REVIEW QUESTIONS AND ANSWERS-HEALTH ASSESSMENT

1.) Objective data can be gathered from the patient during which aspects of the physical assessment process? (Select all that apply.) a. Patient interview b. Health history c. General survey d. Physical examination e. Laboratory testing ANS. a,b,c,d,e Objective data consist of observed information or signs that can be collected during all stages of the physical assessment process. Even while the patient is answering questions, providing subjective or symptom information, the nurse observes for physical signs of abnormalities or impairment. NCLEX: Client Needs: Psychosocial Integrity: Reduction of Risk potential 2.) Which sequence best identifies the order in which the nurse should complete an abdominal assessment? a. Inspection, palpation, percussion, auscultation b. Auscultation, inspection, palpation, percussion c. Auscultation, palpation, percussion, inspection d. Inspection, auscultation, percussion, palpation ANS. d Assessment of the abdominal cavity requires inspection then auscultation, percussion then palpation to avoid stimulating the bowel and eliciting inaccurate assessment results. NCLEX: Client needs: Health Promotion and Maintenance: techniques of physical Assessment 3.) A nurse is preparing to auscultate a patient's chest. In which area should the nurse listen to evaluate the patient's aortic valve? / a. Second right intercostal space ANS. a The second intercostal space on the right is the auscultation point for the aortic valve. The ventricles and pulmonic valve are located on the left. The point of maximal impulse (PMI) over the mitral valve is located between the left fourth and fifth intercostal spaces. b. Third left intercostal space c. Fifth right intercostal space d. Fifth left intercostal space along the midclavicular line 4. The nurse notes the presence of ptosis when assessing an adult patient's eyes. Which potential cause would be considered of most concern, requiring further evaluation as soon as possible? a. Loss of skin elasticity b. Levator muscle weakness c. Congenital ocular abnormality d. Oculomotor cranial nerve III paralysis ANS. d Oculomotor paralysis may indicate the presence of a larger neurologic problem that requires further investigation as soon as possible. Loss of skin elasticity and muscle weakness may be due to aging, and congenital ptosis does not require immediate attention in an adult. NCLEX Client Needs: Physiologic Integrity: Physiological Adaptation 5.) Which type of lung sounds does the nurse expect to auscultate over most of the lung fields? a. Vesicular ANS. a Vesicular breathe sound are heard over most of the lung fields. Resonance is heard with percussion, not auscultation. Dullness is heard over the solid organs (liver, heart). Flat sounds are heard over the stomach and intestines. b. Resonant c. Dull / d. Flat Safety, Security and Emergency Preparedness 1.) When teaching a patient about fire safety, which activity does the nurse know is the leading cause of fire-related death? a. Cooking ANS.a Cooking I the leading cause of residential fires for the last decade, followed by heating, electrical malfunction. And other unintentional causes or carelessness. b. Playing with matches c. Smoking d. Heating with kerosene heaters 2. ) Which measures can the nurse teach to prevent poisoning of children? (Select all that apply.) ANS. a,c,d Child locks for cabinet and childproof caps for medication bottles are recommended to prevent poisoning. The use of alternatives (e.g. plungers) rather than toxic chemicals. (e.g. Drano) is recommended to prevent ingestion of deadly substances. Syrup of ipecac has been used in the past to treat poisoning after it occurred and is not considered a preventive measure. Keeping cleaning supplies under the kitchen sink is dangerous because the area is within reach o children. a. Install safety latches on reachable cabinets. b. Keep syrup of ipecac on hand. c. Use childproof caps on medications. d. Use a plunger rather than a chemical drain cleaner. e. Keep cleaning supplies under the kitchen sink. 3.) Which restraint-free alternative is best for the nurse to use for an 84-year-old patient after hip replacement who has confusion and incontinence? a. A room near the nurses’ station and decreased sensory stimuli b. A pressure sensor alarm and a room near the nurses’ station