Nur 2092 Health Assessment Final Exam Brand New Q&A Included Over 130 Questions With 100% Correct Answers

NUR 2092 Health Assessment Final Exam • The nurse is preparing to conduct a health history. Explain this to the patient. Answer: The purpose of a health history is to provide a database of subjective information about the patient's past and current health history. You might say to the patient, "I will be asking you questions about your past and present health." This information will help the provider along with the physical exam (objective data) to develop a diagnosis or health status. • The nurse is evaluating the reliability of a patient's responses, which of these statements would be correct? The patient: Provided consistent information and therefore is reliable • A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse's best response? "Can you point to where it hurts?" • Describe a genogram. Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family. Usually 3 generations- parents, grandparents, siblings. Also highlight the health of close family members and more details such as communicable disease, environmental hazards (smoke), tobacco use, and alcohol use. Any additional information includes the family history. • The nurse is obtaining health history on an 87-year-old woman. Which of the following areas of questioning would be most useful at this time? Current health promotion activities. • A 90-year-old patient tells the nurse that he cannot remember the names of the medication he is taking or why he is taking them. An appropriate response from the nurse would be? Would you have a family member bring in your medications please? • The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask? "Are you able to dress yourself?" • A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms? "This pain happens every time I sit down to use the computer." • During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for approximately 2 weeks. In trying to find the cause of the rash, which questions would be important for the nurse to ask? Where did the rash first appear- on the nipple, areola, or the surrounding skin? When did you first notice this? • During an annual physical examination, a 43-year-old patient states that she does not perform monthly breast self-examinations (BSEs). She tells the nurse that she believes that mammograms "do a much better job than I ever could to find a lump." The nurse should explain to her that: Breast self-exams may detect lumps that appear between mammograms • List risk factors for breast cancer 1) History of breast cancer - family history—first-degree relative 2) Medications such as estrogen and progestin combined 3) Certain tumor suppressor genes called BRCA1 and BRCA2 (inherited mutation) 4) Age • During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding? Asymmetry is not unusual, but the nurse should verify that this change is not new • During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate? Whether the inversion is a recent change should be determined. • The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have the woman: Slowly lift her arms above her head, and note any retraction or lag in movement. • The nurse is palpating a female patient's breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation? Supine with the arms raised over the head • The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique? The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period. • The nurse is preparing to teach a woman about BSE. Which statement by the nurse is correct? "BSE on a monthly basis will help you become familiar with your own breasts and feel their normal variations." • A 55-year-old postmenopausal woman is being seen in the clinic for her annual examination. She is concerned about changes in her breasts that she has noticed over the past 5 years. She states that her breasts have decreased in size and that the elasticity has changed so that her breasts seem "flat and flabby." The nurse's best reply would be: The decrease in hormones after menopause causes atrophy of the glandular tissue in the breast and is a normal process of aging. • In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. The reason why is... This is the location for most breast tumors. • In performing an assessment of a woman's elixir lymph system, the nurse should assess which of these nodes? Central, lateral, pectoral, and subscapular.  The breast has extensive lymphatic drainage, 75% of the drainage drains into the axillary nodes. There are groups of axillary nodes central, pectoral and subscapular. • A 65-year-old patient remarks that she just cannot believe that her breasts "sag so much". She states it must be from a lack of exercise. What explanation should the nurse offer her? After menopause: The glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in sagging (flat and gabby) breasts. • In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of the following describes the nurse's best course of action? Explain that this is the result of hormonal changes (testosterone) and recommend a visit to their provider. • During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse's most appropriate response to this would be: To seek more specific information about the pain, such as:  When did you first notice it?  Is the pain localized or all over?  Is it painful to touch?  Is the pain in relation to your menstrual cycle?  Is the pain associated with activity or exercise? • A 43-year-old woman is at the clinic for a routine examination. She reports that she has had a breast lump in her right breast for years. Recently, it has begun to change in consistency and is becoming harder. She reports that 5 years ago her physician evaluated the lump and determined that it "was nothing to worry about." The examination validates the presence of a mass in the right upper outer quadrant at 1 o'clock, approximately 5 cm from the nipple. It is firm, mobile, and non-tender, with borders that are not well defined. The nurse replies: Because of the change in consistency of the lump, it should be further evaluated by the physician. • The nurse is discussing BSEs with a postmenopausal woman. The best time for postmenopausal women to perform BSEs is? On the same day every month. • During a discussion about BSEs with a 30-year-old woman, what statement by the nurse is most appropriate? Examine your breast shortly after your menstrual period each month. • Peau d' orange- Lymphatic obstruction causes edema, which thickens the skin and exaggerates the hair follicles; this creates a pigskin or orange peel look. Could be an indication of cancer. • Dullness- A high-pitched muffled thud sound obtained by percussing over relatively dense organs such as liver or spleen, distended bladder, mass of adipose tissue • Tympany- A high-pitchedmusical and drum like note obtained by percussing the surface of a large air-containing space, such as the abdomen • Resonance- A low-pitched, clear, hollow note obtained by percussing over normal lung tissue • Hyperresonance- A low-booming note obtained by percussing over the adult lungs that have increased air such as with a patient who has emphysema, present with distended abdomen • Which structure is located in the left lower quadrant of the abdomen? Sigmoid colon • Aneurysm- defect or sec formed by dilation in artery wall due to atherosclerosis, trauma, or congenital defect (aortic aneurysm) • Dysphasia- Difficulty swallowing • Anorexia- Loss of appetite • Ascites abnormal accumulation of serous fluid within the peritoneal cavity, associated with heart failure, cirrhosis, cancer or portal hypertension • Bruit- blowing, swoishing sound her through a stethoscope when an artery is partially occluded • Hepatomegaly- abnormally enlarged liver • Paralytic ileus- complete absence of peristaltic movement that may follow abdominal surgery or complete bowel obstruction • Peritonitis- inflammation of the peritoneum • Nurse suspects a patient has a distended bladder. How should the nurse assess? Percuss and palpate the midline area above the suprapubic bone. • The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is: Decreased gastric acid secretion. • A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: Peritonitis, • A 29-year-old woman tells the nurse that she has "excruciating pain" in her back. Which would be the nurse's appropriate response to the woman's statement? "How would you say the pain affects your ability to do your daily activities?" • A patient tells the nurse that he is allergic to penicillin. What would be the nurse's best response to this information? "Describe what happens (or the reaction) to you when you take Penicillin." • Stroke or Cerebrovascular Accident (CVA)- Blood flow is interrupted to a part of the brain, the most common type is an ischemic stroke (when a blood clot blocks a blood vessel in the brain) and less common is a hemorrhagic ( a blood vessel in the brain ruptures and causes bleeding). • Common symptoms of a stroke: • Weakness or numbness in the face, arms, or legs, especially when it is on one side of the body