Regis NU304 Week 8 Quiz Latest 2018 November

NU304 Health Assessment in Nursing

Week 8 Quiz   

Question 1A 50-year old patient is seen in the clinic for annual physical examination and screening.  The patient has no known health problems.  This type of care is referred to as:

Select one:

 a.Tertiary prevention

 b.Healthy prevention

 c.Primary prevention

 d.Promotion prevention

Question 2A 62 year-old man states that his doctor told him that he has an “inguinal hernia”.  He asks the nurse to explain what a hernia is.  The nurse should:

Select one:

 a.Refer him to his physician for additional consultation because the physician made the initial diagnosis.

 b.Explain that a hernia is often the result of prenatal growth and abnormalities

 c.Explain that a hernia is a loop of bowel coming through a weak spot in the abdominal muscles

 d.Tell him not to worry and that most men his age develop hernias

Question 3A Nodule is:

Select one:

 a.Solid, elevated hard or soft mass, larger than 1 cm

b.Elevated cavity containing more than 1 cm of free fluid

 c.A hypertrophic scar

 d.A solid, elevated mass smaller than 1 cm

Question 4A normal pupillary light reflex indicates:

Select one:

 a.Light is reflected at the same spot in both eyes

 b.The eyes converge to focus on the light

 c.The eye focuses the image in the center of the pupil

 d.Constriction of both pupils occurs in response to bright light

 Question 5A nurse is assessing her patient with a diagnosis of dehydration.  How would the nurse assess the patient’s skin turgor?

Select one:

 a.Pinch a fold of skin on the patient’s abdomen

 b.Pinch a fold of skin on the patient’s cheek

 c.Pinch a fold of skin on the patient’s upper thigh

 d.Pinch a fold of skin on the patient’s forearm or dorsal surface of hand

Question 6A patient is anxious, dyspneic, pale and using accessory muscles to breathe.  The nurse should initially perform which type of assessment?

Select one:

 a.Acute assessment

b.General exam

 c.Health history

 d.Subjective assessment

Question 7A patient is unable to shrug her shoulders against the nurse’s resistant hands.  What cranial nerve is involved with successful shoulder shrugging?

Select one:

 a.XII (Hypoglossal)

 b.VII (Facial)

 c.XI (Spinal)

 d.IX (Glossopharygeal)

Question 8A patient presents with complaint of a popping sensation in front of his ears when he ‘s opening and closing his mouth.  To further examine this, the nurse would:

Select one:

 a.Place the stethoscope over the temporomandibular joint and listen for bruits.

 b.Place the hands over his ears and ask him to open his mouth “really wide”.

 c.Place one hand on his forehead and the other on his jaw and ask him to try to open his mouth.

 d.Place first and second fingers just anterior to the tragus of the patient’s ear and ask him to open and close his mouth.

Question 9A patient’s annual physical examination reveals a lateral curvature of the thoracic and lumbar segments of his spine standing and when forward bending.  This curvature indicates:

Select one:

 a.Kyphosis

 b.Scoliosis

 c.Lordosis

d.Herniated nucleus pulposus

Question 10A thorough skin assessment is very important because the skin holds information about:

Select one:

 a.Circulatory status

 b.Support systems

 c.Psychological wellness

 d.Socioeconomic status

Question 11Adventitious breath sounds are heard when auscultating a patient’s lungs.  Which of the following would be an important part of the subjective assessment of this patient?

Select one:

 a.Send the patient for a chest x-ray because this is indicative of a potentially serious condition

 b.Question the patient about his/her lifestyle regarding smoking habits

 c.No more information  is needed because adventitious breath sounds in the lower lobes are normal

 d.Assess the thoracic area both anterior and posterior again and have the patient cough prior to auscultation

Question 12After teaching a group of students about age-related changes in the lungs, the instructor determines that the teaching was successful when the students identify which of the following:

Select one:

 a.Increased functional capillaries

 b.Increased resiliency

 c.Loss of subcutaneous fat

 d.Loss of elasticity

Question 13

An elderly man has come in for a physical examination, he tells you that he has been ill with a productive cough for the past week.  This information would be written under the section that covers:

Select one:

 a.Mood and affect

 b.General survey

 c.Objective data

 d.History of present illness

Question 14 An important technique used when auscultating the thorax is moving the stethoscope back and forth from one side to the other.  This is done for:

Select one:

 a.Side to side comparison

b.Interspace by interspace comparison

 c.Posterior to anterior comparison

 d.Top to bottom comparison

Question 15Cyanosis or pallor occurs with:

Select one:

 a.Low cardiac output states as a result of decreased tissue perfusion

b. Increased heart rate in the person who is ambulatory during the day

 c.Elevation of the legs

 d.Increased fatigue from standing all day

Question 16During an assessment of a healthy adult, where would the nurse expect to palpate the point of maximal impulse (PMI)?

Select one:

 a.Fourth left intercostal space at the anterior axillary line

 b.Fourth left intercostal space at the sternal border

 c.Fifth left intercostal space at the midclavicular line

 d.Third left intercostal space at the midclavicular line

Question 17During an examination, the nurse notices that a patient is unable to stick out his tongue.  Which cranial nerve is involved with successful performance of this action?

Select one:

 a.IX (Spinal)

b.V (Trigeminal)

 c.IX (Glossopharyngeal)

 d.XII (Hypoglossal)

Question 18During the abdominal assessment, your patient is complains of tenderness along the costovertebral angle.  This is most often indicative of:

Select one:

 a.Liver enlargement

 b.Spleen enlargement

 c.Kidney inflammation

 d.Ovulation pain

Question 19During the examination of a patient, the nurse notes that the patient has several small, <1cm raised, solid lesions on her posterior thorax. What is another name for this type of lesion?

Select one:

 a.Freckles

 b.Bullas

 c.Nodules

 d.Papules

Question 20For the abdominal assessment, what are the last two assessment techniques?

Select one:

 a.Palpation – light and deep and percussion

 b.Percussion and assessing for CVA tenderness

 c.Auscultation and palpation – light and deep

 d.Percussion and palpation – light and deep

Question 21For the abdominal assessment, what is the second assessment technique?

Select one:

 a.Percussion

 b.Palpation, light and deep

 c.Inspection

 d.Auscultation

 Question 22For the abdominal assessment, what is the third assessment technique?

Select one:

 a.Auscultation

 b.Palpation – deep first and then light

 c.Palpation – light first and then deep

d.Percussion

Question 23For the abdominal

assessment, what is the first step to the assessment?

Select one:

 a.Percussion

 b.Inspection

 c.Auscultation

 d.Palpation

Question 24In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would:

Select one:

 a.Instruct patient to take slow, deep breaths during auscultation

 b.Auscultate with the bell of the stethoscope to assess for bruits

 c.Inspect while you instruct the patient to swallow a sip of water

 d.Palpate both arteries simultaneously to compare amplitude

Question 25In assessing the tonsils of a 24-year old patient, the nurse notes that the tonsils are erythematous with exudates bilaterally, and they are touching each other.  How would you grade the tonsils?

Select one:

 a.4+

 b.1+

 c.2+

 d.3+

Question 26In performing a breast examination, the nurse knows that it is especially important for the healthcare provider to examine the upper, outer quadrant of the breast (Tail of Spence). The reason for this is that the upper, outer quadrant is:

Select one:

 a.More prone to injury and calcifications than other locations in the breast

b.The largest quadrant of the breast

 c.The location of most breast tumors

 d.Where most of the suspensory ligaments attach

Question 27In performing an examination of a 2-year old with a suspected ear infection, the nurse would:

Select one:

 a.Pull the pinna down and back before inserting the speculum

 b.Omit the otoscopic exam if the child has a fever

 c.Ask the mother to leave the room while examining the child

 d.Pull the ear up and back before inserting the speculum

Question 28In performing auscultation of heart sounds, which sequence would the nurse use?

Select one:

 a.Aortic area – pulmonic area – Erb’s point – tricuspid area – mitral area

b.Aortic area – tricuspid area – Erb’s point – mitral area – pulmonic area

 c.Pulmonic area – aortic area – Erb’s point – tricuspid area – mitral area

 d.Pulmonic area – Erb’s point – tricuspid area – pulmonic area – mitral area

Question 29Select the best description of “review of systems” as part of the health history.

Select one:

 a.The recording of the objective findings of the practitioner

 b.A documentation of the problem as described by the patient

 c.A statement that describes the overall health state of the patient

 d.The evaluation of the past and present health state of each body system

Question 30The confrontation test is a gross measure of:

Select one:

 a.Eye strength and muscle movement

 b.Accommodation

 c.Visual acuity

 d.Peripheral vision

Question 31The main reason auscultation precedes percussion and palpation of the abdomen it to:

Select one:

 a.Determine areas of tenderness before using percussion and palpation

 b.Prevent distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation

 c.Allow the patient more time to relax and therefore be more comfortable with the physical examination

 d.Prevent distortion of bowel sounds that might occur after percussion and palpation

Question 32The nurse assesses a patient presenting with nausea, vomiting and diarrhea.  What initial assessment is most appropriate for this patient?

Select one:

 a.Palpate abdomen, percuss abdomen, auscultate heart

 b.Blood draw, auscultate lungs and auscultate heart

 c.Auscultate abdomen, palpate abdomen and check cranial nerves

 d.Vital signs and assessing for dehydration

Question 33The nurse is assessing a patient with left ear conductive hearing loss. During the assessment the nurse performs the Weber test.  The nurse knows that:

Select one:

a.Sound will be louder in the affected ear

 b.Sound will be diminished in both ears

 c.Sound will be louder in the good ear

d.Sound will lateralize equally in both ears

Question 34The nurse is caring for a patient with a nursing diagnosis of impaired skin integrity related to a stage III decubitus ulcer.  What would be the most important assessment tool for the nurse to use in caring for this patient?

Select one:

 a.The Braden Scale

b.The Visual analog Scale

 c.Brief Pain Inventory

 d.McGill Pain Questionnaire

Question 35The nurse is caring for an 88 year-old man hospitalized with a fractured hip.  Assessment findings indicate that the patient is malnourished.  In conducting a comprehensive dietary assessment during the history, what would be the method of choice for determining this patient’s dietary intake?

Select one:

 a.Direct observation

 b.Patient’s weight

 c.24-hour recall

 d.BMI

Question 36The nurse is palpating the lymph nodes of a 25-year old man and notes an enlarged node on the back of his neck near the hairline.  The nurse recognizes this lymph node as the:

Select one:

 a.Infraclavicular

 b.Posterior cervical

 c.Submental

 d.Occipital

Question 37The nurse knows that bronchovesicular breath sounds are:

Select one:

 a.Expected near the major airways

 b.Similar to bronchial sounds except that they are shorter in duration

 c.Usually pathological

 d.Musical in quality

Question 38The sinuses that are not accessible to palpation include:

Select one:

 a.Occipital and mental

 b.Frontal and maxillary

 c.Ethmoid and sphenoid

d.Parotid and jugulodigastric

Question 39When assessing for CVA tenderness, you would tap on:

Select one:

 a.Area of the back overlying the kidneys

 b. Scapula area of posterior thorax

 c.Left lower quadrant

 d.Right upper quadrant

Question 40When assessing the lower extremities, it is critical for the examiner to:

Select one:

 a.Evaluate the venous system and then the arterial system

 b.Start at the femoral area

 c.Start at the head and work his/her way down

 d.Compare side to side

Question 41When assessing the range of motion of the wrist, the nurse asks the patient to move their forearms  so that the hands are facing up.  This movement would create a position known as:

Select one:

 a.Supination

b.Palmation

 c.Inversion

 d.Pronation

Question 42When listening to heart sounds, the nurse knows that which of the following statements concerning S1 is true?

Select one:

 a.S1 is caused by closure of the pyloric valve

 b.S1 is louder than S2 at the base

 c.S1 results from the closure of mitral and tricuspid valves

d.S1 indicates the beginning of diastole

 Question 43When one is testing the triceps reflex, what is the expected response?

Select one:

 a.Extension of the forearm

 b.Pronation of the hand

 c.Flexion and rotation of the forearm

 d.Flexion of the hand and wrist

Question 44When palpating the abdomen of a 20-year old patient, the nurse notes the presence of tenderness in the left, upper quadrant with deep palpation.  Which of the following structures is most likely to be involved?

Select one:

 a.Gallbladder

b.Spleen

 c.Sigmoid

d.Appendix

Question 45When performing the corneal light reflex assessment, the nurse notes that the light is reflected in the same spot in each eye.  The nurse would:

Select one:

 a.Document this as an asymmetric light reflex

 b.Refer the individual for further evaluation

 c.Consider this a normal finding

 d.Perform the confrontation test to validate the findings

Question 46When the nurse asks a 68-year old patient to stand with feet together and arms at his side with his eyes

closed, he starts to sway and moves his feet further apart.  The nurse would document this finding as:

Select one:

 a.Positive Romberg’s sign

b.Negative Homan’s sign

 c.Lack of coordination

 d.Positive Pronator drift

Question 47Which of the following are appropriate locations for eliciting reflexes?

Select one:

 a.Femoral and Popliteal

 b.Abdominal and Thoracic area

 c.Scapular and Femoral

 d.Patellar and Achilles

Question 48Which of the following cranial nerves are used to assess swallowing, voice, gag reflex and tongue movement?

Select one:

 a.CN IX, X XI

 b.CN VII, X, IX

 c.CN IX, X, XII

 d.CN VII, X, XI

Question 49Which of the following statements would be considered subjective data?

Select one:

 a.Thyroid palpable

b.Rash after a bee sting

 c.Denies edema or difficulty breathing after bee sting

 d.Suggest allergy work-up for bee sting allergy

Question 50You are describing how to perform a testicular self examination to a patient.  Which of the following statements is most appropriate?

Select one:

 a.A good time to examine your testicles is just before you take a shower

 b.If you notice enlarged testicles or a painless mass, call your healthcare provider

 c.The testicle is egg shaped and movable.  It feels firm and has a lumpy consistency

 d.Perform testicular exam at least once a week to detect early stages of testicular cancer