HA exam 1 practice

Question 1

While measuring pt’s blood pressure, a nurse should recall which is a factor that influences a patient’s blood pressure?

Accepted Answer

Peripheral vascular resistance

Question 2

Educating your pt is important. Which one of these statements by the nurse is most appropriate?

Accepted Answer

"Your pulse is 80 beats per minute, which is within the normal range.”

Question 3

What technique should the nurse use to accurately assess a rectal temperature in an adult?

Accepted Answer

Use a lubricated blunt tip thermometer.

Question 4

The nurse is performing a general survey of a patient. Which finding is considered normal?

Accepted Answer

Body mass index (BMI) of 20

Question 5

The nurse is preparing to auscultate the abdomen. How should the nurse proceed?

Accepted Answer

Check temp of room + offer blankets to the patient if he or shefeels cold.

Question 6

When evaluating a pt pain, the nurse knows that an example of acute pain would be:

Accepted Answer

kidney stones

Question 7

A nurse is preparing to examine an infant. At what point in examination should the nurse attempt to elicit Moro reflex?

Accepted Answer

At the end of the examination

Question 8

The nurse is preparing to perform a physical assessment. Which statement is TRUE about the inspection phase?

Accepted Answer

takes time and reveals a surprising amount of information

Question 9

Which statement indicates the nurse understands the pain experienced by an older adult?

Accepted Answer

pain indicates pathologic condition or injury + is not normal for aging

Question 10

The nurse should measure rectal temperatures in which of these patients?

Accepted Answer

Comatose adult

Question 11

You are unable to identify any changes in sound when percussing over the abdomen of an obese pt. What should you do?

Accepted Answer

increase amount of strength used when attempting to percuss over abdomen

Question 12

When considering the concepts related to BP, the nurse knows that MAP is best described by which statement?

Accepted Answer

MAP is pressure forcing blood into tissues, averaged over the cardiac cycle

Question 13

While percussing over the liver of a pt, the nurse notices a dull sound. What should the nurse do?

Accepted Answer

consider this a normal finding

Question 14

A patient’s bp is 118/82 mm Hg. He asks the nurse, “What do the numbers mean?” Which is the best reply by the nurse?

Accepted Answer

The top # is systolic bp + reflects pressure of blood against the arteries

Question 15

The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope?

Accepted Answer

it blocks out extraneous room noise but does not magnify sound

Question 16

Which technique is correct when the nurse is assessing the radial pulse of a patient?

Accepted Answer

Palpate for 1 minute, if the rhythm is irregular.

Question 17

What are abnormalities of skin color? SATA

Accepted Answer

lesions, pallor, eryhtema

Question 18

The nurse is performing a general survey. Which action is a component of the general survey?

Accepted Answer

observing the pt body stature and nutritional status

Question 19

The nurse is teaching a class on basic assessment skills. Which of these statements is TRUE regarding the stethoscope?

Accepted Answer

it does not magnify sound, but does block extraneous room noise

Question 20

A nurse is preparing to use stethoscope for auscultation. Which statement is TRUE about the diaphragm of stethoscope?

Accepted Answer

a. Used to listen for high-pitched sounds

Question 21

When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should:

Accepted Answer

consider this a normal finding

Question 22

In a patient with acromegaly, which assessment finding will the nurse expect to find?

Accepted Answer

Overgrowth of bone in the face, head, hands, and feet

Question 23

A nurse is reviewing percussion techniques w/ a new nurse. What action performed by new nurse requires intervention?

Accepted Answer

percussing once over each area

Question 24

When measuring a patient’s body temperature, the nurse should keep in mind that what can influence the temperature?

Accepted Answer

Diurnal cycle

Question 25

A nurse is helping at a health fair. What should they keep in mind when taking blood pressures on a variety of people?

Accepted Answer

Bp of African-Americans is higher than non-Hispanic White adults

Question 26

When assessing the force, or strength, of a pulse, what should the nurse recall about the pulse?

Accepted Answer

Is a reflection of the heart’s stroke volume

Question 27

A nurse is examining a pt’s lower leg and notices a draining ulceration. Which of these actions is most appropriate?

Accepted Answer

Wash hands, put on gloves, continue with the examination of the ulceration.

Question 28

A nurse is unable to notice changes in sound percussing over the abdomen of an obese pt. What should they do next?

Accepted Answer

increase amount of strength used when attempting to percuss over abdomen

Question 29

The nurse is preparing to assess a pt's abdomen by palpation. How should the nurse proceed?

Accepted Answer

begin assessment w/ light palpation to detect surface characteristics

Question 30

The nurse will perform a palpated pressure before auscultating blood pressure. What is the reason for this?

Accepted Answer

Detect the presence of an auscultatory gap.

Question 31

The nurse is preparing to percuss the abdomen of a pt. What characteristic of underlying tissue does percussion assess?

Accepted Answer

density

Question 32

The nurse would use bimanual palpation technique in which situation?

Accepted Answer

palpating the kidneys and uterus

Question 33

What happens if you use a standard sized bp cuff on an obese pt?

Accepted Answer

Yield a falsely high blood pressure

Question 34

Which receiver is most likely to misinterpret a msg by a health care professional?

Accepted Answer

man whose wife has just been diagnosed w/ lung cancer

Question 35

In a pt w/ acromegaly, the nurse will expect to discover which assessment findings?

Accepted Answer

overgrowth of bone in face, head, hands, and feet

Question 36

The nurse is assessing an 80 yr old male pt. Which assessment findings would be considered normal?

Accepted Answer

Presence of kyphosis and flexion in the knee and hips

Question 37

The nurse is preparing to use a stethoscope for auscultation. Which statement is TRUE regarding the diaphragm?

Accepted Answer

used to listen for high pitched sounds

Question 38

A nurse hears bilateral loud, long, + low tones when percussing over lung of 4 yr/o child. How should the nurse proceed?

Accepted Answer

consider this finding as normal for child this age, proceed w/ examination

Question 39

When assessing an older adult, the nurse should recognize that which vital sign changes occur with aging?

Accepted Answer

Widened pulse pressure

Question 40

While performing physical examination, a nurse shares information + briefly teaches the pt. Why does the nurse do this?

Accepted Answer

To build rapport + increase the patient’s confidence in the examiner

Question 41

When measuring a pt body temp, the nurse keeps in mind that body temp is influenced by:

Accepted Answer

diurnal cycle

Question 42

A 75 yr/o pt. has asthma, assumes a tripod position, leaning forward w/ arms braced on chair. What does this mean?

Accepted Answer

A tripod position is often when a patient ihas respiratory difficulty

Question 43

The nurse is examining a patient who is complaining of “feeling cold.” Which is a mechanism of heat loss in the body?

Accepted Answer

Radiation

Question 44

Which of these techniques uses the sense of touch to assess texture, temp, moisture, + swelling during an assessment?

Accepted Answer

palpation

Question 45

The nurse is unable to palpate the right radial pulse on a pt. The best action would be to:

Accepted Answer

use a Doppler device to check for pulsations over the area

Question 46

The nurse is assess a pt's skin. What part of the hand + technique should be used to assess pt's skin temp?

Accepted Answer

dorsal surface of the hand

Question 47

The nurse has used interpretation regarding a pt statement or actions. After using this technique, it would be best to:

Accepted Answer

allow time for pt to confirm the correct interference

Question 48

The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations?

Accepted Answer

palpation

Question 49

The nurse is preparing to use an otoscope for an examination. Which is TRUE regarding the otoscope?

Accepted Answer

Directs light into the ear canal and onto the tympanic membrane

Question 50

A pt. has a round moon face, central trunk obesity, a cervical hump, fragile skin, and bruises. What condition is this?

Accepted Answer

cushing syndrome

Question 51

A nurse is taking an initial bp reading on a 72-year-old pt with documented hypertension. How should the nurse proceed?

Accepted Answer

Cuff should be inflated 30 mm Hg above when the palpated pulse disappears.

Question 52

60-year-old pt has been treated for pneumonia and has unexplained weight loss of 10 lbs/6 weeks. What is the rationale?

Accepted Answer

Unexplained weight loss often accompanies short-term illness

Question 53

While measuring a patients bp, the nurse recalls that certain factors, such as _____ help determine bp.

Accepted Answer

peripheral vascular resistance

Question 54

Which of these situations will result in a falsely high bp reading? SATA

Accepted Answer

the person supports his or her own arm during the bp reading, the cuff is loosely wrapped around the arm, the person is sitting w/ his or her legs crossed, the bp cuff is too narrow for extremity

Question 55

Which should the nurse do when preparing to perform a physical examination on an infant?

Accepted Answer

Have the parent remove all clothing except the diaper on a boy.

Question 56

A nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement?

Accepted Answer

Organizes assessment to ensure that pt does not change positions too often

Question 57

When assessing a patient’s pulse, the nurse should also notice which of these characteristics?

Accepted Answer

Force

Question 58

When performing a physical assessment, the first technique the nurse will always use is:

Accepted Answer

inspection

Question 59

The nurse makes which adjustement in the physical environment to promote the success of an interview?

Accepted Answer

reduces noise by turning off televisions and radios

Question 60

While auscultating heart sounds, nurse hears a murmur. Which of these instruments should be used to assess this murmur?

Accepted Answer

Bell of the stethoscope

Question 61

When evaluating the temp of older adults, the nurse should remember which aspect about older adult’s body temperature?

Accepted Answer

body temp is lower than that of a younger adult.

HA exam 1 practice

Questions 61

HA exam 1 practice

Questions 61