HEALTH ASSESSMENT & PHYSICAL EXAMINATION CORRECT QUESTION AND ANSWERS 100%

A patient has undergone surgery for a femoral artery bypass. The surgeon's orders include assessment of dorsalis pedis pulses. The nurse will use which of the following techniques to assess the pulses? (Select all that apply.) A. Place the fingers behind and below the medial malleolus. B. Have the patient slightly flex the knee with the foot resting on the bed. C. Have the patient relax the foot while lying supine. D. Palpate the groove lateral to the flexor tendon of the wrist. E. Palpate along the top of the foot in a line with the groove between extensor tendons of great and first toes. - ANSWERS-C, E To palpate the dorsalis pedis pulses (located in the feet), ask the patient to relax the foot, and then palpate along the top of the foot in a line with the groove between the extensor tendons of the toe of the great and first toes. Placing fingers behind the medial malleolus is a technique for assessing the posterior tibial pulse. Having a patient slightly flex the knee is a technique for assessing the popliteal artery behind the knee. Palpation of the groove lateral to the flexor tendon of the wrist is the technique to assess the radial artery. .As a nurse prepares to provide morning care and treatments, it is important to question a patient about a latex allergy before which intervention? (Select all that apply.) a) Applying adhesive tape to anchor a nasogastric tube b)vInserting a rubber Foley catheter into the patient's bladder c) Providing oral hygiene using a standard toothbrush and toothpaste d) Giving an injection using plastic syringes with rubbercoated plungers e) Applying a transparent wound dressing - ANSWERS-a) Applying adhesive tape to anchor a nasogastric tube b) Inserting a rubber Foley catheter into the patient's bladder d) Giving an injection using plastic syringes with rubbercoated plungers Adhesive tape, rubber foley catheters, and rubber-coated plungers should be avoided for patients with latex allergies since they can trigger an allergic or anaphylactic response. .Cranial nerve that controls downward, inward eye movements - ANSWERS-IV trochlear .Cranial nerve that controls lateral movement of the eyeballs - ANSWERS-VI Adducens .Cranial nerve that controls Motor innervation to the muscles of the jaw - ANSWERS-V. Trigeminal .Cranial nerve that controls position of the tongue - ANSWERS-XII hypoglossal .Cranial nerve that controls sensation of the pharynx - ANSWERS-X vagus .During assessment of the skin, the nurse assesses a lesion on the arm of the patient. The lesion is irregularly shaped, elevated with edema, and about 3 cm. What type of lesion does the patient have? A. Nodule B. Macule C. Wheal D Pustule - ANSWERS-C. wheal A wheal is an irregularly shaped, elevated area or superficial localized edema. A wheal varies in size (e.g., hive, mosquito bite). A 1-cm firm, solid mass describes a nodule. A flat, brown area measuring 0.5 cm is a macule. A pus-filled circumscribed elevation of the skin is a pustule. .How should the patient be positioned to best palpate for lumps or tumors during an examination of the right breast? A. Supine with both arms overhead with palms upward B. Sitting with hands clasped just above the umbilicus C. Supine with the right arm abducted and hand under the head and neck D. Lying on the right side, adducting the right arm on the side of the body - ANSWERS-C. supine with the r arm abducted and hand under the head and neck .scale rating for the strength of a pulse - ANSWERS-0: absent, not palpable 1+: pulse diminished, barely palpable 2+: expected/normal 3+: full pulse, increased 4+: bounding pulse .The faith community nurse is teaching the community center women's group about breast cancer risk factors. Which factors does the nurse include? (Select all that apply.) A. First child at the age of 26 years B. Menopause onset at the age of 49 years C. Family history with BRCA1 inherited gene mutation D. Age over 40 years - ANSWERS-ALL .The nurse is assessing a patient who returned 1 hour ago from surgery for an abdominal hysterectomy. Which assessment finding would require immediate follow-up? A. Auscultation of an apical heart rate of 76 B. Absence of bowel sounds on abdominal assessment C. Respiratory rate of 8 breaths/min D. Palpation of dorsalis pedis pulses with strength of +2 - ANSWERS-C. RR of 8 breath/min In healthy adults the normal respiratory rates vary from 12 to 20 respirations per minute. A rate of 8 breaths/min is too low and could be caused by anesthesia or opioid sedation effects. .The nurse is assessing a patient who returned 3 hours ago from a cardiac catheterization, during which the large catheter was inserted into the patient's femoral artery in the right groin. Which assessment finding would require immediate follow-up? a) Palpation of a femoral pulse with a heart rate of 76 b) Auscultation of a heart murmur over the left thorax c) Identification of mild bruising at the catheter insertion site d) Palpation of a right dorsalis pedis pulse with strength of +1 - ANSWERS-d) Palpation of a right dorsalis pedis pulse with strength of +1 A weak pulse may indicate disruption of arterial flow and should be reported immediately. Mild bruising is normal, but if it increases in size, the femoral artery may be leaking, requiring further follow-up with the health care provider. Other findings are within normal limits and do not require notification. .The nurse is observing the student nurse perform a respiratory assessment on a patient. Which action by the student nurse requires the nurse to intervene? A. The student stands at a midline position behind the patient observing for position of the spine and scapula. B. The student palpates the thoracic muscles for masses, pulsations, or abnormal movements. C. The student places the bell of the stethoscope on the anterior chest wall to auscultate breath sounds. D. The student places the palm of the hand over the intercostal spaces and asks the patient to say "ninety-nine." - ANSWERS-C. the student places the bell of the stethoscope on the anterior chest wall to auscultate breath sounds Breath sounds should be auscultated using the diaphragm of the stethoscope. Auscultate in a systematic pattern over the posterior and anterior chest wall. .The nurse is performing an abdominal assessment on a patient. In what order does the nurse perform the steps? 1. Percussion 2. Inspection 3. Auscultation 4. Palpation A. 4, 2, 3, 1 B. 1, 2, 3, 4 C. 3, 2, 4, 1 D. 2, 3, 4, 1 - ANSWERS-D. 2, 3, 4, 1 The order of an abdominal examination differs slightly from previous assessments. Begin with inspection and follow with auscultation. By using auscultation before palpation there is less chance of altering the frequency and character of bowel sounds. .The nurse is planning a staff education conference about abdominal assessment. Which point is important for the nurse to include? a) The aorta can be felt using deep palpation in the upper abdomen near the midline. b) The patient should be sitting to best determine the contour and shape of the abdomen. c) Always wear gloves when palpating the skin on the patient's abdomen. d) Avoid palpating the abdomen if the patient reports any discomfort or feelings of fullness. - ANSWERS-a) The aorta can be felt using deep palpation in the upper abdomen near the midline. Complete abdominal assessment includes inspection, followed by auscultation, palpation, and percussion (if warranted). Anatomically the aorta is located in the upper abdomen and can be palpated on an average-sized patient. The assessment should be performed when the patient is supine so all assessment techniques can be included. Unless there is an open wound or other abdominal drainage, the aorta should be palpated without gloves to be able to assess skin texture, temperature, and any unusual pulsations. Palpation should be performed routinely, but leave areas of discomfort or pain until last. .The nurse is planning to teach the student nurse how to assess the hydration status of an older adult. Which techniques are appropriate for this situation? (Select all that apply.) a) Inspect the lips and mucous membranes to determine if they are moist. b) Pinch the skin on the back of the hand to see if the skin tents. c) Check the patient's pulse and blood pressure. d) Weigh the patient daily. - ANSWERS-a) Inspect the lips and mucous membranes to determine if they are moist. c) Check the patient's pulse and blood pressure. d) Weigh the patient daily. By assessing for moisture of the mucous membranes and lips, the nurse can quickly evaluate the patient’s hydration status. Weighing a patient shows increases of fluid volume from day to day that could result from cardiac problems. This provides useful information about fluid status over time. Blood pressure can indicate fluid status, but be aware it also can be related to other diseases. Skin on older individuals loses its elasticity, and assessing skin on the dorsum of the hand provides inaccurate data regarding skin turgor. .The nurse is teaching a patient how to perform a testicular self-examination. Which statement made by the patient indicates a need for further teaching? A. "I'll recognize abnormal lumps because they are very painful." B. "I'll start performing testicular self-examination monthly after I turn 15." Incorrect C. "I'll perform the self-examination in front of a mirror." D. "I'll gently roll the testicle between my fingers." - ANSWERS-A. ill recognize abnormal lumps because they're very painful The examination should be performed monthly in all men 15 years of age and older. Feel for small, pea-size lumps on the front and side of the testicle. Abnormal lumps are usually painless. .The nurse is teaching a patient to prevent heart disease. Which information should the nurse include? (Select all that apply.) A. Limit intake of cholesterol to less than 400 mg/day. Incorrect B. Talk with your health care provider about taking a daily low dose of aspirin. C. Work with your health care provider to develop a regular exercise program. D. Limit daily intake of fats to less than 25% to 35% of total calories. E. Review strategies to encourage the patient to quit smoking - ANSWERS-B, C, D, E Teaching about prevention of heart disease focuses on risk factor reduction. Smoking, lack of regular aerobic exercise, and a diet high in fats (which contributes to higher cholesterol levels) are three major risk factors that can be modified. Quitting smoking, regular exercise, and a diet with lower fat intake are preventive measures. Low-dose aspirin has been shown to be beneficial in reducing the risk of heart disease .The nurse is teaching a patient with poor arterial circulation about checking blood flow in the legs. Which information should the nurse include? (Select all that apply.) a) A normal pulse on the top of the foot indicates adequate blood flow to the foot. b) To locate the dorsalis pedis pulse, take the fingers and palpate behind the knee c) When there is poor arterial blood flow, the leg is generally warm to the touch. d) Loss of hair on the lower leg indicates a long-term problem with arterial blood flow. - ANSWERS-a) normal pulse on the top of the foot indicates adequate blood flow to the foot. d) Loss of hair on the lower leg indicates a long-term problem with arterial blood flow. A normal dorsalis pedis indicates good arterial blood flow to the lower extremities. Chronic loss of arterial flow results in a lack of hair growth and the appearance of shiny tissue. The dorsalis pedis is located along the top of the foot between the great toe and first toe. When there is poor arterial flow, the skin will be cool. .The nurse is teaching a young female patient to practice good skin health. Which information is important for the nurse to include? a) Avoid sunbathing between 3 PM and 7 PM. b)Oral contraceptives and antiinflammatories make the skin more sensitive to the sun. c) Call the health care provider for the presence of a mole on an arm or leg that appears uniformly brown. d) Wear sunscreen with an SPF of 30 or greater if using a sunlamp or tanning parlor. - ANSWERS-b) Oral contraceptives and antiinflammatories make the skin more sensitive to the sun. Some medications such as oral contraceptives or antiinflammatory medications may increase the skin's sensitivity to ultraviolet (UV) rays. Skin self-care and self-evaluation practices include avoiding the sun when UV rays are strongest (10 AM to 4 PM). In addition, good skin practices indicate that skin protection should be used when using a tanning bed or sunlamp. Moles that are uniformly brown are not a cause of concern. .The nurse is teaching a young mother to palpate her 8-year-old child to quickly evaluate if the child has a fever. Which information is important for the nurse to include? a) Place the palm of the hand on the child's back. b) Lightly touch the child's forehead with the fingertips. c) Place the back of your hand against the child's forehead and then on the back of the neck. d) Use the pads of your fingers and press against the child's neck and over the thorax. - ANSWERS-c) Place the back of your hand against the child's forehead and then on the back of the neck. Temperature is best evaluated by palpating the skin with the dorsum or back of the hand. It is best to select two areas to compare to allow you to detect a change in body surface temperature. .The nurse plans to assess the patient's memory. Which task should the nurse ask the patient to perform? A. "Tell me where you are." B. "What can you tell me about your illness?" C. "Repeat these numbers back to me: 7...5...8." D. "What does this mean: 'A stitch in time saves nine?'" - ANSWERS-C. repeat these numbers back to me... .The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship? A. Appearance and behavior B. Measurement of vital signs C. Observing specific body systems D. Conducting a detailed health history - ANSWERS-A. appearance/behavior The first part of the general survey is assessment of the appearance and behavior of the patient. As you are initiating the nurse-patient relationship, observe gender and race, age, signs of distress, body type, posture, gait, body movement, hygiene and grooming, dress, affect and mood, speech, and signs of patient abuse. .The nurse teaches a patient about cranial nerves to help explain why the patient's right side of the mouth droops instead of moving up into a smile. What nerve does the nurse explain to the patient? a) VII — Facial b) V — Trigeminal c) XII — Hypoglossal d) XI— Spinal accessory - ANSWERS-a) VII — Facial The facial nerve innervates the sensory and motor functions of the face above the brow, the cheeks, and the chin and controls face symmetry and smile.