NURS3320 Assessment Final Review Questions With
Complete Solutions
Arterial ulcers Correct Answers Ulcers associated with arterial
disease are usually painful and are often located on the toes,
foot, or lateral ankle.
Assessing urinary incontinence. Correct Answers The nursing
assessment varies somewhat depending on the client's general
health status and whether the problem is an acute or chronic one.
In general, however, a comprehensive nursing assessment can be
described as a five-step process that includes screening for an
infection with urinalysis, obtaining a voiding diary, evaluating
functional status, compiling a health history, and performing a
physical examination. Key features within the five steps follow:
-Record all incontinent and continent episodes for 3 days in a
voiding diary.
-Review medication for any newly prescribed drugs that may be
triggering incontinence. Follow up with physician regarding
need to discontinue therapy or change medication.
-Rule out constipation or fecal impaction as a source of urinary
incontinence. If client has had no bowel movement within last 3
days or is oozing stool continuously, check for impaction by
digital examination or abdominal palpation. Problem should be
treated if identified.
-Assess functional status along with signs and symptoms as they
relate to incontinence. Contributors to incontinence may include
immobility, insufficient fluid intake, and confusion.
Accompanying signs and symptoms include polyuria, nocturia,
,dysuria, hesitancy, poor or interrupted urine stream, straining,
suprapubic or perineal pain, urgency and characteristics of
incontinent episodes (precipitated by walking, coughing, getting
in and out of bed, and so forth).
-Consult physician regarding physical examination and need to
measure postvoid residual volume by straight catheterization
(particularly if client dribbles, reports urgency, has difficulty
starting stream). Components of the physical examination
include direct observation of urine loss using a cough stress test;
abdominal, rectal, genital, and pelvic examination; and
identification of neurolo
Breath odor associated with diabetic ketoacidosis. Correct
Answers Fruity or acetone breath
Breath odor associated with kidney disease Correct Answers
Ammonia breath
Buddhism Correct Answers Suffering is a part of human
existence
Prayer and meditation are used for cleansing and healing.
Terminal illness may be seen as a unique opportunity to reflect
on life's ultimate meaning and the meaning of one's relation with
the world.
Death is associated with rebirth. Serene surroundings are
important to the dignity of dying.
Many are strict vegetarians. Some holy days include fasting
from dawn to dusk.
,Christianity Correct Answers Beliefs focus around the Old and
New Testaments of the Bible and view Jesus Christ as the
Savior. Prayers may be directed to one or all of the Holy Trinity
(God, Holy Spirit, and Jesus Christ).
Most view illness as a natural process for the body and even as a
testing of faith.
There is belief in miracles, especially through prayer.
Western medicine is usually held in high regard.
Memorial services rather than funerals and cremation rather than
burial are more common in Christian religions than in other
sects.
No special or universal food beliefs are common to Christian
religions.
CN I Correct Answers Olfactory; Sensory
-Ask the client to clear the nose to remove any mucus, then to
close eyes, occlude one nostril, and identify a scented object that
you are holding such as soap, coffee, or vanilla. Repeat
procedure for the other nostril.
CN II Correct Answers Optic; Sensory
-Use a Snellen chart to assess far vision in each eye. Have client
stand about 20 feet from chart.
, -Ask the client to read a newspaper or magazine paragraph about
14 inches away to assess near vision.
-Ask client to cover one eye and test for peripheral field view.
Repeat procedure for other eye.
-Use an ophthalmoscope to view the retina and optic disc of
each eye. Normal: Round red reflex is present, optic disc is 1.5
mm, round or slightly oval, well-defined margins, creamy pink
with paler physiologic cup.
CN III Correct Answers Oculomotor; Motor
-Inspect margins of the eyelids of each eye; look for drooping.
-Have client follow your hand in all six cardinal directions,
especially up and in.
CN IV Correct Answers Trochlear; Motor
-Have client look down and in.
CN IX Correct Answers Glossopharyngeal; Sensory & Motor
-Test swallowing and gag reflex.
-Look for soft palate symmetry and midline uvula when saying
"ahhhh".
-Can patient identify sour on anterior 1/3 of tongue?
CN V Correct Answers Trigeminal; Sensory motor
-Ask the client to clench the teeth while you palpate the
temporal and masseter muscles for contraction
-Touch client's face with sharp and dull objects and have them
communicate which was used.
-Test corneal reflex. Ask the client to look away and up while
you lightly touch the cornea with a fine wisp of cotton. Repeat
on the other side.
Complete Solutions
Arterial ulcers Correct Answers Ulcers associated with arterial
disease are usually painful and are often located on the toes,
foot, or lateral ankle.
Assessing urinary incontinence. Correct Answers The nursing
assessment varies somewhat depending on the client's general
health status and whether the problem is an acute or chronic one.
In general, however, a comprehensive nursing assessment can be
described as a five-step process that includes screening for an
infection with urinalysis, obtaining a voiding diary, evaluating
functional status, compiling a health history, and performing a
physical examination. Key features within the five steps follow:
-Record all incontinent and continent episodes for 3 days in a
voiding diary.
-Review medication for any newly prescribed drugs that may be
triggering incontinence. Follow up with physician regarding
need to discontinue therapy or change medication.
-Rule out constipation or fecal impaction as a source of urinary
incontinence. If client has had no bowel movement within last 3
days or is oozing stool continuously, check for impaction by
digital examination or abdominal palpation. Problem should be
treated if identified.
-Assess functional status along with signs and symptoms as they
relate to incontinence. Contributors to incontinence may include
immobility, insufficient fluid intake, and confusion.
Accompanying signs and symptoms include polyuria, nocturia,
,dysuria, hesitancy, poor or interrupted urine stream, straining,
suprapubic or perineal pain, urgency and characteristics of
incontinent episodes (precipitated by walking, coughing, getting
in and out of bed, and so forth).
-Consult physician regarding physical examination and need to
measure postvoid residual volume by straight catheterization
(particularly if client dribbles, reports urgency, has difficulty
starting stream). Components of the physical examination
include direct observation of urine loss using a cough stress test;
abdominal, rectal, genital, and pelvic examination; and
identification of neurolo
Breath odor associated with diabetic ketoacidosis. Correct
Answers Fruity or acetone breath
Breath odor associated with kidney disease Correct Answers
Ammonia breath
Buddhism Correct Answers Suffering is a part of human
existence
Prayer and meditation are used for cleansing and healing.
Terminal illness may be seen as a unique opportunity to reflect
on life's ultimate meaning and the meaning of one's relation with
the world.
Death is associated with rebirth. Serene surroundings are
important to the dignity of dying.
Many are strict vegetarians. Some holy days include fasting
from dawn to dusk.
,Christianity Correct Answers Beliefs focus around the Old and
New Testaments of the Bible and view Jesus Christ as the
Savior. Prayers may be directed to one or all of the Holy Trinity
(God, Holy Spirit, and Jesus Christ).
Most view illness as a natural process for the body and even as a
testing of faith.
There is belief in miracles, especially through prayer.
Western medicine is usually held in high regard.
Memorial services rather than funerals and cremation rather than
burial are more common in Christian religions than in other
sects.
No special or universal food beliefs are common to Christian
religions.
CN I Correct Answers Olfactory; Sensory
-Ask the client to clear the nose to remove any mucus, then to
close eyes, occlude one nostril, and identify a scented object that
you are holding such as soap, coffee, or vanilla. Repeat
procedure for the other nostril.
CN II Correct Answers Optic; Sensory
-Use a Snellen chart to assess far vision in each eye. Have client
stand about 20 feet from chart.
, -Ask the client to read a newspaper or magazine paragraph about
14 inches away to assess near vision.
-Ask client to cover one eye and test for peripheral field view.
Repeat procedure for other eye.
-Use an ophthalmoscope to view the retina and optic disc of
each eye. Normal: Round red reflex is present, optic disc is 1.5
mm, round or slightly oval, well-defined margins, creamy pink
with paler physiologic cup.
CN III Correct Answers Oculomotor; Motor
-Inspect margins of the eyelids of each eye; look for drooping.
-Have client follow your hand in all six cardinal directions,
especially up and in.
CN IV Correct Answers Trochlear; Motor
-Have client look down and in.
CN IX Correct Answers Glossopharyngeal; Sensory & Motor
-Test swallowing and gag reflex.
-Look for soft palate symmetry and midline uvula when saying
"ahhhh".
-Can patient identify sour on anterior 1/3 of tongue?
CN V Correct Answers Trigeminal; Sensory motor
-Ask the client to clench the teeth while you palpate the
temporal and masseter muscles for contraction
-Touch client's face with sharp and dull objects and have them
communicate which was used.
-Test corneal reflex. Ask the client to look away and up while
you lightly touch the cornea with a fine wisp of cotton. Repeat
on the other side.
