Quiz
Chapter 25: Health Assessment
Perguntas do quiz (24)
1A home health care nurse takes the vital signs of a patient who is receiving supplemental oxygen at home for chronic obstructive pulmonary disease (COPD). This is the nurse's fourth visit to the patient's home. The nurse records the data collected on the patient's chart. What type of assessment has this nurse performed?
- AComprehensive
- BOngoing partial assessment
- CFocused assessment
- DEmergency assessment
2A nurse caring for patients in a long-term care facility is performing a functional assessment of a new patient. Which questions would the nurse ask?
- AAre you able to dress yourself?
- BDo you have a history of smoking?
- CWhat is the problem for which you are seeking care?
- DDo you prepare your own meals?
- EDo you manage your own finances?
- FWhom do you rely on for support?
3A nurse is assessing a patient's eyes for extraocular movements. Which actions correctly describes a step the nurse would take when performing this test?
- AAsk the patient to sit about 3 feet away facing the nurse
- BKeep a penlight about one foot from the patient's face and move it slowly through the cardinal positions
- CMove a pen light in a circular motion in front of the patient's eyes
- DAsk the patient to cover one eye with a hand or index card
4Which actions will the nurse perform when using the technique of palpation during the physical assessment of a patient?
- AThe nurse compares the patient's bilateral body parts for symmetry
- BThe nurse takes a patient's pulse
- CThe nurse touches a patient's skin to test for tugor
- DThe nurse checks a patient's lymph nodes for swelling
- EThe nurse taps a patient's body to check the organs
- FThe nurse uses a stethoscope to listen to a patient's heart sounds
5When inspecting the skin of a patient who has cirrhosis of the liver, the nurse notes that the skin has a yellow tint. What would the nurse document related to this finding?
- AJaundice
- BCyanosis
- CErythema
- DPallor
6After inspecting the skin of a patient, the nurse documents the presence of a skin lesion as a palpable solid mass measured at 1cm. What types of skin lesions might this describe?
- AMacule
- BPatch
- CPlaque
- DNodule
- EBulla
- FPustule
7A patient's visual acuity is assessed as 20/40 in both eyes using the Snellen chart. The nurse interprets this finding as
- AThe patient can see twice as well as normal
- BThe patient has double vision
- CThe patient has less than normal vision
- DThe patient has normal vision
8When assessing a patient's breath sounds, the nurse hears a high-pitched continuous sound. What type of breath sound would the nurse document?
- ARhonchi
- BCrackles
- CStridor
- DWheezes
9A nurse is using the FOUR Coma Scale to assess the neurologic status of a patient following surgery to remove a brain tumor. The nurse rates the patient as M2 for motor response. What condition does this number represent.
- ALocalizing to pain
- BFlexion response to pain
- CExtension response to pain
- DNo response to pain
10A nurse auscultates the thorax and lungs and hears coarse, low-pitched, continuous sounds on expiration. When the patient coughs, the sound clear up somewhat. The nurse would document these sounds as
- AAdventitious breath sounds
- BBronchovesicular breath sounds
- CVesicular breath sounds
- DBronchial sounds
11A nurse is assessing a patient's yese for accommodation. What actions would the nurse perform during this test?
- ABring a penlight from the side of the patient's face and briefly shine the light on the pupil
- BHold a forefinger, a pencil, or other straight object about 10 to 15 cm (4" to 6") from the bridge of the patient's nose.
- CHold a finger about 6" to 8" from the bridge of the patient's nose
- DDarken the room
- EAsk the patient to look straight ahead
- FAsk the patient to first look at a close object, then at a distant object, then back to the close object
12A nurse is palpating the breast of a woman during an assessment. Which technique is performed correctly?
- AThe nurse starts at the tail of Spence and moves in increasing smaller circles
- BThe nurse uses the palms of the hands to gently compress the breast tissue against the chest wall
- CThe nurse works in a counterclockwise direction and palpates from the periphery toward the areola
- DThe nurse starts at the inner edge of the breast and palpates up and down the breast
13During a physical assessment, a nurse inspects a patient's abdomen. What assessment technique would the nurse perform next?
- APercussion
- BPalpation
- CAuscultation
- DWhichever is more comfortable for the patient
14A nurse is assessing the level of consciousness of a patient who sustained a head injury in a motor vehicle accident. The nurse notes that the patient appears drowsy most of the time but makes spontaneous movements. The nurse is able to wake the patient by gently shaking him and calling his name. What level of consciousness would the nurse document?
- AAwake and alert
- BLethargic
- CStuporous
- DComatose
15A nurse is conducting an assessment of a patient's cranial nerves. The nurse asks the patient to raise the eyebrows, smile, and show the teeth to assess which cranial nerve?
- AOlfactory
- BOptic
- CFacial
- DVagus
16The acute care nurse is assessing a newly admitted client's abdomen. Which of the following findings would indicate the need to contact the primary care provider?
- APercussion of tympanic sounds over the intestines
- Bauscultation of a bruit
- Cpercussion of dull sounds over the right upper quadrant
- Dauscultation of peristalsis sounds
17A nursing student is getting ready to palpate a client's peripheral pulses. Which of the following pulses should be included?
- ARadial
- BPosterior tibial
- CBrachial
- DPopliteal
- EFemoral
- FDorsalis pedis
18A grating feel and noise with joint movement, particularly in the temperomandibular joint is called what?
- Acrepitus
- Bfremitus
- Cinflammation
- Darthritis
19A nurse performing physical assessments of residents in a long-term care facility describes to the student nurse common head and neck variations in the older adult. Which of the following accurately defines these variations?
- ADecrease color and peripheral vision
- BIncrease adaptation to light and dark
- CEntropion and/or ectropion
- DA blue ring around the cornea (arcus senilis)
- EImpaired conductive hearing
20A nurse auscultates the right carotid artery in an older adult client and identifies a bruit. What does this assessment finding mean?
- ANormal
- BInflamed
- CDissecting
- DDistended
21What respiratory sound indicates an upper airway obstruction?
- AFremitus
- BDyspnea
- CWheeze
- DStridor
22When performing an abdominal assessment, the nurse uses a different order of techniques than with other systems. Which of the following represents this order?
- AInspection, auscultation, percussion, palpation
- Bpalpation, percussion, inspection, auscultation
- Cpercussion, auscultation, inspection, palpation
- DInspection, palpation, percussion, auscultation
23Which of the following senses is used when the nurse performs the inspection phase of assessments?
- Asmell
- Btaste
- Chearing
- Dtouch
- Esight
24You are palpating a client's precordium. Which of the following is an expected clinical finding?
- APalpable heave over the pulmonic area
- BPalpable vibration over the right sternal border
- CPalpable pulsation over the right mitral area
- DPalpable thrill over the aortic area
Informações
- Descrição
- Unit VI: Actions Basic to Nursing Care Chapter 25: Health Assessment
- Autor
- Alexandra Bozan
- Idioma
- English
- Visualizações
- 114
- Etiquetas
- Avaliação
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