HEALTH 3302 QUESTIONS HEALTH ASSESSMENT EXAMS QUESTIONS

HEALTH 3302 QUESTIONS HEALTH ASSESSMENT EXAMS QUESTIONS 1. Which is an example of data a nurse would collect during a physical examination? a. The client’s lack of hair and shiny skin over both shins b. The client’s stated concern about lack of money for prescriptions c. The client’s complaints of tingling sensations in the feet d. The client’s mother’s statements that the client has been very nervous lately 2. During an interview, the client answers questions quietly and appears sad. While answering questions about her marriage, she begins to cry. The appropriate response by the nurse would be to say. a. “Don’t cry I’ll come back when you’ve settled down” b. “I only have a few more questions to go, then I’ll leave you alone for a while?” c. “Everyone has ups and downs in their marriage. What problems are you having?” d. “I see that you are upset, is there something you’d like discuss?” 3. Select the example of an open-ended question from those below. a. “Have you experienced this pain before?” b. “Do you have someone to help you at home?” c. “How many times a day do you use your inhaler?” d. “What were you doing when you left the pain?” 4. When performing a skin assessment of an adult client, the nurse expects what finding?” a. Reddened are does not blanch when gentle pressure is applied b. Indentation of the finger in the skin after palpation c. Flaking or scaling of the skin d. Return of skin to its original position when pinched up slightly 5. In a report, a nurse learns that a client has a macular rash and expects to find: a. Elevated, firm, well-defined lesions less than 1 cm in diameter (papula) b. Depressed, firm, or scaly, rough lesions greater than 1 cm in diameter (vesicula) c. Elevated, fluid-filled lesions less than 1 cm in diameter d. Flat, well-defined, small lesions less than 1 cm in diameter (macula) 6. A nurse notices multiple lesions on a client’s back that are 0.5 cm in width, elevated, circumscribed, and filled with serous fluid. The nurse documents these lesions as: a. Macules b. Patches c. Vesicles d. Bullae 7. While taking a history, the nurse observes that the client’s facial cranial nerve is intact based on which behaviors of the client? (VII) VOLVIO A SALIR a. The client’s eyes move to the left, right up, down and obliquely during conversation b. The client moistens the lips with the tongue c. The sides of the mouth are symmetric when the client smiles d. The client’s eyelids blink periodically 8. To assess jaw movement of an adult client, the nurses uses which technique? (V) SALIO DE NUEVO a. Asking the client to open the mouth and the passively moving the client’s open jaw from side to side b. Placing two fingers in front of each ear and asking the client to slowly open and close the mouth c. Asking the client to open the mouth and to resist the nurse’s attempt to close the mouth d. Using the pads of all fingers to feel along the mandible for tenderness and nodules 9. In preparing to assess visual acuity with a Snellen chart, the nurse instructs the client to: (II) SALIO DE NUEVO a. Remove eyeglasses before attempting to read the lowest line b. Stand 10 feet from the chart and read the first line aloud c. Hold a white card over one eye and read the smallest possible line d. Squint if necessary to improve ability to read the largest letters 10. While using a Snellen visual acuity chart, the nurse records that the client’s vision is 20/40, meaning that: (II) a. A client’s vision is about half what is normally expected b. A client can see the 20/40 line on chart while wearing glasses or contact lenses c. A client with normal vision can see the 20/40 line on the chart at 40 feet d. A client can see at 40 feet what a client with normal vision can see at 20 feet 11. In assessing a client’s visual acuity using the Snellen chart, the nurse is assessing which cranial nerve? (II) VOLVIO A SALIR a. Optic cranial nerve b. Oculomotor cranial nerve c. Abducens cranial nerve d. Trochlear cranial nerve 12. During an eye assessment, a nurse asks the client to cover one eye with a card as the nurse covers his or her eye directly opposite the client’s covered eye. The nurse moves an object into the field of vision and asks the client to tell when the objects can be seen. This assessment technique collects what data about the client’s eyes? (II) VOLVIO A SALIR a. Symmetry of extraocular muscles b. Visual acuity in the uncovered eye c. Peripheral vision of the uncovered eye d. Consensual reaction of the uncovered 13. During an eye assessment the nurse asks the client to keep the head stationary and by moving the eyes only follow the nurse’s finger as it moves side to side, up and down, and obliquely. This assessment technique collects what data about the client’s eyes? VOLVIO A SALIR a. Function of cranial nerves oculomotor (III), trochlear (IV), and abducens (VI) b. Visual acuity c. Peripheral vision of the uncovered d. Consensual reaction of the uncovered eye 14. How does a nurse assess the functions of cranial nerves III, VI and IV that innervate the muscles of the eye? VOLVIO A SALIR a. By assessing peripheral vision b. By noting the symmetry of the corneal light reflex c. By assessing the cardinal fields of gaze d. By performing the cover-uncover test 15. A nurse shines a light in the right pupil to test constriction and notices that the left pupil constricts as well. Based on these data, the nurse should: (III) VOLVIO A SALIR a. Documents this finding as an abnormal finding b. Assess the client for accommodation c. Document this finding as a consensual reaction PUPIL LIGTH REFLEX d. Assess the client’s corneal light reflex 16. During an eye examination of an Asian client, a nurse notices an involuntary rhythmical, horizontal movement of the client’s eyes and documents this finding as: a. An expected racial variation b. Nystagmus c. Exophthalmos d. Myopia 17. During the Weber test, a nurse determines that the client hears the sound of a tuning fork equally in each ear. Based on this finding the appropriate response of the nurse is to: (VIII) a. Repeat the test again using 2000 Hz tuning fork b. Tell the client that this represents a normal finding c. Refer the client for additional testing of the client’s hearing abnormality d. Perform a Rinne test to confirm the findings of this Weber test 17.a) During a hearing assessment, the nurse finds that sound lateralizes to the client’s left ear with the Weber and Rinne tests. What should the nurse conclude from this finding? The patient has: a. A conductive hearing loss in the right ear. b. Lateralization is a normal finding with the Weber test. c. Either a sensorineural or conductive hearing loss. d. The steps in assessing the patient’s hearing were done incorrectly. 18. How does the nurse perform a Weber test to assess hearing function? The nurse: (VIII) VOLVIO A SALIR a. Whispers several words to the client and requests that the client repeat the words heard b. Places a vibrating tuning fork in the middle of the head and asks the client if the sound is heard the same in both ears or if it is louder in one ear than the other c. Places a set of headphones over both ears, plays several tones, and asks the client to identify the sounds d. Places a vibrating tuning fork on the mastoid process until the client no longer hears a sound, and then moves it in front of the ear until the client no longer hears a sound (RINNE TEST) NOTE: WEBER TEST (CONDUCTIVE HEANING LOSS) 19. How does the nurse perform a Rinne test of hearing function? The nurse: (VIII) VOLVIO A SALIR a. Whispers several words to the client and requests that the client repeat the words heard b. Places a vibrating tuning fork in the middle of the head and asks the client if the sounds is head the same in both ears or if it is louder in one ear than the other c. Places a set of headphones over both ears, plays several tones, and asks the client to identify the sounds d. Places a vibrating tuning fork on the mastoid process until the client no longer hears a sound, and then moves it in front of the ear until the client no longer hears a sound 20. A client is being seen in the clinic for suspected nasal obstruction from a foreign body. The nurse recognizes which finding as most consistent with this diagnosis? (I) a. Unilateral foul-smelling drainage b. Bilateral purulent green-yellow discharge c. Bilateral bloody discharge d. Unilateral watery discharge 21. A nurse suspects the client has an infection of the maxillary sinuses and will confirm this suspicion by: a. Using a flashlight to illuminate the floor of the mouth b. Pressing gently with both thumbs into the eyebrow ridges c. Applying firm pressure with the thumbs below the cheekbones d. Standing behind the client and asking him to slowly rotate his head 22. When inspecting a client’s nasal mucous membrane, which finding does the nurse expect to see? a. Deep pink turbinates b. Red, edematous mucous membranes c. Septum that angles to the left d. Clear exudate 23. In assessing a client’s mouth, a nurse observes the rising of the soft palate when the client says “Ahh.” This expected finding reflects the function of which cranial nerve? (VIII) VOLVIO A SALIR a. Facial (VII) b. Acoustic (VIII) c. Glossopharyngeal (IX) d. Hypoglossal (XII) 23.a) Which of the following cranial nerves is appointed correct: a. Optic II, Spinal Accessory XI, Facial VII, Trochlear IV. b. Spinal Accessory X, Vestibularcochlear VIII, Hypoglossal XII, Olfatory I. c. Facial VII, Glossopharyngeal IX, Trochlear V, Trigeminal IV. d. Trochlear V, Oculomotor III, Facial VII, Hypoglossal XII. 24. When inspecting a client’s posterior wall of the pharynx and tonsils, a nurse documents which finding as abnormal? a. Both tonsils have a smooth surface b. Left and right tonsils meet at the midline c. Left and right tonsils extend beyond the posterior pillars d. Both tonsils have a glistening texture 25. A nurse assess neck movement of an adult and documents that the client’s neck muscles are within expected limits if the client: (XI) a. Is unable to resist the nurse’s attempt to move the head upright b. Bends the head to the right and left (ear to shoulder) 15 degrees (lateral bending 45 grados) c. Flexes chin toward the chest 45 degrees (normal % 40 y 60 grados) d. Hyperextends the head 30 degrees from midline (normal is 45 to 70) 25.a) A nurse assesses the neck of an adult and documents that the client’s neck muscles are within expected normal limits if the client: a. Has a convex contour of the posterior cervical spine. b. Bends the head to the right and left (ear to shoulder) 15 degrees. c. Is able to resist the nurse’s attempt to move the head upright. d. Is able to hyperextend the head 30 degrees from midline. 26. In assessing spinal accessory nerve function, the nurse requests the client to: (XI) a. Stick out the tongue and move it side to side against the resistance of a tongue blade b. Shrug the shoulders against the resistance of the nurse’s hands c. Swallow while the nurse applies gentle pressure on the thyroid gland d. Move the chin to the chest and then up toward the ceiling 27. What technique does a nurse use when palpating the right lobe of a client’s thyroid gland using the anterior approach? The nurse: a. Pushes the cricoid process to the left with the right thumb. b. Displaces the trachea to the right with the left thumb. c. Manipulates the thyroid between the thumb and index finger. d. Moves the sternocleidomastoid muscle to the right with the left thumb. 28. What instruction does a nurse give a client to facilitate palpation of the right lobe of the thyroid gland? a. “Swallow for me one time” b. “Flex your head down and to the left” c. “Rotate your head to the right for me” d. “Hold your breath for a few seconds” 29. A nurse who is palpating the lymph nodes in the anterior and posterior cervical chains places the pads of the fingers: a. In front of the ear (preauricular) b. Under the mandible (submandibular) c. On either side of the sternocleidomastoid muscle d. Along the angle of the jaw 30. Nurses inquire about life style behaviors in those clients with specific risks factors for cataracts. The characteristics labeled with numbers a, b, c are associated with risks factors for cataracts. (your answer should appear as numbers separated by commas and spaces (e.g. 1, 2, 3, 4) (Select all that apply) EN ESTA PREGUNTA SE ADICIONO EL ULTIMO INCISO a. Smoking more than 20 cigarettes a day b. Having parents with cataracts c. Chronic consumption of alcohol d. Having a chronic disease, such as diabetes mellitus e. Black American 31. The nurse is reading a family genogram. As she reads the genogram, the nurse detects an error in the symbols. Can you clarify what is this mistake: a. Two people who are married are connect by line that go down and across b. The husband on the right and the wife on the left (husband left wife right) c. Couples that are not married are depicted with a dotted line d. Children are drawn left to right, going from the oldest to the youngest 32. An intimate relationship between a man and a woman living together (not marriage) ESTA IMAGEN LA PUSE YO, PORQUE EN EL WORD ESTA ESCRITA A MANO a. Legal separation (separacion) b. Divorce (divorcio) c. Marriage (Casado) d. engagement (convivientes) 33. During the interview, the client states that she doesn’t use many drugs. The nurse’s appropriate response to this statement is: a. “Tell me about the drugs you use now” b. “To some people six or seven is not many” c. “Do you mean legal drugs or illegal ones?” d. “How often are you using these drugs?” 34. The six steps of the ….. process are shown below, out of order. The correct order is _2, 4, 6, 1, 5, 3 _ your answer should appear as six numbers separated by commas and spaces (e.g. 6, 5, 4, 3, 2, 1) 1. Planning a. 2; 6; 4; 1; 5; 3 1 Assessment 2. Assessment b. 2; 4; 6; 5; 1; 3 2 Diagnosis 3. Evaluation c. 2; 4; 6; 1; 5; 3 3 Outcome identification 4. Diagnosis d. 2; 6; 4; 5; 1; 3 4 Planning 5. Implementation 5 Implementation 6. Outcome identification OTRA FORMA DE RESPUESTA 6 Evaluation 34a. The six steps of the nursing process are shown below, out of order. The correct order is: a. Planning, Assessment, Evaluation, Diagnostic, Implementation, Outcome identification. b. Assessment, Planning, Diagnosis, Outcome identification, Implementation, Evaluation. c. Assessment, Diagnosis, Outcome identification, Planning, Implementation, Evaluation. d. Assessment, Outcome identification, Diagnosis, Planning, Implementation, Evaluation. 35. A nurse inspects a client’s hands and notices bilateral clubbing of the fingers. The nurse correlates this finding with what condition? a. Normal finding b. Trauma to the thorax c. Chronic hypoxia d. Hyper oxygenation 36. A nurse had previously heard crackles over both lungs of a client. The client is improving, and the nurse anticipates hearing normal breath sounds, which would include: a. Vesicular breath sounds heard in peripheral lung fields b. Bronchial breath sounds heard over the bronchi c. Bronchovesicular breath sounds heard over the apices d. Bronchi heard over the main bronchi 37. The nurse is comparing pitch and duration of the various types of breath sounds and recognizes which as an expected finding? a. Bronchial sounds are low-pitched and have 2:1 inspiratory-versus-expiratory ratio b. Bronchovesicular breath sounds have a moderate pitch and 1:1 expiratory-versus-inspiratory ratio c. Vesicular breath sounds are high-pitched and have 1:2 inspiratory-versus-expiratory ratio d. Wheezes are low-pitched and have a 2:5:1 inspiratory-versus-expiratory ratio OTRA FORMA DE PREGUNTAR a. romber are high pitched with a duration of 1:2 inspiration-to-expiration. b. Bronchovesicular sounds have a moderate pitch and 2:1 expiratory-versus-inspiratory ratio. c. Vesicular breath sounds are high-pitched and have 1:2 inspiratory-versus-expiratory ratio. d. Wheezes are low-pitched and have a 2:5:1 inspiratory-versus-expiratory ratio. 38. A nurse suspects a client has a chest wall injury and wants to collect more data about thoracic expansion. Which is the appropriate technique to use? a. Placing the palmar side of each hand against the lateral thorax at the level of the waist, asking the client to take a deep breath, and observing lateral movement of the hands b. Placing both thumbs on either side of the client’s T9 to T10 spinal processes, extending fingers laterally, asking the client to take a deep breath and observing lateral movement of the thumbs c. Placing both thumbs on either side of the client’s T7 to T8 spinal processes, extending fingers laterally, asking the client to exhale deeply, and observing lateral inward movement of the thumbs d. Placing the palmar side of each on the shoulders of the client, asking the client to sit up straight and take a deep breath, and observing symmetric movement of the shoulders 39. A nurse is assessing for vocal (tactile) fremitus on a client with pulmonary edema. Which is the appropriate technique to use? a. Systematically percussing the posterior chest wall following the same pattern that is used for auscultation while listening for a change in tone from resonant to dull b. Placing the pads of the fingers on the right and left thorax and palpating the texture and consistency of the skin feeling for a crackly sensation under the fingers c. Placing the palms of the hands on the right and lef t thorax, asking the client to say “99”, and feeling for vibrations d. Placing both thumbs on either side of the client’s spinal processes, extending fingers laterally, asking the client to take a deep breath, and feeling for vibrations 40. The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply. a. Voice sounds are faint, muffled, and almost inaudible when the patient whispers “one, two, three” in a very sof t voice. b. As the patient says “ninety-nine” repeatedly, the examiner hears the words “ninety-nine” clearly. c. When the patient speaks in a normal voice, the examiner can hear a sound but cannot distinguish exactly what is being said. d. As the patient says a long “ee-ee-ee” sound, the examiner also hears a long “ee-ee-ee” muffled sound. e. As the patient says a long “ee-ee-ee” sound, the examiner also hears a long “aaaaaa” sound. 41. The nurse is assessing diaphragmatic excursion. The nurse knows that it is normal if she has the following result: a. Percuss up from the lower border to the scapular line, were resonance changes to dullness mark that point with a piece of tape, after that percuss down from the scapular line… and mark where the tone changes from dullness to resonance. The distance between the tape marks should be 3 - 6 cm. b. Percuss up from the lower border to the scapular line, were resonance changes to dullness mark that point with a piece of tape, after that percuss down from the scapular line… and mark where the tone changes from resonance to dullness. The distance between the tape marks should be 2 3 - 5 cm. c. Percuss down the scapular line to the lower border, were resonance changes to dullness mark that point with a piece of tape, after that percuss up from the first point… and mark where the tone changes from dullness to resonance. The distance between the tape marks should be 3 – 6 cm. d. Percuss down the scapular line to the lower border, were resonance changes to dullness mark that point with a piece of tape, after that percuss up from the first point… and mark where the tone changes from resonance to dullness. The distance between the tape marks should be 2 – 4 cm. 42. The nurse notes hyperresonant percussion tones when percussing the thorax of an infant. The nurse’s best action would be to: a. Notify the physician b. Suspect a pneumothorax c. Consider this a normal finding d. Monitor the infant’s respiratory rate and rhythm 43. During auscultation of breath sounds, the nurse should use the stethoscope correctly, in which of the following ways? a. Listen to at least one full respiration in each location b. Listen at the patient inhales and then go to the next site during exhalation c. Have the patient breathe in and our rapidly while the nurse listens to the breath d. If the patient is modest, listen to sounds over his or her clothing or hospital gown 44 – 46. When examining the cardiovascular system, the mnemonic PQRST, is very useful in assessing chest pain. May you explain in the meaning of each of these words are true or false? 44. a. _X_ True 45. a. _X_ True 46. a. True b. False b. False b. _X_ False (S) Severity (Q) Quality (T) Tremor P= Provokes Q= Quality R= Radiates S= Severity T= Timing OTRA FORMA DE RESPUESTA (T) Timing a) X True b) False (P) Provocative or Palliative a) X True b) False DUDA (R) Relation a) True b) X False 47. Which statement by the nurse shows that the interview is client-centered? a. “I need to complete this questionnaire about your medical and family history” b. “The hospital requires me to complete this assessment as soon as possible” c. “Tell me about the symptoms you’ve been having” d. “I’ve had the same symptoms that you’ve described” 48. The nurse is reviewing the function of the cranial nerves. Which of the cranial nerves is responsible for conducting nerve impulses to the brain from the organ of Corti? SALIO DE NUEVO a. CN I b. CN III c. CN VIII d. CN XI 48.a) A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved? a. CN V and CN VII b. CN IX and CN VII c. CN VIII and CN V d. CN VI and CN X 49. The mother of a 2-year-old is concerned because her son has had three five ear infections in the past year. What would be an appropriate response by the nurse? a. “It is unusual for a small child to have frequent ear infections unless there is something else wrong” b. “We need to check the immune system of your son to see why he is having so many ear infections” c. “Ear infections are not uncommon in infants and toddlers because they tend to have more cerumen in the external ear” d. “Your son’s eustachian tube is shorter and wider than yours because of this age, which allows for infections to develop more easily” 50. The nurse is preparing to do an otoscopic examination on a 2-year-old. Which of these reflects correct procedure? VOLVIO A SALIR a. Pull the pinna down b. Pull the pinna up and back c. Tilt the child’s head slightly toward the examiner d. Have the child touch his chin to his chest 51. A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to cranial nerve (CN) _XI and proceeds with the examination by _B_ VOLVIO A SALIR a. XI: palpating the anterior and posterior triangles b. XI: asking the patient to shrug her shoulders against resistance c. XII: percussing the sternomastoid and submandibular neck muscles d. XII: assessing for a positive Romberg sign 52. The nurse is testing a patient’s visual accommodation, which refers to which action? a. Pupillary constriction when looking at a near object b. Pupillary dilation when looking at a far object c. Changes in peripheral vision in response to light d. Involuntary blinking in the presence of bright light 53. The nurse is preparing to assess the visual of a 16-year-old patient. How should the nurse proceed? VOLVIO A SALIR a. Perform the confrontation test b. Ask the patient to read the print on a handheld Jaeger card c. Use the Snellen chart positioned 20 feet away from the patient d. Determine the patient’s ability to read newsprint at a distance of 12 to inches 54. A patient’s vision recorded as 15/20 when the Snellen eye chart is used. The nurse interprets these results to indicate that: VOLVIO A SALIR a. At 20 feet the patient can read the entire chart b. The patient can read at 15 feet what a person whit a normal vision can read at 20 feet c. The patient can read the chart from 15 feet in the left eye and 20 feet in the right eye d. The patient can read from 20 feet what a person with normal vision can read from 15 feet 55. When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o’clock in each eye. The nurse should: VOLVIO A SALIR a. Consider this a normal finding or symmetric b. Refer the individual for further evaluation c. Document this as an asymmetric light reflex d. Perform the confrontation test to validate the findings 56. The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has “lazy eye” and should VOLVIO A SALIR a. Examine the external structures of the eye. b. Assess visual acuity with the Snellen eye chart c. Assess the child’s visual fields with the confrontation test d. Test for strabismus by performing the corneal light reflex test 57. The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse would report this as a: a. Bulla b. Wheal c. Nodule d. Papule 58 – 62. Write the number of each cranial nerve 58. Optic: a. I b. II c. III d. IV 59. Spinal Accessory: 60. Facial: a. IX a. V b. X b. VI c. XI c. VII d. XII d. VIII 61. Trochlear: a. III b. IV c. V d. VI 62. Vagus: a. VII b. VIII c. IX d. X 63 – 67. Which of the following cranial nerves is classified as “Sensory” which is classified as “Motor” and which as “Both”: 63. Olfactory: a. Sensory b. Motor c. Both 64. Trochlear: a. Sensory b. Motor c. Both 65. Abducens: a. Sensory b. Motor c. Both 66. Vagus: a. Sensory b. Motor c. Both 67. Trigeminal: a. Sensory b. Motor c. Both 67.b) Which of the following cranial nerves is classified correct: a. Olfactory (sensory), Trigeminal (motor), Facial (sensory), Vagus (both). b. Trochlear (motor), Olfactory (sensory), Abducens (motor), Oculomotor (motor). c. Abducens (both), Hypoglossal (motor), Vagus (motor), Optic (sensory). d. Vagus (sensory), Spinal accessory (motor), Olfactory (sensory), Trochlear (motor). 68. Which heart sound is known as the atrial gallop? a. S1 b. S2 c. S3 ventricular gallop (lub – dub – ta) d. S4 atrial gallop (ta – lub – dub) 68. a) Which heart sound is known as the ventricular gallop? (“lub – dub – ta”) a. S1 b. S2 c. S3 d. S4 69. The nurse is auscultating a patient. She knows that S1 is the “lub” of the “lub-dub”, and this one is produced by: a. S1 is diminished in secund degree heart block b. The closure of aortic & pulmonic valves c. The closure of aortic and mitral valves d. The closure of tricuspid and mitral valves 70. The alteration that the nurse may auscultate that involve S2 is: a. Normal physiological splitting of S2 is best heard at aortic area it occurs on inspiration (“lub-T-dub, lub-dub”) b. Normal physiological splitting of S2 is best heard at pulmonic area. It occurs on inspiration (“lub-T-dub, lub-dub”) c. Splitting of S2 sound can occur when aortic pulmonary, tricuspid and mitral valves do not close at the same time d. Splitting of S2 sound can occur when aortic pulmonary, tricuspid and mitral valves do not open at the same time 71. The nurse is auscultating the second intercostal space left of the sternal border to hear which valve? a. The pulmonic valve space left b. The tricuspid valve 4to sp. Int. left side of the left sternal border c. The mitral valve 5to sp. Int. linea (mid-clavicular line) d. The aortic valve second intercostal space right of sternal border 71. a) The nurse is auscultating the second intercostal space right of the sternal border to hear which valve? a. The pulmonic valve b. The tricuspid valve c. The mitral valve d. The aortic valve space right 72. A nurse learns from a report that a client has aortic stenosis. Where does the nurse place the stethoscope to hear this stenotic valve? a. Second intercostal space, right sternal border Aortic b. Second intercostal space, left sternal border Pulmonic c. Fourth intercostal space, left sternal border Tricuspid d. Firth intercostal space, left midclavicular line Mitral valve 72.a) While listening to a client’s heart sounds, the nurse understands that the first heart sound (S1) is created by the closing of the: a. Pulmonic and tricuspid valves. b. Mitral and aortic valves. c. Aortic and pulmonic valves. d. Mitral and tricuspid valves. 73. Frank’s visual acuity is measured using a Snellen chart. The reading obtained is 20/80 in the right eye and 20/200 in the lef t eye. How should the nurse explain these finding to Frank? VOLVIO A SALIR 1. “You are very far-sighted, especially in your left eye” 2. “You are very near-sighted, especially in your lef t eye” 3. “You are very far-sighted, especially in your right eye” 4. “You are very near-sighted, especially in your right eye” 74. A 78-year-old client is admitted to the Emergency Department (ED) via emergency medical service (EMS) with complains of severe diarrhea with resultant weakness and sings of dehydration. Discussion with the significant other reveals that the patient continually eats spoiled foods. Which of the following might be most directly related to this patient’s behavior? a. Damage to cranial never I b. Damage to cranial never II c. Damage to cranial never III d. Damage to cranial never IV 75. After taking a brief respiratory health history, a nurse would need to complete a more focused assessment on which client? a. A 28-year-old man who works as a painter. b. A 15-year-old man who plays basketball and hockey. c. A 19-year-old woman who recently moved into a college dormitory. d. A 35-year-old man with a history of gout. 76. During a symptom analysis, a client describes his productive cough and states his sputum is thick and yellow. Based on these data, the nurse suspects the cause of the cough may be: a. Viral b. Allergy c. Fungal d. Bacterial 77. A client complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse’s examination, what findings will suggest that the cause of this client’s dyspnea is due to heart disease rather than respiratory disease? a. Increased anteroposterior diameter. b. Clubbing of the fingers. c. Bilateral peripheral edema. d. Increased tactile fremitus. 78. Which client should the nurse assess first? a. The client whose respiratory rate is 26 breaths per minute and whose trachea deviates to the right. b. The client who has pleuritic chest pain, bilateral crackles, a productive cough of yellow sputum, and fever. c. The client who is short of breath, using pursed-lip breathing, and in a tripod position. d. The client whose respiratory rate is 20 breaths per minute and expiratory wheezes. 79. Some symptoms that may be associated with myocardial ischemia may include (select all that apply): a. Weakness b. Percussions c. Syncope d. Dizziness e. Light-headedness 80. When assessing normal circulation in the extremities, you anticipate finding that: a. Blood flow is similar bilaterally. b. The contour and amplitude of pulsations are greater on the left side of the body. c. The contour and amplitude of pulsations are greater on the right side of the body. d. As you move further away from the core of the body, the contour pulsations are more rapid. 81. Which of the fallowing statements is correct: OJO a. S4 is often normal in children and is heard best at the apex in the left lateral decubitus position. b. Pathologic S4 occurs in people over the age of 40, usually due to myocardial failure. c. Pathologic S3 occurs in young adults, usually due to myocardial failure. d. S4 is often normal in older adults and is heard best at the apex in the lef t lateral decubitus position. BUSCAR ESTA RESPUESTA 82. The range of normal liver span in the right midclavicular line in the adult is: a. 2 – 6 cm b. 4 – 8 cm c. 8 – 14 cm d. 6 – 12 cm 83. When inspecting and palpating the sternoclavicular joint, the nurse would distinguish a normal finding as all of the following except: a. No visible bony overgrowths b. No swelling c. No redness d. Painful joints 84. On inspection of a 20-year-old female client’s abdomen, the nurse asks the client to raise her head without using her arms and notes a midline bulge. The appropriate response of the nurse is to: a. Ask the client if she is possibly pregnant. b. Auscultate the client’s abdomen for intestinal obstruction. c. Note this as a normal finding and continue the examination. d. Perform light and deep palpation of the abdomen. 85. After inspecting the abdomen for skin color, surface characteristics, and surface movement, the nurse’s next assessment of the abdomen is to: a. Palpate lightly for tenderness and muscles tone. b. Auscultate for bowel sounds. c. Palpate deeply for masses or aortic pulsation. d. Percuss for tones. 86. To accurately assess bowel sounds, the nurse uses the: a. Diaphragm of the stethoscope pressed firmly against the abdomen in each quadrant. b. Diaphragm of the stethoscope held lightly against the abdomen in each quadrant. c. Bell of the stethoscope pressed firmly against the abdomen in each quadrant. d. Bell of the stethoscope held lightly against the abdomen in each quadrant. 87. On palpation of the left upper quadrant of the abdomen of a female client, the nurse notes tenderness and recognizes this pain is associated with a disorder of the: a. Spleen b. Gallbladder c. Sigmoid colon d. Left ovary 88. A nurse listening with the bell of the stethoscope over the epigastric area of the abdomen of a healthy client normally will hear: a. Bowel sounds b. Venous hum c. Aortic aneurysm d. No sounds 89. Using deep palpation of a client’s epigastrium, a nurse feels the rhythmic pulsation of the aorta. Based on this finding, the appropriate response of the nurse is to: a. Auscultate this area using the bell of the stethoscope b. Percuss the area for tones c. Ask the client if there is pain in this area d. Document this a normal finding 90. A nurse is having difficulty auscultating the heart for sounds of a client because the lung sounds are too loud. What action does the nurse take to hear the heart sounds? a. Asking the client lie in a supine position. b. Asking the client to cough to clear the airways. c. Asking the client to hold his breath for a few seconds. d. Asking the client to sit up and lean forward. 91. In percussing the abdomen, the nurse recognizes which finding as normal? a. Tympany over all quadrants. b. Resonance over the upper quadrants and tympany in the lower quadrants. c. Dull sounds over the upper quadrants and hollow sounds over the lower quadrants. d. Dull sounds over the stomach and resonant sounds over the bladder. 92. To correctly palpate a client’s right kidney, the nurse: a. Ask the client to take a deep breath, elevates the client’s eleventh and twelfth ribs with the left hand, and deeply palpates for the right kidney with the right hand. b. Ask the client to exhale, elevates the client’s eleventh and twelfth ribs with the left hand, and deeply palpates for the right kidney with the right hand. c. Ask the client to take a deep breath, elevates the client’s right flank with the left hand, and deeply palpates for the right kidney with the right hand. d. Ask the client to exhale, elevates the client’s right flank with the left hand, and deeply palpates for the right kidney with the right hand. 93. The nurse recognizes which clinical findings as normal on palpation of the abdomen? a. Inability to palpate the spleen b. Left kidney rounded at 2 cm below the costal margin c. Slight tenderness of the gallbladder on light palpation d. Bounding pulsation of the aorta over the umbilicus 94. The nurse reviews the technique of performing an abdominal assessment and understand that should be performed second to maintain the correct order and client comfort. a. Palpation b. Inspection c. Auscultation d. Percussion 95. The nurse knows that while percute solid organs in the abdominal region, she heard the sounds: a. Tympanic b. Resonance c. Dullness d. Hyperresonant 96. The nurse knows that Babinski reflex is one of the reflexes that occurs in infants. The correct technique is: a. The Babinski reflex occurs after the sole of the foot has been lightly stroked. The big toe the moves upward or toward the top surface of the foot. The other toes fan out. b. The Babinski reflex occurs after the sole of the foot has been firmly stroked. The big toe the moves upward or toward the top surface of the foot. The other toes fan out. c. When the Babinski reflex is present in a child older than 2 years or in an adult, it is normal finding. d. When the Babinski reflex is present in a child older than 6 months, it is often a sign of a brain or nervous system disorder. 97. In assessing the joint range of motion of a client’s knees, the nurse notices the flexion is less than expected in both knees. What is the next appropriate action for the nurse? a. Documenting this finding as normal for this client because it occurs in both knees and comparisons are made of one side with the other. b. Palpating the suprapatellar pouch on each side of the quadriceps for contour, tenderness, and edema. c. Using a goniometer to measure the flexion in both knees and comparing the results with the expected degree of flexion. d. Applying opposing force to the lower leg while the client tries to maintain flexion and extension. 98. The nurse notes that there is audible clicking sound when the client opens and closes the mouth. What is the appropriate response of the nurse at this time? a. Recording this as an abnormal finding requiring additional assessment. b. Measuring the distance between each side of the mandible and the eyes. c. Applying the distance to the maxilla and asking the client to repeat the motion. d. Noting this as a normal finding if there are no other associated signs or symptoms. 99. The nurse palpates the client’s jaw movement, placing two fingers in front of each ear and asking the client to slowly open and close the mouth. The nurse also asks the client to: a. Move the jaw side to side. b. Swallow. c. Smile. d. Clench the teeth together. 100. A nurse assesses the neck of an adult documents that the client’s neck muscles are within normal limits if the client: a. Has a convex contour of the posterior cervical spine. b. Bends the head to the right and left (ear to shoulder) 15 degrees. c. Is able to resist the nurse’s attempt to move the head upright. d. Is able to hyperextend the head 30 degrees from midline. 101. A client asks, “Why is touching my toes necessary? This is a sports physical examination, not exercise class.” The nurse replies: a. “This is the best way to check for symmetry of your arms”. b. “I am looking at the stretch of your ham strings”. c. “This allows me to see how straight your spinal column is”. d. “It is considered abnormal if you can’t touch your toes from this position.” 102. A client reports a history of compression of the left cranial nerve XI (spinal accessory nerve) from an old sports injury. Based on this information, what technique does the nurse include in the focused assessment? a. Asking the client to rotate the head against resistance of the nurse’s hand on the client’s chin. b. Asking the client to flex the chin to the chest against resistance of the nurse’s hand on the client’s forehead. c. Asking the client to extend the head back against resistance of the nurse’s hand on the back of the client head. d. Asking the client to shrug the shoulders while the nurse attempts to push then down. 103. The nurse asks the client to hold the arms straight out, perpendicular to the floor, and the nurse tries to push the client’s arms down. The nurse is testing the strength of which muscles in this procedure? a. Triceps b. Biceps c. Trapezius d. Deltoid 104. When a nurse asks a client to place the right arm behind the back, so that the back of the hand is touching the lower spine, the nurse is testing for which range of motion? a. Pronation of the elbow. b. Hyperextension of the elbow. c. Internal rotation and adduction of the shoulder. d. External rotation and abduction of the shoulder. 105. When the nurse asks a client to place the right arm behind the head, the nurse is testing for which range of motion? a. Flexion of the elbow. b. Hyperextension of the shoulder. c. Internal rotation and adduction of the shoulder. d. External rotation and abduction of the shoulder. 106. The nurse asks the client to rest the left arm on a table and to move the lower arm so that the palm of the hand is up and then down. What motion is the nurse testing? a. Adduction and abduction of the wrist. b. Supination and pronation of the wrist. c. Adduction and abduction of the elbow. d. Supination and pronation of the elbow. 107. The nurse in the figure below is assessing function and strength of the muscle. a. Sternocleidomastoid. b. Trapezius. c. Deltoid. d. Pectoralis major. 107. The nurse assesses for hyperextension of the hip by asking the client to: a. Raise one leg at a time while lying prone. b. Raise one leg at a time while lying supine. c. Move one leg at a time laterally, away from midline, while lying prone. d. Move one leg at a time medially, toward midline, while lying supine. PREGUNTAS QUE SALIERON EN EL EXAMEN… DUDAS 1. When assessing vocal resonance for lung consolidation, the nurse notices that a similar finding among the three procedures is: a. The client is asked to say “e-e-e” in all three procedures. b. The normal finding is a muffled sound in all three procedures. c. The bell of the stethoscope is used in all three procedures. d. The client normally complains of pain on inspiration in all three procedures. 2. During a respiratory assessment of a healthy adult, which findings are expected? (Select all that apply) 1. Thoracic expansion that is symmetric bilaterally. 2. Respiratory rate of 24 12 breaths per minute. 3. Breath sounds clear with vesicular breath sounds heard over most lung fields. 4. Anteroposterior diameter of the chest about a ½ ratio of transverse anteroposterior to lateral diameter. 5. Symmetric thorax with ribs sloping downward at about 45 degrees relative to the spine. / BRONCHOPHONY REVEALING MUFFLED VOICE SOUNDS (OTRA FORMA DE RESPUESTA) 3. In auscultating a client’s chest, the nurse recognizes that bronchovesicular vesicular sounds are considered normal if heard: a. In the lower lobes. b. Over the trachea. c. In the apices of the lungs. d. Near the sternal border. 4. A client has right lower lobe pneumonia creating a consolidation in that lung. In assessing for vocal (tactile) fremitus, the nurse found increased fremitus over the right lower lung. What finding does the nurse anticipate when assessing vocal resonance to confirm the consolidation? a. Bronchophony reveals the client’s spoken “99” as clear and loud. b. No sounds are expected because sounds cannot be transmitted through consolidations. c. Egophony reveals indistinguishable sounds when the client says “e-e-e”. d. Whispered pectoriloquy reveals a muffled sound when the client whispers “1-2-3”. 5. The nurse is assessing an adult patient (He is 34 years old). When comparing the back, sides and front, the nurse sees normal to find: 1.a) The anteroposterior diameter is about half the size of the transverse diameter, as is normally in adults. 2.b) The anteroposterior diameter is likely to be more than half the size of the transverse diameter, as is normally in adults. 3.c) The transverse diameter is about half the size of the anteroposterior diameter, as is normally in adults. 4.d) The transverse diameter is likely to be more than half the size of the anteroposterior diameter, as is normally in adults. RESUMEN DE NEUROLOGICO POR SI NOS SIRVE DE ALGO I Olfactory-Smell II – Optic-Vision III – Oculomotor-Eyelid & eyeball movement IV – Trochlear-Innervates superior oblique turns eye downward & laterally. V – Trigeminal-Chewing Face & mouth touch & pain VI – Abducens- Turns eye laterally VII – Facial-Controls most facial expression Secretion of tears & saliva Taste VIII - Vestibulocochlear (Auditory)-Hearing Equilibrium sensation IX – Glossopharyngeal- Taste Senses carotid blood pressure X – Vagus-Senses aortic blood pressure Slows heart rate Stimulates digestive organs Taste XI - Spinal Accessory - Controls trapezius & sternocleidomastoid Controls swallowing movements XII – Hypoglossal-Controls tongue movements Names of Cranial Nerves CN I: Olfactory - Sensory CN II: Optic - Sensory CN III: Oculomotor - Motor CN IV: Trochlear - Motor CN V: Trigeminal - Both CN VI: Abducens - Motor CN VII: Facial - Both CN VIII: Vestibulocochlear - Sensory CN IX: Glossopharyngeal - Both CN X: Vagus - Both CN XI: Accessory - Motor CN XII: Hypoglossal - Motor Cranial Nerve I: Olfactory Sensory - Sense of smell Olfactory receptors in nasal cavity to olfactory nerve tracts to olfactory area in temporal lobe of brain Cranial Nerve II: Optic Sensory - Vision Visual signals begin in the retina Passes to neurons forming optic nerves, which merge to form the optic chiasm Optic chiasm divides into optic tracts Optic tracts travel to thalamus and then to occipital lobe Cranial Nerve III: Oculomotor Motor (mostly) - Moves eyes Accommodation of lens for near vision Constriction of the iris in response to light Sensory proprioceptive information from the eyes Cranial Nerve IV: Trochlear Motor (mostly) - Moves eyes Only cranial nerve arising from posterior brain stem and crossing midline after leaving brain stem Eye movements Sensory proprioceptive impulses from eyes Cranial Nerve V: Trigeminal Both - Chews food; feels front of head Largest cranial nerve Forms three branches - Ophthalmic, Maxillary & Mandibular Sensory info: touch, pain, temp from face Motor information for chewing muscles Cranial Nerve VI: Abducens Motor (mostly) - Moves eyes Sensory proprioceptive info from eye muscles Cranial Nerve VII: Facial Both - Moves face, tastes, salivates, Sensory information from taste buds on anterior 2/3 of tongue Proprioceptive information from face and scalp Motor information for facial expression and closing the eye Autonomic information for crying and salivation Cranial Nerve VIII: Vestibulocochlear Sensory - Hears & regulates balance Info for equilibrium (vestibular branch) and hearing (cochlear branch) Cranial Nerve IX: Glossopharyngeal Both - Tastes, salivates, swallows, monitors carotid body & sinus Sensory info from ipsilateral taste buds (posterior 2/3 tongue) Receptors in carotid sinus to regulate blood pressure. Motor information for swallowing Autonomic information for salivation Cranial Nerve X: Vagus Both - Tases, swallows, lifts palate, talks; communication to-from thoraco-abdominal viscera The wandering nerve Motor info to innervate larynx and assist swallowing. Sensory info skin of ear, pharynx, larynx, and thoracic and abdominal viscera. Autonomic (parasympathetic) motor info to lungs, heart, and smooth muscle of thoracic Cranial Nerve XI: Accessory Motor - Turns head, lifts shoulders Begins in BOTH brain stem and spinal cord Cranial root motor info for swallowing Spinal root motor info for head movements Spinal root sensory info from neck proprioceptors Cranial Nerve XII: Hypoglossal Motor - Moves tongue Sensory info from tongue proprioceptors Motor info to tongue for speech, swallowing & protrusion of the tongue Mnemonic for Function of Cranial Nerves Some Say Money Matters, But My Brother Says, Big Brains Matter More Which cranial nerve is the largest? Trigeminal nerve Which cranial never is the only one that exits the "posterior" side of the brain stem? Trochlear nerve How many cranial nerves are responsible for eye movements 3: Oculomotor, Trochlear, Abducens What does "Abducens" refer to? The Abducens nerve carries motor impulses to the lateral rectus eye muscle which moves the eye laterally causing abductions of the eye What cranial nerves carry gustatory (taste) information? Facial, Glossopharyngeal, and vagus Which cranial nerve is the longest? Vagus, which reaches from the medulla to the digestive and urinary organs. What two cranial nerves carry sensory information about blood pressure to the brain? Glossopharyngeal, and vagus Which cranial nerve is responsible for pupillary construction? Oculomotor OTHER 1. There are 14 pairs cranial nerves. True False The answer is FALSE. There are 12 pairs of cranial nerves NOT 14. 2. The optic nerve is known as cranial nerve X (ten). True False The answer is FALSE. The optic nerve is known as cranial nerve II (not X). 3. Cranial nerve IV is known as? A. Oculomotor B. Trigeminal C. Hypoglossal D. Trochlear The answer is D. 4. The abducens nerve is known as cranial nerve? A. VI B. VIII C. II D. I The answer is A. 5. Vestibulocochlear nerve is known as cranial nerve VIII? True False The answer is TRUE. 6. Cranial nerve X is known as? A. Vagus B. Accessory C. Trochlear D. Optic The answer is A. 7. The oculomotor nerve is called cranial nerve? A. IX B. IV C. III D. X The answer is C. 8. Cranial nerve I is called the olfactory nerve. True False The answer is TRUE. 9. Cranial nerve V is known as the facial nerve. True False The answer is FALSE. Cranial nerve V (5) is known as the TRIGEMINAL NOT the facial nerve. 10. Hypoglossal nerve is known as cranial nerve? A. XI B. II C. VIII D. XII The answer is D. 11. The facial nerve is called cranial nerve? A. IX B. VIII C. VII D. X The answer is C. 12. Glossopharyngeal is also called the cranial nerve IX. True False The answer is TRUE. 13. Cranial nerve XI is called the optic nerve. True False The answer is FALSE. The ACCESSORY NERVE is known as cranial nerve XI. 14. Which nerve does NOT play a role in swallowing? A. Glossopharyngeal B. Hypoglossal C. Vagus D. Olfactory The answer is D. The glossopharyngeal, hypoglossal, and vagus nerves all play a role in swallowing. The glossopharyngeal nerve is the main center for swallowing, however, but all three play a role together (along with the facial, trigeminal, and spinal accessory). The olfactory nerve does NOT. 15. The function of cranial nerve I is? A. hearing B. moving the eyeballs C. sight D. smell The answer is D. 16. This cranial nerve arises from the cranial and spinal roots which controls swallowing movements and governs movement of the head and shoulders? A. IX B. X C. XI D. VIII The answer is C. 17. Cranial nerve II's function is eyesight. True False The answer is TRUE. 18. This nerve controls the PNS which stimulates contraction and relaxation of the smooth muscle in the GI tract? A. X B. V C. VI D. VII The answer is A. 19. Cranial nerve moves the eyeballs/eyelids and adjusts the pupils and lens of the eye. A. VII B. X c. I D. III The answer is D. 20. Glossopharyngeal nerve is responsible for? A. swallowing and speech B. hearing and equilibrium C. swallowing, taste, and secreting saliva D. none of the options are correct The answer is C. 21. Cranial nerves move the eyeballs. A. I, II, III B. III, IV, VI C. III, V, X D. III, IV The answer is B. 22. This is the largest cranial nerve that controls facial muscles, chewing, and facial sensations? A. X B. IV C. VIII D. V The answer is D. 23. Tears, saliva, taste, and facial expressions are caused by cranial nerve? A. VI B. VII C. II D. I The answer is B. 24. Vestibulocochlear nerve (cranial nerve VIII) is responsible for auditory. True False The answer is TRUE. 25. Cranial nerve X is known as the vagus nerve. True False The answer is TRUE. Chapter 01: Evidence-Based Assessment Test Bank MULTIPLE CHOICE 1. After completing an initial assessment on a patient, the nurse has charted that his respirations are eupneic and his pulse is 58. This type of data would be: A) objective. B) reflective. C) subjective. D) introspective. ANS: A Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical exam. Subjective data is what the person says about himself or herself during history taking. The terms “reflective” and “introspective” are not used to describe data. 2. A patient tells the nurse that he is very nervous, that he is nauseated, and that he “feels hot.” This type of data would be: A) objective. B) reflective. C) subjective. D) introspective. ANS: C Subjective data are what the person says about himself or herself during history taking. Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical exam. The terms “reflective” and “introspective” are not used to describe data. 3. The patient’s record, laboratory studies, objective data, and subjective data combine to form the: A) data base. B) admitting data. C) financial statement. D) discharge summary. ANS: A Together with the patient’s record and laboratory studies, the objective and subjective data form the data base. The other items are not composed of the patient’s record, laboratory studies, and data. 4. When listening to a patient’s breath sounds, the nurse is unsure about a sound that is heard. The nurse’s next action should be to: A) notify the patient’s physician immediately. B) document the sound exactly as it was heard. C) validate the data by asking a coworker to listen to the breath sounds. D) assess again in 20 minutes to note whether the sound is still present. ANS: C Validate any data that you need to make sure are accurate. If you have less experience in an area, ask an expert to listen. 5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience to draw from, are more likely to make their decisions using: A) intuition. B) a set of rules. C) articles in journals. D) advice from supervisors. ANS: B Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive links. 6. Expert nurses learn to attend to a pattern of assessment data and to act without consciously labeling it. This is referred to as: A) intuition. B) the nursing process. C) clinical knowledge. D) diagnostic reasoning. ANS: A Intuition is characterized by pattern recognition—expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. The other items are not correct. 7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects evidence-based practice? A) EBP relies on tradition for support of best practices. B) EBP is simply the use of best practice techniques for treatment of patients. C) EBP emphasizes the use of best evidence with the clinician’s experience. D) The patient’s own preferences are not important with EBP. ANS: C Evidence-based practice (EBP) is a systematic approach to practice that emphasizes the use of best evidence in combination with the clinician’s experience, as well as patient preferences and values, to make decisions about care and treatment. It is more than simply the use of best practice techniques to treat patients, and it is important to question tradition when no compelling research evidence exists to support it. 8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem? A) A patient with postoperative pain B) A newly diagnosed diabetic who needs diabetic teaching C) An individual with a small laceration on the sole of the foot D) An individual with shortness of breath and respiratory distress ANS: D First-level priority problems are those that are emergent, life threatening, and immediate (e.g., establishing an airway, supporting breathing, maintaining circulation, and monitoring abnormal vital signs). See Table 1-1. 9. When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects? A) Low self-esteem B) Lack of knowledge C) Abnormal laboratory values D) Severely abnormal vital signs ANS: C Second-level priority problems are those that require prompt intervention to forestall further deterioration (e.g., mental status change, acute pain, abnormal laboratory values, and risks to safety or security). See Table 1-1. 10. Which critical thinking skill helps the nurse to see relationships among the data? A) Validation B) Clustering related cues C) Identifying gaps in data D) Distinguishing relevant from irrelevant ANS: B Clustering related cues helps the nurse to see relationships among the data. 11. The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the diagnosis. A) nursing B) medical C) admission D) collaborative ANS: A An accurate nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. The other items do not contribute to the development of appropriate nursing interventions. 12. The nursing process is a sequential method of problem solving that nurses use, and includes which steps? A) Assessment, treatment, planning, evaluation, discharge, follow-up B) Admission, assessment, diagnosis, treatment, discharge planning C) Admission, diagnosis, treatment, evaluation, discharge planning D) Assessment, diagnosis, outcome identification, planning, implementation, evaluation ANS: D The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation. 13. A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems? A) Breathing, pain, sleep B) Breathing, sleep, pain C) Sleep, breathing, pain D) Sleep, pain, breathing ANS: A First-level priority problems are immediate priorities (remember the ABCs), followed by second-level problems, and then third-level problems. 14. Which of these would be formulated by a nurse using diagnostic reasoning? A) Nursing diagnosis B) Medical diagnosis C) Diagnostic hypothesis D) Diagnostic assessment ANS: C Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the nursing process calls for a nursing diagnosis. 15. Barriers to incorporating evidence-based practice (EBP) include: A) nurses’ lack of research skills in evaluating quality of research studies. B) lack of significant research studies. C) insufficient clinical skills of nurses. D) inadequate physical assessment skills. ANS: A As individuals, nurses lack research skills in evaluating quality of research studies, are isolated from other colleagues who are knowledgeable in research, and lack time to go to the library to read research. The other responses are not considered barriers. 16. What is the step of the nursing process that includes data collection by health history, physical examination, and interview? A) Planning B) Diagnosis C) Evaluation D) Assessment ANS: D Data collection, including performing the health history, physical examination, and interview, is the assessment step of the nursing process. See Figure 1-2. 17. During a staff meeting, nurses discuss the problems with accessing research studies in order to incorporate evidence-based clinical decision making into their practice. Which suggestion by the nurse manager would best help this problem? A) Form a committee to conduct research studies. B) Post published research studies on the unit’s bulletin boards. C) Encourage the nurses to visit the library to review studies. D) Teach the nurses how to conduct electronic searches for research studies. ANS: D Facilitating support for evidence-based practice would include teaching the nurses how to conduct electronic searches because time to go to the library may not exist for many nurses. Actually conducting research studies may be helpful in the long-run, but is not an immediate solution to reviewing existing research. 18. When reviewing concepts of health, the nurse recalls that components of holistic health include which of these? A) Disease originates from the external environment. B) The individual human is a closed system. C) Nurses are responsible for a patient’s health state. D) Holistic health views the mind, body, and spirit as interdependent. ANS: D Consideration of the whole person is the essence of holistic health, which views the mind, body, and spirit as interdependent. The basis of disease originates from both the external environment and from within the person. Both the individual human and the external environment are open systems, continually changing and adapting, and each person is responsible for his or her own personal health state. 19. The nurse recognizes that the concept of prevention in describing health is essential because: A) disease can be prevented by treating the external environment. B) the majority of deaths among Americans under age 65 years are not preventable. C) prevention places emphasis on the link between health and personal behavior. D) the means to prevention is through treatment provided by primary health care practitioners. ANS: C A natural progression to prevention now rounds out our concept of health. Guidelines to prevention place emphasis on the link between health and personal behavior. 20. The nurse is reviewing the components of the nursing process. Which statement about nursing diagnoses is true? A) They evaluate the etiology of disease. B) They are a process based on the medical diagnosis. C) They are clinical judgments about a person’s response to an actual or potential health state. D) They focus on the function and malfunction of a specific organ system in response to disease. ANS: C Nursing diagnoses are used to evaluate the response of the whole person to actual or potential health problems. The other answers are related to medical issues, not nursing process. 21. The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the: A) patient’s history of allergies. B) patient’s use of medications at home. C) last menstrual period 1 month ago. D) 2 × 5 cm scar present on the right lower forearm. ANS: D Objective data are the patient’s record, laboratory studies, and information that the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The other responses reflect subjective data. 22. A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting? A) A follow-up data base to evaluate changes at appropriate intervals B) An episodic data base because of the continuing, complex medical problems of this patient C) A complete health data base because of the nurse’s primary responsibility for monitoring the patient’s health D) An emergency data base because of the need to rapidly collect information and make accurate diagnoses ANS: C The complete data base is collected in a primary care setting, such as a pediatric or family practice clinic, independent or group private practice, college health service, women’s health care agency, visiting nurse agency, or community health agency. In these settings the nurse is the first health professional to see the patient and has primary responsibility for monitoring the person’s health care. 23. Which situation is most appropriate for the nurse to perform a focused or problem-centered history? A) A patient’s admission to a long-term care facility B) A patient has sudden, severe shortness of breath C) A patient’s admission to the hospital for surgery the following day D) A patient in an outpatient clinic has cold and flu-like symptoms ANS: D In a focused or problem-centered data base, the nurse collects a “mini” data base, smaller in scope than the completed data base. It concerns mai