NURS 5220 ADVANCED HEALTH ASSESSMENT EXAM 3 -
COMPLETE QUESTIONS AND DETAILED SOLUTIONS
LATEST UPDATE JUST RELEASED
Question 1: Mr. Harris presents to the emergency department. On
examination, you note crepitation. For which of the following
clinical problems would crepitation be an expected finding?
A. Myocardial infarction
B. Cardiovascular accident
C. Blunt abdominal trauma
D. Pneumothorax
Answer:
D: Palpate the upper chest and neck for crepitation, a sign of air leakage
into soft tissue. Bruising should alert you to the possibility of a pulmonary
contusion (bruising of the lung tissue caused by the energy of an external
impact transmitted through the chest wall). This injury may result in a
pneumothorax.
Question 2: During the primary assessment, the examiner asks the
patient, "Can you tell me who you are?" Which factor is the
examiner assessing?
A. Airway patency
B. Cardiac output
C. Respiratory efficiency
D. Cerebral blood flow
Answer:
, A: The patency of the upper airway is assessed at the start by asking the
patient a question. If the patient answers, the patient is responsive and
the airway is open at this time. Keep the patient talking so that you know
the airway is maintained.
Question 3: Mr. Jones presents to the emergency department. You
suspect poor peripheral perfusion. Which finding supports your
suspicion?
A. Rapid heart rate
B. Dorsalis pedis pulse with 3+ amplitude
C. Capillary refill greater than 2 seconds
D. Palpable radial pulse
Answer:
C: A capillary refill time in excess of 2 seconds indicates poor perfusion
unless an extremity is cold.
Question 4: A child is struck by a car while riding his bike. On
arrival at the hospital, the child is not breathing. How should the
examiner proceed?
A. Conduct a primary and secondary assessment before deciding
what care to provide.
B. Conduct a primary assessment; support breathing before starting a
secondary assessment.
C. Stop the primary assessment as soon as the apnea is recognized
to resuscitate.
D. Determine appropriate action based on the degree of cyanosis
observed by the examiner.
Answer:
, C: As with the serious injuries, the advanced cardiac life support survey
is interrupted to manage a life-threatening physiologic condition as soon
as it is detected. For example, if a patient is not breathing, rescue
breaths, oxygen, and assisted ventilation must be provided before the
assessment continues.
Question 5: Until life-threatening conditions of a child older than 1
year are stabilized, which formula can you use to approximate the
expected systolic blood pressure?
A. 90 − Child's age in years
B. 80 + (2 × Child's age in years)
C. 70 + Child's respiratory rate
D. Child's pulse divided by 2
Answer:
B: The approximate expected systolic blood pressure for a child older
than 1 year: 80 + (2 × Child's age in years).
Question 6: Mr. Torres is brought to the emergency department
after an auto accident. You suspect that he has a cervical spine
injury. You can rule out this possibility by:
A. examining peripheral motor and sensation.
B. assessing the level of consciousness.
C. assessing for pain and deformity.
D. acquiring x-ray films of all cervical vertebrae.
Answer:
, D: Once the patient's vital functions are more stable, radiologic imaging
of all seven cervical vertebrae is often obtained to diagnose the presence
or absence of cervical spine injury.
Question 7: During the primary assessment, the examiner notes
dampness inside a trauma victim's dark-colored coat. It is
important for the examiner to determine whether this dampness is
caused by:
A. severe sweating.
B. urine.
C. intravenous (IV) fluids.
D. blood.
Answer:
D: Perform a quick total body appraisal for bleeding sites, being
especially careful to look and feel for dampness in dark clothing that may
hide hemorrhage.
Question 8: Mr. Wolf presents with a complaint of sudden flashes
of light in the field of vision. What other symptom commonly
accompanies this primary symptom?
A. Severe nausea and vomiting
B. Partial loss of vision
C. Severe pain to the eye
D. Intense dizziness
Answer:
COMPLETE QUESTIONS AND DETAILED SOLUTIONS
LATEST UPDATE JUST RELEASED
Question 1: Mr. Harris presents to the emergency department. On
examination, you note crepitation. For which of the following
clinical problems would crepitation be an expected finding?
A. Myocardial infarction
B. Cardiovascular accident
C. Blunt abdominal trauma
D. Pneumothorax
Answer:
D: Palpate the upper chest and neck for crepitation, a sign of air leakage
into soft tissue. Bruising should alert you to the possibility of a pulmonary
contusion (bruising of the lung tissue caused by the energy of an external
impact transmitted through the chest wall). This injury may result in a
pneumothorax.
Question 2: During the primary assessment, the examiner asks the
patient, "Can you tell me who you are?" Which factor is the
examiner assessing?
A. Airway patency
B. Cardiac output
C. Respiratory efficiency
D. Cerebral blood flow
Answer:
, A: The patency of the upper airway is assessed at the start by asking the
patient a question. If the patient answers, the patient is responsive and
the airway is open at this time. Keep the patient talking so that you know
the airway is maintained.
Question 3: Mr. Jones presents to the emergency department. You
suspect poor peripheral perfusion. Which finding supports your
suspicion?
A. Rapid heart rate
B. Dorsalis pedis pulse with 3+ amplitude
C. Capillary refill greater than 2 seconds
D. Palpable radial pulse
Answer:
C: A capillary refill time in excess of 2 seconds indicates poor perfusion
unless an extremity is cold.
Question 4: A child is struck by a car while riding his bike. On
arrival at the hospital, the child is not breathing. How should the
examiner proceed?
A. Conduct a primary and secondary assessment before deciding
what care to provide.
B. Conduct a primary assessment; support breathing before starting a
secondary assessment.
C. Stop the primary assessment as soon as the apnea is recognized
to resuscitate.
D. Determine appropriate action based on the degree of cyanosis
observed by the examiner.
Answer:
, C: As with the serious injuries, the advanced cardiac life support survey
is interrupted to manage a life-threatening physiologic condition as soon
as it is detected. For example, if a patient is not breathing, rescue
breaths, oxygen, and assisted ventilation must be provided before the
assessment continues.
Question 5: Until life-threatening conditions of a child older than 1
year are stabilized, which formula can you use to approximate the
expected systolic blood pressure?
A. 90 − Child's age in years
B. 80 + (2 × Child's age in years)
C. 70 + Child's respiratory rate
D. Child's pulse divided by 2
Answer:
B: The approximate expected systolic blood pressure for a child older
than 1 year: 80 + (2 × Child's age in years).
Question 6: Mr. Torres is brought to the emergency department
after an auto accident. You suspect that he has a cervical spine
injury. You can rule out this possibility by:
A. examining peripheral motor and sensation.
B. assessing the level of consciousness.
C. assessing for pain and deformity.
D. acquiring x-ray films of all cervical vertebrae.
Answer:
, D: Once the patient's vital functions are more stable, radiologic imaging
of all seven cervical vertebrae is often obtained to diagnose the presence
or absence of cervical spine injury.
Question 7: During the primary assessment, the examiner notes
dampness inside a trauma victim's dark-colored coat. It is
important for the examiner to determine whether this dampness is
caused by:
A. severe sweating.
B. urine.
C. intravenous (IV) fluids.
D. blood.
Answer:
D: Perform a quick total body appraisal for bleeding sites, being
especially careful to look and feel for dampness in dark clothing that may
hide hemorrhage.
Question 8: Mr. Wolf presents with a complaint of sudden flashes
of light in the field of vision. What other symptom commonly
accompanies this primary symptom?
A. Severe nausea and vomiting
B. Partial loss of vision
C. Severe pain to the eye
D. Intense dizziness
Answer:
