Test Bank for Fundamentals of Nursing 11th Edition Potter Perry, Newest Version-2022

A nurse is performing a mental status examination and asks an adult patient what thestatement ―Don’t cry over spilled milk‖ means. Which area is thenurse assessing? a. Long-term memory b. Abstract thinking c. Recent memory d. Knowledge ANS:B For an individual to explain common phrases such as ―A stitch in time saves nine‖ or ―Don’t cry over spilled milk‖ requires a higher level of intellectual function or abstract thinking. Knowledge-based assessment is factual. Assess knowledge by asking how much thepatient knows about theillness or thereason for seeking health care. To assess past (longterm) memory, ask thepatient to recall themaiden name of thepatient’s mother, a birthday, or a special date in history. It is best to ask open-ended questions rather than simple yes/no questions. Patients demonstrate immediate recall (recent memory) by repeating a series of numbers in theorder in which they are presented or in reverse order. DIF:Apply (application) OBJ:Summarize physical measurements made in assessing each body system. TOP:Assessment MSC:Health Promotion and Maintenance 26. During a routine physical examination of a 70-year-old patient, a blowing sound is auscultated over thecarotid artery. Which assessment finding willthe nurse report to thehealth care provider? a. Bruit b. Thrill c. Phlebitis d. Right-sided heart failure ANS:A A bruit is thesound of turbulence of blood passing through a narrowed blood vessel and is auscultated as a blowing sound. A bruit can reflect cardiovascular disease in thecarotid artery ofmiddle-aged to older adults. Intensity or loudness is related to therate of blood flow through theheart or theamount of blood regurgitated. A thrill is a continuous palpable sensation that resembles thepurring of a cat. Jugular venous distention, not bruit, is a possiblesign of rightsided heart failure. Some patients with heart disease have distended jugular veinswhen sitting. Phlebitis is an inflammation of a vein that occurs commonly after trauma to thevessel wall, infection, immobilization, and prolonged insertion of IV catheters. It affects predominantly peripheral veins. DIF:Understand (comprehension) OBJ:Summarize physical measurements made in assessing each body system. TOP:Implementation MSC: Management of Care 27. The nurse considers several new female patients to receive additional teaching on theneed for more frequent Pap testing and gynecological examinations. Which assessment findings reveal thepatient at highest risk for cervical cancer and having thegreatest need for patient education? a. 13 years old, nonsmoker, not sexually active b. 15 years old, social smoker, celibate c. 22 years old, smokes 1 pack of cigarettes per day, has multiple sexual partners d. 50 years old, stopped smoking 30 years ago, has history of multiple pregnancies ANS:C Females considered to be at higher risk include those who smoke, have multiple sex partners, and have a history of sexually transmitted infections. of all theassessment findings listed, the22-year-old smoker with multiple sexual partners has thegreatest number of risk factors for cervical cancer. theother patients are at lower risk: not sexually active, celibate, and do not smoke. DIF:Analyze (analysis) OBJ:Propose ways to incorporate health promotion and health teaching into an examination. TOP:Assessment MSC:Health Promotion and Maintenance 28. The paramedics transport an adult involved in a motor vehicle accident to theemergency department. On physical examination, thepatient’s level of consciousness is reported as opening eyes to pain and responding with inappropriate words and flexion withdrawal to painful stimuli. Which value willthe nurse report for thepatient’s Glasgow Coma Scale score? a. 5 b. 7 c. 9 d. 11 ANS:C According to theguidelines of theGlasgow Coma Scale, thepatient has a score of 9. Opening eyes to pain is 2 points; inappropriate word use is 3 points; and flexion withdrawal is 4 points. thetotal for this patient is 2 + 3 + 4 = 9. DIF:Apply (application) OBJ:Utilize ways to use physical assessment skills during routine nursing care. TOP:Assessment MSC:Reduction of Risk Potential