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When the nurse performs the confrontation test, the nurse has assessed:
A. Extraocular eye muscles (EOMs)
B. Pupils (PERRLA)
C. Near Vision
D. Visual fields - ANSWER-D. Visual fields
Which statement is true regarding the complete physical assessment?
A. The male genitalia should be examined in the supine position
B. The patient should be in the sitting position for the examination of the head
and neck
C. The vital signs, height and weight should be obtained at the end of the
examination
D. To promote consistency between patients, the examiner should not vary the
order of the assessment - ANSWER-B. The patient should be in the sitting
position for the examination of the head and neck
Which of these is included in an assessment of general appearance ?
A. Height
B. Weight
C. Skin color
D. Vital signs - ANSWER-C. Skin color
,The nurse should wear gloves for which of these examinations?
A. Measuring vital signs
B. Palpation of the sinuses
C. Palpation of the mouth and tongue
D. Inspection of the eye with ophthalmoscope - ANSWER-C. Palpation of the
mouth and tongue
A 75-year-old woman is at the office for a pre-op interview. The nurse is aware
that the interview may take longer then interviews with younger persons. What
is the reason for this?
A. An aged person has a longer story to tell
B. An aged person is usually lonely and likes to have someone with whom to
talk
C. Aged persons lose much of their mental abilities and require longer time to
complete an interview
D. As a person ages he or she is unable to hear, best the interviewer usually
means to repeat much of what is said - ANSWER-A. An aged person has a
longer story to tell
The nurse is interviewing a male patient who has a hearing impairment. What
techniques would be most beneficial in communicating with this patient?
A. Determine the communication method he prefers
B. Avoid using facial and hand gestures because most hearing impaired people
find this degrading
C. Request a sign language interpreter before meeting with him to help facilitate
the communication
D. Speak loudly with exaggerated facial movement when talking with him
because doing so will help him lip read - ANSWER-A. Determine the
communication method he prefers
,During a prenatal check, a patient begins to cry as the nurse asked her about
previous pregnancies. She says that she is remembering her last pregnancy,
which ended in miscarriage. The nurses best response to her crying would be :
A. I am so sorry for making you cry
B. I can see that you are sad remembering this. It is alright to cry
C. Why don't I stepped out for a few minutes until you are feeling better
D. I can see that you feel sad about this, why don't we talk about something
else. - ANSWER-B. I can see that you are sad remembering this. It is alright to
cry
The nurse is documenting the assessment of an infant. During the abdominal
assessment the nurse notice a very loud splash auscultated over the upper
abdomen when the nurse rocked her from side to side. This finding would
indicate:
A. Epigastric hernia
B. Pyloric obstruction
C. Hypoactive bowel sounds
D. Hyperactive bowel sounds - ANSWER-D. Hyperactive bowel sounds
Which of these is most appropriate to perform on a 9 month old infant at a well
child checkup?
A. Testing for the Ortolani sign
B. Assessment for stereognosis
C. Blood pressure measurement
D. Assessment for the presence of the startle reflex - ANSWER-A. Testing for
the Ortolani sign
The nurse is assessing an older adult's functional ability. which definition
correctly describes one's functional abilities? Functional ability:
A. Is the measure of the expected changes of aging that one is experiencing?
B. Refers to the individual's motivation to live independently
C. Refers to the level of cognition present in the older person
, D. Refers to one's ability to perform activities necessary to live in modern
society - ANSWER-D. Refers to one's ability to perform activities necessary to
live in modern society
The nurse is preparing to perform a functional assessment of an older patient
and knows that a good approach would be to:
A. Observe the patient's ability to perform the tasks
B. Ask the patients wife how he does when performing tasks
C. Review the medical record for information on the patient's abilities
D. Ask the patients physician for information on the patient's abilities -
ANSWER-A. Observe the patient's ability to perform the tasks
The nurse needs to assess a patient's ability to perform ADLs and should choose
which tool for this assessment?
A. Direct assessment of functional abilities (DAFA)
B. Lawton Instrumental Activities of Daily Living (IADL) scale
C. Barthel Index
D. Older American Resources and Services Multidimensional Functional
Assessment Questionnaire IADL (OMFAQ-IADL) - ANSWER-A. Direct
assessment of functional abilities (DAFA)
A female nurse is interviewing a man who has recently immigrated. During the
course of the interview he leaned forward and then finally moves his chair close
enough that his knees are nearly touching the nurse's knees. The nurse begins to
feel uncomfortable with his proximity. Which statement most closely reflects
what the nurse should do next
A. The nurse should try to relax, these behaviors are culturally appropriate for
this person
B. Cleaner should discretely move his or her chair back until the distance is
more comfortable and then continue with the interview