NURS 2092 Health Assessment Final Nursing Assessment Final Exam 2026

NURS 2092 Health Assessment Final Nursing Assessment Final Exam 2026 The nurse is preparing to conduct a health history. Explain this to the patient. - -Answer- The purpose of a health history is to provide a database of subjective information about the patient's past and current health history. You might say to the patient, "I will be asking you questions about your past and present health." This information will help the provider along with the physical exam (objective data) to develop a diagnosis or health status. The nurse is evaluating the reliability of a patient's responses, which of these statements would be correct? The patient: - -Provided consistent information and therefore is reliable A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse's best response? - -"Can you point to where it hurts?" A 29-year-old woman tells the nurse that she has "excruciating pain" in her back. Which would be the nurse's appropriate response to the woman's statement? - -"How would you say the pain affects your ability to do your daily activities?" A patient tells the nurse that he is allergic to penicillin. What would be the nurse's best response to this information? - -"Describe what happens (or the reaction) to you when you take Penicillin." The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include: - -Mental illness. The review of systems provides the nurse with... - -Information regarding health promotion practices, the information helps to evaluate the past and present health state of each body system, to obtain any data that may have been omitted in the section about present illness, and to evaluate health promotion and teaching opportunities. Which of these statements represents subjective data the nurse obtained from the patient regarding the patient's skin? - -Patient denies any color change. The nurse is obtaining a history from a 30-year old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient? - -"Do you perform testicular self examinations?" NURS 2092 NURS 2092 Functional Assessment-- What information would you ask if the patient's leg was in a cast? - -A functional assessment includes the activities of daily living and the person's ability to take care of their needs. This area will help to formulate a nursing diagnosis. This could be present to the patient in a standardized form and will include data on the lifestyle and type of living environment. (Page 57) self-esteem, activity/exercise, sleep/rest, nutrition/elimination, interpersonal relationships/resources, spiritual resources, coping and stress management, personal habits, environmental hazards, violence questions, and occupational health questions. If a patient had a cast on their leg, appropriate questions would include how they transfer to bed, another chair, bathing technique, coping with the situation, support during the situation. Regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason why? - -Alcohol can interact with all medications and make some diseases worse. Describe a genogram. - -Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family. Usually 3 generations- parents, grandparents, siblings. Also highlight the health of close family members and more details such as communicable disease, environmental hazards (smoke), tobacco use, and alcohol use. Any additional information includes the family history. The nurse is obtaining health history on an 87-year-old woman. Which of the following areas of questioning would be most useful at this time? - -Current health promotion activities. A 90-year-old patient tells the nurse that he cannot remember the names of the medication he is taking or why he is taking them. An appropriate response from the nurse would be.. - -Would you have a family member bring in your medications please? 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? - -"Are you able to dress yourself?" A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms? - -"This pain happens every time I sit down to use the computer." In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. The reason why is... - -This is the location for most breast tumors. In performing an assessment of a woman's elixir lymph system, the nurse should assess which of these nodes? - -Central, lateral, pectoral, and subscapular. The breast has extensive lymphatic drainage, 75% of the drainage drains into the axillary nodes. There are groups of axillary nodes central, pectoral and subscapular. NURS 2092 NURS 2092 A 65-year-old patient remarks that she just cannot believe that her breasts "sag so much". She states it must be from a lack of exercise. What explanation should the nurse offer her? After menopause: - -The glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in sagging (flat and gabby) breasts. In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of the following describes the nurse's best course of action? - Explain that this is the result of hormonal changes (testosterone) and recommend a visit to their provider. During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse's most appropriate response to this would be: - -To seek more specific information about the pain, such as: When did you first notice it? Is the pain localized or all over? Is it painful to touch? Is the pain in relation to your menstrual cycle? Is the pain associated with activity or exercise? During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for approximately 2 weeks. In trying to find the cause of the rash, which questions would be important for the nurse to ask? - -Where did the rash first appear- on the nipple, areola, or the surrounding skin? When did you first notice this? During an annual physical examination, a 43-year-old patient states that she does not perform monthly breast self-examinations (BSEs). She tells the nurse that she believes that mammograms "do a much better job than I ever could to find a lump." The nurse should explain to her that: - -Breast self-exams may detect lumps that appear between mammograms List risk factors for breast cancer - -History of breast cancer - family history—first degree relative Medications such as estrogen and progestin combined Certain tumor suppressor genes called BRCA1 and BRCA2 (inherited mutation) Age During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding? - Asymmetry isnot unusual, but the nurse should verify that this change is not new During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate? - -Whether the inversion is a recent change should be determined. The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have the woman: - -Slowly lift her arms above her head, and note any retraction or lag in movement. NURS 2092 NURS 2092 The nurse is palpating a female patient's breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation? - -Supine with the arms raised over the head The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique? - -The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period. The nurse is preparing to teach a woman about BSE. Which statement by the nurse is correct - -"BSE on a monthly basis will help you become familiar with your own breasts and feel their normal variations." A 55-year-old postmenopausal woman is being seen in the clinic for her annual examination. She is concerned about changes in her breasts that she has noticed over the past 5 years. She states that her breasts have decreased in size and that the elasticity has changed so that her breasts seem "flat and flabby." The nurse's best reply would be: - -The decrease in hormones after menopause causes atrophy of the glandular tissue in the breast and is a normal process of aging. A 43-year-old woman is at the clinic for a routine examination. She reports that she has had a breast lump in her right breast for years. Recently, it has begun to change in consistency and is becoming harder. She reports that 5 years ago her physician evaluated the lump and determined that it "was nothing to worry about." The examination validates the presence of a mass in the right upper outer quadrant at 1 o'clock, approximately 5 cm from the nipple. It is firm, mobile, and non-tender, with borders that are not well defined. The nurse replies: - -Because of the change in consistency of the lump, it should be further evaluated by the physician. The nurse is discussing BSEs with a postmenopausal woman. The best time for postmenopausal women to perform BSEs is? - -On the same day every month. During a discussion about BSEs with a 30-year-old woman, what statement by the nurse is most appropriate? - -Examine your breast shortly after your menstrual period each month. Peau d'orange- - -Lymphatic obstruction causes edema, which thickens the skin and exaggerates the hair follicles; this creates a pigskin or orange peel look. Could be an indication of cancer. Dullness- - -A high-pitched muffled thud sound obtained by percussing over relatively dense organs such as liver or spleen, distended bladder, mass of adipose tissue Tympany- - -A high-pitchedmusical and drum like note obtained by percussing the surface of a large air-containing space, such as the abdomen NURS 2092 NURS 2092 Resonance- - -A low-pitched, clear, hollow note obtained by percussing over normal lung tissue Hyperresonnance- - -A low-booming note obtained by percussing over the adult lungs that have increased air such as with a patient who has emphysema, present with distended abdomen Which structure is located in the left lower quadrant of the abdomen? - -Sigmoid colon Aneurysm- - -defect or sec formed by dilation in artery wall due to atherosclerosis, trauma, or congenital defect (aortic aneurysm) Dysphasia- - -Difficulty swallowing Anorexia- - -Loss of appetite Ascites - -abnormal accumulation of serous fluid within the peritoneal cavity, associated with heart failure, cirrhosis, cancer or portal hypertension Bruit- - -blowing, swoishing sound her through a stethoscope when an artery is partially occluded Hepatomegaly- - -abnormally enlarged liver Paralytic ileus- - -complete absence of peristaltic movement that may follow abdominal surgery or complete bowel obstruction Peritonitis- - -inflammation of the peritoneum Nurse suspects a patient has a distended bladder. How should the nurse assess? - Percuss and palpate the midline area above the suprapubic bone. The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is: - -Decreased gastric acid secretion. A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: - -Peritonitis, The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? - "Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation." Abdominal borborygmi- - -Hyperactive bowel sounds NURS 2092 NURS 2092 Percussion notes heard during the abdominal assessment may include: - -Tympany, hyperresonnance, and dullness. Causes of Abdominal Distention- - -Obesity, Ascites, Air or Gas, Ovarian cyst, Pregnancy, Tumor Before reporting silent bowel sounds, the nurse should listen for at least: - -5 minutes The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should: - -Examine the tender area first. State the rationale for performing auscultation of the abdomen before palpation or percussion. - -Percussion and palpation may increase peristalsis, which gives a false interpretation of bowel sounds Specific questions to ask a patient with abdominal pain for the past week - -Describe the pain, is it in one spot, or does it move around, have the patient point to the area, when did it start, how long have you had the pain, is it constant or does it come and go, does it occur before a meal or after meals, describe the pain is it a cramping, burning, dull, stabbing, or aching pain, are there any changes associated with meals does the pain become worse or better, what have you tried to relieve the pain, what makes the pain worse, is the pain associated with your menstrual cycle Right Upper Quadrant Organs- - -Liver, Gallbladder, Duodenum, Head of Pancreas, Right Kidney and adrenal gland, Hepatic flexure of colon, Part of ascending and transverse colon Left Upper Quadrant Organs- - -Stomach, spleen, left lobe of liver, Body of Pancreas, Left kidney and adrenal, splenic flexure of colon, part of transverse and descending colon Right Lower Quadrant Organs- - -Cecum, Appendix, Right over and tube, Right ureter, Right spermatic cord Left Lower Quadrant Organs- - -Part of descending colon, Sigmoid colon, Left ovary and tube, left ureter, left spermatic cord Midline- - -Aorta, Uterus, Bladder Specific questions you would ask a patient who is complaining of nausea and vomiting - -How often, how much come up, color, odor, bloody, pain associated, any diarrhea, fever, chills, what did you eat in the last 24 hours, where, is there anyone else in the family with the same symptoms? Functional units of the musculoskeletal system- - -Joints NURS 2092 NURS 2092 Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called: - -Ligaments To jump rope, the should has to be capable of: - -Circumduction Articulation of the mandible and temporal bone is: - -Temporomandibular joint Palpation of the temporomandibular joint: - -Anterior to the tragus An 85-year-old patient comments during his annual physical examination that he seems to be getting shorter as he ages. How would you explain this to the patient? - -With aging, the vertebral column shortens The nurse is teaching a class on preventing osteoporosis to a group of perimenopausal women. An action to prevent or delay bone loss in this group would be? - -Perform physical activity, such as fast walking. A patient states, "I can hear a crunching or grating sound when I kneel." She also states that "it is very difficult to get out of bed in the morning because of stiffness and pain in my joints." The nurse should assess for signs of what problem? - -Crepitation A patient is able to flex his right arm forward without difficulty or pain but is unable to abduct his arm because of pain and muscle spasms. The nurse should suspect: - Rotator cuff lesions During an examination, the nurse asks a patient to bend forward from the waist and notices that the patient has lateral tilting. When his leg is raised straight up, the patient complains of a pain going down his buttock into his leg. The nurse suspects: - Herniated nucleus pulposus Changes with an aging adult - -After 40, loss of bone matrix occurs more rapidly than new bone formation; postural changes occur with decreased height the most noticeable; decreased height is due to shortening of the vertebral column; may see kyphosis; a distribution of subcutaneous fat changes through life; there is a tendency to gain weight; loss of muscle mass; may see a shuffling pattern when walking, arms out to help balance; broader base of support; may hold hand rails and haul their body up with it; may lead with favored leg; may find the aging holding two hands on the rail Osteoporosis- - -your bones are living tissue that are continually growing and changing. Each day old bone tissue dissolves and is replaced with new bone tissue. As we age, the opposite begins to occur. When this happens bone can become weak and more likely to break even with the slightest bump. The bones of the wrist, hip, and spine are most often affected. There is no cure but there is treatment NURS 2092 NURS 2092 Steps to bone health and osteoporosis prevention- - -• Diet- milk products (low fat) with vitamin D, which is needed for absorption of calcium; Fish canned ones which are packed in their bones; Leafy green vegetables; Limit caffeine; • Exercise- weight bearing a regular program of at least 3 times a week. • Lifestyle- avoid smoking and excessive alcohol; seek help for depression • Supplements as directed by your provider Rheumatoid Arthritis- - -Rheumatoid Arthritis is a chronic, systemic inflammatory disease of the joints and surrounding connective tissue. Inflammation of the synovial membrane leads to thickening; then to fibrosis, which limits movement; and finally leads to bony ankylosis. Symmetric and bilateral characterized by heat, redness, swelling, and painful motion of the affected joints; the patient may experience fatigue, weakness, anoxeria, weight loss, low grade fever, and swollen glands Osteoarthritis- - -(Degenerative Joint Disease) is a non-inflammatory localized, progressive disorder involving deterioration of articular cartilage and subchondral bone and formation of new bone (osteophytes) at joint surfaces. It occurs with aging nearly all adult age 60 or older have some signs of osteoarthritis. Asymmetrical involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. Affected joints have stiffness, swelling, bony protuberance, pain with motion, limitation with movement. Adduction, Abduction, Flexion, Extension - -• Adduction - movement of a body part toward the body's midline • Abduction - movement of a body part away from the body's midline • Flexion- describes the movement that decreases the angle between a segment and its proximal segment • Extension- is the opposite of flexion, describing a straightening movement that increases the angle between body parts The 2 parts of the nervous system are: - -Central and Peripheral Personality and ability to understand, crying easily, and becoming angry are associated to which lobe of the brain? - -Frontal A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse? - -Cerebellum A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting, she gets "really dizzy" and feels like she is going to fall over. The nurse's best response would be: - -You need to get up slowly when you have been lying down or sitting. During the taking of the health history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this finding as: - -Vertigo NURS 2092 NURS 2092 When discussing seizures with a patient, the patient asks the nurse, "What is an aura?" How would you explain this to the patient? - -"Do you have any warning signs before the seizure occurs?" An aura is a subjective sensation that preceded a seizure; may be auditory, visual or motor. When the nurse asks a 68-year-old patient to stand with his 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: - -Positive Romberg Sign. During the taking of the health 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." When assessing his sensory system, which action by the nurse is most appropriate? - -Before testing, the nurse would assess the patient's mental status and ability to follow directions. During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with plantar flexion. Which statement concerning these findings is most accurate? This patient's response: - -It is very ominous sign and may indicate brainstem injury. Syncope, Vertigo, Seizure, Tremors, Paralysis- - -Syncope -a sudden loss of strength, a temporary loss of consciousness (a faint) caused by a lack of cerebral blood flow Vertigo- is a rotational spinning caused by neurological disease in the vestibular apparatus of the ear or the vestibular nuclei in the brainstem Seizure- characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances Tremors-- an involuntary shaking Paralysis—decreased or loss of motor power caused by problem with motor nerve or muscle fibers Stroke or Cerebrovascular Accident (CVA)- - -Blood flow is interrupted to a part of the brain, the most common type is an ischemic stroke (when a blood clot blocks a blood vessel in the brain) and less common is a hemorrhagic ( a blood vessel in the brain ruptures and causes bleeding). Common symptoms of a stroke: - -• Weakness or numbness in the face, arms, or legs, especially when it is on one side of the body • Confusion, trouble speaking or understanding • Changes in vision such as blurry vision or partial complete loss of vision in one or both eyes • Trouble walking, dizziness, loss of balance, or coordination • Severe headache with no reason or explanation NURS 2092 NURS 2092 Paresis, Paraplegia, Quadriplegia, Hemiplegia - -• paresis--weakness of muscles rather than paralysis • paraplegia--symmetric paralysis of both lower extremities • quadriplegia--paralysis of all four extremities • hemiplegia--paralysis of one side of the body Symptoms of Meningeal Inflammation- - -Sudden fever, stiff neck, severe headache different than normal, nausea and vomiting, seizures, sleepiness, sensitivity to light The nurse notices that a patient's palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)? - -Cranial Nerve 7- Facial A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN ______ and proceeds with the examination by _____________. - -Cranial Nerve 11- Accessory; asking the patient to shrug her shoulders against resistance A patient says that she has recently noticed a lump in the front of her neck below her "Adam's apple" that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule): - -Mobile and not hard 4 areas of the body where lymph nodes are accessible: - -Head and neck, arms, inguinal area, and axillae A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give her? - More noticeable facial bones are probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin. A patient has come in for an examination and states, "I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is?" The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his: - -Parotid gland A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a __________ sound that is heard best with the __________ of the stethoscope. - -Soft, whooshing, pulsatile; bell A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he has: - -CVA or stroke NURS 2092 NURS 2092 During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be: - -Firm but freely movable The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally: - -Nonpalpable During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement? - -Using gentle pressure, palpate with both hands to compare the two sides Visual accommodation- - -Pupillary constriction when looking at a near object A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that: - -Constriction of both pupils occurs in response to bright light A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that: - -The patient can read at 20 feet what a person with normal vision can read at 30 feet. A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this? - -Observe the distance between the palpebral fissures A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble 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 she may have: - Macular degeneration If your patient presented with an eye injury resulting in an emergency situation what symptoms would you expect to see that would prompt an emergency? - -Loss of vision Sclera is china white, although Blacks occasionally have a gray-blue or muddy color to the sclera. Also in dark-skinned people you normally may see _______________on the sclera. - -Small brown merciless (freckles) Extraocular muscles- - -Cranial nerves 3, 4, and 6 Chronic Open-Angle Glaucome, Macular Degeneration, Cataracts, Presbyopia- - -• Chronic Open-Angle Glaucoma--Increased intraocular pressure that leads to peripheral vision loss. • Macular Degeneration--Breakdown of cells in the Macula or the Retina that leads to loss of central vision-the area of clearest vision. • Cataracts--Lens opacity, resulting from a clumping of protein in the lens. NURS 2092 NURS 2092 • Presbyopia--Loss of lens elasticity decreasing the len's ability to change shape to accommodate for near vision. During an assessment of a patient has had a head injury from a car accident, 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? - -Increase in the intracranial pressure The nurse notes that the patient's teeth are stained yellow and asks the patient about tobacco use. The patient states that he chews one bag of tobacco every other day. What health promotion concepts should the nurse include in the teaching plan? - Smokeless tobacco (SLT) contains cancer-producing chemicals, such as nitrosamines, that increase the risk of oral cancers (pharynx, larynx, and esophagus). Early signs of oral cancer should be discussed, as well as other effects of SLT use, such as gum recession, tooth discoloration, bad breath, nicotine dependence, and unhealthy eating habits. SLT is not a healthy alternative to smoking. Using smokeless tobacco can be detrimental to a person's health. The two types of SLT most commonly used in the United States are chewing tobacco and snuff. The largest group of SLT users is American Indian/Alaskan Native children, but SLT use is also high among young white males. Pain is an early sign of oral cancer What is the purpose of the ciliated mucous membrane in the nose? - -Filters out dust and bacteria. Salivary gland that is the largest and located in the cheek in front of the ear is the ________ gland. - -Parotid The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient? - -Decreased ability to identify odors. Questions to include in aiding adult health history- - -• Any dryness in the mouth? Xerostomia (dry mouth ) is a side effect of many drugs: antidepressants, anticholinergics, antispasmodics, antihypertensives, antipsychotics, bronchodilators • Are you taking any medications? (prescribed and over the counter) • Can you chew all types of food? Have you lost any teeth? • Are you able to care for your teeth or dentures? o Self-care may be due to a physical disability (arthritis), vision loss, confusion, or depression • Have you noticed a change in your sense of taste or smell? How would you control a nosebleed? - -Remain calm, sit up straight, lean your head forward, tilting your head back will cause you to swallow the blood. Pinch the nostrils together with your thumb and index finger for about 10 minutes. NURS 2092 NURS 2092 The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient? - -Are you aware of having any allergies? During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of: - -Dehydration While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess? - -When the patient first noticed the lesion A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds areas of buccal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is: - Candidiasis The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? - -Black, hairy tongue is a fungal infection caused by all the antibiotics you have received. During an assessment, a patient mentions that "I just can't smell like I used to. I can barely smell the roses in my garden. Why is that?" For which possible causes of changes in the sense of smell will the nurse assess? Select all that apply. - -Cigarette smoking, chronic allergies and aging. Functions of the middle ear: - -(1) Conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear. (2) Protects the inner ear by reducing the amplitude of loud sounds. (3) Its eustachian tube allows equalization of air pressure on each side of the tympanic membrane in order to prevent membrane rupture. Pathway of hearing: - -The normal pathway of hearing is known as air conduction (AC) and is the most efficient. An alternate route of hearing is known as bone conduction (BC); here the bones of the skull vibrate and these vibrations are transmitted directly to the inner ear and to cranial nerve VIII Hearing loss: - -• A conductive hearing loss involves a mechanical dysfunction of the external or middle ear and is considered a partial loss because the person is able to hear if the sound amplitude is increased enough to reach the nerve elements in the NURS 2092 NURS 2092 inner ear. Common causes are impacted cerumen, foreign bodies in the ear canal, perforated tympanic membrane, and otosclerosis. • A sensorineural (or perceptive) hearing loss indicates pathology of the inner ear, cranial nerve VIII, or the auditory areas of the brain. A simple increase in amplitude may not enable the person to hear. Common causes are ototoxic drugs and presbycusis, a gradual nerve degeneration that occurs with aging. • A mixed loss is a combination of both types of hearing loss in the same ear. Cerumen: - -Purpose of cerumen is to protect and lubricate the ear. Eustachian tube: - -Helps equalize are pressure on both sides of the tympanic membrane. Air conduction: - -Normal pathway for hearing. Ear examination of an 80-year-old patient; which findings would be normal? - -High-tone frequency loss A 17-year-old student is a swimmer on her high school's swim team. She has had three bouts of otitis externa this season and wants to know what to do to prevent it. The nurse instructs her to: - -Use rubbing alcohol or 2% acetic acid teardrops after every swim "Buzzing sound" in the ear - -Tinnitus Changes in hearing that occur with aging: - -Progression of hearing loss is slow, the aging person may find it harder to hear consonants than vowels, sounds may be garbled and difficult to localize. The anal canal: - -Is the outlet for the gastrointestinal tract. Colonoscopy- - -a test that allows the physician to look at the inner lining of the large intestines, with a thin flexible tube A 60-year-old man has just been told that he has benign prostatic hypertrophy (BPH). He is concerned about cancer. How should the nurse respond? What would you say? - The enlargement of your prostate is caused by hormonal changes, and not cancer Symptoms may include urinary frequency, urgency, hesitancy, straining to urinate, wear stream, intermittent stream, or sensation of not emptying A 30-year-old woman is visiting the clinic because of "pain in my bottom when I have a bowel movement." The nurse should assess for which problem? - -Hemorrhoids After completing an assessment of a 60-year-old man with a family history of colon cancer, the nurse discusses with him early detection measures for colon cancer. The nurse should mention the need for a(n): - -Colonoscopy every 10 years NURS 2092 NURS 2092 What position should a woman be in for a rectal exam - -Left lateral decubitus Pigmentation of anus is darker than the surrounding skin, the anal opening is closed, and a skin sac that is shiny and blue is noted. Pain with bowel movements and occasionally noted some spots of blood- - -Thrombosed hemorrhoid Anal fistula, rectal prolapse, rectal polyp, rectal fissure- - -Anal fistula—An abnormal passage from inner anus or rectum out to the skin surrounding the anus. May occur from chronic GI inflammation, local abscess. The tract may drain serosanguineous or purulent drainage. Rectal prolapse—protrusion of the rectal mucous membrane through the anus Rectal polyp—protruding growth from the rectal mucous membrane Rectal fissure—longitudinal tear in the superficial mucosa at the anal margin Rectal Prolapse- - -Moist, red, doughnut shaped protrusion from the anus A 62-year-old man is experiencing fever, chills, malaise, urinary frequency, and urgency. He also reports urethral discharge and a dull aching pain in the perineal and rectal area. These symptoms are most consistent with which condition? - -Prostatitis During a health history of a patient who complains of chronic constipation, the patient asks the nurse about high-fiber foods. The nurse relates that an example of a high-fiber food would be: - -Broccoli During a digital examination of the rectum, the nurse notices that the patient has hard feces in the rectum. The patient complains of feeling "full," has a distended abdomen, and states that she has not had a bowel movement "for several days." The nurse suspects which condition? - -Fecal impaction Human Papilloma Virus- - -A sexually transmitted disease that may clear on its own but for those that don't clear it can lead to cervical cancer. What is the CDC's recommendation for the HPV vaccine? - -Girls or boys starting at age 11 or 12 years old with a series of 3 injections with a 6month period Is the HPV vaccine recommended for girls/women before they become sexually active? T or F - -True Can the HPV virus linger in a woman's cervix and cause changes that may lead to cervical cancer? T or F - -True Changes normally associated with menopause occur because the cells in the reproductive tract are: - -Aging NURS 2092 NURS 2092 Changes associated with menopause: - -Uterine and ovarian atrophy, along with a thinning of the vaginal epithelium Premenstrual Syndrome, Menarche, Menopause, Menstrual Cycle, Dysmenorrhea- - -o Premenstrual syndrome-refers to physical and emotional symptoms that occur in the one to two weeks before a woman's period. Common symptoms include acne, tender breasts, bloating, feeling tired, irritable and mood changes. o Menarche—onset of first menses, usually occurring between 11 and 13 years of age o Menopause—cessation of menses, usually occurring around 48 to 51 years of age o Menstrual cycle- changes that occur naturally in a woman's body to prepare it for pregnancy. In a normal menstrual cycle, women experience menstruation (also known as a period) followed by the release of an egg. During menstruation blood, cells and mucus are discharged from the uterus. o Dysmenorrhea- abnormal cramping and pain associated with menstruation Plan to begin the annual gynecologic examination with: - -Menstrual history, generally nonthreatening During the interview with a female patient, the nurse gathers data that indicate the patient is perimenopausal. Which of these statements made by this patient leads to this conclusion? - -I have been noticing that I sweat a lot more than I used to, especially at night. A 50-year-old woman calls the clinic because she has noticed some changes in her body and breasts and wonders if these changes could be attributable to the hormone replacement therapy (HRT) she started 3 months earlier. The nurse should tell her: - HRT has several side effects, including fluid retention, breast tenderness and vaginal bleeding. During the interview, a patient reveals that she has some vaginal discharge. She is worried that it may be a sexually transmitted infection. The nurse's most appropriate response to this would be: - -I'd like some information about the discharge. What color is it? A woman states that 2 weeks ago she had a urinary tract infection that was treated with an antibiotic. As a part of the interview, the nurse should ask, "Have you noticed any: - Unusual vaginal discharge or itching? Which statement would be most appropriate when the nurse is introducing the topic of sexual relationships during an interview? - -Women often have questions about their sexual relationship and how it affects their health. Do you have any questions? A 22-year-old woman has been considering using oral contraceptives. As a part of her health history, the nurse should ask: - -If you smoke, how many cigarettes do you smoke per day? NURS 2092 NURS 2092 A nurse is assessing a patient's risk of contracting a sexually transmitted infection (STI). An appropriate question to ask would be: - -Do you use a condom with each episode of sexual intercourse? The nurse is preparing to interview a postmenopausal woman. Which of these statements is true as it applies to obtaining the health history of a postmenopausal woman? - -The nurse should ask a postmenopausal woman if she has ever had vaginal bleeding. During the examination portion of a patient's visit, she will be in lithotomy position. Which statement reflects some things that the nurse can do to make this position more comfortable for her? - -Elevate her head and shoulders to maintain eye contact. A patient calls the clinic for instructions before having a Papanicolaou (Pap) smear. The most appropriate instructions from the nurse are: - -Avoid intervenes, inserting anything into the vagina or douching within 24 hours of your appointment. During a vaginal examination of a 38-year-old woman, the nurse notices that the vulva and vagina are erythematous and edematous with thick, white, curdlike discharge adhering to the vaginal walls. The woman reports intense pruritus and thick white discharge from her vagina. The nurse knows that these history and physical examination findings are most consistent with which condition? - -Candidiasis A 22-year-old woman is being seen at the clinic for problems with vulvar pain, dysuria, and fever. On physical examination, the nurse notices clusters of small, shallow vesicles with surrounding erythema on the labia. Inguinal lymphadenopathy present is also present. The most likely cause of these lesions is: - -Herpes simplex virus type 2 A 25-year-old woman comes to the emergency department with a sudden fever of 38.3° C and abdominal pain. Upon examination, the nurse notices that she has rigid, boardlike lower abdominal musculature. When the nurse tries to perform a vaginal examination, the patient has severe pain when the uterus and cervix are moved. The nurse knows that these signs and symptoms are suggestive of: - -Pelvic inflammatory disease. A 35-year-old woman is at the clinic for a gynecologic examination. During the examination, she asks the nurse, "How often do I need to have this Pap test done?" Which reply by the nurse is correct? - -"After age 30 years, if you have three consecutive normal Pap tests, then you may be screened every 2 to 3 years." What problems occur as a result of atrophic vaginitis? - -Itching, dryness, burning sensation, dyspareunia, mucoid discharge with noticeable blood. What specific questions would you asks an elderly female patient whose period stopped 5 years ago and has recently restarted? - -When did it start, amount, color, taking any medications, history of any cancer in the family, past surgeries, any abdominal pain. NURS 2092 NURS 2092 Changes normally associated with menopause occur because the cells in the reproductive tract are aging? T or F - -True When performing a genital examination on a 25-year-old man, the nurse notices deeply pigmented, wrinkled scrotal skin with large sebaceous follicles. On the basis of this information, the nurse would consider this as normal findings. - -True Inguinal Hernia- - -An inguinal hernia is herniation of bowel (usually small intestine) through a weak area in the lower abdominal wall. The area of the lower abdominal wall is also called the inguinal or groin region. 2 types of inguinal hernias - -• indirect inguinal hernias, which are caused by a defect in the abdominal wall that is congenital, or present at birth • direct inguinal hernias, which usually occur only in male adults and are caused by a weakness in the muscles of the abdominal wall that develops over time A 59-year-old patient has been diagnosed with prostatitis and is being seen at the clinic for complaints of burning and pain during urination. What is the appropriate term for burning and pain during urination? - -Dysuria Stress Incontinence- - -Involuntary urine loss with physical strain, sneezing, or coughing due to weakness of pelvis floor. What specific questions would be most appropriate when obtaining a genitourinary history from an older man? - -Frequency, urgency, nocturia, dysuria, hesitancy, straining, color, difficulty controlling your urine, accidentally urinating when you sneeze, laugh, cough or bear down, any history of kidney disease, prostate problems. When the nurse is performing a genital examination on a male patient, the patient has an erection. The nurse's most appropriate action or response is to: - -Reassure the patient that this is a normal response and continue with the examination. When performing a genitourinary assessment, the nurse notices that the urethral meatus is ventrally positioned. This finding is: - -hypospadias The nurse is aware of which statement to be true regarding the incidence of testicular cancer? - -Men with a history of cryptorchidism are at the greatest risk for the development of testicular cancer. The nurse is describing how to perform a testicular self-examination to a patient. Which statement is most appropriate? - -"If you notice an enlarged testicle or a painless lump, call your health care provider." During an examination of an aging man, the nurse recognizes that normal changes to expect would be: - -Decrease in the size of the penis. NURS 2092 NURS 2092 When performing a genital assessment on a middle-aged man, the nurse notices multiple soft, moist, painless papules in the shape of cauliflower-like patches scattered across the shaft of the penis. These lesions are characteristic of: - -Genital Warts A 55-year-old man is experiencing severe pain of sudden onset in the scrotal area. It is somewhat relieved by elevation. On examination the nurse notices an enlarged, red scrotum that is very tender to palpation. Distinguishing the epididymis from the testis is difficult, and the scrotal skin is thick and edematous. This description is consistent with which of these? - -Epididymis The nurse is performing a genitourinary assessment on a 50-year-old obese male laborer. On examination, the nurse notices a painless round swelling close to the pubis in the area of the internal inguinal ring that is easily reduced when the individual is supine. These findings are most consistent with a(n) ______ hernia. - -Direct Inguinal The nurse is providing patient teaching about an erectile dysfunction drug. One of the drug's potential side effects is prolonged, painful erection of the penis without sexual stimulation, which is known as: - -Priapism During a physical examination, the nurse finds that a male patient's foreskin is fixed and tight and will not retract over the glans. The nurse recognizes that this condition is: - Phimosis A 55-year-old man is in the clinic for a yearly checkup. He is worried because his father died of prostate cancer. The nurse knows which tests should be performed at this time? Select all that apply. - -Blood test for prostate-specific antigen (PSA) and digital rectal examination Activity of Daily Living - -Tasks that are necessary for self-care, such as eating/feeding, bathing, grooming, toileting, walking, and transferring. Advanced Activities of Daily Living - -Activities that an older adult performs as a family member or as a member of society or community, including occupational and recreational activities. Caregiver Assessment - -Assessment of the health and well-being of an individual's caregiver. Caregiver Burden - -The perceived strain by the person who cares for an older, chronically ill, or disabled person. Domains of Cognition - -Domains included in mental status assessments, such as attention, memory, orientation, language, visuospatial skills, and higher cognitive functions. NURS 2092 NURS 2092 Environment - -Assessment of an indovodual's home environment and community systems, including hazards at home. Functional Ability - -The ability of a person to perform activities necessary to live in modern society; may include driving, using the telephone, or performing personal tasks such as baking or toileting. Functional Assessment - -A systematic assessment that includes assessment of an individual's activities of daily living, instrumental activities of daily living, and mobility. Functional Status - -A person's actual performance of activities and tasks associated with current life roles. Geriatric Assessment - -Multidimensional assessment; physical examination and assessments of mental status, functional status, social and economical status, pain, and physical environment safety. Home Care - -Supportive services provided in the home: skilled nursing care, primary care, therapy (physical, occupational, speech), social work, nutrition, case management, ADL assistance, durable medical equipment. Instrumental Activities of Daily Living - -Functional abilities necessary for independent community living, such as, shopping, meal preparation, housekeeping, laundry, managing finances, taking medications, and using transportation. Katz Index of Independence in Activities of Daily Living - -An instrument used to measure physical function in older adults and the chronically ill. Lawton Instrumental Activities of Daily Living - -An instrument used to measure an individual's ability to perform instrumental activities of daily living; may assist in assessing one's ability to live independently. Physical Performance Measures - -Tests that measure balance, gait, motor coordination, and endurance. Social Domain - -The domain that focuses on an individual's relationships within family, social groups, and the community. Social Networks - -Informal supports accessed by older adults, such as family members and close friends, neighbors, church societies, neighborhood groups, and senior centers. Spiritual Assessment - -Assessment of the individual's spiritual health. An appropriate tool to assess an individual's instrumental activities of daily living is a tool by: - -a. Katz NURS 2092 NURS 2092 b. Lawton *CORRECT ANSWER* c. Tinetti d. Norbeck Which statement is true regarding an individual's functional status? - -a. Functional status refers to one's ability to care for another person. b. An older adult's functional status is usually static over time. c. An older adult's functional status may vary from independence to disability. *CORRECT ANSWER* d. Dementia is an example of functional status. An older person is experiencing an acute change in cognition. You recognize that this disorder is? - -a. Alzheimer dementia b. Attention deficit disorder c. Depression d. Delirium *CORRECT ANSWER* Assessment of the social domain includes: - -a. Family relationships *CORRECT ANSWER* b. Ability to cook meals c. Ability to balance the checkbook and pay bills d. Hazards found in the home You will use which technique when assessing an older individual who has cognitive impairment? - -a. Ask open-ended questions b. Complete the entire assessment in one session c. Ask the family members for information instead of the older individual d. Ask simple questions that have yes or no answers. *CORRECT ANSWER* An older person needs to be assessed before going home as to whether he or she is able to go outside alone safely. Which test is best for this assessment? - -a. Up and go test *CORRECT ANSWER* b. Performance of activities of daily living c. Older americans resources and services multidimensional functional assessment questionnaire d. Lawton IADL Instrument An older adult has had surgery for a fractured hip and has a history of dementia. You should keep in mind that older adults with cognitive impairment: - -a. Experience less pain b. can provide a self-report of pain *CORRECT ANSWER8 c. Cannot be relied on to self-report pain d. Will not express pain sensations. An appropriate use of the caregiver strain index would be which situation? - -a. A daughter who is taking her older father home to live with her NURS 2092 NURS 2092 b. An older patient who lives alone c. A wife who has cared for her husband for the past 4 years at home *CORRECT ANSWER* d. A son whose parents live in an assisted living facility Which is an example of a formal social support network for the aging adult? - -a. A neighbor who drops by with newspapers and magazines on a regular basis b. An area church that offers a weekly activity an luncheon for seniors in the neighborhood c. A home health care agency that provides weekly blood pressure screenings at the church luncheon *CORRECT ANSWER* d. A senior citizen chess club whose members hold classes at the local boys club When completing a spiritual assessment you should? - -a. Use yes and no questions as the foundation for future dialogue b. Use open-ended questions to help the patient understand potential coping mechanisms *CORRECT ANSWER* c. Try to complete this assessment as soon as possible after meeting the patient d. Wait until a member of the clergy can be involved in the assessment When you perform a functional assessment of an older patient, which is most appropriate? - -a. Observe the patient's ability to perform the tasks *CORRECT ANSWER* b. Ask the patient's wife or husband how he or she does when performing tasks c. Review the medical record for information on the patient's abilities d. Ask the pastient's physician for information on the patient's ability The Lawton IADL instrument is described by which of the following? - -a. The nurse uses direct observation to implement this tool b. It is designed as a self-report measure of performance rather than ability *CORRECT ANSWER* c. It is not useful in the acute hospital setting d. It is best used for those residing in an institutional setting An older adult's advanced activities of daily living would include: - -a. Recreational activities *CORRECT ANSWER* b. Meal Preparation c. Balancing the checkbook d. Self-grooming activities When using the various instruments to assess an older person's activities of daily living, remember that a disadvantage of these instruments includes: - -a. The reliability of the tools b. Self or proxy report of functional activities *CORRECT ANSWER* c. Lack of confidentiality during the assessment d. Insufficient detail about the deficiencies identified NURS 2092 NURS 2092 Acculturation - -Process of social and psychological exchanges with encounters between persons of different cultures, resulting in changes in either group. Cultural and Linguistic Competence - -A set of congruent behaviors, attitudes and policies that come together in a system among professionals that enables work in cross cultural situations. Culture - -The nonphysical attributes of a person-the thoughts, communications, actions, beliefs, values, and institutions of racial, ethnic, religious, or social groups. Cultural Care - -Professional health care that is culturally sensitive, appropriate, and competent. Ethnicity - -A social group within the social system that claims to possess variable traits such as common geographic origin, migratory status, and religion. Ethnocentrism - -Tendency to view your own life as the most desirable, acceptable, or best and to act superior to another culture's way of life. Folk Healer - -Lay healer in the person's culture apart from the biomedical or scientific health care system Health or Illness - -the balance or imbalance of the person, both within one's being (physical, mental, and/or spiritual) and in the outside world (natural, communal, and/or metaphysical) Religion - -The belief in a divine subhuman power or powers to be obeyed and worshiped as the creator and ruler of the universe and a system of beliefs, practices, and ethical values Socialization - -The process of being raised within a culture and acquiring the characteristics of that group Spirituality - -A person's personal effort to find purpose and meaning in life Title VI of the Civil Rights Act of 1964 - -A federal law that mandates that when people with limited English proficiency (LEP) seek health care settings such as hospitals, nursing homes, clinics, daycare centers, and mental health centers, services cannot be denied to them Values - -A desirable or undesirable state of affairs and a universal feature of all cultures Which statement best describes religion? - -a. an organized system of beliefs concerning the cause, nature, and purpose of the universe *CORRECT ANSWER* NURS 2092 NURS 2092 b. Belief in a divine or superhuman to be obeyed and worshiped c. Affiliation with one of the 1200 recognized religions in the United states d. The following of established rituals, especially in conjunction with health seeking behaviors The major factor contributing to the need for cultural care nursing is? - -a. an increasing birth rate b. limited access to health care services c. demographic change *CORRECT ANSWER* d. a decreasing rate of immigration The term culturally competent implies that the nurse: - -a. is prepared in nursing b. possesses knowledge of the traditions of diverse peoples c. applies underlying knowledge to providing nursing care d. understands the cultural context of the patient's situation *CORRECT ANSWER* You are the triage nurse in the emergency department and perform the initial intake assessment on a patient who does not speak English. Based on your understanding of linguistic competence, which action would present as a barrier to effective communication? - -a. maintaining a professional respectful demeanor b. allowing for additional time to complete the process c. providing the patient with a paper and pencil so he or she can write down the questions that you are going to ask *CORRECT ANSWER* d. seeing if there are any family members present who may assist with the interview process Which culture would describe illness as hot and cold imbalance? - -a. Asian-American heritage b. African-American heritage c. Hispanic-American heritage *CORRECT ANSWER* d. American Indian heritage Of what does the patient believe the amulet is protective? - -a. the evil eye *CORRECT ANSWER* b. being kidnapped c. exposure to bacterial infections d. an unexpected fall Which statement best illustrates the difference between religion and spirituality? - -a. religion reflects an individual's reaction to life events whereas spirituality is based on whether the individual attends religious services b. religion is characterized by identification of a higher being shaping one's destiny while spirituality reflects the individual's perception of one's life having worth or meaning *CORRECT ANSWER* c. Religion is the expression of spiritual awakening whereas spirituality is based on belief in divine right NURS 2092 NURS 2092 d. religion is the active interpretation of one's spirituality The first step to cultural competency by a nurse is to: - -understand your own heritage and its basis in cultural values Which statement is true in regard to pain? - -The cultural background of the patient is important in a nurses's assessment of that patient's pain. Which factor is identified as a priority influence on a patient's health status? - -Poverty Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American Indian patient? - -What cultural or spiritual beliefs are important to you. Which statement best describes ethnocentrism? - -The tendency to view your own way of life as the most desirable. Which category is appropriate in a cultural assessment? - -Health-related beliefs Which health belief practice is associated with patients who are of American Indian heritage? - -Eating compatible foods in one's diet. Which statement best reflects the Magicoreligious causation of illness? - -Belief in the struggle between good and evil is reflected in the regulation of health and illness. Auscultatory gap - -A brief period when Korotkoff sounds disappear during auscultation of blood pressure; common with hypertension. Bradycardia - -Heart rate fewer than 50 or 60 beats per minute in the adult (depending on agency). Sphygmomanometer - -Instrument for measuring arterial blood pressure. Stroke Volume - -Amount of blood pumped out of the heart with each heartbeat. Trachycardia - -Heart rate greater than 95 beats per minute in the adult. The 4 areas to consider during the general survey include: - -Physical appearance, body structure, mobility, and behavior. You are assessing a patient's gait. What do you expect to find? - -Gait is as wide as the shoulder width. An 18-month old child is brought into the clinic for a health screening visit. To assess the height of the child: - -Use a horizontal measuring board. NURS 2092 NURS 2092 Which changes in head circumference measurements in relation to chest measurements will occur from infancy through early childhood? - -The newborn's head will be 2 cm larger than the chest circumference, but between 6 months and 2 years, they will be about the same. Which changes regarding height and weight occur during the 80's and 90's? - -Both decrease. During an initial home visit, the patient's temperature is noted to be 97.4 degrees F. How would you interpret this? - -It cannot be evaluated without knowledge of the person's age. Select the best description of an accurate assessment of a patient's pulse: - -Begin counting with zero; count for 30 seconds. After assessing the patient's pulse, the practitioner determines it to be normal. This would be recorded: - -2+ Select the best description of an accurate assessment of a patient's respiration: - -Count for 30 seconds after pulse assessment. Pulse pressure is described as? - -The difference between the systolic and diastolic pressure. The examiner suspects a patient has coarctation of the aorta. Which assessment finding supports this suspicion? - -The pressure is lower than in the arm. Mean arterial pressure is: - -Diastolic pressure plus one third of the pulse pressure. Why is it important to match the appropriate size of blood pressure cuff to the person