Which of the following clients has the greatest risk of developing hypertension?

obese men with diabetes mellitus

Area of skin on feet turned white HCP told her condition is vitiligo The nurse explains

caused by the complete absence of melanin pigment

Assessing VS 3 yr old appears irregular respiratory pattern How should nurse assess childs resp

count resperations full min noting rate & rhythym

Examination notes lesion on the pts upper back What is best way to document size of lesion?

Use a centimeter rule to measure the lesion

To assess the dorsalis pedis artery, the nurse would palpate:

lateral to the extensor tendon of the great toe.

Pt asks Why is touching my toes necessary? This is a sports examination not an exercise class

This allows me to see how straight your spinal column is

Which assessments appropriate for evaluating cerebellar function? (Select all that apply)

Heel to shin test, Rapid alternating fingers, Finger to nose test

The main functions of the skin include: (Select All)

Endocrine function e.g. re. Vitamin D, Excretion from the body of certain types of waste materials, Temperature regulation

Education for staff on epidermal layer of skin Which of the following should be included?

the epidermis is replaced every 4 weeks

Which statement is true regarding the Glasgow Coma Scale?

it assesses the functional ability of the client

During an assessment of a dark skinned pt w/ hepatitis B Nurse would note

yellowish-green color of palms & hands and soles of feet

50 yr old elevated serum total cholesterol & triglyceride What would be important in teaching?

information regarding a low saturated fat diet

Rash itches denies fever SOB/other s/s ?'s nurse ask to help determine allergic reaction?

Have you been exposed to any new cleaning solutions?, Have you been using any different soaps?, Are you taking any new medications?

Assessment of newborn mother concerned head big ?s If wrong? Nurse knows following of newborns

head circumference greater than chest circumference at birth

Pt s/s severe headache, vomiting and rash. Nurse would suspect meningitis?

The rash does not blanch with pressure

Pts thyroid is enlarged nurse to auscultate the thyroid for the presence of a bruit. A bruit is

soft whooshing pulsatile sound best heard w/bell side

What would the nurse tell pt to perform to determine function of cranial nerve X vagus?

have pt say "AH" and watch uvula

What does tactile fremitus assess?

Difference in density of lung tissue

The nurse is aware that the four areas in the body where lymph nodes are accessible are the?

head and neck, arms, inguinal area, and axillae

Which is an example of objective data a nurse would collect during a physical examination?

The clients radial and pedal pulses

Newborn for well-baby checkup observes infant possibility fluid loss because of which factors?

The newborn's skin is more permeable than that of the adult

S/S nurse considers cataract as diagnosis?

clouding of the lens of the eye

Assessment of older adult Which assessment data would indicate potential complications w/ skin?

lesion with an irregular border

Breast health interview pt states noticed pain L breast Most appropriate response would be:

I would like more information about pain in your L breast.

Common change seen in geriatric clients?

Skin thins due to loss of collagen

Student learning B/P technique ?'s instructor normal B/P reading Which response appropriate?

normal is considered to be less than 120/80 & above 100/60

Which of the following situations will result a falsely high B/P reading? (Select All)

the person is sitting w/ his/her legs crossed, the B/P cuff is too narrow for the extremity

studbud

HEALTH ASSESSMENT FINAL STUDY REVIEW QUESTIONS

165 termsStudBud Administration50 plays

2019HEALTHASSESSMENT03

Flashcards165 cardsFPractice quizPHost liveL

Questions 165

Answers

1
Which of the following clients has the greatest risk of developing hypertension?
hispanic men
clients with high cholesterol levels
postmenopausal women
obese men with diabetes mellitus
2
What are the characteristics of lymph nodes in clients with an acute infection?
Soft, mobile and painless
Hard fixed and painless
Round, rubbery and mobile
Enlarged and tender
3
Area of skin on feet turned white HCP told her condition is vitiligo The nurse explains
caused by the excess of melanin pigment
related to impetigo and can be treated with an ointment
caused by the complete absence of melanin pigment
caused by an excess of apocrine glands in her feet
4
Assessing VS 3 yr old appears irregular respiratory pattern How should nurse assess childs resp
check childs resp minimum 5 min identify variations pattern
count pts resp 15 sec & multiply X4 obtain # of resp/min
check childs pulse & resp simultaneously for 30 seconds
count resperations full min noting rate & rhythym
5
Examination notes lesion on the pts upper back What is best way to document size of lesion?
Trace the lesion onto a piece of paper
Estimate its size to the nearest inch
Compare its size to the size of a coin
Use a centimeter rule to measure the lesion
6
Perform spinal assessment and note excessive inward curvature of lumbar spine.
lordosis
spndylosis
kyphosis
scoliosis
7
To assess the dorsalis pedis artery, the nurse would palpate:
over the lateral malleolus
lateral to the extensor tendon of the great toe.
in the groove behind the medial malleolus.
behind the knee
8
All of the following data is collected during a head-to-toe assessment except?
mood or affect
laboratory results
gait
hearing and speech abilities
9
Pt asks Why is touching my toes necessary? This is a sports examination not an exercise class
This allows me to see how straight your spinal column is
This is the best way to check for symmetry of your arms
I am looking at the stretch of your ham strings
Considered abnormal can’t touch your toes from this position
10
Which assessments appropriate for evaluating cerebellar function? (Select all that apply)
Heel to shin test
Rapid alternating fingers
Finger to nose test
Weber test
11
The nurse inspects and palpates the throat as the client swallow which cranial nerve checking?
VII, facial
X, vagus
IV, trochlear
XII, hypoglossal
12
Herberden & Bouchard nodes are associated with what condition?
osteoarthritis
Rheumatoid arthritis
Dupuytren contracture
Gout
13
The main functions of the skin include: (Select All)
Endocrine function e.g. re. Vitamin D
perception
Excretion from the body of certain types of waste materials
Temperature regulation
14
Which assessment would be appropriate for evaluating cerebellar function?
Stereognosis
Testing cranial nerve X, Vagus
Rapid alternating fingers
Dull or sharp testing
15
Education for staff on epidermal layer of skin Which of the following should be included?
the epidermis is very vascular
the epidermis is replaced every 4 weeks
the epidermis is thick and tough
the epidermis is thin and nonstratified
16
A thorough skin assessment is very important because the skin holds information about
Psychological wellness
Socioeconomic status
Support systems
Circulatory status
17
Which statement is true regarding the Glasgow Coma Scale?
it assessed your balance
it assesses the functional ability of the client
it assesses whether depressed or not
it assesses your coping strategies
18
What part of cardiac cycle ventricles are contracting and pushing blood out of the chambers?
hypotension
symptom
diastole
systole
19
During an assessment of a dark skinned pt w/ hepatitis B Nurse would note
ashen, gray color of palm & hands and soles of feet
reddish color of palms & hand and soles of feet
yellowish-green color of palms & hands and soles of feet
bluish color of palm & hand and soles of feet
20
When evaluating a pt's pain the nurse knows that an example of acute pain would be?
kidney stones
arthritic pain
low back pain
fibromyalgia
21
50 yr old elevated serum total cholesterol & triglyceride What would be important in teaching?
the risks of undernutrition
information regarding a low saturated fat diet
methods to reduce stress in her life
the fact hereditary & nothing she can do to change levels
22
Rash itches denies fever SOB/other s/s ?'s nurse ask to help determine allergic reaction?
Have you been exposed to any new cleaning solutions?
Have you been using any different soaps?
Is your skin usually dry or flaky?
Are you taking any new medications?
23
Aging process hair look gray/white & begin feel thin& fine occurs d/t decrease # of functioning
Fungacytes
Melanocytes
Phagocytes
Metrocytes
24
4 yr old boy in ER pointing to stomach "It hurts so bad" Which pain assessment be best choice?
the Wong-Baker scale
the brief pain inventory
the descripter scale
the number rating scale
25
Assessment of newborn mother concerned head big ?s If wrong? Nurse knows following of newborns
anterior frontanel closes @ 2 m head more equal to body
at birth the head is 1/5 the total length
the head size reaches 90% its final size when the child is 3
head circumference greater than chest circumference at birth
26
Pt s/s severe headache, vomiting and rash. Nurse would suspect meningitis?
The client has a resting tremor
The client has upper respiratory symptoms
The rash does not blanch with pressure
The client has seizures
27
B/P on thin female w/ large cuff available Would correctly anticipate which following reading?
a falsely low reading
the size of the cuff doesn't make any difference
a falsely elevated reading
an accurate reading
28
Which statement will elicit the most information?
Did you try home remedies for your symptoms?
What are your symptoms today?
Didn’t you call your doctor?
Did you drive yourself today?
29
Pts thyroid is enlarged nurse to auscultate the thyroid for the presence of a bruit. A bruit is
high pitched tinkling sound best heard w/ diaphram side
loud whooshing blowing sound best heard w/bell side
low gurgling sound best heard w/diaphram side
soft whooshing pulsatile sound best heard w/bell side
30
The client complains of ringing, crackling or buzzing in the ear. Choose the best term.
otitis media
tinnitus
tympanic
pinna
31
What would the nurse tell pt to perform to determine function of cranial nerve X vagus?
have pt say "AH" and watch uvula
move tongue from side to side
shrug shoulders while nurse pushes down
say "E-E-E" while nurses hands on pts back
32
What does tactile fremitus assess?
Difference in density of lung tissue
Breath sounds
Firmness of skin tissue
Symmetry of lung inflation
33
The nurse is aware that the four areas in the body where lymph nodes are accessible are the?
head and neck, arms, inguinal area, and axillae
arms, breasts, inguinal area, and legs
head and neck, arms, breasts, and axillae
head, breasts, groin, and abdomen
34
Which is an example of objective data a nurse would collect during a physical examination?
The clients complaints of tingling sensations in the feet
Mother states that the client has been very nervous lately
The clients stated concern about lack of money for meds
The clients radial and pedal pulses
35
When performing a physical assessment, the technique the nurse will always use first is
inspection
palpation
auscultation
percussion
36
A client has a left femur fracture repair. Which is of most concern to the nurse?
Pulse are 1+ bilaterally
Swelling at the break site
Capillary refill of less than 2 seconds
Left foot is cool and pale
37
Newborn for well-baby checkup observes infant possibility fluid loss because of which factors?
Sebaceous glands are over productive in the newborn
Amount of vernix caseosa dramatically rises in the newborn
The newborn's skin is more permeable than that of the adult
Subcutaneous fat deposits are high in the newborn
38
Infant large soft lump side head& noticed approx 8 hrs after birth & getting bigger Explanation
Hydrocephalus
Cephalohematoma
Craniosynostosis
Caput succedaneum
39
What test would nurse instruct pt w/ pneumonia to do for assessment?
Whispered Pectoriloquy
Bronchophony
Egophony
Cheyne-Stokes
40
S/S nurse considers cataract as diagnosis?
eye pain
purulent discharge
clouding of the lens of the eye
complaint of seeing red rings around lights
41
Assessment of older adult Which assessment data would indicate potential complications w/ skin?
wrinkling
lesion with an irregular border
deeping of expression lines
thinning and loss of elasticity in the skin
42
The nurse is preparing to percuss to assess the underlying?
tissue texture
tissue density
tissue turgor
tissue consistency
43
Breast health interview pt states noticed pain L breast Most appropriate response would be:
Almost always result benign breast disease & just ignore it.
Don t worry about the pain; breast cancer is not painful.
I would like more information about pain in your L breast.
I would like more information about pain in your R breast.
44
Common change seen in geriatric clients?
Hair becomes more abundant
Heart beat usually slows with age
Skin thins due to loss of collagen
Blood pressure decreases due to decreased vessel elasticity
45
Nurse has patient takes deep breaths to check for lung movement which assessment is this?
bronchophony assessment
Egophony assessment
thoracic expansion assessment
tactile fremitus assessment
46
When the nurse assesses an apical HR & notes bradycardia. What was the apical HR?
greater than 100 beats per minute
60-90 beats per minute
greater than 150 beats per minute
less than 60 beats per minute
47
A patient presents with a raised firm lesion almost 2 cm in size.
bullae
pustule
nodule
macule
48
Student learning B/P technique ?'s instructor normal B/P reading Which response appropriate?
ask the client what is usual for them
that depends on the client
a normal reading is 140/80
normal is considered to be less than 120/80 & above 100/60
49
Which technique of assessment used to determine the presence of crepitus swelling & pulsations?
inspection
ascultation
palpatation
percussion
50
Assessing capillary refill note color return of 4 sec on each hand documented correctly as?
brisk
normal
absent
sluggish
51
Which of the following situations will result a falsely high B/P reading? (Select All)
the person is sitting w/ his/her legs crossed
the B/P cuff is too narrow for the extremity
the cuff has a small tear on the side of it
the nurse does not inflate the cuff high enough
52
Examination nurse finds a pt has excessive dryness of the skin term to best describe this?
Seborrhea
Xerosis
Alopecia
Pruritus
53
What s/s of migraine headaches? (Select all that apply)
visual auras
throbbing
nasal stiffness
mild to severe pain
54
What term best describes this type of fracture in the picture?
spiral
oblique
compound
transverse
55
Which statement indicates that the nurse understands pain experience in the elderly?
older pts percieve pain to lesser degree than younger pts
pain indicates pathology/injury & not norm process of aging
older persons must learn to tolerate pain
pain is a normal process of aging and is to be expected
56
50 year old to have colonoscopy. What level of health promotion is this?
primary prevention
tertiary
secondary prevention
risk factor prevention
57
Identify which reflex is being tested in this picture.
plantar
patellar
achille's
triceps
58
Pain med not working rate postoperative pain 10 Which following assessment indicates acute pain
confusion
increased blood pressure and pulse
decreased blood pressure and pulse
hyperventilation
59
Swooshing sound loudest 2nd intercostal space, Right. Border. Problem valve?
tricuspid
aortic
mitral
pulmonic
60
Heard loudest in 2nd intercostal space Right & Left of sternal boarders?
thrill
murmur
S1
S2
61
Pt dx w/ DMII gained more wt & BGs high Suspects non-compliant Response for data collection?
You want to learn reduce your blood sugar levels dont you?
You need to follow what Dr prescribed in order to get better
Don’t you know anything about diabetes?
Tell me how you managed w/ diet for these past few months?
62
Which finding should the nurse expect to find when assessing the nails of a healthy adult?
the nail base angle is not more than 90 degrees
smooth and rounded nails with a flat surface
whitish-to-clear nails in darker skinned clients
gradual enlargement of the distal finger
63
Which statement is true regarding the use of standard precautions in the health care setting?
use w/all regardless of risk/presumed infection status
nonintact skin visible blood/contact w/mucous membranes
apply to all body fluids, including sweat
airborne, droplet & contact transmission based included
64
Notation of petechiae in client's chart observed, what finding does nurse expect on inspection?
purplish-red pinpoint lesions
generalized reddish discoloration of an area of skin
small raised fluid-filled pinkish nodules
deep purplish or red patches of skin
65
Assessing pt a number/letter drawn onto hand while visually occluded is known as what test?
sensory integration test
graphesthesia
stereognosis
Romberg's test
66
What occurs in the diagnosis step of the nursing process?
Setting goals & selecting interventions
Assess & plan
Clustering and interpreting data
Evaluating goal achievement
67
Documenting results of palpating pulse the nurse is correct making which following notations?
rhythm noted 100 beats/minute
bounding contour
rhythm noted 2+
irregular rhythm
68
What would the nurse expect to note when assessing a lesion diagnosed as malignant?
black lesion with irregular edges
reddened lesion with regular edges
symmetric lesion
raised firm lesion
69
Pts lab data reveal elevated thyroxine level The nurse would proceed with an examination of?
parotid gland
thyroid gland
adrenal gland
thyroxine gland
70
What is being tested when the client is being assessed utilizing a Snellen Chart?
ability to read or see items in close proximity
ability to see items from a distance
accomodation
pupillary reaction
71
On performing a spinal assessment noted pt to have excessive outward appearance?
spondilosis
lordosis
kyphosis
scoliosis
72
Pt admitted to hospital w/ stage 2 pressure ulcer. Which findings are characteristics? (SA)
lesion superficial looks like abrasion, blister/shallow
partial thickness loss involving epidermis, dermis, or both
warm to the touch and red
full thickness loss w/ extensive destruction tissue necrosis
73
The nurse knows that the incidence of osteoporosis is greatest in which group?
black women
black men
white women
American India men
74
Assessing pt nutritional status nurse recalls the best definition optimal nutritional status is
sufficient nutrient body required &increase metabolic demand
sufficient nutrient for body not increased metabolic demand
nutrients in excess of daily body requirements
sufficient nutrients to provide for the minimum body needs
75
Inspecting ear canal of adult pt method to straighten ear canal to better visualize the area?
Gently pull the pinna down and back
Pull the pinna horizontal to the side of the head
Gently pull the pinna up and back
There is no need to move the pinna
76
Assessing skin @ risk dehydration d/t excessive vomiting dry & loose Best site to check turgor?
anterior chest
upper arm
facial cheek
mid-thigh
77
Yrly physical 43yr-old states doesnt perform monthly breast selfexams believes mammogram better
mammography may not detect all palpable lumps
no need for breast selfexam as long as Dr check breasts yrly
breast self-examination is unnecessary until age of 50 yrs.
correct is good replacement for breast self-examination
78
Mole on scalp started itching and bleeds What other findings would be danger sign?
symmetry of the lesion
irregular border
color consistent
size less than 6 mm wide
79
Where can the bronchial breath sounds be heard?
pulmonic area
bronchial area
tricuspid area
right lung area
80
Tongue movement and tongue strength. Which cranial nerve is being tested?
XII, hypoglossal
VII, facial
IX, glossopharyngeal
X, vagus
81
Where can bronchial breath sounds be heard?
Peripheral lung fields
Tracheal area
Sternal area
Between the scapula
82
A thorough skin assessment is very important because the skin holds information about?
psychological wellness
support systems
circulatory status
socioeconomic status
83
The nurse fanning of the toes when the sole of the foot of a newborn is stiff is called?
Romberg's Test
Positive Babinski
Negative Babinski
Wong-baker scale
84
A black pt intensive care unit impending shock after accident characteristics in patients skin?
pale with blue extremities
ruddy blue
patchy areas of pallor
ashen, gray or dull
85
Physical growth is the best index of a child’s?
General makeup
General health
activity and exercise patterns
nutritional status
86
Nurse notes a client has had a black, tarry stool and recalls that a possible cause would be ?
gallbladder disease
overuse of laxatives
gastrointestinal bleeding
localized bleeding around the anus
87
80 yr old skin wrinkled thin lax & dry This finding is related to which factor in the elderly?
increased loss of elastin & decrease in subcutaneous fat
increased vascularity of the skin
increase in elastin and decrease in subcutaneous fat
increased numbers of sweat and subcutaneous glands
88
Detects irregularity in pts radial pulse Which of the following should the nurse perform?
count the radial pulse again for 15 sec & multiply X4
use stethoscope to check the bradial pulse
count the clients apical pulse for full minute
record this as normal for the client
89
When assessing a pts pain, the nurse knows that an example of visceral pain would be?
cholecystitis
hip fracture
pain after a leg amputation
second degree burns
90
When documenting palpation of a pulse correct recording in which notation about the rhythm?
rhythm 100 beats per minute
rhythm noted at 2+
bounding rhythm
irregular rhythm
91
Auscultating the R carotid artery hears a swishing sound (a bruit). What would this suggest?
Decreased cardiac output
Right ventricular failure
Increased central venous pressure
A narrowed vessel
92
Client w/ small elevated superficial lesionw/ purulent fluid & nurse records lesion as which?
pustule
cysts
wheals
bullae
93
The best way to assess general temperature of skin is for nurse to use which part of the hand?
back (dorsum) of the hand
palmar surface (underside) of the hand
ulnar surface of the hand
pads of the fingers
94
Pt crying says "Please get me something to relieve this pain" What should nurse do next?
assess pain & give meds accordingly, then reassess pain
check for pain med order and administer as directed
reposition pt then reassess pain after intervention
Assess pain ? what usually works give pain med prn& reassess
95
Ausculates ABD aorta, hears swishing sound. Nurse suspects?
an aneurysm
nothing, it's normal finding
myocardial infarction
aortic stenosis
96
Assessing preschool child hospital setting Interventions assessing child effectively? (SA)
Communicate with the child during the assessment
Examine the child's head, eye, throat, and nose first
Allow the child to play with toys during the assessment
Demonstrating the use of the B/P on a teddy bear
97
Client has macular rash Which of the following best describes a macular rash?
elevated firm well defined lesion less than 1 cm in diameter
flat well defined small lesion less than 1 cm in diameter
depressed firm/scaly rough lesion greater 1 cm in diameter
elevated fluid filled lesion less than 1 cm in diameter
98
When assessing a pts pulse the nurse should note which of the following characteristics?
force
timing in the cardiac cycle
capillary refill time
pallor
99
Dietary habit which tool would be the best to use as quick screen tool to assess dietary intake
24 hour recall
calorie count
comprehensive diet history
food diary
100
Testing stool for occult blood, the nurse is aware that a false-positive result may occur with
increased fat content
absent bile
a large amount of red meat within the last 3 days
increased ingestion of fruit
101
What is a symptom of nephrolithiasis?
indigestion
high fever
flank pain
blood in stool
102
Assessing ROM client’s ankles nurse expects client to perform?
Supine & extension
Circumduction and peonation
Dorsiflexion and inversion
Extension and hyperflexion
103
Assess pt pain nonverbal behaviors w/ acute pain Which of the following noted w/ acute pain(SA)
moaning
diaphoresis
sleeping
smiling
104
58 yr old finds small lump in breast What data history risk factor breast cancer?
Menarche occurred at age 14, menopause at 46
Her husband’s mother died from breast cancer
She has wine every evening
She had radiation Tx for Hodgkin’s disease at age 17
105
Pts mole started to burn & bleed Assessing danger signs for pigmented lesions & concerns?
symmetry of lesions
border regularity
diameter of less than 6 mm
color variation
106
What is a sign of right sided congestive heart failure?
jugular venous distention
moist skin
orthopnea
fever
107
What is appropriate tool to evaluate pain on a 5 year old broken arm?
0-5 numeric rating scale
NIPS scale
Simple pain descriptor
Wong Baker faces pain scale
108
When assessing a pts lung sounds hears rhonchi bilaterally nurse suspects?
mucus in the smaller airway
asthma
pneumonia
mucus in the larger airway
109
A 85 yr old women complaining about face bones in face becoming more noticeable. Explanation?
does not use a dermatologically approved moisturizer
Diets low protein & high carbohydrates enhance facial bones
increased elasticity causes skin to be more taught
related to aging decreased elasticity SQ fat & moisture
110
The nurse knows that which statement is true regarding the pain experienced by infants?
the Wong-Baker scale can be used to assess pain in infants
procedure induces pain in adults also induces pain infant
pain in infant only assessed physiologic change increased HR
infants feel pain less than adults do
111
Discover decreased skin turgor in pt & knows is expected finding in which following condition?
with condition of connective tissue disorders as scleroderma
in an individual who is severely dehydrated
during childhood growth spurts
cases of severe obesity
112
What is a non-modifiable colon cancer risk factor?
smoking
alcohol use
obesity
African American
113
Inspect legs pt skin shiny & taut w/ little hair Additional data indicate PAD?
No cramping pain thighs, legs & calf walking/climbing stairs
Pale, cool legs with diminished to absent dorsalis pulses
Legs color WNL
The feet warmer as compared to other parts of the body
114
Nurse knows deformities noted with Rheumatoid arthritis are? (Select All that apply)
Hitchhiker’s thumb
Boutonniere deformity
Swan-neck deformity
Claw toe deformity
115
How does nurse document a raised 0.6 cm, firm lesion noted on a client’s arm?
nodule
papule
macule
wheal
116
Examining face aware that 2 pairs of salivary glands are accessible to examination are ? glands
Occipital and submental
Occipital and submental
Parotid and jugulodigastric
Parotid and submandibular
117
2 month old rolled against wall notice soft spot top of head ?Wrong? Nurses best response is?
perhaps result of dietary intake during pregnancy
soft spot indication of cretinism/congenital hypothyroidism
may have a craiosynostosis disease of sutures of the brain
soft spot normal allows for growth of brain during 1st yr
118
Glasgow Coma Scale is used to grade neurological responses to which three parameters?
Verbal response, pain response, reflexes
Pupil response, motor response, reflexes
Eye opening, verbal response, motor response
Motor movement & strength reflexes pupillary size &reaction
119
65 yr old man w/ emphysema & bronchitis in for F/U Assessment of his skin might expect to find?
scleroderma
clubbing of the nails
anasarca
pedal erythema
120
What order does nurse ausculate heart valves?
Aortic, tricuspid, mitral, pulmonic
Aortic, pulmonic, tricuspid, mitral
Tricuspid, mitral, aortic, pulmonic
Mitral, tricuspid, pulmonic, aortic
121
To assess for jaundice the nurse would inspect?
very pale skin on the palms
ashen-gray color in the oral mucous membranes
yellow pigmentation in the sclera
bluish color in the axilla and groin
122
75 yr old hx DM & peripheral vascular disease remove corn bottom ft w/ scissors encourage stop?
d/t her age & unable to see places her @ greater injury risk
peripheral vascular disease range of motion limited unsafe
DM increased circulation to foot cause severe bleeding
increased risk for infection & lesions d/t chronic diseases
123
Pt in for yearly exam nurse notes a sideways curvature of the spine noting this is?
Kyphosis
Scoliosis
Spina Bifida
Spondylosis
124
Which lymph node is noted to be enlarged in this picture?
post auricular
submental
preauricular
occipital
125
What is the meaning of the term PERRLA?
Pupils equally react with roundness and light accommodation
Pupils equal and reactive to light assessment
Pupils equate to roundness and reactiveness always
Pupils equal, round, reaction to light and accommodation
126
Which pulse is the nurse palpating in this picture?
femoral
popiteal
posterior tibial
dorsalis pedis
127
When assessing a young child what is important to consider?
Speak loudly, clearly, and directly
Perform traumatic procedures first
access using least invasive techniques to most invasive
Initiate contact with child when parent is not present
128
Nurse uses hand to press down into the abdomen to assess for tenderness Which technique?
inspection
auscultation
percussion
palpation
129
What are risk factors for osteoporosis? Select all that apply)
opioid use
female gender
family history
steroid use
130
Nutritional assessment 80 yr old pshysiologic changes directly affect nutritional status like?
slowed gastrointestinal motility
decrease gastrointestinal absorption cause esophageal reflux
an increased sensitivity to spicy and aromatic foods
hyperstimilation of the salivary glands
131
Trip to Hawaii pt DM & takes PO hypoglycemic agents pt concerns with possible effects of meds
importance of sunscreen and avoiding direct sunlight
skin sensitivity as a result of exposure to salt water
increased possibility of bruising
lack of availability of glucose monitoring supplies
132
Which pulse is the nurse palpating in this picture?
femoral
dorsalis pedis
popiteal
posterior tibial
133
A nurse arranges for pt w/ colon cancer to attend support group What level health prevention?
Tertiary prevention
Health maintenance
Secondary prevention
Primary prevention
134
What would be an expected finding on auscultation of the heart?
The S2 heart sound is louder at the apex of the heart
The S2 heart sound is quieter at the apex of the heart
The S1 heart sound is quieter at the apex of the heart
The S1 heart sound is louder at the apex of the heart
135
Pt states I have to sleep propped up w/ 3 pillows so I can breath This is?
lithotomy position
orthopnea
supine
fowler position
136
Auscultation pt's lungs hears low-pitched coarse loud & low snoring sound Term use to document?
crackles
rhonchi
pneumonia
wheezing
137
What occurs in the intervention step of the nursing process?
develops specific nursing intervention for each nursing dx
promoting or enhancing a patient’s level of wellness
collecting validating & recording data a pts health status
performing nursing actions & documenting them
138
Which of the following statements is true concerning the nutritional assessment?
I is only useful in patients who are overweight
it identifies patient who are at risk of malnutrition
This assessment can only be thoroughly done by a dietician
provides nurse w/ physical findings related to all systems
139
Assessing pt w/ a HR of 55 Which of the following pts would most likely have pulse rate of 55?
A 67-year-old who presented with an exacerbation of his COPD
A 70-year-old telephone salesman who is dehydrated
20 yr old runner had surgery 4 days ago for fx leg
And infant who has a temperature of 100.1 degrees F
140
The client has continuous tonic spasm of a muscle. Choose the correct term
atrophy
tetany
myalgia
tremor
141
What guideline may be used to identify which heart sound is S1?
S1 is louder than S2 at base of heart
S1 coincides with the Q wave of the QRS EKG.
S1 coincides with the carotid artery pulse
S1 coincides with A wave of the jugular venous pulse wave
142
When performing a general survey, the examiner is?
observing specific body systems during physical assessment
observing pts body stature & nutritional status
measuring the pts temp pulse respirations & B/P
interpreting subjective information pt has reported
143
Assessing pts pain The nurse know which of the following is considered most reliable indicator?
the subjective report
the physical examination
computerized axial tomography scan finding
Vital signs
144
Muscle is relaxed and nurse moves body part?
atrophy
passive ROM
abduction
active ROM
145
Assessing pts major risk factors for heart disease, which would nurse include taking a history?
Personality type high cholesterol diabetes intense exercise
Sugar consumption anorexia diabetes stress high cholesterol
"Smoking, hypertension, obesity, diabetes, high cholesterol"
"Work history, hypertension, stress, age"
146
In which situation should the nurse screen for intimate partner violence (IPV)?
When a history of abuse in the family is known
When a woman has an unexplained injury
When IPV is suspected
As a routine part of each health care encounter
147
Which of the following is true regarding the stethescope and its use
does not magnify sound but does block out room noise
fit & quality not as important as its ability magnify sound
ideal tubing length 22 in long to dampen distortion of sound
slope of the earpieces point posteriorly (toward occiput)
148
Multiple lesions pts back 0.5 cm width elevated circumscribed filled w/serous fluid Documents
vesicles
patches
bullae
macules
149
Yearly Health Assessment Nurse renews heart hx Client mentions light exercise Nurse should?
Record "Light" exercises
Ask if the client does their own housekeeping
Record that the client "walks each day"
Ask what the client means by light exercises
150
To accurately assess the carotid pulse the nurse would do which of the following?
place fingers gently space between triceps & biceps muscles
place 2 fingers each hand firmly over R & L temple same time
palpate groove between trach& R&L sternocleidomastoid 1@time
visualize the palsation at the jugular angle
151
Older women ER found lying on kitchen floor for 2 days extremely dehydrated Examination finding
white patches on the mucous membranes
dry mucous membranes and cracked lips
smooth mucous membranes and lips
pale mucous membranes
152
A raised firm lesion almost 4 cm. Nurse documents?
vesicle
wheal
tumor
nodule
153
Pt has hypoactive bowel sounds knows that a potential cause of hypoactive bowel sounds is:
diarrhea.
laxative use.
gastroenteritis.
peritonitis.
154
Nutritional assessment why is it important for the nurse to ask pt what meds he/she are taking?
meds need to be documented for HCP's review
the nurse needs to assess the patient for allergic reactions
meds affect memory & ability to identify food eaten last 24h
certain drugs can affect the metabolism of nutrients
155
Which following factors is most likely to affect the nutritional status of an 82-yr-old person?
Increase in taste and smell
Increase in gastrointestinal motility and absorption
Living alone on a fixed income
Change in cardiovascular status
156
Nurse aware that a change that may occur in the gastrointestinal system of an aging adult is:
increased salivation
increased esophageal emptying
decreased gastric acid secretion
megacolon
157
Pt reports having red black tarry stool what does the nurse suspect with this finding?
gastrointestinal bleeding
hemorrhoids
duodenal ulcer
anemia
158
Pt answers quietly& appears sad answering ?s about marriage begins to cry Appropriate response?
I see that you are upset Is something you’d like to discuss?
I only have a few more questions then I’ll leave you alone
Don’t cry. I’ll come back when you’ve settled down.
Everyone has ups& downs in marriage What problems having?
159
A pt tells nurse noted bright red blood in stool recently what does nurse suspect?
gastrointestinal bleeding
anemia
hemorrhoids
UTI
160
Romberg: Pt sways and moves feet farther apart. Document?
negative Homan's sign
normal
lack of coordination
positive Romberg's sign
161
Medication administration or procedural errors can be prevented by completing which task?
Ensuring the room is temperature controlled
Asking the client to give their name and date of birth
Washing your hands
Closing the door and curtain
162
Nurse explaining to pt shock absorbers in back to cushion spine and to help it move response?
Intervertebral discs
Vertebral foramen
Nucleus Pulposus
Costal Facets
163
Which activity by student nurse would require the intervention of the teacher?
inspects abdomen prior to auscultation
palpates abd after auscultation of abd
auscultates abd starting in LRQ
after inspection of the abdomen, they percuss for the liver
164
When assessing the radial pulse of a patient the nurse should count the?
initial pulse 2 min to detect any variation in amplitude
pulse 10 sec & multiply X6 if pt no hx of cardiac abnormal
pulse for 1 min if the rhythm is irregular
pulse for 15 sec & multiply X4 if the rhythm is regular
165
The nurse is assessing cranial nerve XI (spinal acessory) Instruct pt to?
move tongue from side to side
smile for me
follow my finger w/out moving your head
shrug your shoulders as I push down on them

HEALTH ASSESSMENT FINAL STUDY REVIEW QUESTIONS Flashcards | StudBud