Which of the following is a good example of a well-written chief complaint?

Complain of chest pain for 3 days that is worse with activit

Areas covered under self-esteem and self-concept include:

education, financial status, and value-belief system.

The tympanic membrane thermometer (TMT):

provides an accurate measurement of core body temperature.

nurse infers patient uncomfortable asking for a different treatment b/c of fear. This...

helps patient understand feelings in regards of verbal msg

Which of the following statements describing a headache would warrant an immediate referral?

“I never had a headache like this before; I can’t function.”

Which of the following children is at risk of recurrent otitis media (OM)?

18-month-old 3 episode of ear infections in a 5-month period

Endogenous obesity is:

excess adrenocorticotropin production by the pituitary gland

A common error in blood pressure measurement is:

waiting less than 1-2 mins before repeating BP on same arm

When recording information for the review of systems, the interviewer must document:

presence or absence of all symptoms under the system heading

The components of a nail examination include:

contour, consistency, and color.

Aphasia is best described as:

a language disturbance in speaking, writing or understanding

An older adult with dementia rates 5 out of 10 pain. The Nurse should...

administer prescribed pain meds

A full mental status examination should be completed if the patient:

has a change in behavior and the family is concerned

Patient cries and says: "please get me something to relieve this pain" What should the nurse do

Assess the level of pain, and administer meds based patient

The tympanic membrane of a child with acute otitis media would be:

bulging with a distinct red color.

the examiner notices a bifid uvula on the mouth of an American Indian.

This is expected variation associated with this individual

Which of the following statements cultural/racial differences in the treatment of pain is true?

Whites receive more analgesic therapy black or Hispanic

The general survey consists of four distinct areas. These areas include:

physical appearance, body structure, mobility, and behavior

When preparing the physical setting for an interview, the interviewer should:

conduct the interview at eye level & distance of 4 to 5 ft

Which of the following behaviors demonstrated may be indicative of hearing loss?

Frequently asking for the question to be repeated

One of the purposes of the paranasal sinuses is to:

lighten the weight of the skull bones

Teaching 4th graders about sweat glands, which should be included while discussing this topic?

Newborn infants do not sweat, use compensatory mechanisms

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McGovern Physical Assessment Final Exam Part 1

139 termsStudBud Administration27 plays

A #Nursing #Physical Assessment Exam Review

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Questions 139

Answers

1
Which of the following is a good example of a well-written chief complaint?
Pain is a 10/10.
“I don’t know what this pain is. This is the worst"
Complain of chest pain for 3 days that is worse with activit
A patient complaining of chest pain. R/O MI.
2
Areas covered under self-esteem and self-concept include:
stressors, coping mechanisms, and change in past year.
exercise, leisure activities, and level of independence.
education, financial status, and value-belief system.
family role, relationship, social support, & time spent alon
3
The duct in the parotid gland that opens into the mouth opposite the second molar is:
the Stensen duct.
the Wharton duct.
the sublingual duct.
the salivary duct.
4
The extraocular muscles consist of four straight or ___muscles and two slanting or __ muscles.
palpebral; conjugate
rectilinear; diagonal
superior; inferior
rectus; oblique
5
The tympanic membrane thermometer (TMT):
accurately measures temperature in 20 to 30 seconds.
provides an accurate measurement of core body temperature.
senses the infrared emissions of the cerebral cortex.
is not used in unconscious patients.
6
What type of database is most appropriate for an individual who is admitted to a long-term care
Complete
Follow-up
Emergency
Episodic
7
Pain signals are carried to the central nervous system by way of:
referred pain
perception.
afferent fibers.
modulation.
8
nurse infers patient uncomfortable asking for a different treatment b/c of fear. This...
affects the nurse-physician relationship.
impedes further discussion.
helps nurse understand own feelings abt patient’s verbal msg
helps patient understand feelings in regards of verbal msg
9
What three bones are these?
Cricoid, thyroid, lacrimal
incus, malleus, staples
stapes, malleus, incus
Femur, Tibia, Fibula
10
The labyrinth of the inner ear is responsible for maintaining the body’s:
binaural interaction.
pressure equalization
air conduction
equilibrium.
11
A medical diagnosis is used to evaluate:
a person’s culture.
the cause of disease.
a person’s state of health
the response of the whole person to actual or risks.
12
Which of the following statements describing a headache would warrant an immediate referral?
“I never had a headache like this before; I can’t function.”
“This is the worst headache I’ve had since puberty.”
“I have had daily headaches for years.”
“This is the worst migraine of my life.”
13
Which of the following children is at risk of recurrent otitis media (OM)?
18-month-old 3 episode of ear infections in a 5-month period
A 2-year-old with two ear infections in the past 6 months
An 18-month-old infant who lives with a smoker
6-month-old with sibling who had tubes inserted at 3 years
14
Endogenous obesity is:
excess adrenocorticotropin production by the pituitary gland
excessive secretion of growth hormone in adulthood.
characterized by evenly distributed excess body fat.
inadequate secretion of cortisol by the adrenal glands
15
Bleeding into the periosteum during birth is known as:
molding.
cephalhematoma
caput succedaneum
craniosynostosis.
16
The nasal mucosa of an individual with rhinitis would be:
bright red and swollen
swollen, boggy, and gray.
moist and pink.
pale with bright red bleeding.
17
What is this?
Vestibular
Incus
Cochlea
Concha
18
A common error in blood pressure measurement is:
deflating the cuff about 2 mm Hg per heartbeat.
waiting less than 1-2 mins before repeating BP on same arm
taking the blood pressure in an arm that is at lvl of heart.
using blood pressure cuff whose bladder length is 80% of arm
19
Which of the following is included in documenting a history source?
Reliability of informant
Documented relationship of support systems
Cognition and literacy level
Appearance, dress, and hygiene
20
the nurse asks, "What makes the headaches worse?" the nurse is seeking information about:
aggravating factors
relieving factors.
the patient's perception of pain
the nature or character of the headache.
21
When recording information for the review of systems, the interviewer must document:
presence or absence of all symptoms under the system heading
“negative” under the system heading
physical findings to support historic data.
objective data that support the history of present illness.
22
What is this?
inner ear canals
Semi-circular canals
oval canals
half circle canals
23
A severe deficiency of thyroid hormone nonpitting edema, coarse hair & face, dry skin & hair
congenital hypothyroidism.
myxedema.
scleroderma
Hashimoto thyroiditis.
24
Physical appearance includes statements that compare appearance with:
nutrition.
gait.
mood and affect.
stated age.
25
The components of a nail examination include:
clubbing, pitting, and grooving.
contour, consistency, and color.
texture, toughness, and translucency.
shape, surface, and circulation
26
What lymph node is this?
Deep cervical
Superficial cervical
superficial jugular
superior cervical
27
Pairs of sinuses is absent at birth, is well developed at 7 yrs, fully developed after puberty?
Maxillary
Ethmoid
Sphenoid
Frontal
28
Aphasia is best described as:
a language disturbance in speaking, writing or understanding
unable to do motor activities despite intact motor function
a disturbance in executive functioning
unable to identify things despite intact sensory function.
29
What lymph node is this?
Inferior cervical
Posterior cervical
deep jugular
inferior jugular
30
An older adult with dementia rates 5 out of 10 pain. The Nurse should...
administer prescribed pain meds
ask the patient to verify pain rating
use only nonpharmacological pain relief interventions
reassess pain level in 3-4 hours
31
A full mental status examination should be completed if the patient:
has a change in behavior and the family is concerned
complains of insomnia.
has a new diagnosis of type 2 diabetes mellitus.
develops dysphagia
32
What lymph node is this?
Intraclavicular
Interclavicular
Inferior clavicular
Supraclavicular
33
What is the source of deep somatic pain?
Bones and joints
Skin and subcutaneous tissues
Intestine
Pancreas
34
Patient cries and says: "please get me something to relieve this pain" What should the nurse do
Verify that the patient has an order for pain medications
Assess level of pain and give meds according to pain lvl
Assess the level of pain, and administer meds based patient
Reposition patient, then reassess pain
35
The tympanic membrane of a child with acute otitis media would be:
mobile and would flutter with the Valsalva maneuver.
flat and slightly pulled in at the center.
bulging with a distinct red color.
shiny and translucent, with a pearly gray color.
36
the examiner notices a bifid uvula on the mouth of an American Indian.
This condition is frequently associated with cleft palate
This is expected variation associated with this individual
his may indicate the presence of oral cancer.
This is rare and indicates other congenital anomalies may be
37
A slight protrusion of the eyeballs may be noticed in which ethnic/cultural group?
African American
Hispanic
Asian
American Indian
38
Which of the following statements cultural/racial differences in the treatment of pain is true?
Neurotransmitters r more concentrated in white than blacks
Black and Hispanic individuals have a higher pain tolerance
Pain modulation more highly developed in black and Hispanic
Whites receive more analgesic therapy black or Hispanic
39
An adult patient’s pulse is 46 beats per minute. The term used to describe this rate is:
weak and thready.
tachycardia.
sinus arrhythmia.
bradycardia.
40
The lens of the eye functions as a:
refracting medium.
sensory facilitator
mediator of light.
controller of intraocular pressure.
41
The general survey consists of four distinct areas. These areas include:
physical appearance, body structure, mobility, and behavior
gait, range of motion, mental status, and behavior.
A/O, personal hygiene, mental status, & physical condition
mental status, speech, behavior, and mood and affect.
42
The nurse records that the patient’s pulse is 3+ or full and bounding. Which is the cause?
Anxiety
Bleeding
Dehydration
Shock
43
When preparing the physical setting for an interview, the interviewer should:
reduce noise by turning the volume of t.v. or radio down.
stand next to the patient to convey a professional demeanor.
set the room temperature between 64° F and 66° F.
conduct the interview at eye level & distance of 4 to 5 ft
44
Which of the following behaviors demonstrated may be indicative of hearing loss?
Talking in a high-pitched voice
Frequently asking for the question to be repeated
Speaking slowly with well-articulated consonants
Not looking at the examiner when being questioned
45
Viewing the world from another person’s inner frame of reference is called:
empathy.
clarification.
reflection.
sympathy.
46
What type of database is most appropriate when rapid collection of data is required
Follow-up
Emergency
Complete
Episodic
47
One of the purposes of the paranasal sinuses is to:
augment the sensory sensation of smell.
amplify sound.
lighten the weight of the skull bones
warm and moisten the inspired air.
48
A patient with asthma has the following problems. Which problem is a a first-level priority?
Impaired gas exchange
Ineffective self–health management
Readiness for enhanced spiritual well-being
Risk for infection
49
Teaching 4th graders about sweat glands, which should be included while discussing this topic?
The evaporation of sweat, increases body temperature.
2 type of sweat glands: eccrine glands and sebaceous glands.
Newborn infants do not sweat, use compensatory mechanisms
Eccrine glands located in axillae, anogenital area, & navel.
50
Neuropathic pain implies an abnormal:
degree of pain interpretation.
transmission of pain signals.
processing of the pain message
modulation of pain signals.
51
What tests visual acuity?
Visual Reflex Test
Snellen Eye Test
Hinhberg Eye Test
Rohenberg Eye Test
52
A scooped-out, shallow depression in the skin is called a(n):
ulcer.
erosion.
fissure
excoriation
53
What is this?
Inner Ear canal
Eustachian tube
auditory canal
nasal tube
54
What is this?
Auricle
Internal Auditory Canal
Eustachian Tube
External Auditory Canal
55
Otoscopic examination is performed on an older adult patient, the tympanic membrane may be:
thinner than that of a younger adult
more mobile than that of a younger adult.
whiter than that of a younger adult.
pinker than that of a younger adult.
56
What is this?
Stapes
Malleus
Concha
Vestibule
57
What lymph node is this?
Superior auricular
Preauricular
superior mandibular
Post Auricular
58
What is this?
Trachea
Thyroid Cartilage
Isthmus of Thyroid
Thyroid Gland
59
A complete database is:
used to perform a thorough or comprehensive health history
used to evaluate the cause or etiology of disease.
used for a limited or short-term problem
used to collect data rapidly & compiled with lifesaving
60
A nursing diagnosis is best described as:
a pattern of coping
a concise statement of actual or risks or level of wellness.
an individual’s perception of health.
a determination of the etiology of disease.
61
The normal color of the optic disc is:
red.
creamy red to yellow-orange.
creamy yellow-orange to pink.
creamy pink
62
What is the major cause of decreased saliva production in older adults?
A diminished sense of taste and smell
Decreased fluid intake
Normal aging process
Use of anticholinergic medications
63
What term refers to a linear skin lesion that runs along a nerve route?
Zosteriform
Dermatome
Annular
Shingles
64
What lymph node is this?
Preauricular
Submaxillary
Submandibular
Submental
65
What is this?
Clavicle
Manubrium
Hyoid
Femur
66
A flat macular hemorrhage is called a(n):
ecchymosis
petechiae
purpura
hemangioma
67
What nerve is this?
VIII
VII
VI
V
68
Performing an abdominal examination, what is the proper sequence
Auscultation, percussion, inspection, palpation
Inspection, auscultation, percussion, palpation
Palpation, percussion, inspection, auscultation
Inspection, palpation, auscultation, percussion
69
Craniosynostosis is a severe deformity caused by
localized bone disease that softens, thickens,& deforms bone
increased intracranial pressure
excess growth hormone or a deficit in thyroid hormone.
premature closure of the sutures
70
What information is included in greater detail when taking a health history on an infant?
Nutritional data
Family history
Environmental hazards
History of present illness
71
The external structure of the ear is identified as the:
atrium.
auricle.
aureole.
auriga
72
PQRSTU is a mnemonic that helps clinician to remember to address characteristics specific to:
severity of dementia.
pain presentation.
the ability to perform activities of daily living (ADLs).
substance use and abuse.
73
What lymph node is this?
cervical
jugulodigastric
deep jugular
throat
74
When taking health history, the patient complains of pruritus. what is a common cause of this?
Drug reactions
Excessive bruising
Melasma
Hyperpigmentation
75
Which of the following is the most reliable indicator for chronic pain?
Tissue enzyme levels
Magnetic resonance imaging (MRI) results
Patient self-report
Blood drug levels
76
examiner notices fine tremor in patients tongue. What disorder is consistent with this finding?
Diabetic ketoacidosis
Halitosis
Alcoholism
Hyperthyroidism
77
What lymph node is this?
Submaxillary
Submandibular
Preauricular
Submental
78
What kind of cancer is this?
epithelial carcinoma
dermis carcinoma
Squamous cell carcinoma
basal cell carcinoma
79
When taking a health history from an adolescent, the interviewer should:
interview the youth alone with a parent in the waiting area.
Ask about violence and abuse before asking abt alcohol & dru
have at least one parent present during the interview.
ask every youth about the use of condoms.
80
To perform an accurate assessment of respirations, the examiner should:
assess respirations for a full 2 minutes if an abnormality
inform the person of the procedure and count for 1 minute.
count for 30 seconds after completing a pulse assessment
count for 15 seconds while keeping fingers on the pulse
81
PA on Patient who is end-stage HIV positive. What should the nurse do for self-protection?
Wash hands and don two pairs of gloves and gown.
Don gloves & wash hands after examination
Wash hands and don gloves, gown, and protective face shield.
Wash hands, don gloves, and wash hands after examination
82
Dehydration signs and symptoms in older adults
hot spots
Has bloody or black stool
cold spots
Is irritable or disoriented
83
What type of pain is short and self-limiting and dissipates after the injury heals?
Breakthrough
Acute
Chronic
Persistent
84
Which of the following is an example of objective data?
Alert and oriented
A sore throat
An earache
Dizziness
85
What occurs during transduction (the first phase of nociceptive pain)?
The pain impulse moves from the spinal cord to the brain.
The brain interprets the pain signal.
Chemical mediators neutralized to lower perception of pain.
Pain signals move from the site of origin to the spinal cord
86
The location in the brain where optic nerve fibers cross over is identified as
fovea centralis.
optic disc.
optic chiasm
choroid.
87
Nonverbal communication is the primary form of communication for which group of individuals?
Infants
Adolescents
Preschoolers
Older adults
88
Signs and Symptoms of Dehydration in Infants. (SATA)
Sunken soft spot on top of skull
blood spots on skin
No wet diapers for three hours
No tears when crying
89
The CAGE test is a screening questionnaire that helps to identify:
depression.
unhealthy lifestyle behaviors.
personal response to stress
excessive or uncontrollable drinking.
90
An example of subjective data is:
left knee has been swollen and hot for the past 3 days.
decreased range of motion.
crepitation in the left knee joint.
arthritis.
91
What is this?
Tympanic canal
Tympanic Window
Tympanic Membrane
Tympanic fluid
92
Which questions would the examiner ask to determine whether an individual has epistaxis?
“Do you experience nosebleeds?”
"Do you have any difficulty with swallowing?”
“Have you noticed unusual lesions on inside of your mouth?”
“Do you experience a runny nose frequently?”
93
The Doppler technique:
augments Korotkoff sounds during blood pressure measurement.
measures arterial oxygenation saturation.
is used to assess the apical pulse.
provides easy and accurate measurement diastolic pressure.
94
The "review of systems" in the health history is:
a documentation of the problem as perceived by the patient
a record of objective findings.
evaluation past & present health state of each body system.
a short statement of general health status.
95
Which statements regarding the results obtained from the Snellen chart is true?
The larger the denominator, the poorer the vision
The smaller the numerator, the poorer the vision.
The smaller the denominator, the poorer the vision.
The larger the numerator, the better the vision.
96
According to the holistic model, a narrow definition of holistic health includes:
an optimal functioning of mind, body, and spirit
the internal and external environment.
the response of the whole person to actual or risks.
the absence of disease.
97
What lymph node is this?
Occipital
Preauricular
Jugulodigital
Posterior Auricular
98
Risk factors that may lead to skin disease and breakdown include:
increased thickness of the skin.
a lifetime of environmental trauma.
loss of protective cushioning of the dermal skin layer.
decreased vascular fragility.
99
When inspecting the eyeballs of an African American individual, which might be expected
Small brown macules on the sclera
A slight misalignment of the eyeballs
A slight amount of drainage around the lacrimal apparatus
A slight yellow discoloration of the sclera
100
Which of the following has been found to increase sensitivity to pain in women?
Hormonal Changes
Age
Parity
Weight
101
An example of objective data is:
impaired left knee motion from inability to walk, swelling,
left knee has been swollen and hot for the past 3 days.
a complaint of left knee pain.
crepitation in the left knee joint.
102
The nurse obtained review of eye. What would require emergency situation?
“My eyes feel tired all the time.”
“I see flashing lights and spots.”
“My eyes get watery when I am gardening.”
“I’m having trouble seeing when I drive at night.”
103
To determine if a dark-skinned patient is pale, the nurse should assess the color of the:
skin in the antecubital space.
earlobes.
palms of the hands.
conjunctivae
104
Kyphosis of the spine is common with aging. To compensate, older adults:
shuffle.
increase their center of gravity.
stiffen their gait.
extend their heads and jaws forward.
105
Narrow palpebral fissures, epicanthal folds, and midfacial hypoplasia are characteristic of:
fetal alcohol syndrome.
chronic childhood allergies.
congenital hypothyroidism.
Down syndrome.
106
What kind of Cancer is this?
epithelial carcinoma
squamous cell carcinoma
dermis cell carcinoma
Basal cell carcinoma
107
An example of an open-ended question or statement is:
“Tell me about your pain.”
“I can see that you are quite uncomfortable.”
“On a scale of 1 to 10, how would you rate your pain?”
“You are upset about the level of pain, right?”
108
When addressing a toddler during the interview, the health care provider should:
use detailed explanations.
use short, simple, concrete sentences.
ask the child, before the caretaker, about symptoms.
use nonverbal communication
109
Which of the following is an expected response on the cover test?
The covered eye maintains its position when uncovered.
The uncovered eye is unable to maintain gaze on fixed object
The covered eye moves into a relaxed position.
The covered eye jumps to reestablish fixation when uncovered
110
If the tympanic membrane has white dense areas, the examiner suspects:
perforation from a ruptured membrane.
scarring from recurrent ear infections.
serous fluid from serous otitis media.
a fungal infection.
111
Which of the following findings is associated with Horner syndrome?
Unilateral dilated pupil with no reaction
Bilateral mydriasis
Unilateral tinyregular pupil reacts to light & accommodation
Bilateral miosis
112
Which of the following statements related to symptoms or triggers of headaches is true?
premenstrual hormonal fluctuations may caus cluster headache
Chocolate or cheese may cause tension headaches.
Poor posture may trigger a migraine headache.
Alcohol consumption may cause cluster or migraine headaches
113
The most appropriate introduction to use to start an interview with an older adult patient is:
David, I am here to ask you questions about your illness
“Mr. Jones, I want ask you some questions about your health
Mr. Jones is it okay if I ask several questions this morning
I will just get the information from the chart.”
114
Best electronic resource for incorporating evidence-based practice into health assessment?
WebMD.com
Nursingworld.org
Mayoclinic.com
Wikipedia.org
115
The use of euphemisms to avoid reality or to hide feelings is known as:
avoidance language.
distancing language.
ethnocentric language.
sympathetic language
116
What disease flat, expressionless face; a staring gaze; oily skin; and elevated eyebrows?
Cushing syndrome
Acromegaly
Parkinson disease
Scleroderma
117
Which of the following groups need to be tested for the presence of color blindness?
White girls between the ages of 4 and 8 years
White boys between the ages of 4 and 8 years
Asian girls between the ages of 3 and 6 years
Black boys between the ages of 10 and 15 years
118
One method to verify information within the context of the interview is to:
call a family member to confirm information.
ask the patient if there is someone who could verify info
rephrase the same questions later in the interview.
review previous medical records
119
An example of a primary lesion is a(n):
urticaria.
port-wine stain.
erosion.
ulcer.
120
Binaural interaction at the level of the brainstem permits:
amplification of sound.
direction of sound toward the appropriate conduction pathway
interpretation of sound.
identification and location of the direction of the sound.
121
What lymph node is this
Deep Cervical Chain
Deep Throat Chain
Deep Jugular Chain
Deep Thoracic Chain
122
What lymph node is this?
postauricular
Preauricular
Occipital
jugulodigastric
123
Signs and Symptoms of Dehydration in Adults (SATA)
Dark-colored urine
Fatigue
Increased urination.
Confusion
124
The tympanic membrane in neonate is more _____ making it hard to visualize with the otoscope.
perpendicular
horizontal
oblique
vertical
125
What is this?
Cricoid Cartilage
Thyroid Glad
Stenoid Cartilage
Thyroid Cartilage
126
Starting at ___ years of age, the interviewer asks child directly about presenting symptoms.
11
5
7
9
127
In addition to initiating digestion of food, saliva:
inhibits overgrowth of bacteria in the mouth.
cleans and protects the mucosa.
augments taste sensation.
protects the mucosa from caustic substances.
128
A patient was in a motor vehicle accident. The trachea deviates to the left side. this means...
aortic arch aneurysm.
right-sided atelectasis.
right pleural adhesion.
right pneumothorax
129
Decreased vision in an elderly patient may be due to which of the following conditions?
Fixation
Retinoblastoma
Presbyopia
Macular degeneration
130
Which of the following tests provides a precise quantitative measure of hearing?
Whispered voice test
Tuning fork tests
Audiometer test
Romberg test
131
What is this?
Superficial cervical
Sternomastoid muscle
posterior cervical
trapezius muscle
132
Most facial bones articulate at a suture. Which facial bone articulates at a joint?
Nasal bone
Maxilla
Mandible
Zygomatic bone
133
An enlarged tongue (macroglossia) may accompany:
hairy tongue.
Down syndrome
cleft palate.
fissured tongue.
134
What is this?
Fissure, Erosion
Papule, Plaque
Bulla, Vesicle
Wheal, Hives
135
Functions of the skin include:
secretion of a drying substance called sebum.
production of new cells by melanocytes.
production of vitamin C.
temperature regulation
136
Specialized nerve endings that are designed to detect painful stimuli are?
nociceptors
c fibers
dorsal horns
synapses
137
Which of the following statements made by the interviewer would be an appropriate response?
“Tell me what you mean by ‘bad blood.’”
“I know just how you feel.”
“Why did you wait so long to make an appointment?”
“If I were you, I would have the surgery.”
138
What is this?
Thyroid Gland
Parotid Gland
Thymus Gland
Salivary Gland
139
Data collection for the general survey begins
at the first encounter
at the beginning of the physical examination.
during the mental status examination.
while taking vital signs.

McGovern Physical Assessment Final Exam Part 1 Flashcards | StudBud