HEALTH ASSESSMENT TEST 1 Evolve 70 Questions with Verified Answers,100% CORRECT

Document Content and Description Below

HEALTH ASSESSMENT TEST 1 Evolve 70 Questions with Verified Answers An example of subjective data is: A) decreased range of motion. B) crepitation in the left knee joint. C) left knee has b... een swollen and hot for the past 3 days. D) arthritis. - CORRECT ANSWER C) left knee has been swollen and hot for the past 3 days. Subjective data is what the patient says about himself or herself during history taking. Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Range of motion is assessed by inspection. Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Crepitation is assessed by palpating. Arthritis is a medical diagnosis. An example of objective data is: A) complaints of left knee pain. B) crepitation in the left knee joint. C) left knee has been swollen and hot for the past 3 days. D) report of impaired mobility from left knee pain as evidenced by an inability to walk, swelling, and pain on passive range of motion. - CORRECT ANSWER B) crepitation in the left knee joint. Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Crepitation is assessed by palpation. Subjective data is what the person says about himself or herself during history taking.Subjective data is what the person says about himself or herself during history taking.Subjective data is what the person says about himself or herself during history taking. A medical diagnosis is used to evaluate: A) a person's state of health. B) the response of the whole person to actual or potential health problems. C) a person's culture. D) the cause of disease. - CORRECT ANSWER D) the cause of disease. Medical diagnoses are used to evaluate the cause or etiology of disease. Nursing diagnoses are clinical judgments about a person's response to an actual or potential health state. Nursing diagnoses are used to evaluate the response of the whole person to actual or potential health problems. The holistic model of health care is used in nursing, and culture is an important factor to consider in a nursing assessment. According to the holistic model, a narrow definition of holistic health includes: A) an optimal functioning of mind, body, and spirit within the environment. B) the absence of disease C) the response of the whole person to actual or potential problems. D) the internal and external environment. - CORRECT ANSWER B) the absence of disease. From a biomedical perspective, health is defined as the absence of disease or elimination of symptoms and signs of disease, whereas a holistic model approach examines mind, body, and spirit working interdependently within the environment to maintain health and well-being.Nursing has an expanded concept of health; holistic health includes the mind, body, and spirit as interdependent and functioning as a whole within the environment. Nursing diagnoses are clinical judgments about a person's response to an actual or potential health state. In a holistic model approach to health, both the internal and the external environment affect a patient's health and well-being. Which of the following is an example of objective data? A) Alert and Oriented B) Dizziness C) an Earache D) Sore Throat - CORRECT ANSWER A)Alert and oriented Objective data is what the health professional observes; level of consciousness and orientation are observations. Subjective data is what the person says about himself or herself during history taking.Subjective data is what the person says about himself or herself during history taking.Subjective data is what the person says about himself or herself during history taking. A complete database is: A. used to collect data rapidly and is often compiled concurrently with lifesaving measures. B. used for a limited or short-term problem usually consisting of one problem, one cue complex, or one body system. C. used to evaluate the cause or etiology of disease. D. used to perform a thorough or comprehensive health history and physical examination. - CORRECT ANSWER D)used to perform a thorough or comprehensive health history and physical examination. A complete database includes a complete health history and a full physical examination; it describes the current and past health state and forms a baseline against which all future changes can be measured. An emergency database is rapid collection of data often obtained concurrently with lifesaving measures. An episodic database is for a limited or short-term problem; this database concerns mainly one problem, one cue complex, or one body system. Medical diagnoses are used to evaluate the cause or etiology of disease. What type of database is most appropriate when rapid collection of data is required and often compiled concurrently with lifesaving measures? A) Episodic B) Follow-up C) Emergency D) Complete - CORRECT ANSWER C) Emergency An emergency database includes rapid collection of data often obtained concurrently with lifesaving measures. An episodic database is for a limited or short-term problem; this database concerns mainly one problem, one cue complex, or one body system. A follow-up database is used to follow up short-term or chronic health problems; the statuses of identified problems are evaluated at regular and appropriate intervals. A complete database includes a complete health history and a full physical examination; it describes the current and past health state and forms a baseline against which all future changes can be measured. A nursing diagnosis is best described as: A) a determination of the etiology of disease. B) a pattern of coping. C) an individual's perception of health. D) a concise statement of actual or potential health concerns or level of wellness. - CORRECT ANSWER D) a concise statement of actual or potential health concerns or level of wellness. Nursing diagnoses are clinical judgments about a person's response to an actual or potential health state. Medical diagnoses determine the cause or etiology of disease. Coping patterns include methods to relieve stress. Health perception is how the person describes and defines personal health. What type of database is most appropriate for an individual who is admitted to a long-term care facility? A) Episodic B) Follow-up C) Emergency D) Complete - CORRECT ANSWER D)Complete A complete database includes a complete health history and a full physical examination; it describes the current and past health state and forms a baseline against which all future changes can be measured. An episodic database is for a limited or short-term problem; this database concerns mainly one problem, one cue complex, or one body system. A follow-up database is used to follow up short-term or chronic health problems; the statuses of identified problems are evaluated at regular and appropriate intervals. An emergency database includes rapid collection of data often obtained concurrently with lifesaving measures. A patient admitted to the hospital with asthma has the following problems identified based on an admission health history and physical assessment. Which problem is a first-level priority? A) Ineffective self-health management B) Risk for infection C) Impaired gas exchange D)Readiness for enhanced spiritual well-being - CORRECT ANSWER C) Impaired gas exchange First-level priority problems are problems that are emergent, life-threatening, and immediate. Impaired gas exchange is an emergent and immediate problem. Third-level priority problems are problems that are important to the patient's health but can be addressed after more urgent health problems are addressed. Ineffective self-health management is an example of a third-level priority. Second-level priority problems are problems that are next in urgency; these problems require prompt intervention to forestall further deterioration. Risk for infection is an example of a second-level priority. Third-level priority problems are problems that are important to the patient's health but can be addressed after more urgent health problems are addressed. Wellness diagnoses are third-level priority problems. The use of euphemisms to avoid reality or to hide feelings is known as: A) distancing language. B) sympathetic language. C) avoidance language. D) ethnocentric language. - CORRECT ANSWER C) avoidance language. Euphemisms are used to avoid reality or to hide feelings. Using direct language is the best way to deal with frightening topics instead of using avoidance language. Distancing is the use of impersonal speech to put space between a threat and the self. Empathy means viewing the world from the other person's inner frame of reference. Empathy is therapeutic; sympathy is nontherapeutic. Ethnocentrism is the belief that one's ethnic or cultural group is more important or superior. While discussing the treatment plan, the nurse infers that the patient is uncomfortable asking the physician for a different treatment because of fear of the physician's reaction. In this situation, the nurse's verbal interpretation: A) affects the nurse-physician relationship. B) impedes further discussion. C) helps the patient understand personal feelings in relation to his or her verbal message. D) helps the nurse understand his or her own feelings in relation to the patient's verbal message. - CORRECT ANSWER C) helps the patient understand personal feelings in relation to his or her verbal message. Patients may experience barriers to communication with a health care provider seen as an authority figure. The patient may not share personal feelings if fear is experienced. In this situation, the nurse identified the patient's personal feelings in relation to the patient's verbal message. The nurse-physician relationship is not the barrier to communication in this situation. The interpretation by the nurse will improve communication. The nurse's feelings are not the barrier to communication in this situation. Which of the following statements made by the interviewer would be an appropriate response? A) "I know just how you feel." B) "If I were you, I would have the surgery." C) "Why did you wait so long to make an appointment?" D) "Tell me what you mean by 'bad blood.'" - CORRECT ANSWER D) "Tell me what you mean by 'bad blood.'" "Tell me what you mean by 'bad blood'" is an appropriate communication technique referred to as seeking further clarification. "I know just how you feel" is an inappropriate communication technique referred to as false reassurance. "If I were you, I would have the surgery" is an inappropriate communication technique referred to as giving unwanted advice. "Why did you wait so long to make an appointment?" is an inappropriate communication technique referred to as using "Why" questions. While discussing the treatment plan, the nurse infers that the patient is uncomfortable asking the physician for a different treatment because of fear of the physician's reaction. In this situation, the nurse's verbal interpretation: A) Affects the nurse-physician relationship. B) Impedes further discussion. C) helps the patient understand personal feelings in relation to his or her verbal message. D) helps the nurse understand his or her own feelings in relation to the patient's verbal message - CORRECT ANSWER C) helps the patient understand personal feelings in relation to his or her verbal message. Patients may experience barriers to communication with a health care provider seen as an authority figure. The patient may not share personal feelings if fear is experienced. In this situation, the nurse identified the patient's personal feelings in relation to the patient's verbal message. The nurse-physician relationship is not the barrier to communication in this situation. The interpretation by the nurse will improve communication. The nurse's feelings are not the barrier to communication in this situation. When preparing the physical setting for an interview, the interviewer should: A) set the room temperature between 64° F and 66° F. B) reduce noise by turning the volume on the television or radio down. C) conduct the interview at eye level and at a distance of 4 to 5 feet. D) stand next to the patient to convey a professional demeanor. - CORRECT ANSWER C) conduct the interview at eye level and at a distance of 4 to 5 feet. Both the interviewer and the patient should be at eye level at a distance of 4 to 5 feet. The room temperature should be set at a comfortable level; a temperature between 64° F and 66° F is too cool. Turn off the television or radio and any unnecessary equipment to reduce noise. The interviewer and the patient should be comfortably seated; standing communicates haste and assumes superiority. The use of euphemisms to avoid reality or to hide feelings is known as: A) distancing language. B) sympathetic language. C) avoidance language. D) ethnocentric language. - CORRECT ANSWER C) avoidance language. Euphemisms are used to avoid reality or to hide feelings. Using direct language is the best way to deal with frightening topics instead of using avoidance language. Distancing is the use of impersonal speech to put space between a threat and the self. Empathy means viewing the world from the other person's inner frame of reference. Empathy is therapeutic; sympathy is nontherapeutic. Ethnocentrism is the belief that one's ethnic or cultural group is more important or superior. Which of the following statements made by the interviewer would be an appropriate response? A) "I know just how you feel." B) "If I were you, I would have the surgery." C) "Why did you wait so long to make an appointment?" D) "Tell me what you mean by 'bad blood.'" - CORRECT ANSWER D) Tell me what you mean by 'bad blood.'" "Tell me what you mean by 'bad blood'" is an appropriate communication technique referred to as seeking further clarification. "I know just how you feel" is an inappropriate communication technique referred to as false reassurance. "If I were you, I would have the surgery" is an inappropriate communication technique referred to as giving unwanted advice. "Why did you wait so long to make an appointment?" is an inappropriate communication technique referred to as using "Why" questions. Parents or caretakers accompany children to the health care setting. Starting at __ years of age, the interviewer asks the child directly about his or her presenting symptoms. A) 5 B) 7 C) 9 D) 11 - CORRECT ANSWER B) 7 School-age children (starting at age 7) have the verbal ability to add important data to the history. The nurse should interview the parent and child together, but when a presenting symptom or sign exists, the nurse should ask the child about it first and then gather data from the parent. Nonverbal communication is the primary form of communication for which group of individuals? A) Infants B) Preschoolers C) Adolescents D) Older adults - CORRECT ANSWER A) Infants Nonverbal communication is the primary communication method for infants. Preschoolers' communication is direct, concrete, literal, and set in the present. Adolescents should be treated with respect; the nurse should use open, honest, professional communication. Older adults may need special considerations related to physical limitations (e.g., adjusted pace to avoid fatigue, impaired hearing). Viewing the world from another person's inner frame of reference is called: A) reflection. B) empathy. C) clarification. D) sympathy. - CORRECT ANSWER B) empathy. Empathy means viewing the world from the other person's inner frame of reference. Reflection is repeating part of what the person has just said. Clarification is used to summarize the person's words or to simplify the words to make them clearer. Sympathy is a social affinity in which one person stands with another person, closely understanding his or her feelings. The nurse questions the reliability of the history provided by the patient. One method to verify information within the context of the interview is to: A) review previous medical records. B) rephrase the same questions later in the interview. C) ask the patient if there is someone who could verify information. D) call a family member to confirm information. - CORRECT ANSWER B) rephrase the same questions later in the interview. A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. This option is not within the context of the interview. Although this may possibly lead to verification of information, asking the patient for corrobation of information from another individual is not within the context of the present interview. This would occur outside the context of the interview. Which of the following is included in documenting a history source? A) Appearance, dress, and hygiene B) Cognition and literacy level C) Documented relationship of support systems D) Reliability of informant - CORRECT ANSWER D) Reliability of informant The source of history is a record of who furnishes the information, how reliable the informant seems, and how willing he or she is to communicate. In addition, there should be a note of any special circumstances, such as the use of an interpreter. Appearance, dress, and hygiene are observations included in the general survey. Cognition and literacy level are part of the mental status assessment. Interpersonal relationships and resources such as support systems are assessed during the functional assessment of the complete health history. PQRSTU is a mnemonic that helps the clinician to remember to address characteristics specific to: A) severity of dementia. B) substance use and abuse. C) pain presentation. D) the ability to perform activities of daily living (ADLs). - CORRECT ANSWER pain presentation. The eight critical characteristics of pain symptoms reported in the history are: P = provocative or palliative; Q = quality or quantity; R = region or radiation; S = severity scale; T = timing; and U = understand patient's perception. Tests used to assess for dementia include the Mini-Mental State Examination, the Set Test, the Short Portable Mental Status Questionnaire, the Mini-Cog, and the Blessed Orientation-Memory-Concentration Test. Functional assessment includes questions on substance use and abuse. Functional assessment measures a person's self-care ability including the ability to perform ADLs. When taking a health history from an adolescent, the interviewer should: A) ask about violence and abuse before asking about alcohol and drug use. B) have at least one parent present during the interview. C) interview the youth alone with a parent in the waiting area. D) ask every youth about the use of condoms. - CORRECT ANSWER C) interview the youth alone with a parent in the waiting area. The adolescent interview during the health history should be with the youth alone; a parent may wait in the waiting area and complete other past health questionnaire forms. Questions should move from expected and less threatening questions to questions that are more personal. Ask about alcohol and drug use before asking about safety (related to injury and violence). Questions about condom use would be appropriate only if the youth is sexually active. The HEEADSSS method of interviewing adolescents has essential questions, important questions, and situational questions. A patient seeks care for "debilitating headaches that cause excessive absences at work." On further exploration, the nurse asks, "What makes the headaches worse?" With this question, the nurse is seeking information about: A) the patient's perception of pain. B) the nature or character of the headache. C) aggravating factors. D) relieving factors. - CORRECT ANSWER C) aggravating factors. Aggravating factors are determined by asking the patient what makes the pain worse. To determine the patient's perception of pain, the nurse would determine the meaning of the symptom by asking how it affects daily activities and what the patient thinks the pain means. The nature or character calls for specific descriptive terms to describe the pain. Relieving factors are determined by asking the patient what relieves the pain, what is the effect of any treatment, what the patient has tried, and what seems to help. Assessment of self-esteem and self-concept is part of the functional assessment. Areas covered under self-esteem and self-concept include: A) education, financial status, and value-belief system. B) exercise and activity, leisure activities, and level of independence. C) family role, interpersonal relations, social support, and time spent alone. D) stressors, coping mechanisms, and change in past year. - CORRECT ANSWER A) education, financial status, and value-belief system. Functional assessment measures a person's self-care ability. The areas assessed under the self-esteem and self-concept section of the functional assessment include education, financial status, and value-belief system. These areas are related to the activity and exercise section of the functional assessment. These areas are related to the interpersonal relationships and resources section of the functional assessment. These areas are related to the coping and stress management section of the functional assessment. The CAGE test is a screening questionnaire that helps to identify: A) unhealthy lifestyle behaviors. B) personal response to stress. C) excessive or uncontrollable drinking. D) depression. - CORRECT ANSWER C) excessive or uncontrollable drinking. CAGE is a screening questionnaire to identify excessive or uncontrolled drinking (C = Cut down; A = Annoyed; G = Guilty; E = Eye opener). The health history assesses lifestyle, including factors such as exercise, diet, risk reduction, and health promotion behaviors. Coping and stress management are assessed during the functional assessment of the complete health history. Depression is assessed during the review of systems and during the mental status assessment (mood and affect). The Geriatric Depression Scale, Short Form is an assessment instrument for use with older adults. When recording information for the review of systems, the interviewer must document: A) physical findings, such as skin appearance, to support historic data. B) "negative" under the system heading. C) the presence or absence of all symptoms under the system heading. D) objective data that support the history of present illness. - CORRECT ANSWER C) the presence or absence of all symptoms under the system heading. When recording information for the review of systems, the interviewer should record the presence or absence of all symptoms; otherwise it is unknown which factors were asked. Recording physical findings in the review of systems is incorrect; review of systems is limited to the patient's statements or subjective data. Writing "negative" after the system heading is also incorrect because it would be unknown which factors were asked. Recording objective data in the review of systems is incorrect; review of systems is limited to the patient's statements or subjective data. The "review of systems" in the health history is: A) an evaluation of past and present health state of each body system. B) a documentation of the problem as perceived by the patient. C) a record of objective findings. D) a short statement of general health status. - CORRECT ANSWER A) an evaluation of past and present health state of each body system. The purpose of the review of systems is to evaluate the past and present health state of each body system, to double-check in case any significant data were omitted in the present illness section, and to evaluate health promotion practices. The reason for seeking care is a statement in the person's own words that describes the reason for the visit. This is typically known as a "chief complaint" or the reason for the health care visit. Objective data are the observations obtained by the health care professional during the physical examination. A short statement related to the patient's general health status is typically included in the complete physical assessment record. What information is included in greater detail when taking a health history on an infant? A) Nutritional data B) History of present illness C) Family history D) Environmental hazards - CORRECT ANSWER A)Nutritional data The amount of nutritional information needed depends on the child's age; the younger the child is, the more detailed and specific the data should be. The health history is adapted to include information specific for the age and developmental stage of the child (e.g., mother's health during pregnancy, labor, and delivery and the perinatal period). The developmental history and nutritional data are important for current health of infants and children. An older adult: A) experiences a 10-point decrease in intelligence. B) has diminished recent and remote memory recall. C) has a slower response time. D) has difficulty with problem solving. - CORRECT ANSWER C) has a slower response time. Response time is slower in an aging adult; it may take longer for the brain to process information and react. Timed intelligence testing may be lower for an aging adult; intelligence has not declined, but it may take longer to respond to questions. Recent memory requires processing and may decrease with aging. Remote memory is not affected by the aging process. Aging does not usually have an impact on mental status (e.g., intelligence, reasoning abilities, and problem solving). Which of the following statements about mental status testing of children is correct? A) The results of the Denver II screening test are valid for white, middle-class children only. B) The behavioral checklist is useful to assess children who are 3 to 5 years old. C) Abnormal findings are usually related to not achieving an expected developmental milestone. D) Input from parents and caretakers is discouraged when assessing psychosocial - CORRECT ANSWER C) Abnormal findings are usually related to not achieving an expected developmental milestone. Abnormalities in mental status in children are often problems of omission; the child does not achieve a milestone that is expected. The validity of the Denver II screening test is based on more than 2000 children in Colorado; the sample represented a broad spectrum of children and was representative of the U.S. population with only minor demographic differences. The behavioral checklist is useful as a mental status assessment for school-age children (7 to 11 years old). A child's psychosocial development and mental status assessment is mostly based on information obtained from the parent. Which of the following best illustrates an abnormality of thought process? A) Lability B) Blocking C) Compulsion D) Aphasia - CORRECT ANSWER B) Blocking Thought process is defined as the way a person thinks or as the logical train of thought. Blocking is a sudden interruption in train of thought. Lability is an abnormality of mood and affect; the person has a rapid shift of emotions. A compulsion is an abnormality of thought content; the person displays unwanted repetitive, purposeful acts. Aphasia is a speech abnormality; the person is unable to comprehend language, produce language, or both. The mental status examination: A) should be completed at the end of the physical examination. B) will not be affected if the patient has a language impairment. C) is usually not assessed in children younger than 2 years of age. D) assesses mental health strengths and coping skills and screens for any dysfunction. - CORRECT ANSWER D) assesses mental health strengths and coping skills and screens for any dysfunction. The purpose of the mental status examination is to assess mental health strengths and coping skills and to screen for any dysfunction. The mental status assessment usually can be completed during the context of the entire health history interview. If basic functions (e.g., language) are abnormal, other assessments (of new learning or abstract reasoning) may be erroneous. A mental status examination can be performed on all patients. A patient in whom a seizure disorder was recently diagnosed plans to continue a career as a pilot. At this time in the interview, the nurse begins to question the patient's: A) thought process. B) judgment. C) perception. D) intellect. - CORRECT ANSWER B) judgment. To assess judgment in the interview, the nurse should notice what the person says about job plans, social or family obligations, and plans for the future. Job and future plans should be realistic and should take into account the person's health situation. Thought processes should be consistent, coherent, relevant, and logical. Perceptions should be congruent; the person should be consistently aware of reality. Intellectual functioning is measured by problem-solving and reasoning abilities. A major characteristic of dementia is: A) impaired short-term and long-term memory. B) hallucinations. C) sudden onset of symptoms. D) cognitive deficits that are substance-induced. - CORRECT ANSWER A) impaired short-term and long-term memory. Dementia is the presence of cognitive deficits; the deficits include memory impairment (impaired ability to learn new information or to recall previously learned information). Hallucinations are a form of delirium. Delirium is a disturbance that develops over a short period of time. Delirium may be substance-induced. Although a full mental status examination may not be required for every patient, the health care provider must address the four main components during a health history and physical examination. The four components are: A) memory, attention, thought content, and perceptions. B) language, orientation, attention, and abstract reasoning. C) appearance, behavior, cognition, and thought processes. D) mood, affect, consciousness, and orientation. - CORRECT ANSWER C) appearance, behavior, cognition, and thought processes. The four main components of a full mental status examination are appearance, behavior, cognition, and thought processes. Select behaviors that are assessed with a mental status examination include memory, attention, thought content, and perceptions. Select behaviors that are assessed with a mental status examination include language, orientation, attention, and abstract reasoning. Select behaviors that are assessed with a mental status examination include mood, affect, consciousness, and orientation. A full mental status examination should be completed if the patient: A) has a change in behavior and the family is concerned. B) develops dysphagia. C) has a new diagnosis of type 2 diabetes mellitus. D) complains of insomnia. - CORRECT ANSWER A) has a change in behavior and the family is concerned. A full mental status examination is indicated if there is any abnormality in affect or behavior and in the following situations: family members concerned about a person's behavioral changes; brain lesions; aphasia; or symptoms of psychiatric mental illness, especially with acute onset. A full mental status examination is not indicated for dysphagia or difficulty with swallowing. A full mental status examination is not indicated for a medical problem such as type 2 diabetes mellitus. A full mental status examination is not indicated for a symptom such as insomnia. Mental status assessment documents: A) emotional and cognitive functioning. B) intelligence and educational level. C) artistic or writing ability in the mentally ill person. D) schizophrenia and other mental health disorders. - CORRECT ANSWER A) emotional and cognitive functioning. Mental status assessment is a systematic check of emotional and cognitive functioning. Intelligence testing measures problem-solving and reasoning abilities; results of intelligence testing should be assessed considering educational and cultural background. Mental status assessment evaluates appearance, behavior, cognition, and thought processes, not artistic or writing ability. Abnormalities in mood and affect may indicate schizophrenia and other mental health disorders. Aphasia is best described as: A) a language disturbance in speaking, writing, or understanding. B) the impaired ability to carry out motor activities despite intact motor function. C) the impaired ability to recognize or identify objects despite intact sensory function. D) a disturbance in executive functioning (planning, organizing, sequencing, abstracting). - CORRECT ANSWER A) a language disturbance in speaking, writing, or understanding. Aphasia is a language disturbance. Apraxia is an impaired ability to carry out motor activities despite intact motor function. Agnosia is an impaired ability to identify objects correctly despite intact sensory function. A disturbance in executive functioning is a cognitive disturbance. Dementia is the development of multiple cognitive deficits with both memory impairment and a cognitive disturbance. Deep palpation is used to: A) identify abdominal contents. B) evaluate surface characteristics. C) elicit deep tendon reflexes. D) determine the density of a structure. - CORRECT ANSWER A) identify abdominal contents. Deep palpation is used to identify abdominal contents. Light palpation is used to evaluate surface characteristics. Percussion with a reflex hammer is used to elicit deep tendon reflexes. Percussion is used to determine the density (air, fluid, or solid) of a structure by a characteristic note. Amplitude is: A) the intensity (soft or loud) of sound. B) the length of time the note lingers. C) the number of vibrations per second. D) the subjective difference in a sound's distinctive overtones. - CORRECT ANSWER A) the intensity (soft or loud) of sound. Amplitude is the intensity of sound. Duration is the length of time the note lingers. Pitch is the number of vibrations per second (high or low). Quality is the subjective difference owing to a sound's distinctive overtones. The dorsa of the hands are used to determine: A) vibration. B) temperature. C) position of an organ. D) fine tactile discrimination. - CORRECT ANSWER B) temperature. The dorsa (back) of hands and fingers are best for determining temperature because the skin is thinner than on the palms. The base of the fingers or ulnar surface of the hand is best for vibration. A grasping action of the fingers and thumb is the best way to detect the position, shape, and consistency of an organ or mass.The fingertips are best for fine tactile discrimination. To examine a toddler, the nurse should: A) allow the child to sit on the parent's lap. B) remove the child's clothing at the beginning of the examination. C) ask the child to decide whether parents or siblings should be present. D) perform the assessment from head to toes. - CORRECT ANSWER A) allow the child to sit on the parent's lap. A toddler should be sitting up on the parent's lap for the examination. An infant will not object to having clothing removed; a toddler does not like to take off his or her clothing. A school-age child has a sense of modesty; to maintain privacy, ask a child who is 11 or 12 years old to decide whether parents or siblings should be present. The sequence of the examination for a toddler should start with nonthreatening areas first; save distressing procedures such as assessment of the head, ears, nose, or throat for last. The examiner should use handwashing instead of an alcohol-based hand rub: A) if the patient has an infection with Mycobacterium tuberculosis. B) if the patient has an infection with Clostridium difficile. C) if the patient has an infection with hepatitis B virus. D) if the patient is HIV positive. - CORRECT ANSWER B) if the patient has an infection with Clostridium difficile. The examiner should use the mechanical action of soap-and-water handwashing when hands are visibly soiled and when patients are infected with spore-forming organisms (e.g., C. difficile or Bacillus anthracis). An alcohol-based hand rub would be effective against M. tuberculosis. An alcohol-based hand rub would be effective against hepatitis B virus. An alcohol-based hand rub would be effective against HIV. A funduscopic examination is an examination of the: A) inner ear. B) pharynx. C) internal structures of the eye. D) nasal turbinates. - CORRECT ANSWER C) internal structures of the eye. An ophthalmoscope is used for a funduscopic examination, which is an examination of the internal structures of the eye. An otoscope is used to visualize the ear canal and tympanic membrane. A flashlight or penlight and tongue depressor are used to examine the pharynx. An otoscope may also be used with a short, broad speculum to view the nasal turbinates and nares. Which of the following is considered when preparing to examine an older adult? A) Base the pace of the examination on the patient's needs and abilities. B) Avoid physical touch to avoid making the older adult uncomfortable. C) Be aware that loss will result in poor coping mechanisms. D) Confusion is a normal, expected finding in an older adult. - CORRECT ANSWER A) Base the pace of the examination on the patient's needs and abilities. The pace of the examination should be adjusted to match the possible slowed pace of the aging person. Use physical touch (if it is not a cultural contraindication) to offset the disadvantages of diminishing vision and hearing. Be aware that loss is inevitable, and adaptation to loss affects health status. Confusion with a sudden onset may signify a disease state and is not a normal process of aging. At the end of the examination, the examiner should: A) complete documentation before leaving the examination room. B) have findings confirmed by another provider. C) compare objective and subjective data for discrepancies. D) review the findings with the patient. - CORRECT ANSWER D) review the findings with the patient. At the end of the examination, the examiner should summarize the findings and share necessary information with the patient. The examiner may take short notes during the examination; complete documentation should occur after leaving the examination room. The examiner should have findings confirmed only if the finding is abnormal and requires confirmation from another examiner. Subjective and objective data should be compared throughout the history and physical examination. Fine tactile discrimination is best achieved with the: A) opposition of the fingers and thumb. B) fingertips. C) back of the hands and fingers. D) base of the fingers. - CORRECT ANSWER B) fingertips. The grasping action of the fingers and thumb is used to detect the position, shape, and consistency of an organ or mass. The fingertips are best for fine tactile discrimination such as skin texture, swelling, pulsation, and presence of lumps. The dorsa (back) of hands and fingers are best for determining temperature because the skin is thinner than on the palms. The base of the fingers or ulnar surface of the hand is best for detecting vibration. When performing percussion, the examiner: A) strikes the flank area with the palm of the hand. B) strikes the stationary finger at the distal interphalangeal joint. C) strikes the stationary finger at the proximal interphalangeal joint. D) taps fingertips over bony processes. - CORRECT ANSWER B) strikes the stationary finger at the distal interphalangeal joint. To perform percussion, the examiner strikes the stationary finger at the distal interphalangeal joint (just behind the nail bed). The nurse records that the patient's pulse is 3+ or full and bounding. Which of the following could be the cause? A) Dehydration B) Shock C) Bleeding D) Anxiety - CORRECT ANSWER D) Anxiety A full, bounding pulse (3+) reflects an increased stroke volume, as with anxiety and exercise. A weak, thready pulse may reflect a decreased stroke volume, as with dehydration. A weak, thready pulse may reflect a decreased stroke volume, as with shock. A weak, thready pulse reflects a decreased stroke volume, as with bleeding. Endogenous obesity is: A) due to inadequate secretion of cortisol by the adrenal glands. B) caused by excess adrenocorticotropin production by the pituitary gland. C) characterized by evenly distributed excess body fat. D) a result of excessive secretion of growth hormone in adulthood. - CORRECT ANSWER B) caused by excess adrenocorticotropin production by the pituitary gland. Endogenous obesity is caused by either the administration of adrenocorticotropin or excessive production of adrenocorticotropin by the pituitary. Adrenocorticotropin stimulates the adrenal cortex to secrete excess cortisol and causes Cushing syndrome, which is characterized by weight gain and edema with central trunk and cervical obesity. Excessive catabolism causes muscle wasting with thin arms and legs. Body fat is evenly distributed in exogenous obesity because of excessive caloric intake. Acromegaly is caused by an excessive secretion of growth hormone in adulthood. Physical appearance includes statements that compare appearance with: A) mood and affect. B) stated age. C) gait. D) nutrition. - CORRECT ANSWER B) stated age. Physical appearance includes statements that compare appearance with age, sex, level of consciousness, skin color, and facial features. Behavior is compared with mood and affect. Mobility is compared with gait. Body structure is compared with nutrition. The general survey consists of four distinct areas. These areas include: A) mental status, speech, behavior, and mood and affect. B) gait, range of motion, mental status, and behavior. C) physical appearance, body structure, mobility, and behavior. D) level of consciousness, personal hygiene, mental status, and physical condition. - CORRECT ANSWER C) physical appearance, body structure, mobility, and behavior. The general survey is a study of the whole person, covering the general health state and any obvious physical characteristics. The four areas of the general survey are physical appearance, body structure, mobility, and behavior. A general survey does not include assessment of mental status and physical condition. The Doppler technique: A) is used to assess the apical pulse. B) augments Korotkoff sounds during blood pressure measurement. C) provides an easy and accurate measurement of the diastolic pressure. D) measures arterial oxygenation saturation. - CORRECT ANSWER B) augments Korotkoff sounds during blood pressure measurement. The Doppler technique may be used to locate peripheral pulse sites and for blood pressure measurement to augment Korotkoff sounds. A stethoscope is used to assess an apical pulse. The systolic blood pressure is more easily identified with the Doppler technique than the diastolic pressure. A pulse oximeter measures arterial oxygenation saturation. A common error in blood pressure measurement is: A) taking the blood pressure in an arm that is at the level of the heart. B) waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm. C) deflating the cuff about 2 mm Hg per heartbeat. D) using a blood pressure cuff whose bladder length is 80% of the arm circumference. - CORRECT ANSWER B) waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm. Waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm will result in a falsely high diastolic pressure related to venous congestion in the forearm. The patient's arm should be positioned at the level of the heart when obtaining a blood pressure measurement. The cuff should be deflated at a rate of 2 mm Hg per heartbeat. The blood pressure cuff bladder length should be about 80% of the arm circumference. The tympanic membrane thermometer (TMT): A) provides an accurate measurement of core body temperature. B) senses the infrared emissions of the cerebral cortex. C) is not used in unconscious patients. D) accurately measures temperature in 20 to 30 seconds. - CORRECT ANSWER A) provides an accurate measurement of core body temperature. The TMT accurately measures core body temperature. The TMT senses the infrared emissions of the tympanic membrane; the tympanic membrane shares the same vascular supply that perfuses the hypothalamus. The TMT is used with unconscious patients or patients in the emergency department, recovery areas, and labor and delivery units. The temperature is displayed in 2 to 3 seconds. An adult patient's pulse is 46 beats per minute. The term used to describe this rate is: A) tachycardia. B) bradycardia. C) weak and thready. D) sinus arrhythmia. - CORRECT ANSWER B) bradycardia. A heart rate of less than 50 beats per minute in an adult is bradycardia. A heart rate of greater than 90 beats per minute in an adult is tachycardia. Weak and thready describes the force of the pulse reflecting a decreased stroke volume. Sinus arrhythmia is a pulse that is irregular; the heart rate varies with the respiratory cycle. To perform an accurate assessment of respirations, the examiner should: A) inform the person of the procedure and count for 1 minute. B) count for 15 seconds while keeping fingers on the pulse and then multiply by four. C) count for 30 seconds after completing a pulse assessment and multiply by two. D) assess respirations for a full 2 minutes if an abnormality is suspected. - CORRECT ANSWER C) count for 30 seconds after completing a pulse assessment and multiply by two. Respirations should be counted for 30 seconds (if regular) and multiplied by two. The respirations should be counted after the pulse assessment. Patients have conscious control over respirations; the examiner should not mention that respirations will be counted. Avoid counting respirations for 15 seconds because the results can vary +4 or -4 with such a small number. Respirations should be counted for 1 minute if abnormalities are suspected. Data collection for the general survey begins: A) at the first encounter. B) at the beginning of the physical examination. C) while taking vital signs. D) during the mental status examination. - CORRECT ANSWER A) at the first encounter. The general survey is initiated at the first encounter with the patient. Which of the following statements regarding cultural/racial differences in the treatment of pain is true? A) White individuals receive more analgesic therapy than black or Hispanic individuals with similar symptoms. B) Black and Hispanic individuals have been found to have a higher pain tolerance than white individuals. C) Pain modulation is more highly developed in black and Hispanic individuals. D) Neurotransmitters are more concentrated in white individuals than in black and Hispanic individuals. - CORRECT ANSWER A)White individuals receive more analgesic therapy than black or Hispanic individuals with similar symptoms. Various studies describe how black and Hispanic patients are often prescribed less analgesic therapy than white patients, although most of these differences are small. No evidence supports anything else. What occurs during transduction (the first phase of nociceptive pain)? A) Pain signals move from the site of origin to the spinal cord. B) The pain impulse moves from the spinal cord to the brain. C) The brain interprets the pain signal. D) Chemical mediators are neutralized to decrease the perception of pain. - CORRECT ANSWER A) Pain signals move from the site of origin to the spinal cord. Transduction is the first phase of nociceptive pain. During this phase, injured tissue releases chemicals that propagate the pain message; an action potential moves along an afferent fiber to the spinal cord. During transmission (the second phase), the pain impulse moves from the level of the spinal cord to the brain. The third phase is perception; the person has conscious awareness of a painful sensation. In phase four, modulation, the neurons from the brainstem release neurotransmitters that block the pain impulse. Which of the following has been found to influence pain sensitivity in women? A) Age B) Hormonal changes C) Parity D) Weight - CORRECT ANSWER B) Hormonal changes Gender differences are influenced by societal expectation, hormones, and genetic makeup. Hormonal changes are found to have strong influences on pain sensitivity for women. Age has not been found to influence pain sensitivity in women. Parity has not been found to influence pain sensitivity in women. Weight has not been found to influence pain sensitivity in women. Neuropathic pain implies an abnormal: A) degree of pain interpretation. B) processing of the pain message. C) transmission of pain signals. D) modulation of pain signals. - CORRECT ANSWER B) processing of the pain message. Neuropathic pain results from abnormal processing of the pain message. Neuropathic pain does not adhere to the typical and predictable phases inherent in nociceptive pain. Which of the following is the most reliable indicator for chronic pain? A) Magnetic resonance imaging (MRI) results B) Patient self-report C) Tissue enzyme levels D) Blood drug levels - CORRECT ANSWER B) Patient self-report The most important and reliable indicator for chronic pain is the patient's self-report. Chronic pain is transmitted on a cellular level, and current technology such as MRI cannot reliably detect this process. Chronic pain is transmitted on a cellular level, and current technology such as tissue enzyme levels cannot reliably detect this process. Chronic pain is transmitted on a cellular level, and blood drug levels cannot reliably detect this process. Pain signals are carried to the central nervous system by way of: A) perception. B) afferent fibers. C) modulation. D) referred pain. - CORRECT ANSWER B) afferent fibers. Nociceptors carry the pain signal to the central nervous system by two primary sensory (or afferent) fibers. Perception indicates the conscious awareness of a painful sensation. Modulation inhibits the pain message producing an analgesic effect. Referred pain is pain felt at a particular site that originates from another location. An older adult patient with dementia has a pain rating of 5 on the Pain Assessment in Advanced Dementia (PAINAD) scale. The nurse should: A) reassess the pain level in 3 to 4 hours. B) administer prescribed pain medication. C) ask the patient to verify the pain rating. D) use only nonpharmacologic pain relief interventions. - CORRECT ANSWER B) administer prescribed pain medication. A patient with a pain score of 4 or greater on the PAINAD scale should receive pain intervention. Patients with dementia can be given an analgesic trial or option. The nurse should not wait an additional 3 to 4 hours for another pain assessment. A patient with dementia may say "no" if asked about having pain even if he or she is having pain. Words lose their meaning with dementia. Nonpharmacologic pain relief interventions can be implemented with or without prescribed pain medication. What is the source of deep somatic pain? A) Skin and subcutaneous tissues B) Bones and joints C) Pancreas D) Intestine - CORRECT ANSWER B) Bones and joints Deep somatic pain comes from the blood vessels, joints, tendons, muscles, and bones. Cutaneous pain is derived from skin surface and subcutaneous tissues. Visceral pain originates from the larger interior organs such as the pancreas. Visceral pain originates from the larger interior organs such as the intestine. What type of pain is short and self-limiting and dissipates after the injury heals? A) Chronic B) Persistent C) Acute D) Breakthrough - CORRECT ANSWER C) Acute Acute pain is short-term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals. Chronic pain lasts 6 months or longer; the pain persists after the predicted trajectory. Persistent pain is another term for chronic pain. Breakthrough pain starts again or escalates before the next scheduled analgesic dose. Specialized nerve endings that are designed to detect painful sensations are: A) synapses. B) dorsal horns. C) nociceptors. D) C fibers. - CORRECT ANSWER C) nociceptors. Nociceptors are specialized nerve endings designed to detect painful sensations from the periphery and transmit them to the central nervous system. A synapse is a region (or small gap) where nerve impulses are transmitted and received. The dorsal horn is a longitudinal subdivision of gray matter in the dorsal part of each lateral half of the spinal cord that receives terminals from some afferent fibers of the dorsal roots of the spinal nerves. C fibers are one of two primary sensory or afferent fibers that are unmyelinated and smaller; C fibers transmit the signal slowly. [Show More]

Last updated: 4 months ago

Preview 1 out of 35 pages