NUR 2065 PHYSICAL ASSESSMENT FINAL EXAM REVIEW:

NUR 2065 PHYSICAL ASSESSMENT FINAL EXAM REVIEW: 1. During an interview the nurse states, “you mentioned shortness of breath, tell me more about that”. Which verbal skill is used with this statement? • OPEN-ENDED QUESTIONS 2. Receiving is a part of the communication process. Which receiver is most likely to misinterpret a message sent by a health care professional? • A MAN WHOSE WIFE HAS JUST BEEN DIAGONSED WITH LUNG CANCER. 3. The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history? • TO PROVIDE A DATABASE OF SUBJECTIVE INFORMATIONABOUT THE PATIENT’S PAST AND CURRENTL HEALTH 4. The nurse is taking a family history. Important diseases or problems to ask the patient about specifically include: • MENTAL ILLNESS 5. During an assessment, the nurse uses the CAGE test. The patient answers “yes” to two of the questions. What could this be indicating? • THE NURSE SHOULD SUSPECT ALCOHOL ABUSE AND CONTINUE WITH A MORE THOROUGH SUBSTANCE ABUSE ASSESSMENT. 6. A patient has been in the intensive care unit for 10 days. He has just been moved to the medical- surgical unit, and the admitting nurse is planning to perform a mental status examination. During the tests of cognitive function, the nurse would expect that he: • WILL BE ORIENDTED TO PLACE AND PERSON, BUT THAT PATIENT MAY NOT BE CERTAIN OF THE DATE. 7. A 20-year-old construction worker has been brought into the emergency ... He has delirium as a result of a fluid and electrolyte imbalance. For the mental status examination, the nurse should first assess the patient's: • LEVEL OF CONSCIOUSNESS AND COGNITIVE ABILITIES 8. The nurse is assessing a patient who is admitted with possible delirium. Which of these are manifestations of delirium? Select all that apply. • DEVELOPS OVER A SHORT PERIOD • PERSON IS EXHIBITING MEMORY IMPAIRMENT OF DEFICITS • OCCURS AS A RESULT OF A MEDICAL CONDITION, SUCH AS SYSTEMATIC INFECTION 9. The nurse is administering a Mini-Cog test to an older adult woman. When asked to draw a clock showing the time of 10:45, the patient drew a clock with the numbers out of order and with an incorrect time. This result indicates which finding? • COGNITIVE IMPAIRMENT 10. The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient: • MAY TAKE A LITTLE LONGER TO RESPOND, BUT HIS GENERAL KNOWLEDGE AND ABILITIES SHOULD NOT HAVE DECLINED. 11. The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination? • GATHERING MENTAL STATUS INFORMATION DURING THE HEALTH HISTORY INTERVIEW IS USUALLY SUFFICIENT. 12. A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse's best course of action? • PERFORM A COMPLETE MENTAL STATUS EXAMINATION. 13. A woman who has just discovered that she is pregnant is in the clinic for her first obstetric visit. She asks the nurse, "How many drinks a day is safe for my baby?" The nurse's best response is: • “NO AMOUNT OF ALCOHOL HAS BEEN DETERMINED TO BE SAFE DURING PREGNANCY.” 14. The nurse is aware that intimate partner violence (IPV) screening should occur with which situation? • AS A ROUTINE PART OF EACH HEALTH CARE ENCOUNTER 15. Which term refers to a wound produced by the tearing or splitting of body tissue, usually from blunt impact over a bony surface? • LACERATION 16. A female patient has denied any abuse when answering the Abuse Assessment Screen, but the nurse noticed some other conditions that are associated with IPV. Examples of such conditions include: • DEPRESSION 17. When performing a physical assessment, the first technique the nurse will always use is: • INSPECTION 18. When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination? • HANDS ARE WASHED BEFORE AND AFTER EVERY PHYSICAL PATIENT ENCOUNTER 19. The nurse is providing instructions to newly hired graduates for the Mini-Mental State Examination (MMSE). Which statement best describes this examination? • THIS EXAMINATION IS A GOOD TOOL TO DETECT DELIRIUM AND DEMENTIA AND TO DIFFERENTITATE THESE FROM PSYCHIATRIC MENTAL ILLNESS. 20. When assessing a 75-year-old patient who has asthma, the nurse notes that he assumes a tripod position, leaning forward with arms braced on the chair. On the basis of this observation, the nurse should: • RECONGIZE THAT A TRIPOD POSTION IS OFTEN USED WHEN A PATIENT IS HAVING RESPIRATORY DIFFICULITIES. 21. A 75-year-old man has a history of hypertension and was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate his blood pressure? • ASSESS BLOOD PRESSURE AND PULSE IN THE SUPINE, SITTING, AND STANDING POSITIONS. 22. The nurse has collected the following information on a patient: palpated blood pressure– 180 mm Hg; auscultated blood pressure–170/100 mm Hg; apical pulse–60 beats per minute; radial pulse–70 beats per minute. How should the nurse record this patient's blood pressure? • 70 23. A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings? • THE CHANGE IN BLOOD PRESSURE READINGS IS CALLED ORTHOSTATIC HYPOTENSION 24. The patient has an order to be off the floor for 15 minutes to smoke a cigarette. The patient has just returned from his "cigarette break." The nurse is about to take the patient's temperature orally and should? • WAIT ABOUT 15 MINUTES BEFORE TAKING HIS TEMPERTURE 25. Which of these individuals would the nurse consider at highest risk for a suicide attempt? • OLDER ADULT MAN WHO TELLS THE NURSE THAT HE S GOING TO “JOIN HIS WIFE IN HEAVEN TOMORROW” AND PLANS TO USE A GUN 26. The direction of blood flow through the heart is best described by which of these? • RIGHT ATRIUM, RIGHT VENTRICLE, PULMONARY ARTERY, LUNGS, PULMONARY VEIN, LEFT ATRIUM, LEFT VENTRICLE. 27. Which of the following examples would be a hallucination? • A MAN BELIEVES THAT HIS DEAD WIFE IS TALKING TO HIM 28. The nurse is preparing to assess a patient’s abdomen by palpation. How should the nurse proceed? • THE ASSESSMENT BEGINS WITH LIGHT PALPATION TO DETECT SURFACE CHARACTERISTICS AND TO ACCUSTOM THE PATIENT TO BEING TOUCHED. 29. The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope: • DIRECTS LIGHT INTO THE EAR CANAL AND ONTO THE TYMPANIC MEMBRANE 30. TO HEAR FOR MURMURS? USE THE BELL 31. A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which of the following? • CLUBBING OF THE NAILS 32. While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices that presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in color. No increased redness or tenderness is observed over his lower legs, and peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely Cause of edema is which condition? • HEART FAILURE 33. Which of these statements concerning areas of the brain is true? • THE HYPOTHALAMUS CONTROLS TEMPERATURE AND REGULATES SLEEP. 34. During an assessment of an 80-year-old patient, the nurse notices the following: inability to identify vibrations at the ankle and to identify position of big toe, slower and more deliberate gait, and slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate? • NORMAL CHANGES DUE TO AGING. 35. A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination? • COMPLETE NEUROLOGIC EXAMINATION