in the ancient Chinese philosophy of Tao. The nurse recognizes which statement that most accurately reflects "health" in an Asian with this belief? A) A person is able to work and produce. B) A person is happy, stable, and feels good. C) All aspects of the person are in perfect balance. D) A person is able to care for others and function socially.
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C) All aspects of the person are in perfect balance. Page: 21 Many Asians believe in the yin/yang theory, in which health is believed to exist when all aspects of the person are in perfect balance. The other statements do not describe this theory.
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13. An individual who takes the magicoreligious perspective of illness and disease is likely to believe that his or her illness was caused by: A) germs and viruses. B) supernatural forces. C) eating imbalanced foods. D) an imbalance within his or her spiritual nature.
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B) supernatural forces. Page: 21 The basic premise of the magicoreligious perspective is that the world is seen as an arena in which supernatural forces dominate. The fate of the world and those in it depends on the actions of supernatural forces for good or evil. The other answers do not reflect the magicoreligious perspective.
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14. If an American Indian has come to the clinic to seek help with regulating her diabetes, the nurse can expect that she: A) will comply with the treatment prescribed. B) has obviously given up her beliefs in naturalistic causes of disease. C) may also be seeking the assistance of a shaman or medicine man. D) will need extra help in dealing with her illness and may be experiencing a crisis of faith.
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C) may also be seeking the assistance of a shaman or medicine man. Page: 23 When self-treatment is unsuccessful, the individual may turn to the lay or folk healing systems, to spiritual or religious healing, or to scientific biomedicine. In addition to seeking help from a biomedical or scientific health care provider, patients may also seek help from folk or religious healers.
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15. An elderly Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally-sensitive nurse would: A) contact the hospital administrator about the best course of action. B) automatically get a curandero for her because it is not culturally appropriate for her to request one. C) further assess the patient's cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires. D) ask the family what they would like to do because Mexican-Americans traditionally give control of decisions to their families.
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C) further assess the patient's cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires. Pages: 22-23 In addition to seeking help from the biomedical/scientific health care provider, patients may also seek help from folk or religious healers. Some people, such as those of Mexican-American or American Indian origins, may believe that the cure is incomplete unless the body, mind, and spirit are also healed (although the division of the person into parts is a Western concept).
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16. The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain? A) All patients will behave the same way when in pain. B) Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain. C) Cultural norms have very little to do with pain tolerance, because pain tolerance is always biologically determined. D) A patient's expression of pain is largely dependent on the amount of tissue injury associated with the pain.
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B) Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain. Page: 25 In addition to expecting variations in pain perception and tolerance, the nurse should expect variations in the expression of pain. It is well known that individuals turn to their social environment for validation and comparison. The other statements are incorrect.
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17. The nurse recognizes that working with children with a different cultural perspective may be especially difficult because: A) children have spiritual needs that are influenced by their stages of development. B) children have spiritual needs that are direct reflections of what is occurring in their homes. C) religious beliefs rarely affect the parents' perceptions of the illness. D) parents are often the decision makers, and they have no knowledge of their children's spiritual needs.
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A) children have spiritual needs that are influenced by their stages of development. Page: 20. Illness during childhood may be an especially difficult clinical situation. Children, as well as adults, have spiritual needs that vary according to the child's developmental level and the religious climate that exists in the family. The other statements are not correct.
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18. When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an elderly American Indian patient? A) "Are you of the Christian faith?" B) "Do you want to see a medicine man?" C) "How often do you seek help from medical providers?" D) "What cultural or spiritual beliefs are important to you?"
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D) "What cultural or spiritual beliefs are important to you?" Page: 17. The nurse needs to assess the cultural beliefs and practices of the patient. American Indians may seek assistance from a medicine man or shaman, but the nurse should not assume this. An open-ended question regarding cultural and spiritual beliefs is best used initially when performing a cultural assessment.
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19. When planning a cultural assessment, the nurse should include which component? A) Family history B) Chief complaint C) Medical history D) Health-related beliefs
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D) Health-related beliefs Pages: 19-20. Health-related beliefs and practices are one component of a cultural assessment. The other items reflect other aspects of the patient's history.
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20. 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.
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B. provided consistent information and therefore is reliable. Page: 50. A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. The other statements are not correct.
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21. In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate? A. Patient denies usual childhood illnesses. B. Patient states he was a "very healthy" child. C. Patient states sister had measles, but he didn't. D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
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D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat. Page: 51. Childhood illnesses include measles, mumps, rubella, chickenpox, pertussis, and strep throat. Avoid recording "usual childhood illnesses" because an illness common in the person's childhood may be unusual today (e.g., measles).
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22. The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response? A. "Maybe she is just teething." B. "I will check her ear for an ear infection." C. "Are you sure she is really having pain?" D. "Please describe what she is doing to indicate she is having pain."
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D. "Please describe what she is doing to indicate she is having pain." Page: 60. With a very young child, ask the parent, "How do you know the child is in pain?" Pulling at ears alerts parent to ear pain. The statements about teething and questioning whether the child is really having pain do not explore the symptoms, which should be done before a physical examination.
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23. A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure? A. The child's birth weight B. The age at which he crawled C. Whether he has had the measles D. Reactions to previous hospitalizations
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D. Reactions to previous hospitalizations Assess how the child reacted to hospitalization and any complications. If the child reacted poorly, he or she may be afraid now and will need special preparation for the examination that is to follow. The other items are not significant for the procedure.
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24. The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? A. It assesses how the individual is coping with life at home. B. It determines how children are meeting developmental milestones. C. It can identify any problems with memory the individual may be experiencing. D. It helps to determine how a person is managing day-to-day activities.
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D. It helps to determine how a person is managing day-to-day activities. Page: 67. The functional assessment measures how a person manages day-to-day activities. The other answers do not reflect the purpose of a functional assessment.
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25. The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask? A. "Do you wear glasses?" B. "Are you able to dress yourself?" C. "Do you have any thyroid problems?" D. "How many times a day do you have a bowel movement?"
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B. "Are you able to dress yourself?" Page: 67. Functional assessment measures how a person manages day-to-day activities. For the older person, the meaning of health becomes those activities that they can or cannot do. The other responses do not relate to functional assessment.
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26. The nurse is conducting a developmental history on a 5-year-old child. Which questions are appropriate to ask the parents for this part of the assessment? Select all that apply. A. "How much junk food does your child eat?" B. "How many teeth has he lost, and when did he lose them?" C. "Is he able to tie his shoelaces?" D. "Does he take a children's vitamin?" E. "Can he tell time?" F. "Does he have any food allergies?"
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B. "How many teeth has he lost, and when did he lose them?" C. "Is he able to tie his shoelaces?" E. "Can he tell time?" Page: 61. Questions about tooth loss, ability to tell time, and ability to tie shoelaces are appropriate questions for a developmental assessment. Questions about junk food intake and vitamins are part of a nutritional history. Questions about food allergies are not part of a developmental history.
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27. During an examination, the nurse can assess mental status by which activity? A) Examining the patient's electroencephalogram B) Observing the patient as he or she performs an IQ test C) Observing the patient and inferring health or dysfunction D) Examining the patient's response to a specific set of questions
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C) Observing the patient and inferring health or dysfunction Page: 71. Mental status cannot be scrutinized directly like the characteristics of skin or heart sounds. Its functioning is inferred through assessment of an individual's behaviors, such as consciousness, language, mood and affect, and other aspects.
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28. The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient: A) will have no decrease in any of his abilities, including response time. B) will have difficulty on tests of remote memory because this typically decreases with age. C) may take a little longer to respond, but his general knowledge and abilities should not have declined. D) will have had a decrease in his response time because of language loss and a decrease in general knowledge.
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C) may take a little longer to respond, but his general knowledge and abilities should not have declined. Page: 72. The aging process leaves the parameters of mental status mostly intact. There is no decrease in general knowledge and little or no loss in vocabulary. Response time is slower than in youth. It takes a bit longer for the brain to process information and to react to it. Recent memory, which requires some processing is somewhat decreased with aging, but remote memory is not affected.
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29. The nurse is preparing to do a mental status examination. Which statement is true regarding the mental status examination? A) A patient's family is the best resource for information about the patient's coping skills. B) It is usually sufficient to gather mental status information during the health history interview. C) It takes an enormous amount of extra time to integrate the mental status examination into the health history interview. D) It is usually necessary to perform a complete mental status examination to get a good idea of the patient's level of functioning.
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B) It is usually sufficient to gather mental status information during the health history interview. Page: 73. The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described here, though, rarely need to be taken in their entirety. Usually, one can assess mental status through the context of the health history interview.
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30. During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question? A) "How do you feel today?" B) "Would you please repeat the following words?" C) "Have these medications had any effect on your pain?" D) "Has this pain affected your ability to get dressed by yourself?"
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A) "How do you feel today?" Page: 74. Judge mood and affect by body language and facial expression and by asking directly, "How do you feel today?" or "How do you usually feel?" The mood should be appropriate to the person's place and condition and should change appropriately with topics.
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31. During a mental status assessment, which question by the nurse would best assess a person's judgment? A) "Do you feel that you are being watched, followed, or controlled?" B) "Tell me about what you plan to do once you are discharged from the hospital." C) "What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?" D) "What would you do if you found a stamped, addressed envelope lying on the sidewalk?"
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B) "Tell me about what you plan to do once you are discharged from the hospital." Pages: 76-77. A person exercises judgment when he or she can compare and evaluate the alternatives in a situation and reach an appropriate course of action. Rather than testing the person's response to a hypothetical situation (as illustrated in the option with the envelope), the nurse should be more interested in the person's judgment about daily or long-term goals, the likelihood of acting in response to delusions or hallucinations and the capacity for violent or suicidal behavior.
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32. The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status? A) Mental status assessment diagnoses specific psychiatric disorders. B) Mental disorders occur in response to everyday life stressors. C) Mental status functioning is inferred through assessment of an individual's behaviors. D) Mental status can be assessed directly, just like other systems of the body (e.g., cardiac and breath sounds).
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C) Mental status functioning is inferred through assessment of an individual's behaviors. Page: 71. Mental status functioning is inferred through assessment of an individual's behaviors. It cannot be assessed directly like characteristics of the skin or heart sounds.
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33. When performing a physical assessment, the technique the nurse will always use first is: A) palpation. B) inspection. C) percussion. D) auscultation.
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B) inspection. Pages: 115-116. The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, where auscultation takes place before palpation and percussion). The assessment of each body system begins with inspection. A focused inspection takes time and yields a surprising amount of information.
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34. The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best assess the patient's skin temperature? Use the: A) fingertips because they're more sensitive to small changes in temperature. B) dorsal surface of the hand because the skin is thinner than on the palms. C) ulnar portion of the hand because there is increased blood supply that enhances temperature sensitivity. D) palmar surface of the hand because it is most sensitive to temperature variations because of increased nerve supply in this area.
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B) dorsal surface of the hand because the skin is thinner than on the palms. The dorsa (backs) of hands and fingers are best for determining temperature because the skin there is thinner than on the palms. Fingertips are best for fine, tactile discrimination; the other responses are not useful for palpation.
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35. The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed? A) Avoid palpation of reported "tender" areas because this may cause the patient pain. B) Quickly palpate a tender area to avoid any discomfort that the patient may experience. C) Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths. D) Start with light palpation to detect surface characteristics and to accustom the patient to being touched.
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D) Start with light palpation to detect surface characteristics and to accustom the patient to being touched. Pages: 115-116. Light palpation is performed initially to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first.
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36. The nurse would use bimanual palpation technique in which situation? A) Palpating the thorax of an infant B) Palpating the kidneys and uterus C) Assessing pulsations and vibrations D) Assessing the presence of tenderness and pain
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B) Palpating the kidneys and uterus Pages: 115-116. Bimanual palpation requires the use of both hands to envelop or capture certain body parts or organs such as the kidneys, uterus, or adnexa. The other situations are not appropriate for bimanual palpation.
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37. When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should: A) consider this a normal finding. B) palpate this area for an underlying mass. C) reposition the hands and attempt to percuss in this area again. D) consider this an abnormal finding and refer the patient for additional treatment.
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A) consider this a normal finding. Pages: 116-117. Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound. The other responses are not correct.
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38. The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: A) auscultate over the area with a fetoscope. B) use a goniometer to measure the pulsations. C) use a Doppler device to check for pulsations over the area. D) check for the presence of pulsations with a stethoscope.
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C) use a Doppler device to check for pulsations over the area. Page: 120. Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal heart tones. Stethoscopes are used to auscultate breath, bowel, and heart sounds.
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39. When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination? A) There is no need to wash one's hands after removing gloves, as long as the gloves are still intact. B) Wash hands before and after every physical patient encounter. C) Wash hands between the examination of each body system to prevent the spread of bacteria from one part of the body to another. D) Wear gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.
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B) Wash hands before and after every physical patient encounter. Page: 120. The nurse should wash his or her hands before and after every physical patient encounter; after contact with blood, body fluids, secretions, and excretions; after contact with any equipment contaminated with body fluids; and after removing gloves. Hands should be washed after gloves have been removed, even if the gloves appear to be intact. Gloves should be worn when there is potential contact with any body fluids.
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40. The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination? A) When the infant is sleeping B) At the end of the examination C) Before auscultation of the thorax D) Halfway through the examination
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B) At the end of the examination Page: 123. Elicit the Moro or "startle" reflex at the end of the examination because it may cause the infant to cry.
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41. A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination? A) Auscultate the lungs and heart while the infant is still sleeping. B) Examine the infant's hips because this procedure is uncomfortable. C) Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach. D) Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems.
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A) Auscultate the lungs and heart while the infant is still sleeping. Pages: 122-124. When the infant is quiet or sleeping is an ideal time to assess the cardiac, respiratory, and abdominal systems. Assessment of the eye, ear, nose, and throat are invasive procedures and should be performed at the end of the examination.
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42. The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal? A) An increase in body weight from younger years B) Additional deposits of fat on the thighs and lower legs C) The presence of kyphosis and flexion in the knees and hips D) A change in overall body proportion, a longer trunk, and shorter extremities
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C) The presence of kyphosis and flexion in the knees and hips Page: 149. Changes that occur in the aging person include more prominent bony landmarks, decreased body weight (especially in males), a decrease in subcutaneous fat from the face and periphery, and additional fat deposited on the abdomen and hips. Postural changes of kyphosis and slight flexion in the knees and hips also occur.
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43. When assessing the force, or strength, of a pulse, the nurse recalls that it: A) is usually recorded on a 0- to 2-point scale. B) demonstrates elasticity of the vessel wall. C) is a reflection of the heart's stroke volume. D) reflects the blood volume in the arteries during diastole.
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C) is a reflection of the heart's stroke volume. Page: 134. The heart pumps an amount of blood (the stroke volume) into the aorta. The force flares the arterial walls and generates a pressure wave, which is felt in the periphery as the pulse.
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44. When assessing the quality of a patient's pain, the nurse should ask which question? A) "When did the pain start?" B) "Is the pain a stabbing pain?" C) "Is it a sharp pain or dull pain?" D) "What does your pain feel like?"
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D) "What does your pain feel like?" Page: 164. To assess the quality of a person's pain, have the patient describe the pain in his or her own words.
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45. The nurse is providing care for a 68-year-old woman who is complaining of constipation. What concern exists regarding her nutritional status? A) The absorption of nutrients may be impaired. B) The constipation may represent a food allergy. C) She may need emergency surgery for the problem. D) The gastrointestinal problem will increase her caloric demand.
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A) The absorption of nutrients may be impaired. Page: 182. Gastrointestinal symptoms such as vomiting, diarrhea, or constipation may interfere with nutrient intake or absorption. The other responses are not correct.
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46. During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking? A) Certain drugs can affect the metabolism of nutrients. B) The nurse needs to assess the patient for allergic reactions. C) Medications need to be documented on the record for the physician's review. D) Medications can affect one's memory and ability to identify food eaten in the last 24 hours.
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A) Certain drugs can affect the metabolism of nutrients. Page: 183 Analgesics, antacids, anticonvulsants, antibiotics, diuretics, laxatives, antineoplastic drugs, steroids, and oral contraceptives are drugs that can interact with nutrients, impairing their digestion, absorption, metabolism, or use. The other responses are not correct.
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47. The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of these factors is most likely to affect the nutritional status of an elderly person? A) Increase in taste and smell B) Living alone on a fixed income C) Change in cardiovascular status D) Increase in gastrointestinal motility and absorption
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B) Living alone on a fixed income Page: 176. Socioeconomic conditions frequently affect the nutritional status of the aging adult; these factors should be closely evaluated. Physical limitations, income, and social isolation are frequent problems that interfere with the acquisition of a balanced diet. A decrease in taste and smell and decreased gastrointestinal motility and absorption occur with aging. Cardiovascular status is not a factor that affects an elderly person's nutritional status.
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48. When the mid-upper arm circumference and triceps skinfold of an 82-year-old man are evaluated, which is important for the nurse to remember? A) These measurements are no longer necessary for the elderly. B) Derived weight measures may be difficult to interpret because of wide ranges of normal. C) These measurements may not be accurate because of changes in skin and fat distribution. D) Measurements may be difficult to obtain if the patient is unable to flex his elbow to at least 90 degrees.
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C) These measurements may not be accurate because of changes in skin and fat distribution. Page: 191 Accurate mid-upper arm circumference and triceps skinfold measurements are difficult to obtain and interpret in older adults because of sagging skin, changes in fat distribution, and declining muscle mass. Body mass index and waist-to-hip ratio are better indicators of obesity in the elderly.
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49. The nurse needs to perform anthropometric measures of an 80-year-old man who is confined to a wheelchair. Which of the following is true in this situation? A) Changes in fat distribution will affect the waist-to-hip ratio. B) Height measurements may not be accurate because of changes in bone. C) Declining muscle mass will affect the triceps skinfold measure. D) Mid-arm circumference is difficult to obtain because of loss of skin elasticity.
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B) Height measurements may not be accurate because of changes in bone. Page: 191. Height measures may not be accurate in individuals confined to a bed or wheelchair or those over 60 years of age because of osteoporotic changes.
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50. The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiological changes that directly affect the nutritional status of the elderly include: A) slowed gastrointestinal motility. B) hyperstimulation of the salivary glands. C) an increased sensitivity to spicy and aromatic foods. D) decreased gastrointestinal absorption causing esophageal reflux.
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A) slowed gastrointestinal motility. Page: 176. Normal physiological changes in aging adults that affect nutritional status include slowed gastrointestinal motility, decreased gastrointestinal absorption, diminished olfactory and taste sensitivity, decreased saliva production, decreased visual acuity, and poor dentition.
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51. The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person's: A) support systems. B) circulatory status. C) socioeconomic status. D) psychological wellness.
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B) circulatory status. Page: 211. The skin holds information about the body's circulation, nutritional status, and signs of systemic diseases as well as topical data on the integument itself.
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52. A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse would pay special attention to the danger signs for pigmented lesions and would be concerned with which additional finding? A) Color variation B) Border regularity C) Symmetry of lesions D) Diameter less than 6 mm
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A) Color variation Pages: 212-213. Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.
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53. An elderly woman is brought to the emergency department after being found lying on the kitchen floor 2 days, and she is extremely dehydrated. What would the nurse expect to see upon examination? A) Smooth mucous membranes and lips B) Dry mucous membranes and cracked lips C) Pale mucous membranes D) White patches on the mucous membranes
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B) Dry mucous membranes and cracked lips Page: 215. With dehydration, mucous membranes look dry and lips look parched and cracked. The other responses are not found in dehydration.
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54. A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which assessment finding? A) Anasarca B) Scleroderma C) Pedal erythema D) Clubbing of the nails
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D) Clubbing of the nails Pages: 217-218. Clubbing of the nails occurs with congenital cyanotic heart disease, neoplastic, and pulmonary diseases. The other responses are assessment findings not associated with pulmonary diseases.
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55. The nurse has discovered decreased skin turgor in a patient and knows that this is an expected finding in which of these conditions? A) Severe obesity B) Childhood growth spurts C) Severe dehydration D) Connective tissue disorders such as scleroderma
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C) Severe dehydration Page: 215. Decreased skin turgor is associated with severe dehydration or extreme weight loss.
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56. A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would: A) tell the patient to watch the lesion and report back in 2 months. B) refer the patient because of the suspicion of melanoma on the basis of her symptoms. C) ask additional questions regarding environmental irritants that may have caused this condition. D) suspect that this is a compound nevus, which is very common in young to middle-aged adults.
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B) refer the patient because of the suspicion of melanoma on the basis of her symptoms. The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, development of itching, burning, bleeding, or a new-pigmented lesion. Any of these signs raise suspicion of malignant melanoma and warrant immediate referral.
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57. The nurse is assessing for clubbing of the fingernails and would expect to find: A) a nail base that is firm and slightly tender. B) curved nails with a convex profile and ridges across the nail. C) a nail base that feels spongy with an angle of the nail base of 150 degrees. D) an angle of the nail base of 180 degrees or greater with a nail base that feels spongy.
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D) an angle of the nail base of 180 degrees or greater with a nail base that feels spongy. Pages: 217-218. The normal nail is firm at its base and has an angle of 160 degrees. In clubbing, the angle straightens to 180 degrees or greater and the nail base feels spongy.
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58. A patient has been admitted for severe psoriasis. The nurse can expect to see what finding in the patient's fingernails? A) Splinter hemorrhages B) Paronychia C) Pitting D) Beau lines
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C) Pitting Pages: 248-250. Pitting nails are characterized by sharply defined pitting and crumbling of the nails with distal detachment, and they are associated with psoriasis. See Table 12-13 for descriptions of the other terms.
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59. The nurse suspects that a patient has hyperthyroidism and laboratory data indicate that the patient's thyroxine and tri-iodothyronine hormone levels are elevated. Which of these findings would the nurse most likely find on examination? A) Tachycardia B) Constipation C) Rapid dyspnea D) Atrophied nodular thyroid
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A) Tachycardia Thyroxine and tri-iodothyronine are thyroid hormones that stimulate the rate of cellular metabolism, resulting in tachycardia. With an enlarged thyroid as in hyperthyroidism, the nurse might expect to find diffuse enlargement (goiter) or a nodular lump, but not an atrophied gland. Dyspnea and constipation are not findings associated with hyperthyroidism.
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60. During an examination, the nurse knows that Paget's disease would be indicated by which of these assessment findings? A) Positive Macewen sign B) Premature closure of the sagittal suture C) Headache, vertigo, tinnitus, and deafness D) Elongated head with heavy eyebrow ridge
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C) Headache, vertigo, tinnitus, and deafness Paget's disease occurs more often in males and is characterized by bowed long bones, sudden fractures, and enlarging skull bones that press on cranial nerves causing symptoms of headache, vertigo, tinnitus, and progressive deafness.
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61. A woman comes to the clinic and states, "I've been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry." The nurse will assess for other signs and symptoms of: A) cachexia. B) Parkinson's syndrome. C) myxedema. D) scleroderma.
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C) myxedema. Pages: 276-277. Myxedema (hypothyroidism) is a deficiency of thyroid hormone that, when severe, causes a nonpitting edema or myxedema. The patient will have a puffy edematous face especially around eyes (periorbital edema), coarse facial features, dry skin, and dry, coarse hair and eyebrows. See Table 13-4, Abnormal Facial Appearances with Chronic Illnesses, for descriptions of the other responses.
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62. The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is aware that this means that the patient's trachea is: A) pulled to the affected side. B) pushed to the unaffected side. C) pulled downward. D) pulled downward in a rhythmic pattern.
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B) pushed to the unaffected side. Pages: 262-263. The trachea is pushed to the unaffected side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, and pneumothorax. The trachea is pulled to the affected side with large atelectasis, pleural adhesions, or fibrosis. Tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm.
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63. During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition? A) Rickets B) Dehydration C) Mental retardation D) Increased intracranial pressure
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B) Dehydration Pages: 265-266. Depressed and sunken fontanels occur with dehydration or malnutrition. Mental retardation and rickets have no effect on fontanels. Increased intracranial pressure would cause tense or bulging, and possibly pulsating fontanels.
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64. The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. These findings are characteristic of: A) allergies. B) a sinus infection. C) nasal congestion. D) an upper respiratory infection.
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A) allergies. Page: 275. Chronic allergies often develop chronic facial characteristics. These include blue shadows below the eyes, a double or single crease on the lower eyelids, open-mouth breathing, and a transverse line on the nose.
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65. A mother asks when her newborn infant's eyesight will be developed. The nurse should reply: A) "Vision is not totally developed until 2 years of age." B) "Infants develop the ability to focus on an object at around 8 months." C) "By about 3 months, infants develop more coordinated eye movements and can fixate on an object." D) "Most infants have uncoordinated eye movements for the first year of life."
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C) "By about 3 months, infants develop more coordinated eye movements and can fixate on an object." Page: 284. Eye movements may be poorly coordinated at birth, but by 3 to 4 months of age, the infant should establish binocularity and should be able to fixate on a single image with both eyes simultaneously.
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66. The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal? A) A decrease in tear production B) Unequal pupillary constriction in response to light C) The presence of arcus senilis seen around the cornea D) Loss of the outer hair on the eyebrows due to a decrease in hair follicles
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B) Unequal pupillary constriction in response to light Pages: 305-308. Pupils are small in old age, and the pupillary light reflex may be slowed, but pupillary constriction should be symmetric. The assessment findings in the other responses are considered normal in older persons.
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67. The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should: A) check for the presence of exophthalmos. B) suspect that the patient has hyperthyroidism. C) ask the patient if he or she has a history of heart failure. D) assess for blepharitis because this is often associated with periorbital edema.
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C) ask the patient if he or she has a history of heart failure. Page: 312. Periorbital edema occurs with local infections, crying, and systemic conditions such as heart failure, renal failure, allergy, and hypothyroidism. Periorbital edema is not associated with blepharitis.
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68. A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include: A) loss of central vision. B) shadow or diminished vision in one quadrant or one half of the visual field. C) loss of peripheral vision. D) sudden loss of pupillary constriction and accommodation.
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B) shadow or diminished vision in one quadrant or one half of the visual field. Page: 316. With retinal detachment, the person has shadows or diminished vision in one quadrant or one half of the visual field. The other responses are not signs of retinal detachment.
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69. A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble with reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that: A) she may have macular degeneration. B) her vision is normal for someone her age. C) she has the beginning stages of cataract formation. D) she has increased intraocular pressure or glaucoma.
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A) she may have macular degeneration. Page: 285. Macular degeneration is the most common cause of blindness. It is characterized by loss of central vision. Cataracts would show lens opacity. Chronic open-angle glaucoma, the most common type of glaucoma, involves a gradual loss of peripheral vision.
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70. An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates: A) retinal detachment. B) diabetic retinopathy. C) acute-angle glaucoma. D) increased intracranial pressure.
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D) increased intracranial pressure. Pages: 319-320. Papilledema, or choked disk, is a serious sign of increased intracranial pressure, which is caused by a space-occupying mass such as a brain tumor or hematoma. This pressure causes venous stasis in the globe, showing redness, congestion, and elevation of the optic disc, blurred margins, hemorrhages, and absent venous pulsations. Papilledema is not associated with the conditions in the other responses.
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71. During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma? Select all that apply. A) The patient may experience sensitivity to light, nausea, and halos around lights. B) The patient experiences tunnel vision in late stages. C) Immediate treatment is needed. D) Vision loss begins with peripheral vision. E) It causes sudden attacks of increased pressure that cause blurred vision. F) There are virtually no symptoms.
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B) The patient experiences tunnel vision in late stages. D) Vision loss begins with peripheral vision. F) There are virtually no symptoms. Pages: 308-309. Open-angle glaucoma is the most common type of glaucoma; there are virtually no symptoms. Vision loss begins with the peripheral vision, which often goes unnoticed because individuals learn to compensate intuitively by turning their heads. The other characteristics are those of closed-angle glaucoma.
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72. The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation? A) "Do you ever notice ringing or crackling in your ears?" B) "When was the last time you had your hearing checked?" C) "Have you ever been told you have any type of hearing loss?" D) "Was there any relationship between the ear pain and the discharge you mentioned?"
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D) "Was there any relationship between the ear pain and the discharge you mentioned?" Pages: 327-328. Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then drainage occurs.
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73. The nurse is performing an ear examination of an 80-year-old patient. Which of these would be considered a normal finding? A) A high-tone frequency loss B) Increased elasticity of the pinna C) A thin, translucent membrane D) A shiny, pink tympanic membrane
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A) A high-tone frequency loss Pages: 337-338. A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging. The pinna loses elasticity, causing earlobes to be pendulous. The eardrum may be whiter in color and more opaque and duller than in the young adult.
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74. During an examination, the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" The nurse recognizes that this symptom indicates: A) vertigo. B) pruritus. C) tinnitus. D) cholesteatoma.
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C) tinnitus. Pages: 328-329. Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders.
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75. The nurse is testing the hearing of a 78-year-old man and keeps in mind the changes in hearing that occur with aging include which of the following? Select all that apply. A) Hearing loss related to aging begins in the mid 40s. B) The progression is slow. C) The aging person has low-frequency tone loss. D) The aging person may find it harder to hear consonants than vowels. E) Sounds may be garbled and difficult to localize. F) Hearing loss reflects nerve degeneration of the middle ear.
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B) The progression is slow. D) The aging person may find it harder to hear consonants than vowels. E) Sounds may be garbled and difficult to localize. Page: 326. Presbycusis is a type of hearing loss that occurs with aging and is found in 60% of those older than 65 years. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve, and it slowly progresses after age 50. The person first notices a high-frequency tone loss; it is harder to hear consonants (high-pitched components of speech) than vowels. This makes words sound garbled. The ability to localize sound is impaired also.
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76. When assessing a patient's lungs, the nurse recalls that the left lung: A) consists of two lobes. B) is divided by the horizontal fissure. C) consists primarily of an upper lobe on the posterior chest. D) is shorter than the right lung because of the underlying stomach.
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A) consists of two lobes. Pages: 413-414. The left lung has two lobes, and the right lung has three lobes. The right lung is shorter than the left lung because of the underlying liver. The left lung is narrower than the right lung because the heart bulges to the left. The posterior chest is almost all lower lobe.
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77. During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of: A) adventitious sounds and limited chest expansion. B) increased tactile fremitus and dull percussion tones. C) muffled voice sounds and symmetrical tactile fremitus. D) absent voice sounds and hyperresonant percussion tones.
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C) muffled voice sounds and symmetrical tactile fremitus. Pages: 429-430. Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds.
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78. A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath." Which action by the nurse is most appropriate? A) Obtain a detailed history of the patient's allergies and history of asthma. B) Tell the patient to sleep on his or her right side to facilitate ease of respirations. C) Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. D) Assure the patient that this is normal and will probably resolve within the next week.
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C) Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. Pages: 419-420. The patient is experiencing paroxysmal nocturnal dyspnea: being awakened from sleep with shortness of breath and the need to be upright to achieve comfort.
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79. When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? A) Between the scapulae B) Third intercostal space, MCL C) Fifth intercostal space, MAL D) Over the lower lobes, posterior side
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A) Between the scapulae Page: 424. Normally, fremitus is most prominent between the scapulae and around the sternum. These are sites where the major bronchi are closest to the chest wall. Fremitus normally decreases as one progress down the chest because more tissue impedes sound transmission.
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80. The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? "Tactile fremitus: A) is caused by moisture in the alveoli." B) indicates that there is air in the subcutaneous tissues." C) is caused by sounds generated from the larynx." D) reflects the blood flow through the pulmonary arteries."
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C) is caused by sounds generated from the larynx." Pages: 422-423. Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall where they are felt as vibrations. Crepitus is the term for air in the subcutaneous tissues.
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81. When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are: A) sounds normally auscultated over the trachea. B) bronchial breath sounds and are normal in that location. C) vesicular breath sounds and are normal in that location. D) bronchovesicular breath sounds and are normal in that location.
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C) vesicular breath sounds and are normal in that location. Pages: 428-429. Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than expiration. These breath sounds are expected over peripheral lung fields where air flows through smaller bronchioles and alveoli.
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82. The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs would reveal: A) dullness. B) tympany. C) resonance. D) hyperresonance.
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A) dullness. Pages: 424-425. A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor.
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83. The nurse knows that auscultation of fine crackles would most likely be noticed in: A) a healthy 5-year-old child. B) a pregnant woman. C) the immediate newborn period. D) association with a pneumothorax.
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C) the immediate newborn period. Pages: 436-437. Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and clearing of fluid. Persistent fine crackles would be noticed with pneumonia, bronchiolitis, or atelectasis.
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84. During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition? A) Airway obstruction B) Emphysema C) Pulmonary consolidation D) Asthma
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C) Pulmonary consolidation Page: 446. Pathologic conditions that increase lung density, such as pulmonary consolidation, will enhance transmission of voice sounds, such as bronchophony. See Table 18-7.
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85. The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? A) Wheezes B) Bronchial sounds C) Bronchophony D) Whispered pectoriloquy
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A) Wheezes Page: 445. Wheezes are caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic emphysema.
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86. An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with: A) asthma. B) atelectasis. C) lobar pneumonia. D) heart failure.
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A) asthma. Page: 451. Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a reaction of bronchospasm, which increases airway resistance, especially during expiration. Increased respiratory rate, use of accessory muscles, retraction of intercostal muscles, prolonged expiration, decreased breath sounds, and expiratory wheezing are all characteristic of asthma. See Table 18-8 for descriptions of the other conditions.
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87. During auscultation of breath sounds, the nurse should use the stethoscope correctly, in which of the following ways? A) Listen to at least one full respiration in each location. B) Listen as the patient inhales and then go to the next site during exhalation. C) Have the patient breathe in and out rapidly while the nurse listens to the breath sounds. D) If the patient is modest, listen to sounds over his or her clothing or hospital gown.
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A) Listen to at least one full respiration in each location. Pages: 426-427. During auscultation of breath sounds with a stethoscope, it is important to listen to one full respiration in each location. During the examination, the nurse should monitor the breathing and offer times for the person to breathe normally to prevent possible dizziness.
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88. During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects: A) tactile fremitus. B) crepitus. C) friction rub. D) adventitious sounds.
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B) crepitus. Page: 424. Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as after open thoracic injury or surgery.
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89. The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are: A) atelectatic crackles, and that they are not pathologic. B) fine crackles, and that they may be a sign of pneumonia. C) vesicular breath sounds. D) fine wheezes.
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A) atelectatic crackles, and that they are not pathologic. Pages: 429-430. One type of adventitious sound, atelectatic crackles, is not pathologic. They are short, popping, crackling sounds that sound like fine crackles but do not last beyond a few breaths. When sections of alveoli are not fully aerated (as in people who are asleep or in the elderly), they deflate slightly and accumulate secretions. Crackles are heard when these sections are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough.
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90. The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply. A) Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. B) As the patient says "ninety-nine" repeatedly, the examiner hears the words "ninety-nine" clearly. C) When the patient speaks in a normal voice, the examiner can hear a sound but cannot distinguish exactly what is being said. D) As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. E) As the patient says a long "ee-ee-ee" sound, the examiner hears a long "aaaaaa" sound.
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A) Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. C) When the patient speaks in a normal voice, the examiner can hear a sound but cannot distinguish exactly what is being said. D) As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. Page: 446. As a patient says "ninety-nine" repeatedly, normally, the examiner hears sound but cannot distinguish what is being said. If a clear "ninety-nine" is auscultated, then it could indicate increased lung density, which enhances transmission of voice sounds. This is a measure of bronchophony. When a patient says a long "ee-ee-ee" sound, normally the examiner also hears a long "ee-ee-ee" sound through auscultation. This is a measure of egophony. If the examiner hears a long "aaaaaa" sound instead, this could indicate areas of consolidation or compression. With whispered pectoriloquy, as when a patient whispers a phrase such as "one-two-three," the normal response when auscultating voice sounds is to hear sounds that are faint, muffled, and almost inaudible. If the examiners hears the whispered voice clearly, as if the patient is speaking through the stethoscope, then consolidation of the lung fields may exist.
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91. During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate: A) a valvular disorder. B) blood flow turbulence. C) fluid volume overload. D) ventricular hypertrophy.
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B) blood flow turbulence. Page: 471. A bruit is a blowing, swishing sound indicating blood flow turbulence; normally none is present.
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92. During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse? A) Third left intercostal space at the midclavicular line B) Fourth left intercostal space at the sternal border C) Fourth left intercostal space at the anterior axillary line D) Fifth left intercostal space at the midclavicular line
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D) Fifth left intercostal space at the midclavicular line Pages: 473-474. The apical impulse should occupy only one intercostal space, the fourth or fifth, and it should be at or medial to the midclavicular line.
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93. The nurse is preparing to auscultate for heart sounds. Which technique is correct? A) Listen to the sounds at the aortic, tricuspid, pulmonic, and mitral areas. B) Listen by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex. C) Listen to the sounds only at the site where the apical pulse is felt to be the strongest. D) Listen for all possible sounds at a time at each specified area.
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B) Listen by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex. Pages: 475-476. Do not limit auscultation of breath sounds to only four locations. Sounds produced by the valves may be heard all over the precordium. Inch the stethoscope in a rough Z pattern from the base of the heart across and down, then over to the apex. Or, start at the apex and work your way up. See Figure 19-22. Listen selectively to one sound at a time.
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94. The nurse is assessing a patient's apical impulse. Which of these statements is true regarding the apical impulse? A) It is palpable in all adults. B) It occurs with the onset of diastole. C) Its location may be indicative of heart size. D) It should normally be palpable in the anterior axillary line.
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C) Its location may be indicative of heart size. Page: 473 | Page: 492. The apical impulse is palpable in about 50% of adults. It is located in the fifth left intercostal space in the midclavicular line. Horizontal or downward displacement of the apical impulse may indicate an enlargement of the left ventricle.
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95. During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process? A) Hormonal changes causing vasodilation and a resulting drop in blood pressure B) Progressive atrophy of the intramuscular calf veins, causing venous insufficiency C) Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure D) Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities
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C) Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure Pages: 504-505. Peripheral blood vessels grow more rigid with age, resulting in a rise in systolic blood pressure. Aging produces progressive enlargement of the intramuscular calf veins, not atrophy. The other options are not correct.
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96. During an assessment, the nurse uses the "profile sign" to detect: A) pitting edema. B) early clubbing. C) symmetry of the fingers. D) insufficient capillary refill.
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B) early clubbing. Page: 506. The nurse should use the profile sign (viewing the finger from the side) to detect early clubbing.
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97. When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. The nurse should next: A) check for the presence of claudication. B) refer the individual for further evaluation. C) consider this a normal finding and proceed with the peripheral vascular evaluation. D) ask the patient if he or she has experienced any unusual cramping or tingling in the arm.
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C) consider this a normal finding and proceed with the peripheral vascular evaluation. Pages: 506-507. It is not usually necessary to palpate the ulnar pulses. The ulnar pulses are often not palpable in the normal person. The other responses are not correct.
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98. The nurse is attempting to assess the femoral pulse in an obese patient. Which of these actions would be most appropriate? A) Have the patient assume a prone position. B) Ask the patient to bend his or her knees to the side in a froglike position. C) Press firmly against the bone with the patient in a semi-Fowler position. D) Listen with a stethoscope for pulsations because it is very difficult to palpate the pulse in an obese person.
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B) Regular "lub, dub" pattern Pages: 510-511. To help expose the femoral area, particularly in obese people, the nurse should ask the person to bend his or her knees to the side in a froglike position.
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99. When using a Doppler ultrasonic stethoscope, the nurse recognizes arterial flow when which sound is heard? A) Low humming sound B) Regular "lub, dub" pattern C) Swishing, whooshing sound D) Steady, even, flowing sound
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C) Swishing, whooshing sound Pages: 515-516. When using the Doppler ultrasonic stethoscope, the pulse site is found when one hears a swishing, whooshing sound.
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100. The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the documentation states that the radial pulses are "2+." The nurse recognizes that this reading indicates what type of pulse? A) Bounding B) Normal C) Weak D) Absent
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B) Normal Pages: 506-507. When documenting the force, or amplitude, of pulses, 3+ indicates an increased, full, or bounding pulse, 2+ indicates a normal pulse, 1+ indicates a weak pulse, and 0 indicates an absent pulse.
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101. 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
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A) Dullness Page: 541. The liver is located in the right upper quadrant and would elicit a dull percussion note.
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102. Which structure is located in the left lower quadrant of the abdomen? A) Liver B) Duodenum C) Gallbladder D) Sigmoid colon
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D) Sigmoid colon Page: 530. The sigmoid colon is located in the left lower quadrant of the abdomen.
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103. The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? A) Percuss and palpate in the lumbar region. B) Inspect and palpate in the epigastric region. C) Auscultate and percuss in the inguinal region. D) Percuss and palpate the midline area above the suprapubic bone.
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D) Percuss and palpate the midline area above the suprapubic bone. Pages: 539-540. Dull percussion sounds would be elicited over a distended bladder, and the hypogastric area would seem firm to palpation.
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104. While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are: A) pulsations of the renal arteries. B) pulsations of the inferior vena cava. C) normal abdominal aortic pulsations. D) increased peristalsis from a bowel obstruction.
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C) normal abdominal aortic pulsations. Pages: 538-539. Normally, one may see the pulsations from the aorta beneath the skin in the epigastric area, particularly in thin persons with good muscle wall relaxation.
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105. A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: A) diarrhea. B) peritonitis. C) laxative use. D) gastroenteritis.
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B) peritonitis. Page: 561. Diminished or absent bowel sounds signal decreased motility from inflammation as seen with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction.
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106. The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to: A) a loud continuous hum. B) a peritoneal friction rub. C) hypoactive bowel sounds. D) hyperactive bowel sounds.
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D) hyperactive bowel sounds. Pages: 539-540. Borborygmi is the term used for hyperperistalsis when the person actually feels his or her stomach growling.
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107. During an abdominal assessment, the nurse would consider which of these findings as normal? A) The presence of a bruit in the femoral area B) A tympanic percussion note in the umbilical region C) A palpable spleen between the ninth and eleventh ribs in the left midaxillary line D) A dull percussion note in the left upper quadrant at the midclavicular line
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B) A tympanic percussion note in the umbilical region Pages: 539-540. Tympany should predominate in all four quadrants of the abdomen because air in the intestines rises to the surface when the person is supine. Vascular bruits are not usually present. Normally the spleen is not palpable. Dullness would not be found in the area of lung resonance (left upper quadrant at the midclavicular line).
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108. During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least: A) 1 minute. B) 5 minutes. C) 10 minutes. D) 2 minutes in each quadrant.
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B) 5 minutes. Pages: 539-540. Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding bowel sounds are completely absent.
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109. A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition? A) Obturator test B) Test for Murphy's sign C) Assess for rebound tenderness D) Iliopsoas muscle test
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B) Test for Murphy's sign Page: 551. Normally, palpating the liver causes no pain. In a person with inflammation of the gallbladder, or cholecystitis, pain occurs as the descending liver pushes the inflamed gallbladder onto the examining hand during inspiration (Murphy's test). The person feels sharp pain and abruptly stops inspiration midway.
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110. During an assessment the nurse notices that a patient's umbilicus is enlarged and everted. It is midline, and there is no change in skin color. The nurse recognizes that the patient may have which condition? A) Intra-abdominal bleeding B) Constipation C) Umbilical hernia D) An abdominal tumor
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C) Umbilical hernia Page: 537. The umbilicus is normally midline and inverted, with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. The other responses are incorrect.
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111. The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply. A) Test for Murphy's sign. B) Test for Blumberg's sign. C) Test for shifting dullness. D) Perform iliopsoas muscle test. E) Test for fluid wave.
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B) Test for Blumberg's sign. D) Perform iliopsoas muscle test. Pages: 543-544 | Page: 551. Testing for Blumberg's sign (rebound tenderness) and performing the iliopsoas muscle test should be used to assess for appendicitis. Murphy's sign is used to assess for an inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is done to assess for ascites.
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112. When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale? A) 2 B) 3 C) 4 D) 5
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D) 5 Pages: 578-579. Complete range of motion against gravity is normal muscle strength and is recorded as Grade 5 muscle strength.
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113. The nurse is assessing the joints of a woman who has stated, "I have a long family history of arthritis, and my joints hurt." The nurse suspects that she has osteoarthritis. Which of these are symptoms of osteoarthritis? Select all that apply. A) Symmetric joint involvement B) Asymmetric joint involvement C) Pain with motion of affected joints D) Affected joints are swollen with hard, bony protuberances E) Affected joints may have heat, redness, and swelling
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B) Asymmetric joint involvement C) Pain with motion of affected joints D) Affected joints are swollen with hard, bony protuberances Page: 608. In osteoarthritis, asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. Affected joints have stiffness, swelling with hard bony protuberances, pain with motion, and limitation of motion. The other options reflect signs of rheumatoid arthritis.
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114. During an assessment of an 80-year-old patient, the nurse notices the following: inability to identify vibrations at the ankle and to identify position of big toe, slower and more deliberate gait, and slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate: A) cranial nerve dysfunction. B) lesion in the cerebral cortex. C) normal changes due to aging. D) demyelinization of nerves due to a lesion.
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C) normal changes due to aging. Page: 629. Some aging adults show a slower response to requests, especially for those calling for coordination of movements. The findings listed are normal in the absence of other significant abnormal findings. The other responses are incorrect.
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115. In obtaining a history on a 74-year-old patient the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what should the nurse's response be? A) "Does your family know you are drinking every day?" B) "Does the tremor change when you drink the alcohol?" C) "We'll do some tests to see what is causing the tremor." D) "You really shouldn't drink so much alcohol; it may be causing your tremor."
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B) "Does the tremor change when you drink the alcohol?" Page: 632. Intention tremor/ senile tremor is relieved by alcohol, although this is not a recommended treatment. The nurse should assess whether the person is abusing alcohol in an effort to relieve the tremor.
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116. During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find? A) Firm, rigid resistance to movement B) Mild, even resistance to movement C) Hypotonic muscles as a result of total relaxation D) Slight pain with some directions of movement
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B) Mild, even resistance to movement Page: 637. Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It shows a mild resistance to passive stretch. Normally, the nurse will notice a mild, even resistance to movement. The other responses are not correct.
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117. When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as a(n): A) ataxia. B) lack of coordination. C) negative Homans' sign. D) positive Romberg sign.
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D) positive Romberg sign. Page: 638. Abnormal findings for Romberg test include swaying, falling, and widening base of feet to avoid falling. Positive Romberg sign is loss of balance that is increased by closing of the eyes. Ataxia is uncoordinated or unsteady gait. Homans' sign is used to test the legs for deep vein thrombosis.
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118. During the history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." In doing the assessment of his sensory system, which action by the nurse is most appropriate? A) The nurse would not do this part of the examination because results would not be valid. B) The nurse would perform the tests, knowing that mental status does not affect sensory ability. C) The nurse would proceed with the explanations of each test, making sure the wife understands. D) Before testing, the nurse would assess the patient's mental status and ability to follow directions at this time.
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D) Before testing, the nurse would assess the patient's mental status and ability to follow directions at this time. The nurse should ensure validity of the sensory system testing by making sure the patient is alert, cooperative, comfortable, and has an adequate attention span. Otherwise, the nurse may obtain misleading and invalid results.
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119. In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side? A) Lack of reflexes B) Normal reflexes C) Diminished reflexes D) Hyperactive reflexes
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D) Hyperactive reflexes Hyperreflexia is the exaggerated reflex seen when the monosynaptic reflex arc is released from the influence of higher cortical levels. This occurs with upper motor neuron lesions (e.g., a cerebrovascular accident). The other responses are incorrect
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120. During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. There is no associated rigidity with movement. Which of these statements is most accurate? A) These are normal findings resulting from aging. B) These could be related to hyperthyroidism. C) These are the result of Parkinson disease. D) This patient should be evaluated for a cerebellar lesion.
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A) These are normal findings resulting from aging. Page: 659. Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson disease include rigidity, slowness, and weakness of voluntary movement. The other responses are incorrect.
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121. While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of: A) a great sense of humor. B) uncooperative behavior. C) inability to understand questions. D) decreased level of consciousness.
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D) decreased level of consciousness. Pages: 660-661. A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. The other responses are incorrect.
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122. The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment? A) Cranial nerves, motor function, and sensory function B) Deep tendon reflexes, vital signs, and coordinated movements C) Level of consciousness, motor function, pupillary response, and vital signs D) Mental status, deep tendon reflexes, sensory function, and pupillary response
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C) Level of consciousness, motor function, pupillary response, and vital signs Pages: 660-661. Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process. These people must be monitored closely for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure. The nurse should use an abbreviation of the neurologic examination in the following sequence: level of consciousness, motor function, pupillary response, and vital signs.
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123. During an assessment of a 22-year-old woman who has a head injury from a car accident 4 hours ago, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated and nonreactive, left pupil is 4 mm and reacts to light. What does finding this suggest? A) Injury to the right eye B) Increased intracranial pressure C) Test was not performed accurately D) Normal response after a head injury
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B) Increased intracranial pressure Pages: 662-663. In a brain-injured person, a sudden, unilateral, dilated, and nonreactive pupil is ominous. Cranial nerve III runs parallel to the brainstem. When increasing intracranial pressure pushes the brainstem down (uncal herniation), it puts pressure on cranial nerve III, causing pupil dilation. The other responses are incorrect.
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124. The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which of these structures? A) Cerebrum B) Cerebellum C) Cranial nerves D) Medulla oblongata
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A) Cerebrum Pages: 621-622 | Page: 660. The cerebral cortex is responsible for thought, memory, reasoning, sensation, and voluntary movement. The other options structures are not responsible for a person's level of consciousness.
