NYU HAP Exam 1 with complete solutions

The nurse notices a colleague is preparing to check the blood pressure of a patient who is sitting with his legs crossed. The nurse knows that this will: a. yield a falsely low blood pressure. b. have no effect on the blood pressure reading. c. produces an auscultatory gap. d. yield a falsely high blood pressure. - Answer- D (Blood pressure increases when legs are crossed and care should be taken to ensure that feet are flat on the floor to avoid a *false high blood pressure.) Which activity illustrates the concept of *primary prevention*? a. exercising three times a week b. monthly breast self-examination c. education about living with asthma d. colonoscopy after age of 50 - Answer- A (a primary prevention aimed at preventing the individual from developing an illness.) A 75- y/o man reports he stopped playing cards with his friends because, over time, he noticed their voices began to sound mumbled. How does the nurse explain the possible cause of this change? a. sudden low-frequency hearing loss b. damage to the middle ear from ear infections c. gradual high-frequency hearing loss d. lack of earwax in the outer ear - Answer- C (High-frequency hearing loss, or *presbycusis*, can occur as we age. It involves problems w]usually with discerning certain constant sounds like F, S, T and Z. Vowels are easier to hear for a person with high-frequency loss. Not being able to hear certain letter sounds may make speech sound mumbled. Older adults can become disheartened or frustrated when not being able to make out speech adequately and can become withdrawn. The issue is not related to a low-frequency hearing loss, lack of earwax, or ear infections.) A nurse is assessing a patient who complains of "awful" hip pain after suffering a fracture and rates it as a 9 on a scale of 0 to 10. Which of the following physiologic signs may accompany acute pain? (Select all that apply) a. depression b. tachycardia c. increased blood pressure d. loss of weight and appetite - Answer- CB (Tachycardia and increased bp are associated with the sympathetic nervous system response that occurs in acute pain. Depression and loss of appetite are more associated with chronic pain.) A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the aggravating factors for his symptoms? a. "It is a sharp, burning pain in my stomach." b. "When I sit down to use the computer, it gets worse." c. "I think this pain is telling me that something bad is wrong with me." d. "I also have the sweats and nausea when I feel this pain." - Answer- B (Aggravating factors are things the patient does or that happen to the patient that make the symptom worse or more pronounced. This answer is the only one that was *associated with a symptom.*) A patient drifts off to sleep when she is not being stimulated. The nurse can arouse her easily when calling her name, but she remains drowsy during the conversation. The best description of this patient's level of consciousness would be: a. semialert b. obtunded c. stuporous d. lethargic - Answer- D (When a patient is lethargic, they may be drowsy but awaken easily to stimulation. They can answer questions and follow commands. A patient who is obtunded is difficult to arouse and needs constant stimulation in order to keep them awake. They may answer basic, direct questions. Wen a patient is stuporous, they require vigorous stimulation to arouse and will not be able to answer questions to follow commands. Semialert is not a term used in a mental health assessment.) During shift report, a nurse learns that a patient has a *macular rash*. As the nurse inspects the patient's skin, what finding will confirm the rash? a. elevated, firm, well-defined lesions less than 1 cm in diameter b. depressed, firm, or scaly, rough lesions greater than 1 cm in diameter. c. flat, well-defined, small lesions less than 1 cm in diameter d. elevated fluid-filled lesions less than 1 cm in diameter - Answer- C (A macule is a lesion that is flat, circumscribed, less than 1cm. An elevated lesion would be a *papule*. An elevated, fluid-filled lesion is a vesicle.) When assessing the severity of a patient's pain, which question by the nurse is appropriate? a. "What makes your pain better or worse?" b. "How much pain do you have now?" c. "how does pain limit your activities?" d. "What does your pain feel like?" - Answer- B (In rating the severity of the pain, you want to determine how strong or intense it is. The nurse can ask them how much pain they are having often using some type of rating scale.) When taking a temperature, the nurse understands that which route would yield the highest temperature? a. axillary b. oral c. rectal d. tympanic - Answer- C The nurse is examining a patient who came in for sore throat. The tonsils appear red and swollen and are touching each other. How would the nurse grade the tonsils? a. 1+ b. 2+ c. 3+ d. 4+ - Answer- D A patient's vision is recorded as 20/50 when the Snellen eye chart is used. The nurse interprets these results to indicate that: a. at 50 feet the patient can read the entire chart. b. the patient can read at 20 feet what a person with normal vision can read at 50 feet. c. the patient can read the chart from 20 feet in the left eye and 50 feet in the right eye. d. the patient can read from 50 feet what a person with normal vision can read from 250 feet. - Answer- B In an interview, the nurse may find it necessary to take notes to aid his or her memory later. A competent nurse understands that note-taking: a. allows the nurse to break eye contact with the patient b. may impede the nurse's observation of the patient's nonverbal behaviors. c. allows the patient to continue at his or her own pace as the nurse records everything that is said. d. allows the nurse to shift attention away from the patient, resulting in increased comfort level. - Answer- B The nurse is checking for mobility and turgor in a patient with severe, non-pitting edema. The nurse will most likely note which finding? a. decreased mobility b. increased mobility c. decreased turgor d. increased turgor - Answer- A (Mobility relates to how well you can pinch and lift the skin. In a patient with *severe edema*, it will be difficult to pinch and lift the skin, thus there is decreased mobility. Turgor relates to how well skin goes back into place and decreased turgor would be seen in someone with severe dehydration.) Which of these responses might the nurse expect during a functional assessment of the health history for a patient whose leg is in a cast? a. "I'm able to transfer myself from the wheelchair to the bed without help." b. "I check the color of my toes every evening just like I was taught." c. "The pain is decreasing, but I still need to take acetaminophen." d. "I broke my right leg in a car accident two weeks ago." - Answer- A (Functional assessment has to do with activities of daily living, such as transferring, mobility, bathing, feeding, etc.) With the exception of an abdominal assessment, which is the correct order of assessment techniques for each body system? a. inspection, auscultation, percussion, palpation b. palpation, inspection, percussion, auscultation c. auscultation, inspection, percussion, palpation d. inspection, palpation, percussion, auscultation - Answer- D cranial nerve 1 - Answer- olfactory cranial nerve 2 - Answer- optic cranial nerve 3 - Answer- Oculomotor cranial nerve 4 - Answer- Trochlear cranial nerve 5 - Answer- Trigeminal cranial nerve 6 - Answer- Abducens cranial nerve 7 - Answer- Facial cranial nerve 8 - Answer- Vestibulocochlear (whispered voice test) cranial nerve 9 - Answer- Glossopharyngeal (gag, swallowing) cranial nerve 10 - Answer- vagus (say ahh) cranial nerve 11 - Answer- spinal accessory cranial nerve 12 - Answer- Hypoglossal (stick tongue out) A student nurse is taking public transportation home after clinical. When she sees a friend, she immediately takes a seat next to her and begins a conversation, saying, "You know that older man who lives in the apartment next to you? Well, I took care of him today in the hospital". The student nurse is not respecting which of the following principles? A.Benevolence B.Veracity C.Fidelity D. Confidentiality - Answer- D. confidentiality When recording information for the review of systems, the interviewer must document: A. "negative" under the system heading. B. physical findings, such as skin appearance, to support historic data. C. objective data that supports the history of present illness. D. the presence or absence of all symptoms under the system heading. - Answer- D. the presence or absence of all symptoms under the system heading The nurse is conducting a heath history on an adult client. Which technique can facilitate open communication between the client and the nurse? A. Sit on the stretcher next to the patient. B. Stand about 2 feet away from the patient's stretcher. C. Stand about 12 feet away from the patient's stretcher. D. Sit on a chair that is 4 feet away from the patient's stretcher. - Answer- D. sit on a chair that is 4 feet away from the patient's stretcher Which phase of the interview uses communication techniques to collect health data? A. Beginning phase B. Preinteraction Phase C. Closing phase D. Working phase - Answer- D. Working phase OLDCARTS is a mnemonic that helps the clinician to remember to address characteristics specific to: A. severity of dementia. B. the ability to perform activities of daily living (ADLs). C. substance use and abuse. D. symptoms. - Answer- D. symptoms The most appropriate introduction to use to start an interview with an older adult patient is: A. "Because so many people have already asked you questions, I will just get the information from the chart." B. "Mr. Jones, I am going to ask you some questions about your health so that we can plan your care." C. "David, I am here to ask you questions about your illness; we want to determine what is wrong." D. "Mr. Jones, is it okay if I ask you some quick questions this morning about your health?" - Answer- B. "Mr. Jones, I am going to ask you some questions about your health so that we can plan your care." The nurse is caring for a client who is scheduled for surgery. Which of the following responses from the nurse is appropriate? A. "Tell me how you feel about having surgery." B. "If I were you, I would have the surgery." C. "Why did you wait so long to make an appointment?" D. "That is exactly how I would feel." - Answer- A. "Tell me how you feel about having surgery" A patient seeks care for "debilitating headaches that cause excessive absences at work." On further exploration, the nurse asks, "What makes the headaches worse?" With this question, the nurse is seeking information about: A. the nature or character of the headache. B. relieving (alleviating) factors. C. the patient's perception of pain. D. aggravating factors. - Answer- D. aggravating factors Spirituality is defined as: A. a personal effort to find meaning and purpose in life. B. a social group that claims to possess variable traits. C. the process of being raised within a culture. D. participating in religious services on a regular basis. - Answer- A. personal effort to find meaning and purpose in life What is one way nurses use critical thinking in regard to the nursing process? A. Critical thinking helps nurses decide which parts of the nursing process are not needed in regard to a particular client B. Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions C. Critical thinking allows nurses to make decisions regarding client care without involving the client in decisions. D. Nurses do not need to think critically; they just need to follow orders - Answer- B. Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions To perform an accurate assessment of heart rate, the examiner can do which of the following? Select all that apply A. Count the radial pulse for 30 seconds, if the pulse is regular, and multiply by two. B. If irregular, palpate the radial pulse and count beats for 1 minute. C. Count the radial pulse for 2 full minutes if the pulse is irregular. D. Count the radial pulse for 15 seconds, if the pulse is regular, and multiple by 4. - Answer- A, B The nurse is conducting an exam on a five year-old child. Which finding would require immediate follow up by the nurse? A. Blood pressure 90/58 mmHG B. Heart rate 60 beats per minute C. Axillary temperature of 97.2 F (36.2 C) D. Respiratory rate 24 - Answer- B The nurse knows that elements of the general survey include: A. Patient's level of consciousness, personal hygiene, vital signs, and physical condition. B. Patient's gait, behavior, physical appearance and duration of their of pain. C. Patient's hygiene and dress, speech, posture, and mobility. D. Patient's overall appearance, facial expression, vital signs, and gait. - Answer- C When performing a physical assessment, the technique the nurse will always use first is: A. palpation B. inspection C. auscultation D. percussion - Answer- B When working with a patient in acute pain, the nurse knows that the most reliable indicator of pain is: A. Patient self-report B. Magnetic resonance imaging (MRI) results C. Tissue enzyme levels D. Blood drug levels - Answer- A The nurse knows that the first Korotkoff sound when taking a patient's blood pressure indicates: A. Diastolic pressure B. Systolic pressure C. Brachial pressure D. Cuff malfunction - Answer- B When conducting a respiratory assessment with an adult patient, which of the following would the nurse consider as a normal respiratory rate range? A. 12-20 B. 18-30 C. 24-40 D. 30-60 - Answer- A When examining a patient, the nurse remembers to follow which principle of Standard Precautions? A. Wear gloves when in contact with patient's mucous membranes B. Wear gloves throughout the entire examination of patients C. Wear eye protection and gown during the examination of the patient D. Wear gloves to reduce the need for handwashing - Answer- A The dorsa of the hands are used to determine: A. temperature B. texture C. an organ's location D. vibration - Answer- A A common error in blood pressure measurement includes: A. taking the blood pressure in an arm that is at the level of the heart. B. deflating the cuff about 2 mm Hg per heart beat. C. waiting less than 15 seconds before repeating the reading on the same arm. D. palpating the brachial artery before placing the blood pressure cuff. - Answer- C When taking the health history, the patient complains of pruritus. What is a common cause of this symptom? A. Cancer B. Allergic response C. Excessive bruising D. Hyperpigmentation - Answer- B What term refers to a linear skin lesion that runs along a nerve route? A. Dermatome B. Zosteriform C. Shingles D. Annular - Answer- B The components of a nail examination include: A. contour, consistency, and color. B. clubbing, pitting, and grooving. C. shape, surface, and circulation. D. texture, toughness, and translucency. - Answer- A The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor? A. Increased vascularity of the skin in the elderly B. Increased numbers of sweat and sebaceous glands in the elderly C. An increase in elasticity and an increase in subcutaneous fat in the elderly D. An increased loss of elasticity and a decrease in subcutaneous fat in the elderly - Answer- D A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse would pay special attention to the danger signs for pigmented lesions and would be concerned with which additional finding? A. Diameter less than 6 mm B. Color variation C. Border regularity D. Symmetry of lesions - Answer- B 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. nodule. B. bulla. C. papule. D. wheal. - Answer- C The nurse has discovered decreased skin turgor in a patient and knows that this is an expected finding in which of these conditions? A. Connective tissue disorders such as scleroderma B. Severe obesity C. Childhood growth spurts D. Severe dehydration - Answer- D The nurse is assessing for clubbing of the fingernails and would expect to find: A. a nail base that is firm and slightly tender. B. curved nails with a convex profile and ridges across the nail. C. a nail base that feels spongy with an angle of the nail base of 150 degrees. D. an angle of the nail base of 180 degrees or greater with a nail base that feels spongy. - Answer- D While inspecting the skin, a nurse notices a lesion on the patient's upper right arm. What is the best way to document the size of this lesion? A. Compare its size to the size of a coin. B. Estimate its size to the nearest inch. C. Use a centimeter ruler to measure the lesion. D. Trace the lesion onto a piece of paper. - Answer- C A nurse is performing an admission physical examination on a patient who has been bedridden for a month. The nurse notices a pressure injury on the patient's left trochanter area that involves partial-thickness skin loss with no damage to the subcutaneous tissue. The nurse reports this pressure injury at what stage? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 - Answer- B Most facial bones articulate at a suture. Which facial bone articulates at a joint? A. Nasal bone B. Maxilla C. Zygomatic bone D. Mandible - Answer- D The nurse is assessing a patient's visual acuity. Which of the following statements is true in regard to the patient's results obtained from use of the Snellen chart? A. The smaller the denominator, the poorer the vision. B. The larger the denominator, the poorer the vision. C. The larger the numerator, the better the vision. D. The smaller the numerator, the poorer the vision. - Answer- B The nurse is assessing a patient's extra ocular muscles. Which of the following is most important for the nurse to remember about extra ocular movements? A. Stimulated by cranial nerves I and II. B. Decreased in the elderly. C. Stimulated by cranial nerves III, IV, and VI. D. Impaired in a patient with cataracts. - Answer- C The nurse is testing a patient's visual accommodation, which refers to which action? A. Changes in peripheral vision in response to light B. Pupillary dilation when looking at a near object C. Involuntary blinking in the presence of bright light D. Pupillary constriction when looking at a near object - Answer- D When assessing the pupillary light reflex, the nurse should use which technique? A. Shine a penlight from directly in front of the patient and inspect for pupillary constriction. B. Ask the patient to follow the penlight in eight directions and observe for bilateral pupil constriction. C. Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction. D. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to about 7 cm from the nose. - Answer- C During symptom analysis, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates vertigo? A. "I was afraid that I was going to lose consciousness." B. "I felt faint, like I was going to pass out." C. "I just could not keep my balance when I sat up." D. "It seemed that the room was spinning around." - Answer- D Which of the following behaviors demonstrated by an individual may be indicative ofhearing loss? A. Speaking slowly with well-articulated consonants B. Not looking at the examiner when being questioned C. Talking in a high-pitched voice D. Frequently asking for the question to be repeated - Answer- D The external structure of the ear is identified as the: A. aureole. B. auriga. C. atrium. D. auricle. - Answer- D Which test provides a precise quantitative measure of hearing? A. Whispered voice test B. Tuning fork tests C. Audioscope test D. Romberg test - Answer- C In performing a voice test to assess hearing, which of these actions would the nurse do? (SELECT ALL THAT APPLY) A. Ensure that the patient cannot see his/her lips. B. Whisper a set of random numbers and letters and ask the patient to repeat them. C. Stand about 4 feet away to ensure that the patient can really hear at this distance. D. Stand to the side of the patient. - Answer- A,C When assessing a patient's lungs, the nurse recalls that the left lung: A. is divided by the horizontal fissure. B. consists primarily of an upper lobe on the posterior chest. C. consists of two lobes. D. is shorter than the right lung because of the underlying stomach. - Answer- C The student nurse is reviewing the pathophysiology of inspiration and understands that the primary muscles of inspiration are the diaphragm and the ____________. A. pectoral muscles B. intercostal muscles C. abdominal muscles D. scalene muscles - Answer- B What are the functions of the upper airways? (SELECT ALL THAT APPLY) A. Conduct air to lower airway B. Provide area for gas exchange C. Prevent foreign matter from entering respiratory system D. Warm, humidify, and filter air entering lungs E. Provide transportation of oxygen and carbon dioxide between alveoli and cells - Answer- A,C,D A patient tells the nurse that she has smoked two packs of cigarettes a day for 20 years. The nurse records this as how many pack-years? A. 10 B. 20 C. 40 D. 60 - Answer- C Stridor is a high-pitched, inspiratory crowing sound commonly associated with: A. atelectasis. B. upper airway obstruction. C. congestive heart failure. D. pneumothorax. - Answer- B The nurse is comparing pitch and duration of the various types of a patient's breath sounds and recognizes which one of these as an expected finding? A. Bronchial sounds are low-pitched and have a 2:1 inspiratory-versus-expiratory ratio. B. Bronchovesicular sounds have a moderate pitch and 1:1 expiratory-versus-inspiratory ratio. C. Vesicular breath sounds are high-pitched and have a 1:2 inspiratory-versus-expiratory ratio. D. Wheezes are low-pitched and have a 2.5:1 inspiratory-versus-expiratory ratio. - Answer- B Where does a nurse expect to hear bronchovesicular lung sounds in a healthy adult? A. Near the sternal border B. Over the trachea C. In the apices of the lungs D. In the lower lobes - Answer- A A nurse hears inspiratory and expiratory wheezes bilaterally. What is the meaning of this finding? A. Sputum in the bronchi B. Fluid in the alveoli C. Narrowed airways