NURSING 620 ADVANCE PHYSICAL ASSESSMENT FINALS

NURSING 620 ADVANCE PHYSICAL ASSESSMENT FINALS 1 What step of the nursing process includes data collection by heath history, physical examination, and interview? a Planning b Diagnosis c Evaluation d Assessment1/7 q 16 2 The nurse is performing a physical assessment on newly admitted patient. An example of objective information obtained during the physical assessment includes: a Patient’s history of allergies b Patients use of medication at home c Last menstrual period 1 month ago. d 2x5 cm scar on the right lower forearm.1/7 q 21 3 A 42-year old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his health assessment is important to: a Identify the cause of his illness. b Make accurate disease diagnoses. c Provide cultural health rights for the individual. d Provide culturally sensitive and appropriate care.1/9 q 26 4 In the health promotion model, the focus of the health professional includes: a Changing the patient’s perception of disease. b Identifying biomedical model interventions. c Identifying negative health acts of the consumer. d Helping the consumer choose a healthier lifestyle. 1/9 q 27 5 The nursing process is a sequential method of problem solving that nurses use and includes which steps. a Assessment, treatment, planning, evaluation, discharge, and follow up b Admission, assessment, diagnosis, treatment, and discharge planning. c Admission, diagnosis, treatment, evaluation, and discharge planning. d Assessment, diagnosis, outcome identification, planning, implementation, and evaluation.1/4 q 12 6 The nurse is preparing to conduct a health history. Which of this statements best describes the purpose of health history? a To provide an opportunity for interaction between the patient and the nurse. b To provide a form for obtaining the patients biographic information c To document the normal and abnormal findings of a physical assessment. d To provide a database of subjective information about the patients past and current health.4/1 q 1 7 A patient tell the nurse that he is allergic to penicillin. What would be the nurse’s best response to this information? a “Are you allergic to any other drugs?” b “How often have you received penicillin?” c “I’ll write your allergy on your chart so you won’t receive any penicillin.” d “Describe what happen to you when you take penicillin”4/3 q 8 8 The nurse is asking a patient for his reason for seeking care and ask a about the signs and symptoms he is experiencing. Which of this is an example of a symptoms? a Chest pain 4/10 q 27 b Clammy skin c Serum potassium level at 4.2 mEq/L d Body temperature of 100 deg F 9 When performing a physical assessment, the first technique the nurse will always use is: a Palpation b Inspection 8/1 q 1 c Percussion d Auscultation 10 The nurse is assessing a patient’s skin during an office visit. What part of the hand and technique should be used to best assess the patients skin temperature? a Fingertips; they are more sensitive to small changes in temperature. b Dorsal surface of the hand; the skin is thinner on this surface than on the palm 8/2 q 3. c Ulnar portion of the hand; increased blood supply in this area enhances temperature sensitivity. d Palmar surface of the hand; this surface is the most sensitive to temperature variations because of it’s increased nerve supply in this area. 11 Which of this techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient? a Palpation 8/2 q 4 b Auscultation c Inspection d Percussion 12 The nurse is preparing to assess a patients abdomen by palpitation. How should the nurse proceed? a Palpation of reportedly “tender” areas are avoided because palpation in these areas may cause pain. b Palpating a tender area is quickly performed to avoid any discomfort that the patient may experience. c The assessment begins with deep palpation, while encouraging the patient to relax and to take deep breaths. d The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched.8/2 q 5 13 The nurse would use bimanual palpation technique in which situation? a Palpating the thorax of an infant. b Palpating the kidneys and uterus 8/2 q 6 c Assessing pulsations and vibrations d Assessing the presence of tenderness and pain.4444 14 The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the of the underlying tissue. a Turgor b Texture c Density 8/3 q 7 d Consistency 15 The nurse is preparing to use stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: a Is used to listen for high-pitched sounds8/5 q 14 b Is use listen for low- pitched sounds c Should be lightly held against the person’s skin to block out low pitch-sounds d Should be lightly held against the person’s skin to listen for extra heart sounds and murmurs. 16 The nurse is preparing to use otoscope for an examination. Which statement is true regarding the otoscope? The otoscope: a Is often used to direct light onto the sinuses. b Uses a short broad speculum to help visualize the ear. c Is use to examine the structure of the internal ear. d Directs light into the ear canal and onto the tympanic membrane.8/6 q 17 17 An examiner is using an ophthalmoscope to examine a patient’s eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being correctly performed? a Using the large full circle of light when assessing pupils that are not dilated b Rotating the lens selector dial to the black numbers to compensate for astigmatism c Using the grid on the lens aperture dial to visualize the external structure of the eye d Rotating the lens selector to bring the object into focus.8/7 q 18 18 The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? The nurse: a Performed the examination from the left side of the bed. b Examines tender or painful areas first to help to relieve the patient’s anxiety. c Follows the same examination sequence, regardless of the patient’s age or condition. d Organizes the assessment to ensure that a patient does not change positions too often. 8/7 q 20 19 The nurse keeps in mind that the most important reason to share information and to offer brief teaching while performing the physical examination is to help the: a Examiner feel more comfortable and to gain control of the situation. b Examiner to build rapport and to increase the patient’s confidence in him or her.8/9 q 25 c Patient understands his or her disease process and treatment modalities. d Patient identify questions about his or her disease and the potential areas of patient education. 20 When examining a 16 year old male teenager, the nurse should: a Discuss health teaching with the parent because the teen is unlikely to be interested in promoting wellness. b Ask his parent to stay in the room during the history and physical examination to answer any question and to alleviate his anxiety. c Talk to him the same manner as one would talk to younger child because a teens level of understanding may not match his or her speech. d Provide feedback that his body is developing normally, and discuss the wide variation among teenagers on the rate and development. 8/12 q 33 21 When examining an older adult, the nurse should use which technique: a Avoid touching the patient too much b Attempt to perform the entire physical examination during one visit c Speak loudly and slowly because most aging adults have hearing deficits. d Arrange the sequence of the examination to allow as few position changes as possible.8/12 q 34 22 While auscultating heart sounds, the nurse hears a murmur. Which of these instruments should be used to assess this murmur? a Electrocardiogram b Bell of the stethoscope8/14 q 39 c Diaphragm of the stethoscope d Palpation with the nurse’s palm of the hand 23 During an examination of a patient’s abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drum-like quality of the sounds across the quadrants. This type of sound indicates: a Constipation. b Air-filled areas.8/15 q 40 c Presence of a tumor. d Presence of dense organs. 24 The nurse is performing a general survey. Which action is a component of the general survey? a Observing the patient’s body stature and nutritional status9/1 q 1 b Interpreting the subjective information the patient has reported c Measuring the patient’s temperature pulse respirations and blood pressure d Observing specific body systems while performing the physical assessment 25 Which technique is correct when the nurse is assessing the radial pulse of a patient? The pulse is counted for: a 1 minute, if the rhythm is irregular.9/7 q 19 b 15 seconds and then multiplied by 4, if the rhythm is regular. c 2 full minutes to detect any variation in amplitude. d 10 seconds and then multiplied by 6, if the patient has no history of cardiac abnormalities. 26 A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: a Bell palsy. b Damage to the trigeminal nerve. c Frostbite with resultant paresthesia to the cheeks. d Scleroderma. 27 A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN and proceeds with the examination by . a XI; palpating the anterior and posterior triangles b XI; asking the patient to shrug her shoulders against resistance c XII; percussing the sternomastoid and submandibular neck muscles d XII; assessing for a positive Romberg sign 28 When examining a patient’s CN function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the: a Sternomastoid and trapezius. b Spinal accessory and omohyoid. c Trapezious and sternomandibular. d Sternomandibular and spinal accessory. 29 A patient’s laboratory data reveal an elevated thyroxine (T4) level. The nurse would proceed with an examination of the gland. a Thyroid 13/3 q 8 b Parotid c Adrenal d Parathyroid 30 A patient says that she has recently noticed a lump in the front of her neck below her “Adam’s apple” that seems to be bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule): a Is tender. b Is mobile and not hard.13/3/q/9 c Disappears when the patient smiles. d Is hard and fixed to the surrounding structures.