Health Assessment Jarvis Final Updated & Combined 2022 (Answered)

Health Assessment Jarvis Final Updated & Combined 2022 (Answered) 1. A hospitalized patient does not require a full neurologic examination during every shift assessment. What is a method of assessing the neurologic status of a patient without performing a full neurological examination? a. Palpate the carotid pulse. b. Offer the patient a glass of water. c. Look at the significant other throughout the examination. d. Assign the nursing assistant to ask the patient questions and report the findings. b A physician tells the nurse that a patient's vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is: a.Just above the diaphragm. b.Just lateral to the knee cap. c.At the level of the C7 vertebra. d.At the level of the T11 vertebra. C The C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable when the head is flexed. 1. The nurse is assessing an older adult's functional ability. Which definition correctly describes one's functional ability? a. It denotes an older person's cognitive level. b. It is the measure of the expected changes of aging that one is experiencing. c. It describes the individual's motivation to live independently. d. It refers to one's ability to perform activities necessary to live in modern society. d After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be: a. Objective. b. Reflective. c. Subjective. d. Introspective. A The nurse is reviewing the development of culture. Which statement is correct regarding the development of one's culture? Culture is: a. Genetically determined on the basis of racial background. b. Learned through language acquisition and socialization. c. A nonspecific phenomenon and is adaptive but unnecessary. d. Biologically determined on the basis of physical characteristics. B The nurse is conducting an interview with a woman who has recently learned that she is pregnant and has come to the clinic today to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs loudly. Considering the concept of communication, the nurse knows that which statement is most accurate? The woman: 1. is excited about her pregnancy but nervous about labor. 2. is exhibiting verbal and nonverbal behavior that does not match. 3. is excited about her pregnancy but her husband is not and this is upsetting to her. 4. is not excited about her pregnancy but believes the nurse will respond negatively to her if she states this. ANS: 2 Communication is all behavior, conscious and unconscious, verbal and nonverbal. All behavior has meaning. The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history? a.To provide an opportunity for interaction between the patient and the nurse b.To provide a form for obtaining the patient's biographic information c.To document the normal and abnormal findings of a physical assessment d.To provide a database of subjective information about the patient's past and current health D During an examination, the nurse can assess mental status by which activity? a. Examining the patients electroencephalogram b. Observing the patient as he or she performs an intelligence quotient (IQ) test c. Observing the patient and inferring health or dysfunction d. Examining the patients response to a specific set of questions C 1. A woman has come to the clinic to seek help with a substance abuse problem. She admits to using cocaine just before arriving. Which of these assessment findings would the nurse expect to find when examining this woman? a. Dilated pupils, pacing, and psychomotor agitation b. Dilated pupils, unsteady gait, and aggressiveness c. Pupil constriction, lethargy, apathy, and dysphoria d. Constricted pupils, euphoria, and decreased temperature ANS: A A cocaine users appearance includes pupillary dilation, tachycardia or bradycardia, elevated or lowered blood pressure, sweating, chills, nausea, vomiting, and weight loss. The persons behavior includes euphoria, talkativeness, hypervigilance, pacing, psychomotor agitation, impaired social or occupational functioning, fighting, grandiosity, and visual or tactile hallucinations. When performing a physical assessment, the first technique the nurse will always use is: a. Palpation. b. Inspection. c. Percussion. d. Auscultation. B The nurse is performing a general survey. Which action is a component of the general survey? A) Observing the patient's body stature and nutritional status B) Interpreting the subjective information the patient has reported C) Measuring the patient's temperature, pulse, respirations, and blood pressure D) Observing specific body systems while performing the physical assessment A Which of these statements is true regarding the vertebra prominens? The vertebra prominens is: the spinous process of C7 1. At the beginning of rounds, when the nurse enters the room, what should the nurse do first? A. Check the intravenous infusion site for swelling or redness. B. Check the infusion pump settings for accuracy. C. Make eye contact with the patient and introduce himself or herself as the patient's nurse. D. Offer the patient something to drink ANS: C As a mandatory reporter of elder abuse, which of these must be present before a nurse notifies the authorities? ANS: Suspicion of elder abuse and/or neglect Many health care workers are under the erroneous assumption that proof is required before notification of suspected abuse can occur. Only a suspicion of elder abuse or neglect is necessary. The sac that surrounds and protects the heart is called the: a. Pericardium. b. Myocardium. c. Endocardium. d. Pleural space. ANS: pericardium. The pericardium is a tough fibrous double-walled sac that surrounds and protects the heart. It has two layers that contain a few milliliters of serous pericardial fluid. The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the: a. Auricle. b. Concha. c. Outer meatus. d. Mastoid process. A. auricle The external ear is called the auricle or pinna and consists of movable cartilage and skin. The nurse recognizes which of these persons is at greatest risk for undernutrition? a. 5-month-old infant b. 50-year-old woman c. 20-year-old college student d. 30-year-old hospital administrator A Which of these statements about the anal canal is true? The anal canal: A) is about 2 cm long in the adult. B) slants backward toward the sacrum. C) contains hair and sebaceous glands. D) is the outlet for the gastrointestinal tract. ANS: D The anal canal is the outlet for the gastrointestinal tract, and it is about 3.8 cm long in the adult. It is lined with a modified skin that does not contain hair or sebaceous glands, and it slants forward toward the umbilicus. During a health history, a 22-year old woman asks, "Can I get that vaccine for HPV? I have genital warts and I'd like them to go away!" What is the nurse's best response? A) "The HPV vaccine is for girls and women ages 9 to 26, so we can start that today." B) "This vaccine is only for girls who have not started to have intercourse yet." C) "Let's check with the physician to see if you are a candidate for this vaccine." D) "The vaccine cannot protect you if you already have an HPV infection." ANS: D The HPV (human papillomavirus) vaccine is appropriate for girls and women age 9 to 26 and is given to prevent cervical cancer by preventing HPV infections before girls become sexually active. However, it cannot protect the woman if an HPV infection is already present. Statement by the patient would indicate a need for further teaching? A. "The best time to check my breasts is a week before my cycle." B. "I will check my breasts in the shower one week after my cycle." C. "I will exam my breast in a clock-like sequence so that I don't miss any surface area." D. "I will be sure to check my arm pits." A The week before a woman's cycle is not the best time to check for lumps because the breasts become sore and tender and may also be "lumpy" a week prior to the cycle. Answer 2 is incorrect because the week after a woman's cycle is the best time to do the examination, and the shower allows for ease of palpation. Answer 3 in incorrect because a clock-like sequence is the proper way to perform a BSE. Answer 4 is incorrect because under the arms houses lymph nodes and the axillary tail of Spence, which is a common site for breast cancer. When examining the eye, the nurse notices that the patient's eyelid margins approximate completely. The nurse recognizes that this assessment finding: a. Is expected. b. May indicate a problem with extraocular muscles. c. May result in problems with tearing. d. Indicates increased intraocular pressure. A is expected The palpebral fissure is the elliptical open space between the eyelids, and, when closed, the lid margins approximate completely, which is a normal finding. The external male genital structures include the: ANS: scrotum. The external male genital structures include the penis and scrotum. The testis, epididymis, and vas deferens are internal structures. The primary purpose of the ciliated mucous membrane in the nose is to: a.Warm the inhaled air. b.Filter out dust and bacteria. c.Filter coarse particles from inhaled air. d.Facilitate the movement of air through the nares. B. filter out dust and bacteria Because hair for humans is no longer needed for protection from cold or trauma, it is called: vestigial. Hair is vestigial for humans. It no longer is needed for protection from cold or trauma. The two parts of the nervous system are the: a. Motor and sensory. b. Central and peripheral. c. Peripheral and autonomic. d. Hypothalamus and cerebral. B A patient is being assessed for range of joint movement, The nurse asks him to move his arm in toward the center of his body. This movement is called: Adduction 1. The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? A) Dullness B) Tympany