TEST BANK for Essential Health Assessment 1st Edition by Janice Thompson ISBN 9780803669871. (All 24 by StudyGuide

Chapter 1: Understanding Health Assessment

1. The World Health Organization (WHO) established a global strategy called “Health for All.” The goal for this strategy is: 1. All individuals to get the same health care throughout their life spans. 2. The government to supply money to care for all the people in the world. 3. Resources for health care to be evenly distributed and accessible. 4. Health-care providers can never deny patients health care.

2. Health assessment is a foundational and priority nursing skill. This essential skill requires registered nurses (RNs) to: 1. Diagnose and treat patients. 2. Identify normal and abnormal findings. 3. Refer patients with abnormal findings. 4. Counsel patients with psychosocial needs.

3. You are assessing a patient with five gunshot wounds on a trauma unit. There is a police presence outside his door because theGRADESMORE.COM patient is a known drug dealer in the community. You know that nurses must treat all patients as persons. This is called: 1. Caring. 2. Holistic process. 3. Person-centered care (PCC). 4. Standards of care.

4. The science-based framework updated every 10 years by the U.S. Department of Health and Human Services that has set national goals and objectives for health promotion and disease prevention is: 1. Healthy People. 2. Healthy People 2020. 3. U.S. Preventive Task Force. 4. World Health Organization.

5. A 38-year-old male has a family history of colon cancer. His father died of colon cancer at age 48. The doctor recommended that this patient have a colonoscopy this year. This is an example of: 1. Primary health prevention.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. Secondary health prevention. 3. Tertiary health prevention.

6. A patient in the hospital puts on his call light and tells the person answering that he “thinks he is running a fever and has stomach discomfort.” You are the registered nurse in charge. What should you do? 1. Ask the medical assistant to go to the patient’s room and assess his complaints. 2. Go check to see if the patient has an order for Tylenol for a fever. 3. Page the resident on call immediately to assess the patient. 4. Go to the patient’s room and assess for fever and the epigastric discomfort.

7. You are leading an interdisciplinary team conference to discuss how to provide better care for a challenging patient who has behavioral problems. There are several areas that need to be problem solved and new ideas formulated to create an improved plan of care. What cognitive skills are you using? 1. Critical thinking 2. Clinical decision making 3. Intuitive thinking GRADESMORE.COM 4. Clinical reasoning

8. Best practice assessment techniques and instruments have been validated by: 1. American Nurses Association. 2. Code of Ethics for Nurses With Interpretive Statements. 3. Research and evidence-based practice. 4. Patient Protection and Affordable Care Act.

9. Health and illness are determined by many factors. What are the determinants of health identified by the Centers for Disease Control and Prevention (CDC)? Select all that apply. 1. Genetics and biology 2. Gender and occupation 3. Individual behavior 4. Social environment 5. Physical environment 6. Health services

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

10. The U.S. health-care system is evolving, and care is becoming more focused on which of the following? Select all that apply. 1. Wellness 2. Functional status 3. Disease prevention 4. Health promotion 5. Acute illness management

11. You are performing a health assessment on a 32-year-old female patient who reports “feeling fatigued all the time.” She states, “I have not had a physical in over 8 years because I did not have medical insurance.” The patient will be having a physical today. What will be part of the health assessment? Select all that apply. 1. Collecting data on past health 2. Collecting data on present health 3. Collecting data on significant other’s health 4. Assessing factors influencing health 5. Performing a physical examination

12. You are working with a patient as a copartner in care. The patient has multiple medical problems. Put the following steps of GRADESMORE.COM the nursing process in the correct order (1–5). (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234.) 1. Planning 2. Evaluation 3. Assessment 4. Implementation 5. Diagnosis

14. The four techniques of health assessment include inspection, palpation, percussion, and .

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers 1. The World Health Organization (WHO) established a global strategy called “Health for All.” The goal for this strategy is: 1. All individuals to get the same health care throughout their life spans. 2. The government to supply money to care for all the people in the world. 3. Resources for health care to be evenly distributed and accessible. 4. Health-care providers can never deny patients health care. ANS: 3 Page: 1

1. 2. 3. 4.

Feedback This is incorrect. “Health for All” does not mean that all individuals get the same health care throughout their life spans. This is incorrect. “Health for All” does not mean the government will supply money to care for all the people in the world. This is correct. “Health for All” means that resources for health care are evenly distributed and accessible to everyone. This is incorrect. “Health for All” does not mean that health-care providers can deny patients health care.

GRADESMORE.COM 2. Health assessment is a foundational and priority nursing skill. This essential skill requires registered nurses (RNs) to: 1. Diagnose and treat patients. 2. Identify normal and abnormal findings. 3. Refer patients with abnormal findings. 4. Counsel patients with psychosocial needs. ANS: 2 Page: 5-6

1. 2. 3. 4.

Feedback This is incorrect. The role of the RN is not to diagnose and treat patients. This is correct. Assessing patients and being able to identify normal from abnormal findings is an essential role of the RN. This is incorrect. RNs in collaboration with the health-care providers do refer patients. This is not the essential and foundational role in health assessment. This is incorrect. RNs do counsel patients, but it is not the essential and foundational role in health assessment.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. You are assessing a patient with five gunshot wounds on a trauma unit. There is a police presence outside his door because the patient is a known drug dealer in the community. You know that nurses must treat all patients as persons. This is called: 1. Caring. 2. Holistic process. 3. Person-centered care (PCC). 4. Standards of care. ANS: 3 Page: 2

1. 2. 3. 4.

Feedback This is incorrect. Caring is displaying a concern for patients. This is incorrect. The holistic caring process is a relational process; the nurse collaborates with the individual to pursue goals for health and well-being. This is correct. The new movement in health care is person-centered care (PCC), which emphasizes the intrinsic value of treating all patients as persons. This is incorrect. Standards of care identify standards of professional nursing practice.

4. The science-based framework updated every 10 years by the U.S. Department of Health and Human Services that has set nationalGgR oA alD s aEnS dMoO bjR ecEti. veCsOfoMr health promotion and disease prevention is: 1. Healthy People. 2. Healthy People 2020. 3. U.S. Preventive Task Force. 4. World Health Organization. ANS: 2 Page: 2

1. 2.

Feedback This is incorrect. Healthy People is the general title for the nation’s federal initiative. This is correct. Healthy People 2020 specifically identifies science-based, national goals and objectives with 10-year targets designed to guide national health promotion and disease prevention efforts to improve the health of all people in the United States. This is incorrect. The U.S. Preventive Services Task Force’s goal is to use evidencebased medicine to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications. This is incorrect. The World Health Organization is a specialized agency of the United Nations working to improve the health of the world’s people.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 2 Page: 4

2. 3.

Feedback This is incorrect. This is not an example of primary prevention. Primary prevention is the prevention of disease and disability and focuses on improving an individual’s overall health and well-being. Immunizations and health education are examples of primary prevention. This is correct. Colonoscopy is an example of secondary prevention, which encompasses early screenings and detection of disease and treatment of diseases. This is incorrect. This is not an example of tertiary prevention. Tertiary prevention encompasses the restoration of health after illness or disease has occurred. A rehabilitation program for stroke patients is an example of tertiary prevention.

GRADESMORE.COM

1. 2. 3. 4.

Feedback This is incorrect. The medical assistant role should never be to assess a patient. This is incorrect. The first priority would be to assess the patient prior to checking medication orders for fever. This is incorrect. The nurse should first assess the patient to give an objective report to the resident. This is correct. Assessing a patient is always a priority role of the RN. This is a role that should never be delegated to the licensed practical nurse or unlicensed assistive personnel.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3.

Feedback This is correct. Critical thinking is a unique problem-solving, reflective process. This is incorrect. Clinical decision making determines what is needed and when it is needed. This is incorrect. Intuitive thinking is a “gut feeling” that something is wrong or that the nurse should do something, even if there is no real evidence to support that feeling. This is incorrect. Clinical reasoning uses an individual’s history, physical signs, RAdiagnostic DESMOREimaging .COM to arrive at a diagnosis and symptoms, laboratory data,Gand formulate a treatment plan.

Feedback This is incorrect. The American Nurses Association is the professional nursing organization providing standards of nursing care, promoting a safe and ethical work environment, and advocating health-care issues. This is incorrect. The Code of Ethics for Nurses With Interpretive Statements provides a statement of the ethical values and duties of every individual who enters the nursing profession. This is correct. Best practice assessments and instruments have been validated by research. Nursing research and evidence-based practice guide our assessments and

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

clinical decisions to provide safe and effective care. This is incorrect. The Patient Protection and Affordable Care Act, known as Obamacare, has goals to provide higher-quality, safer, and more affordable and accessible care.

1. 2. 3. 4. 5. 6.

Feedback This is correct. The CDC identifies genetics and biology (i.e., age and sex) as a determinant of health. This is incorrect. Occupation is not identified as a determinant of health. GRADESMORE.COM This is correct. The CDC identifies individual behavior (i.e., alcohol use, unprotected sex, smoking) as a determinant of health. This is correct. The CDC identifies social environment (i.e., income and lifestyle) as a determinant of health. This is correct. The CDC identifies physical environment (i.e., where the individual lives) as a determinant of health. This is correct. The CDC identifies health services (i.e., insurance and access to health care) as a determinant of health.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4. 5.

This is correct. The U.S. health-care system is evolving, and care is becoming more focused on wellness. This is incorrect. The U.S. health-care system is not becoming more focused on the individual’s functional status. This is correct. The U.S. health-care system is evolving, and care is becoming more focused on disease prevention. This is correct. The U.S. health-care system is evolving, and care is becoming more focused on health promotion. This is incorrect. The U.S. health-care system is becoming more focused on chronic illness management, not acute illness management.

GRADESMORE.COM

ANS: 1, 2, 4, 5, Page: 4

1. 2. 3.

4. 5.

Feedback This is correct. Data on past health will be collected and reviewed. This is correct. Data on present health will be collected and reviewed. This is incorrect. Data on a significant other’s health will not be included; however, discussing who the patient lives with may be discussed as part of the psychosocial history. This is correct. Factors influencing health and health promotion topics will be reviewed. This is correct. A physical examination will be done on this patient.

12. You are working with a patient as a copartner in care. The patient has multiple medical problems. Put the following steps of the nursing process in the correct order (1–5). (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234.) 1. Planning 2. Evaluation 3. Assessment 4. Implementation 5. Diagnosis

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 35142 Page: 5 Feedback: The five steps of the nursing process are as follows: Assessment is the first, essential step requiring the nurse to collect and analyze information about the whole individual. Diagnosis involves analyzing a patient’s potential or actual health problem. Planning/Outcomes involves working with the individual as a copartner in care to meet the needs or short- and long-term goals of the individual. Implementation of interventions includes the nursing and individual actions and plan of care to meet the individual’s goals. Evaluation is the ongoing process that assesses whether the short- and long-term goals have been met.

13. You are working on a medical surgical unit and are caring for a 24-year-old patient who is 3 hours post-op. The patient seems confused and restless since you assessed her an hour ago. You have a gut feeling that something is very wrong. This is an example of thinking. ANS: intuitive Page: 6 Feedback: Intuitive thinking is a “gut feeling” that something is wrong or that the nurse should RADESMtoOsupport RE.COthat M feeling. do something, even if there is no realGevidence

14. The four techniques of health assessment include inspection, palpation, percussion, and . ANS: auscultation Page: 6 Feedback: Assessment is a “doing” process. The four techniques of physical assessment are inspection (looking), palpation (using your hands to feel surface characteristics), percussion (tapping different areas of the body to assess underlying structures), and auscultation (listening for sounds).

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 2: Interviewing the Patient for the Health History

1. The nursing instructor is teaching a group of students the components of the health history interview. Which principles of behavior should the student remember when conducting a health assessment history? Select all that apply. 1. Remain sensitive. 2. Be nonjudgmental. 3. Give the appearance only of being genuine. 4. Demonstrate professional behaviors. 5. Show indifference.

2. In order to conduct effective assessments and health histories, the nurse must use a patientcentered approach using therapeutic communication. Which dimensions of patient-centered care should the nurse include? Select all that apply. 1. Empathy and compassion 2. Conditional regard 3. Genuineness 4. Respect 5. Caring

GRADESMORE.COM 3. A patient comes to the clinic for an annual examination. To prepare for the health history interview the nurse knows to include all of the following components EXCEPT (Select all that apply): 1. Reading the patient record as the health history is being conducted 2. Leaving the patient dressed until it is time to perform the physical assessment 3. Conducting the interview in a private place away from noise 4. Allowing a short, limited amount of time to conduct the interview 5. Standing at all times when talking to the patient.

4. The nurse is preparing to conduct a complete health history on a new patient who has just arrived at the walk-in clinic. The nurse is going to use the CLEAR mnemonic to collect information. What does CLEAR stand for? Select all that apply. 1. Center 2. Communicate 3. Listen 4. Empathy 5. Empower 6. Attention

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

7. Advocate 8. Respect

5. You are taking a health history on a patient who has not seen a health-care provider in many years. He states, “I do not want to be here, but my wife is forcing me to see this doctor. All doctors want to do is put patients on drugs!” You know that communication skills will be very important during this patient encounter. What is the purpose of communication? Select all that apply. 1. Share information. 2. Share and exchange thoughts and feelings. 3. Send data only. 4. Confirm patient complaints. 5. Make a diagnosis.

6. Communication is both verbal and nonverbal. The following are nonverbal visual cues to be aware of during an interview. Select all that apply. 1. Slouching in the chair 2. Frowning 3. No eye contact GRADESMORE.COM 4. Gestures 5. Age-appropriate appearance 6. Tone of voice 7. Crying and moaning

7. A patient and her husband arrive at the community health center for a follow-up assessment. The patient has recently had a stroke and is aphasiac. She understands what you are saying but is unable to talk. Which of the following nursing interventions should be followed? Select all that apply. 1. Ask the husband the best way to communicate with his wife. 2. Find a large blackboard to write your questions on. 3. Offer the patient a white board or paper and pen. 4. Speak slowly and loudly so the patient understands. 5. Communicate one question or sentence at a time.

8. Communication is a reciprocal conversation. Identify barriers to communication. Select all that apply. 1. Asking too many questions 2. Leading the patient

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. Silence 4. Offering false reassurance 5. Stereotyping 6. Summarizing

9. As the nurse prepares for a patient interview he or she recalls that effective communication includes which of the following? Select all that apply. 1. Avoid medical jargon. 2. Be authoritative. 3. Keep questions simple and clear. 4. Stand over the patient. 5. Avoid excessive note taking.

10. The mnemonic CLEAR is foundational for successful interviewing. The student nurse recognizes that this stands for which of the following terms? 1. Center, Listen, Empathy, Attention, and Respect 2. Calm, Listen, Empathy, Attention, and Respect 3. Center, Listen, Eye Contact, Attention, and Respect 4. Calm, Listen, Eye Contact, Attention, and Respect

GRADESMORE.COM 11. The nurse is conducting a health history interview and suspects that the patient may have a hearing deficit. Which consideration is most appropriate for the nurse to make? 1. Write down all questions for the patient. 2. Reduce any background noise in the room. 3. Speak quickly and use short, simple sentences. 4. Complete the health history as quickly as possible to reduce stress.

12. The patient has disclosed a visual impairment to the nurse. Which is the priority action for the nurse to remember before starting the physical assessment? 1. Speak clearly and loudly at all times during the assessment. 2. Acknowledge the patient by putting a hand on his or her shoulder. 3. Give short directions throughout the assessment. 4. Ask the patient how much he or she can see.

13. A patient’s culture can influence the interview process. The nursing student recognizes that which of the following is true about how culture can influence the interview process?

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. A patient may have different definitions and perceptions of health and illness. 2. A patient cannot refuse to discuss personal matters out of concern for privacy. 3. A patient may project his or her own cultural beliefs on the nurse. 4. A patient may try to portray the cultural beliefs of the nurse.

14. When conducting the interview, the nurse needs to determine the reliability of the data collected. Which primary source would be considered the most reliable for the health history information? 1. The patient who is alert and oriented to person, place, and time 2. The significant other who is answering all the questions 3. The patient’s medical record from the primary care provider 4. An interpreter who speaks the patient’s native language

15. The nurse is preparing to conduct a health history on a patient and organizes the interview in a head-to-toe sequence. Which type of health history is the nurse going to conduct? 1. Comprehensive 2. Focused 3. Problem-based 4. Follow-up

GRADESMORE.COM 16. The nurse is preparing to conduct a health history on a patient seen in the health clinic 2 days ago. Which type of health history is the nurse going to conduct? 1. Comprehensive 2. Focused 3. Problem-based 4. Follow-up

17. The nurse is preparing to conduct a health history on a patient being seen in the emergency room. Which type of health history is the nurse going to conduct? 1. Comprehensive 2. Focused 3. Basic 4. Follow-up

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

18. While conducting a health history during admission to the medical floor, the nurse asks the patient “Have you ever had surgery?” This question is an example of which type of communication technique? 1. Open-ended question 2. Closed question 3. Indirect question 4. Clarification question

19. The nursing student is learning how to use various therapeutic communication techniques. The student recognizes which of these as an example of confrontation? 1. “You look angry.” 2. “This must be very hard for you.” 3. “Do you feel worried about your dog?” 4. “How can I help you?”

20. You are completing a health history on a 32-year-old woman who is reporting that “she may have a problem using heroin and other drugs.” You are being attentive to the patient’s report and nonverbal cues. The patient is looking down as she is telling her story. What communication technique is the nurse demonstrating? 1. Silence GRADESMORE.COM 2. Respect 3. Active listening 4. Exploring

21. A home health nurse is assessing a 94-year-old patient with a severe cognitive impairment. The daughter with whom the patient lives states that her mom only eats less than half of all her meals. What will you document? 1. Patient is reliable. Cared for by her daughter. Eating half of her meals. 2. Report by daughter. Eating 50% of her meals. Patient lives with her daughter. 3. Patient is unreliable. Report by daughter. Patient is only eating less than 50% of each meal. 4. Patient is unreliable. Eating about 50% of each meal.

22. A nurse in the emergency department is completing an emergency assessment for a teenager just admitted for injuries from a motor vehicle accident. Which of the following documentations is a pertinent negative report? 1. “My leg hurts so bad. I can’t stand it.” 2. Denies headache and blurry vision. 3. Reports feeling nauseous and dizzy.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. “It wasn’t my fault. I couldn’t stop.”

23. Which question or statement would be the best approach to elicit further information when conducting a health history interview? 1. “Why didn’t you go to the doctor when you began to have this pain?” 2. “Are you feeling better now than you did during the night?” 3 “Tell me more about what you think is causing your pain.” 4. “You should not wait to get medical help next time.”

24. A resident at an assisted living facility comes to the nurse’s office and states, “My bowel movements have been fluctuating for the last 2 weeks.” How should the nurse respond? 1. “What do you mean by fluctuating?” 2. “Why don’t you use a laxative every night?” 3. “When was the last time that you moved your bowels?” 4. “Everyone experiences bowel problems as they age.”

25. During the summarization phase of the interview it is important to 1. Encourage the patient to tell his orGhRerAhDisEtoSrM yO ofRpEre.sC enOt M illness. 2. Complete documenting the data as told by the patient. 3. Clarify the patient’s report, needs, feelings, and concerns. 4. Ask the patient if he or she has any questions.

26. The nurse has completed a health history. Both objective and subjective information have been obtained during the assessment. Which is classified as subjective data? 1. Patient appears sleepy 2. No distress noted 3. Abdomen is soft and nontender 4. Patient states she feels anxious and tense

27. You are assessing a patient who does not seem to understand your questions and explanations. What should be your next action? 1. Continue on with the assessment. 2. Speak slowly and loudly so the patient can hear you. 3. Ask the patient if he or she understands what you are saying. 4. Omit the explanations and continue with the assessment.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

28. A patient is having his annual physical examination. You are doing a health history related to male breasts. You ask the patient if he has ever palpated his breasts. He responds, “I cannot believe that you asked me that question. I am not a woman and cannot get breast cancer.” The nurse responds, “You sound surprised. You don’t think that men can get breast cancer?” What type of communication technique is the nurse using? 1. Focusing 2. Facilitation 3. Reflecting 4. Exploring

29. Your patient reports that he thinks that he may have a problem with drinking too much beer. The nurse states, “So, do you drink about two beers every day?” What type of communication technique is this question? 1. Leading the patient 2. Transitional statement 3. Clarification 4. Exploring

GRADESMORE.COM 30. You are about to start the health history. The patient is present with his daughter. Which of the following priority steps should you take before you start the health history? 1. Organize your thoughts prior to the assessment. 2. Wash your hands in front of the patient. 3. Obtain permission from the patient for the daughter to be present. 4. Assess your professional appearance and demeanor.

31. The patient just had abdominal surgery and reports that she is feeling bloated and crampy. The nurse inspects her abdomen and finds it to be bloated. The nurse tells the patient, “You will feel better tomorrow.” This is an example of which communication technique? 1. Respect 2. Using clichés 3. Giving opinions 4. Using patronizing language

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Speak in simple, focused sentences. 2. Ask to have the television volume turned down. 3. Be descriptive when giving directions. 4. Use drawings and a white board to ask questions.

33. You are about to start an interview with the husband and wife present. The husband tells the nurse that his wife may not tell her everything that she needs to know. He states that in his wife’s culture, feelings are considered private and difficult to share. Sharing one’s feelings with others often creates a sense of vulnerability or is looked on as evidence of weakness. What culture is his wife? 1. Chinese heritage 2. German heritage 3. American Eskimo 4. Italian heritage

34. Which consideration should the nurse recognize as priority when interviewing the patient? 1. Gender 2. Socioeconomic status 3. Developmental level GRADESMORE.COM 4. Education

35. The patient is telling you that she is very upset because her mother passed away last month. She states, “I do not know how I am going to survive without my mom. I loved her so much.” The nurse says, “I am so sorry to hear about the passing of your mom. This must be a very difficult time for you.” What communication technique is the nurse demonstrating? 1. Empathy 2. Facilitation 3. Reflecting 4. Clarification

36. The hospital nurse is conducting the initial interview with a patient who does not speak the same language as the nurse. What is a general principle when finding an interpreter? 1. Direct all your questions to the interpreter without looking at the patient. 2. Use your resources to find a trained face-to-face interpreter. 3. If a family member is available, ask him or her to be the interpreter. 4. Ask all the questions first so the interpreter can then ask the patient all at once.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

37. As you enter the examination room to start the health history interview, the patient immediately starts yelling at you because he waited 45 minutes in the waiting room. He is angry and upset. You should: 1. Tell the patient to lower his voice and stop yelling. 2. Put your hand on the patient’s shoulder and tell him it will never happen again. 3. Not argue with the patient and be empathetic. 4. Tell the patient that you will be right back and go get the health-care provider.

38. The three phases of the interview, in order, are: 1) , and 3)

, 2) .

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers 1. The nursing instructor is teaching a group of students the components of the health history interview. Which principles of behavior should the student remember when conducting a health assessment history? Select all that apply. 1. Remain sensitive. 2. Be nonjudgmental. 3. Give the appearance only of being genuine. 4. Demonstrate professional behaviors. 5. Show indifference. ANS: 1, 2, 4 Page: 8

1. 2. 3.

Feedback This is correct. The exchange of information, feelings, and concerns takes place during the assessment process. The nurse should be sensitive to the patient’s report. This is correct. The exchange of information, feelings, and concerns takes place during the assessment process. The nurse should be nonjudgmental to the patient’s report. This is incorrect. The exchange of information, feelings, and concerns takes place during the assessment process. The nurse should not only give the appearance of being genuine but be authentically genuine during the health history. This is correct. The exchange of information, feelings, and concerns takes place during the assessment process. The nuGrR seAsD hoEuSldMdOeR mEo. nsCtrO atM e professionalism during the health history interview. This is incorrect. The exchange of information, feelings, and concerns takes place during the assessment process. The nurse should show interest and concern to the patient’s report.

Feedback This is correct. Therapeutic communication encompasses empathy and compassion during a health history interview. Empathy and compassion are a deep awareness of and

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

insight into the feelings, emotions, and behavior of another person and their meaning and significance. This is incorrect. Therapeutic communication encompasses unconditional regard, not conditional regard, during a health history interview. Unconditional regard means respecting and accepting a patient as a unique individual. This is correct. Therapeutic communication encompasses being genuine during a health history interview. Genuineness is being honest with the patient. This is correct. Therapeutic communication encompasses respect during a health history. Respect is a moral value. It demonstrates that you have a positive feeling for every patient and accept each patient as a person who has unique qualities. This is correct. Therapeutic communication encompasses caring during a health history. Caring is the essence of nursing and connotes responsiveness between the nurse and the patient.

3. A patient comes to the clinic for an annual examination. To prepare for the health history interview the nurse knows to include all of the following components EXCEPT (Select all that apply): 1. Reading the patient record as the health history is being conducted 2. Leaving the patient dressed until it is time to perform the physical assessment 3. Conducting the interview in a private place away from noise 4. Allowing a short, limited amount of time to conduct the interview 5. Standing at all times when talkingGtoRtAhD eE paStiM enOt.RE.COM ANS: 1, 4, 5 Page: 10

1. 2. 3. 4.

Feedback The nurse should not read the patient record during the health history interview. This should be done prior to seeing the patient. To provide for patient comfort, the nurse should leave the patient dressed until it is time to perform the physical assessment. To prevent distractions, the nurse should conduct the interview in a private place away from noise. The nurse should not have a short, limited amount of time to collect a thorough health history. The nurse should allow for plenty of time to conduct the interview so that the patient can answer all questions thoroughly. The nurse should not always stand when talking to the patient. The nurse should stand or sit at the level of the patient during the interview.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Center 2. Communicate 3. Listen 4. Empathy 5. Empower 6. Attention 7. Advocate 8. Respect ANS: 1, 3, 4, 6, 8 Page: 9

1. 2. 3. 4. 5. 6. 7. 8.

Feedback This is correct. The C in the CLEAR mnemonic in communication stands for center. CLEAR stands for Center, Listen, Empathy, Attention, and Respect. This is incorrect. The C in the CLEAR mnemonic in communication stands for center, not communicate. This is correct. The L in the CLEAR mnemonic in communication stands for listen. CLEAR stands for Center, Listen, Empathy, Attention, and Respect. This is correct. The E in the CLEAR mnemonic in communication stands for empathy. CLEAR stands for Center, Listen, Empathy, Attention, and Respect. This is incorrect. The E in the CLEAR mnemonic in communication stands for empathy, not empower. GRADESMORE.COM This is correct. The A in the CLEAR mnemonic in communication stands for attention. CLEAR stands for Center, Listen, Empathy, Attention, and Respect. This is incorrect. The A in the CLEAR mnemonic in communication stands for attention, not advocate. This is correct. The R in the CLEAR mnemonic in communication stands for respect. CLEAR stands for Center, Listen, Empathy, Attention, and Respect.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4. 5.

Feedback This is correct. The purpose of communication is to share content: the actual subject matter, words, gestures, and substance of the message. This is correct. The purpose of communication is to share and exchange thoughts, perceptions, and feelings. This is incorrect. The purpose of communication is not to only send data but to send, receive, and gather data. This is incorrect. The purpose of communication is not to confirm patient complaints but to share patient concerns. This is incorrect. Nurses do not diagnose patients.

6. Communication is both verbal and nonverbal. The following are nonverbal visual cues to be aware of during an interview. Select all that apply. 1. Slouching in the chair 2. Frowning 3. No eye contact 4. Gestures 5. Age-appropriate appearance 6. Tone of voice 7. Crying and moaning ANS: 1, 2, 3, 4, 6, 7 Page: 11

1. 2. 3. 4. 5. 6. 7.

GRADESMORE.COM

Feedback This is correct. Slouching in the chair is considered to be nonverbal body language. This is correct. Frowning is a facial expression and is considered to be nonverbal body language. This is correct. If the patient does not make eye contact, this is considered nonverbal body language. This is correct. Gestures are considered to be nonverbal body language. This is incorrect. Age-appropriate appearance is a general survey of the patient for objective data during a physical assessment. This is correct. A person’s tone of voice is nonverbal body language. This is correct. Nonverbal sounds such as crying or moaning are considered to be nonverbal body language.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. Find a large blackboard to write your questions on. 3. Offer the patient a white board or paper and pen. 4. Speak slowly and loudly so the patient understands. 5. Communicate one question or sentence at a time. ANS: 1, 3, 5 Page: 14 Difficulty:

4. 5.

Feedback This is correct. Asking too many questions is a barrier to communication because it increases the chances for misunderstanding what the patient is reporting. Only ask one question at a time for clarity and to disallow misunderstanding. This is correct. Leading the patient is a barrier to communication. When you lead patients, they may tell you what they want you to hear and may not always be truthful in their self-reports. This is incorrect. Silence is an effective communication technique. Refrain from speaking. Planned absence of verbal remarks allows the patient and the nurse to think over or feel what is being discussed. If silence does not prompt a response within 5 to 10 seconds, the interviewer should try another skill, as prolonged silence may make the patient feel uncomfortable. This is correct. Offering false reassurance is a barrier to communication. Never tell the patient that everything will be fine when it may not be. Em .uCnOicMation. Be objective during the This is correct. Stereotyping isGaRbAaD rrE ieS r tM oOcoRm assessment. Every patient is unique and should be respected regardless of race, religion, gender, sexual preference, or age. This is incorrect. Summarizing is an effective communication technique. State a brief summary at the end of the interview. This allows for clarification and accurate data of the patient’s history or problem.

Feedback This is correct. Effective communication includes avoiding medical terminology that may not be understood by the patient.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4. 5.

This is incorrect. Effective communication is not being authoritative during the patient encounter. Patients need to feel comfortable. Nurses should make sure that they have a shared understanding of the patient’s report, problems, and concerns. This is correct. Effective communication will keep the questions simple for clear understanding. This is incorrect. Standing over the patient can be intimidating. You should be either sitting or standing at the same level of the patient. This is correct. Nurses should avoid taking excessive notes and concentrate on listening to the patient and taking notes as needed.

GRADESMORE.COM

This is correct. The mnemonic CLEAR is foundational for successful interviewing. It stands for Center, Listen, Empathy, Attention, and Respect. This is incorrect. The mnemonic CLEAR is foundational for successful interviewing. It stands for Center, Listen, Empathy, Attention, and Respect. This is incorrect. The mnemonic CLEAR is foundational for successful interviewing. It stands for Center, Listen, Empathy, Attention, and Respect. This is incorrect. The mnemonic CLEAR is foundational for successful interviewing. It stands for Center, Listen, Empathy, Attention, and Respect.

11. The nurse is conducting a health history interview and suspects that the patient may have a hearing deficit. Which consideration is most appropriate for the nurse to make? 1. Write down all questions for the patient. 2. Reduce any background noise in the room. 3. Speak quickly and use short, simple sentences. 4. Complete the health history as quickly as possible to reduce stress. ANS: 2 Page: 13

Feedback This is incorrect. The patient has a hearing deficit, not total hearing loss. You do not

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3. 4.

need to write down all questions for the patient. This is correct. You should reduce background noise for a patient who is hard of hearing. This is incorrect. Face the patient and speak slowly and clearly. You should use short and simple sentences for a patient who is hard of hearing. This is incorrect. You should not complete the health history as quickly as possible because the patient who is hard of hearing requires extra time. Allow for extra time and do not rush the assessment.

1. 2. 3. 4.

Feedback This is incorrect. The patient has a visual impairment, not a hearing impairment. You do GRADESMORE.COM not need to speak loudly. This is incorrect. You should always ask permission first before touching a visually impaired patient. This is incorrect. You should be descriptive when giving directions to a visually impaired patient. This is correct. Introduce yourself and explain the purpose and sequence of the patient assessment. Ask the patient: “How much can you see?”

13. A patient’s culture can influence the interview process. The nursing student recognizes that which of the following is true about how culture can influence the interview process? 1. A patient may have different definitions and perceptions of health and illness. 2. A patient cannot refuse to discuss personal matters out of concern for privacy. 3. A patient may project his or her own cultural beliefs on the nurse. 4. A patient may try to portray the cultural beliefs of the nurse. ANS: 1 Page: 15-16

Feedback This is correct. A patient’s culture can influence the interview process. A patient may have different definitions and perceptions of health and illness.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3 4.

This is incorrect. A patient can refuse to discuss personal matters out of concern for privacy. This is incorrect. A patient cannot project his or her own cultural beliefs on the nurse. This is incorrect. The patient would not know the cultural beliefs of the nurse and therefore could not portray the cultural beliefs of the nurse.

3. 4.

Feedback This is correct. When conducting the interview, the nurse needs to determine the reliability of the data collected. The most reliable person is the patient, as long as the patient is cognitively intact. GRADESMORE.COM This is incorrect. When conducting the interview, the nurse needs to determine the reliability of the data collected. A significant other who is answering all the questions is a secondary source. The most reliable source in this case is the patient who is alert and oriented. This is incorrect. When conducting the interview, the nurse needs to determine the reliability of the data collected. The patient’s medical record is a secondary source. This is incorrect. When conducting the interview, the nurse needs to determine the reliability of the data collected. The most reliable person is the patient, as long as the patient is cognitively intact. There is no indication in the scenario that an interpreter is needed.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3.

Feedback This is correct. A comprehensive health history looks at the whole patient and reviews all body systems. This health history takes time. This is incorrect. A focused health history focuses specifically on an acute problem or symptom that the patient is experiencing. This is incorrect. A problem-based health history is the same as a focused health history, which focuses specifically on an acute problem or symptom that the patient is experiencing. This is incorrect. A follow-up health history occurs after a patient has been seen and concentrates on new data since the last history.

16. The nurse is preparing to conduct a health history on a patient seen in the health clinic 2 days ago. Which type of health history is the nurse going to conduct? 1. Comprehensive 2. Focused 3. Problem-based 4. Follow-up ANS: 4 Page: 18

1. 2. 3. 4.

GRADESMORE.COM Feedback This is incorrect. The comprehensive health history looks at the whole patient and reviews all body systems, head to toe. This is incorrect. The focused health history focuses specifically on an acute problem or symptom that the patient is experiencing. This is incorrect. The problem-based health history focuses specifically on an acute problem or symptom that the patient is experiencing. This is correct. The follow-up history occurs after a patient has been seen and is concentrated on new data since the last history.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

This is incorrect. The patient is presenting at the emergency room with a specific complaint. The health history will focus on the health problem. Comprehensive health history looks at the whole patient and reviews all body systems, head to toe. This is correct. Because this patient is presenting at the emergency room with a specific symptom, a focused or problem-based health history focuses specifically on an acute problem or symptom that the patient is experiencing. This is incorrect. A basic health history is too generalized. The health history needs to focus on the specific problem. This is incorrect. The patient needs a focused health history related to the reason for seeking care. A follow-up history occurs after a patient has been seen and concentrates on new data since the last history.

2. 3. 4.

GRADESMORE.COM

Feedback This is incorrect. This is an example of a closed or direct question. This type of question is used by the nurse to obtain specific information. Open-ended questions are used for collection of narrative information and are not answered with a one- or two-word response. This is correct. This is an example of a closed or direct question. This type of question is used by the nurse to obtain specific information. This is incorrect. This is not an indirect question. The question is a focused or direct question to identify specific information. This is incorrect. This is not a clarification question. Clarification questions are used to clarify responses that are ambiguous or confusing, or to summarize a person’s words to ensure that the interviewer is on the right track.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 1 Page: 12

2. 3. 4.

Feedback This is correct. This is an effective communication technique that best demonstrates a confrontation statement: “You look angry.” Give the patient honest and respectful feedback about what you see or hear that is inconsistent with what the patient is telling you. This is incorrect. The statement “This must be very hard for you” is an example of empathy. This is incorrect. The question “Do you feel worried about your dog?” is an example of reflection. This is incorrect. “How can I help you?” is an example of an open-ended question.

20. You are completing a health history on a 32-year-old woman who is reporting that “she may have a problem using heroin and other drugs.” You are being attentive to the patient’s report and nonverbal cues. The patient is looking down as she is telling her story. What communication technique is the nurse demonstrating? 1. Silence 2. Respect GRADESMORE.COM 3. Active listening 4. Exploring ANS: 3 Page: 12

2. 3.

Feedback This is incorrect. The patient is speaking and telling her story. Silence is refraining from speaking. Planned absence of verbal remarks allows the patient and the nurse to think over or feel what is being discussed. This is incorrect. There are no respectful comments in this scenario. The patient is telling her story. This is correct. The communication technique of active listening pays close attention to the patient’s report and nonverbal cues. The nurse will maintain good eye contact and express a willingness to listen. This is incorrect. The nurse is not encouraging the patient to give more details in this scenario.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Patient is reliable. Cared for by her daughter. Eating half of her meals. 2. Report by daughter. Eating 50% of her meals. Patient lives with her daughter. 3. Patient is unreliable. Report by daughter. Patient is only eating less than 50% of each meal. 4. Patient is unreliable. Eating about 50% of each meal. ANS: 3 Page: 18

1. 2. 3.

Feedback This is incorrect. The patient has severe cognitive impairment and is not reliable. This is incorrect. Reliability is not documented in this statement. This is correct. Some patients may be unreliable because of decreased cognitive ability or mentation. Secondary sources will be needed to provide information for the health history. If this occurs, document: “Patient is unreliable. Report by patient’s daughter.” This is incorrect. The daughter is a secondary source and this needs to be documented. Also, the patient is eating less than half her meals.

1. 2. 3. 4.

Feedback This is incorrect. The report of pain as a symptom is a pertinent positive. This is correct. Patient denial of specific symptoms are pertinent negatives. This is incorrect. A report of feeling nauseous is a pertinent positive. This is incorrect. This is neither a pertinent positive nor pertinent negative. The patient is trying to tell someone that the motor vehicle accident was not his fault.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 3 Page: 12 Difficulty: Moderate

2. 3.

Feedback This is correct. This question is seeking clarification of the word “fluctuating.” Obtain clarification if the patient does not clearly express the problem or issue and you are confused about what the patient is saying to you. This is incorrect. This is a barrier to communication. The nurse needs to further assess the patient’s constipation. The patient is not clear by what she means by “fluctuating.” This is incorrect. Determining the onset of the constipation is important, but the patient is not clear by what she means by “fluctuating.” It could mean that she has periods of diarrhea and periods of constipation. This is incorrect. This is a barrier communication technique. This is stereotyping older adults.

25. During the summarization phase of the interview it is important to 1. Encourage the patient to tell his or her history of present illness. 2. Complete documenting the data as told by the patient. 3. Clarify the patient’s report, needs, feelings, and concerns. 4. Ask the patient if he or she has any questions.

GRADESMORE.COM

ANS: 3 Page: 17

1. 2. 3. 4.

Feedback This is incorrect. Encouraging the patient to tell his or her history of present illness is done during the working phase of the interview. This is incorrect. Completing documenting the data as told by the patient is done after the interview is finished. This is correct. Clarifying the patient’s report, needs, feelings, and concerns is completed during the summarization phase. This is incorrect. Asking the patient if he or she has any questions is done at the end of the working phase.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 4 Page: 16

1. 2. 3. 4.

Feedback This is incorrect. This is objective data because you are making an observation that the patient is sleepy. This is incorrect. This is objective data because you are making an observation that the patient is not in distress. This is incorrect. This is objective data because you are making an observation that the abdomen is soft and nontender. This is correct. Subjective data is defined as: what the person says about himself or herself. Of the responses above, patient states she feels anxious and tense is the only subjective statement. All other responses are objective.

GRADESMORE.COM

ANS: 3 Page: 15

2. 3. 4.

Feedback This is incorrect. You should first establish whether the patient understands what you are saying or explaining. If the patient does not understand, an alternative approach would be recommended. This is incorrect. It does not appear that the patient is hard of hearing. If the patient does not understand, the nurse should speak in very simple and clear language. This is correct. You do not want to assume that the patient does not understand. He or she may be illiterate. The best action is to ask the patient to confirm your suspicion. This is incorrect. Explanations should not be omitted. The patient should be a co-partner in care and the nurse should use an alternative approach to help the patient understand.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. Reflecting 4. Exploring ANS: 3 Page: 12

1. 2.

Feedback This is incorrect. This is not a focused question. Focusing asks specific questions to collect and clarify data that the patient may not be stating during the interview. This is incorrect. This is not facilitation. Facilitation uses simple verbal statements or words to encourage the patient to continue to tell the story. Use statements like “uhhuh,” “Mmmm,” or “Tell me more about …” This is correct. Reflecting or stating the observed repeats the patient’s words specifically to encourage elaboration of the patient’s self-report. This encourages more discussion. This is incorrect. This is not exploring. Exploring encourages the patient to give you more details.

29. Your patient reports that he thinks that he may have a problem with drinking too much beer. The nurse states, “So, do you drink about two beers every day?” What type of communication technique is this question? GRADESMORE.COM 1. Leading the patient 2. Transitional statement 3. Clarification 4. Exploring ANS: 1 Page: 13

2. 3. 4.

Feedback This is correct. The nurse is leading the patient by putting numbers on the number of beers the patient may drink. Do not lead the patient. Patients tell you what they want you to hear and may not always be truthful in their self-reports. This is incorrect. This is not a transitional statement. Transitional statements help direct the interview to another significant area. This is incorrect. This is not a clarification question. A clarification question would ask, “What do you mean that you are drinking too much beer?” This is incorrect. This is not an exploring question. An exploring question or statement would ask, “Tell me more about how much beer you drink.”

30. You are about to start the health history. The patient is present with his daughter. Which of the following priority steps should you take before you start the health history?

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Organize your thoughts prior to the assessment. 2. Wash your hands in front of the patient. 3. Obtain permission from the patient for the daughter to be present. 4. Assess your professional appearance and demeanor. ANS: 3 Page: 17

Feedback This is incorrect. This is not the priority step prior to taking the health assessment. Because the patient has his daughter present, the priority step is to obtain permission for the daughter to be present. This is incorrect. This is not the priority step prior to taking the health assessment. Because the patient has his daughter present, the priority step is to obtain permission for the daughter to be present. This is correct. If family members are present during the interview, the nurse should clarify who is present rather than assume it is the wife, daughter, parent, or significant other. It is the nurse’s responsibility to obtain permission from the patient for the family members to be present and participate in the interview process. This is incorrect. This is not the priority step prior to taking the health assessment. Because the patient has his daughter present, the priority step is to obtain permission for the daughter to be present.

GRADESMORE.COM 31. The patient just had abdominal surgery and reports that she is feeling bloated and crampy. The nurse inspects her abdomen and finds it to be bloated. The nurse tells the patient, “You will feel better tomorrow.” This is an example of which communication technique? 1. Respect 2. Using clichés 3. Giving opinions 4. Using patronizing language ANS: 2 Page: 13 Feedback 1. 2. 3. 4.

This is incorrect. This is not showing respect. This statement is minimizing the symptoms the patient is feeling. This is correct. Clichés (e.g., “You will feel better tomorrow”) show disregard for the patient’s feelings. This is giving false reassurance. This is incorrect. This statement is not giving your opinion. The patient did not ask “What should I do?” This is incorrect. Patronizing language communicates superiority or disapproval. This statement did not communication disapproval.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

32. The visiting nurse is going to start an interview at a patient’s home. The patient is watching television. The patient is hard of hearing and reports that her left ear is her good ear. Which nursing intervention should take highest priority? 1. Speak in simple, focused sentences. 2. Ask to have the television volume turned down. 3. Be descriptive when giving directions. 4. Use drawings and a white board to ask questions. ANS: 2 Page: 13

1. 2. 3 4.

Feedback This is incorrect. Speaking in simple, focused sentences is advantageous for the cognitively impaired patient. This is correct. Hearing loss is a common human sensory deficit affecting the patient’s ability to communicate. Reduce background noise in the room. This is incorrect. Being descriptive when giving directions is for the visually impaired patient. This is incorrect. Use drawings and a white board to ask questions for the aphasic patient who has brain dysfunction.

GRADESMORE.COM 33. You are about to start an interview with the husband and wife present. The husband tells the nurse that his wife may not tell her everything that she needs to know. He states that in his wife’s culture, feelings are considered private and difficult to share. Sharing one’s feelings with others often creates a sense of vulnerability or is looked on as evidence of weakness. What culture is his wife? 1. Chinese heritage 2. German heritage 3. American Eskimo 4. Italian heritage ANS: 2 Page: 16

Feedback This is incorrect. Chinese speak in a moderate to low voice tone and consider Americans to be loud. Be aware of your tone of voice when interacting with Chinese patients. This is correct. The wife is of German heritage. Feelings are considered private and difficult to share. Sharing one’s feelings with others often creates a sense of vulnerability or is looked on as evidence of weakness. This is incorrect. American Eskimos prefer using silence. They may wait for several

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

minutes before replying to a simple statement or greeting. If American Eskimos sense some intolerance from the nurse toward the use of silence they may feel dominated and inferior, so the nurse should be cautious and not try to fill any silences. This is incorrect. Italian Americans tend to over-report symptoms or report their symptoms in a very dramatic manner.

34. Which consideration should the nurse recognize as priority when interviewing the patient? 1. Gender 2. Socioeconomic status 3. Developmental level 4. Education ANS: 3 Page: 10

3. 4.

Feedback This is incorrect. Gender is not a priority when interviewing a patient. It is important for the nurse to consider the developmental level of the patient and use words that the patient will understand during the interview. This is incorrect. Socioeconomic status should not be a priority when interviewing a patient. It is important for the nurse to consider the developmental level of the patient and use words that the patient G wR ilA l uDnE deSrM stO anRdEd. urCinOgMthe interview. This is correct. It is important for the nurse to consider the developmental level of the patient and use words that the patient will understand during the interview. This is incorrect. Education should not be a priority when interviewing a patient. It is important for the nurse to consider the developmental level of the patient and use words that the patient will understand during the interview.

Feedback This is correct. Empathy shares and accepts the patient’s feelings. Empathy is caring

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3.

about and for the patient as you are speaking together. In this scenario, the nurse is caring about and for the patient who just lost her mother. This is incorrect. Facilitation uses simple verbal statements or words to encourage the patient to continue to tell the story such as “uh-huh” or “Mmmm.” This is incorrect. Reflecting is stating the observed. The nurse would repeat the patient’s words specifically to encourage elaboration of the patient’s self-report. This encourages more discussion. This is incorrect. This is not clarification. You would obtain clarification if the patient does not clearly express the problem or issue and you are confused about what the patient is saying to you.

1. 2.

GRADESMORE.COM Feedback This is incorrect. You should not look at the interpreter when asking questions. During the interview and assessment look at the patient, not the interpreter. This is correct. Use your resources to find a trained face-to-face interpreter. A professional interpreter will be able to convey objective information between you and the patient. Ask the patient about any preference for a same-gender interpreter. This is incorrect. It is not recommended to use family members during an assessment to interpret for the patient because they could be subjective, give their own answers, or omit information. This is incorrect. You should not cluster the questions. Ask simple and clear questions one at a time. The nurse should also provide time for the patient to ask questions.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Page: 12

1. 2. 3. 4.

Feedback This is incorrect. You should not try to confront the patient but be calm and reassuring. This is incorrect. You should never touch a patient without his or her permission. In this situation the patient is very angry and it may be unsafe to touch the patient. This is correct. Be calm, reassuring, and empathetic. Do not argue with the patient. This is incorrect. This may provoke the patient to become angrier because he already waited 45 minutes. Stay with the patient and start the interview by speaking softly and using simple questions.

38. The three phases of the interview, in order, are: 1) , and 3)

, 2) .

ANS: introductory, working, summarization Page: 17 Feedback: The three phases of the interview are: the introductory phase, the working phase, and the summarization phase.

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 3: Taking the Health History

1. A nurse is taking a health history on a 59-year-old female patient. All of the following are purposes of the health history EXCEPT: 1. To identify the patient’s teaching needs. 2. To identify self-care and health promotion practices. 3. To assess the patient’s vital signs. 4. To document the patient’s past and present health.

2. A patient’s medication history is part of his or her health history. A nurse will inquire about: 1. Over-the-counter medications. 2. Herbal and nonherbal supplements. 3. Prescription medications. 4. All of the above.

3. The nurse is asking a patient about his past medical history (PMH). PMH includes: 1. Accidents or injuries. GRADESMORE.COM 2. Height and weight. 3. Living situation. 4. Reason for admission.

4. The four fundamental topics of a psychosocial assessment are: 1. Education, occupation, finances, and safety. 2. Behavioral, environmental, social, and financial/economic. 3. Behavioral, education, cognitive, and safety. 4. Cognitive, developmental, safety, and behavioral.

5. A student nurse is assessing a 28-year-old female patient and suspects she is a victim of domestic violence. The student will include which of the following in her assessment of the patient? 1. Ask questions about possible domestic violence in front of the patient’s partner. 2. Wait for the patient to tell you about any possible domestic violence. 3. Assume there is no domestic violence if there are no obvious physical signs of abuse. 4. Ask the patient, in private, if she has ever been physically abused in any way.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

6. It is not always easy to discuss sexual history with patients. A nurse is assessing the sexual history of a newly admitted patient and wants him to feel more comfortable. The nurse will reassure the patient using which of the following statements? 1. “You are required to answer the questions so we have a complete health history.” 2. “We do not need to have this conversation if you are uncomfortable.” 3. “Tell me what you think is important to share about your sexual history.” 4. “I understand these questions are personal, but they are important for your overall health.”

7. As part of a mental health assessment, a nurse considers the patient’s appearance to be of importance. The nurse will observe all the following EXCEPT: 1. General appearance. 2. Speech. 3. Mood. 4. Behavior.

8. A patient arrives in the emergency department and the nurse suspects she is at risk for suicide. The nurse realizes her priority action is: 1. To never leave the patient alone in the room. EpStM 2. To ask the patient about past suiciG deRaAttD em s. ORE.COM 3. To leave to get the health-care provider to come assess the patient. 4. To allow the patient to go to the bathroom unattended.

9. The nurse understands that health assessment is an optimal time for patient education. When educating a patient during a health assessment, a nurse knows that: 1. Only educating the patient about health-care topics the patient asks about is necessary. 2. It is an optimal time to discuss health screenings and health promotion with the patient. 3. Education should only be done with the patient if time allows for patient education. 4. Educating the family about health-care topics important to the patient should be done.

10. During an assessment of a veteran, a nurse knows the goal is to improve the quality of veterans’ health care. Which of the following questions will the nurse ask the veteran? 1. “How has military service affected you?” 2. “Do you think your veterans’ benefits cover enough?”" 3. “Do you feel veterans are treated fairly?” 4. “Do you feel you are respected as a veteran?”

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

11. Vaccines are important in preventing diseases. Looking at a patient’s health-care history, a nurse needs to assess the immunization history, which should include all vaccines the patient has received throughout his or her life. All of the following are vaccines EXCEPT: 1. Pneumococcal. 2. Varicella. 3. Human papillomavirus (HPV). 4. Tuberculin Mantoux.

12. A patient arrives in the emergency department with a complaint of an injury at work. As part of the admission assessment, the nurse needs to determine how the injury occurred. What priority question or statement will the nurse ask to determine the cause of the injury? 1. “Tell me how this injury occurred.” 2. “Do you think it is time to find a new job?” 3. “Do you think your employer will pay your health-care costs?” 4. “Will you continue to get paid even while you are injured?”

13. A patient arrives at the primary care physician’s (PCP’s) office smelling of cigarette smoke. She has a documented history of cigarette use and admits to smoking cigarettes. The nurse EhSaMt O assesses for the patient’s smoking hiG stoRrA y.DW isRthEe.inCitOiaMl question the nurse is going to ask the patient? 1. “Do other members of your family smoke?” 2. “Have you ever tried quitting smoking?” 3. “How many packs of cigarettes do you smoke daily?” 4. “What brand of cigarettes do you smoke?”

14. A nurse is concerned that a patient recently admitted for surgery has a problem with alcohol. The nurse will ask all of the following assessment questions EXCEPT: 1. “This is a difficult topic. Do you want to talk about it?”" 2. “How often do you drink alcohol?” 3. “What kind of alcohol do you drink?” 4. “Have you ever been arrested for a driving under the influence (DUI)?”

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. Encouraging the patient to be open and share his beliefs, concerns, and practices with you. 3. Telling the patient that due to a busy assignment you do not have time to learn about his culture. 4. Telling the patient there is only one meal option and the hospital does not have dietary options for other cultures.

16. Ideally, a health history should come from a patient, but there are circumstances in which the patient is unable to answer health history questions. In the case that the patient is unable to answer the health history questions, which is acceptable documentation? 1. Patient is unable to answer questions and is unreliable due to decreased cognition. 2. Patient’s family member is reporting the health history on behalf of the patient. 3. Patient is unable to answer health history questions due to recent mild stroke. 4. All of the above.

17. While performing a health history, the patient seems to be sad with a loss of interest in daily activities. The nurse wants to do a thorough assessment for depression. The nurse knows, in assessing the patient for depression, to ask which of the following questions? 1. “Is it okay if we talk about your feelings of sadness?” 2. “Many patients feel sad when they are in the hospital. Do you feel alone?” 3. “Over the past 2 weeks have you fG elR tA doDwEnS , dMeO prReE ss. edC, O orMhopeless?” 4. “You seem to be sad. Do you want me to get someone for you to talk to?”

18. Cognitive impairment can occur as part of aging, disease, trauma, or surgery. Cognitive assessments need to be performed on all patients and include all of the following EXCEPT: 1. Thinking skills. 2. Perception. 3. Memory. 4. Speech.

19. A patient’s reason for seeking health care may focus on: 1. The history of present health. 2. The history of present illness. 3. The presenting symptoms. 4. All of the above.

20. A nursing student is performing her first health assessment on a patient. The student

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

remembers one important fact that she learned in class about health assessments is that when talking with patients: 1. Do not use medical terminology. 2. Ask closed-ended questions. 3. Allow the patient limited time. 4. Ask general questions.

21. A student nurse is preparing to take a health history on her first patient. She had learned that biographical data is part of a patient’s health history. Which of the following are considered biographical data in a patient’s health history? Select all that apply. 1. Race 2. Occupation 3. Gender 4. Medications 5. Height

22. A nurse is using the CAGE-AID questionnaire to assess whether a 21-year-old male patient recently admitted to the emergency department is abusing drugs or alcohol. The nurse will ask which of the following questions as part of questionnaire? Select all that apply. 1. “Do you ever feel the need to use G drR ugAsDoE rS drM inOkRinEt.hC eO mM orning as an eye-opener?” 2. “Have you ever felt guilty about your drinking or drug use?” 3. “Do you ever feel you crave alcohol or drugs?” 4. “Do you feel alcohol or drugs aid you in getting through your day?” 5. “Have you ever felt you needed to cut down on your drinking or drug use?”

23. In assessing a patient’s activities of daily living (ADLs) the nurse needs to ask the patient if he or she is independent in ADLs or if he or she needs assistance. The activities that the nurse will question the patient about include which of the following? Select all that apply. 1. Sleeping 2. Meal preparation 3. Driving 4. Dressing 5. Bathing

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. Any genetic or familial tendencies for a disease 3. Family health patterns or tendencies 4. History of family eating patterns 5. History of family obesity trends

25. A 33-year-old female has arrived in the emergency department after being hit by a car. It is evident she will have a long recovery ahead of her. The nurse wants to be sure she has a support system in place. What questions will the nurse ask the patient to assess her support system? Select all that apply. 1. “Does anyone else live with you?” 2. “Tell me about your family and friends.” 3. “Do you think you will need to go to a rehab facility?” 4. “Who is your support system?” 5. “Who would you like on your visitor list?”

26. The BATHE assessment technique serves as a tool for screening patients for anxiety, depression, and situation stress disorders. Which of the following are topics of the BATHE assessment? Select all that apply. 1. Empathy GRADESMORE.COM 2. Trouble 3. Background 4. Anxiety 5. Handling

27. Documentation in a patient’s electronic medical record should be which of the following? Select all that apply. 1. Handwritten 2. Clear 3. Concise 4. Detailed 5. General

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

29. The nurse is performing a mental health assessment on a 42-year-old male patient. As part of the mental health assessment, the nurse needs to assess the patient’s orientation to , , and .

30. a health history.

data are pieces of information specifically reported by the patient in

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers 1. A nurse is taking a health history on a 59-year-old female patient. All of the following are purposes of the health history EXCEPT: 1. To identify the patient’s teaching needs. 2. To identify self-care and health promotion practices. 3. To assess the patient’s vital signs. 4. To document the patient’s past and present health. ANS: 3 Page: 19

1. 2. 3. 4.

Feedback Identifying the patient’s teaching needs is part of the patient’s health history. Identifying the patient’s self-care and health promotion practices is part of the patient’s health history. This is the correct answer. Assessing vital signs is not a part of the patient’s health history. This is part of the present physical assessment. Documenting the patient’s past and present health is part of the patient’s health history.

2. A patient’s medication history is pGarRt A ofDhEisSoMr O hR erEh. eaCltO h Mhistory. A nurse will inquire about: 1. Over-the-counter medications. 2. Herbal and nonherbal supplements. 3. Prescription medications. 4. All of the above. ANS: 4 Page: 22

1. 2. 3. 4.

Feedback The nurse should ask the patient about any over-the-counter medications when asking about the medication history. The nurse should ask the patient about any herbal and nonherbal supplements when asking about the medication history. The nurse should ask the patient about any prescription medications when asking about the medication history. All of the above are correct.

3. The nurse is asking a patient about his past medical history (PMH). PMH includes: 1. Accidents or injuries. 2. Height and weight.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. Living situation. 4. Reason for admission. ANS: 1 Page: 24

1. 2. 3. 4.

Feedback This is correct. Accidents or injuries are considered part of the patient’s past medical history. This is incorrect. Height and weight are part of the physical assessment, not the past medical history. This is incorrect. Living situation is part of the psychosocial assessment, not the past medical history. This is incorrect. Reason for admission pertains to the reason for seeking care and is not part of the patient’s past medical history.

GRADESMORE.COM

ANS: 2 Page: 25-26

1. 2. 3. 4.

Feedback This is incorrect. Fundamental topics included in the psychosocial assessment include behavioral, environmental, social, and financial/economic. This is correct. Fundamental topics included in the psychosocial assessment include behavioral, environmental, social, and financial/economic. This is incorrect. Fundamental topics included in the psychosocial assessment include behavioral, environmental, social, and financial/economic. This is incorrect. Fundamental topics included in the psychosocial assessment include behavioral, environmental, social, and financial/economic.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 4 Page: 27

1. 2. 3. 4.

Feedback This is incorrect. The patient should be assessed alone for possible domestic violence. This is incorrect. During all assessments the nurse must assess the patient’s safety, domestic violence, and interpersonal violence. This is incorrect. During all assessments the nurse must assess the patient’s safety, domestic violence, and interpersonal violence. This is correct. The patient should be assessed alone for possible domestic violence.

1. 2. 3. 4.

GRADESMORE.COM Feedback This is incorrect. Try to put the patient at ease and let him know that taking a sexual history is an important part of a regular medical examination or physical history. This is incorrect. Try to put the patient at ease and let him know that taking a sexual history is an important part of a regular medical examination or physical history. This is incorrect. Try to put the patient at ease and let him know that taking a sexual history is an important part of a regular medical examination or physical history. This is correct. Try to put the patient at ease and let him know that taking a sexual history is an important part of a regular medical examination or physical history.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback General appearance is considered part of the mental health assessment. This is the correct answer. Speech is not considered part of the mental health assessment. Mood is considered part of the mental health assessment. Behavior is considered part of the mental health assessment.

8. A patient arrives in the emergency department and the nurse suspects she is at risk for suicide. The nurse realizes her priority action is: 1. To never leave the patient alone in the room. 2. To ask the patient about past suicide attempts. 3. To leave to get the health-care provider to come assess the patient. 4. To allow the patient to go to the bathroom unattended. ANS: 1 Page: 38

1. 2. 3. 4.

Feedback This is correct. Never leave a patient alone if you suspect that she is having suicidal tendencies.

GRADESMORE.COM

This is incorrect. Past suicide attempts are not the priority right now when assessing if the patient has a potential suicide risk. This is incorrect. Never leave a patient alone if you suspect that she is having suicidal tendencies. This is incorrect. Never leave a patient alone if you suspect that she is having suicidal tendencies.

1. 2.

Feedback This is incorrect. Patient education is an optimal time to share all recommended health screenings and not just topics the patient asks about. This is correct. Patient education is an optimal time to share recommended health

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

screenings and discuss health promotion with the patient This is incorrect. The nurse will be learning about the patient during the health assessment and should use this time as a teaching moment to share knowledge. This is incorrect. Patient education is primarily done with the patient. Family is included if the patient requests the family to be included or if the patient is cognitively impaired.

1. 2. 3. 4.

Feedback This is correct. This question allows the veteran to discuss how military experience has affected him. This is incorrect. The veteran’s opinion of his veterans’ benefits does not impact the quality of veterans’ healthGcR arA e.DESMORE.COM This is incorrect. Whether veterans are treated fairly or not has no impact on the quality of veterans’ health care. This is incorrect. Whether veterans feel respected or not has no impact on the quality of veterans’ health care.

1. 2. 3.

Feedback The pneumococcal vaccine is used to prevent some types of pneumonia. The varicella vaccine is used to prevent chicken pox. The HPV vaccine is used to prevent most genital warts from the HPV virus.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is the correct answer. The tuberculin Mantoux is a screening test used to detect the presence of tuberculosis.

2. 3. 4.

Feedback This is correct. This is an open-ended statement asking the patient to elaborate on the details of how the injury occurred. Understanding what the patient does for a living will help to assess the cause of the present injury. This is incorrect. It is not appropriate to suggest the patient seek a new job and this will not help to identify the cause of the injury. This is incorrect. The patient’s opinion about the employer paying health-care costs does help to identify the caGuRseAoDfEthSeMinOjR urE y..COM This is incorrect. Asking the patient if he or she will continue to get paid will not help to identify how the injury was caused.

13. A patient arrives at the primary care physician’s (PCP’s) office smelling of cigarette smoke. She has a documented history of cigarette use and admits to smoking cigarettes. The nurse assesses for the patient’s smoking history. What is the initial question the nurse is going to ask the patient? 1. “Do other members of your family smoke?” 2. “Have you ever tried quitting smoking?” 3. “How many packs of cigarettes do you smoke daily?” 4. “What brand of cigarettes do you smoke?” ANS: 3 Page: 26

1. 2.

Feedback This is incorrect. It is not a priority to know if other family members smoke because you need to focus on the patient’s smoking history. This is incorrect. The patient’s history of quitting is not pertinent when assessing for present cigarette usage.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is correct. Asking how many cigarettes the patient smokes daily is the most important question to ask to obtain information for a pack-year history. The next question will be related to how many years the patient has smoked. This is incorrect. The brand of cigarettes the patient smokes is not important when assessing the patient’s cigarette use.

1. 2. 3. 4.

Feedback This is the correct answer. It is important to perform a thorough substance abuse assessment prior to surgery. It is important to assess how often the patient drinks alcohol. It is important to ask whatGRADESMORE.COM type of alcohol the patient drinks. It is important to ask the ory of DUI(s), which may give patient if he or she has a hist information about alcohol use.

15. A nurse has been assigned to care for a patient from a cultural background that he is not familiar with. He knows that it is important to provide culturally competent care to all of his patients. In order to do this, the nurse understands there are some important practices to follow, including; 1. Telling the patient that you do not understand his culture and practices. 2. Encouraging the patient to be open and share his beliefs, concerns, and practices with you. 3. Telling the patient that due to a busy assignment you do not have time to learn about his culture. 4. Telling the patient there is only one meal option and the hospital does not have dietary options for other cultures. ANS: 2 Page: 30-32

1. 2.

Feedback This is incorrect. Nurses should use resources to try to understand cultural practices. The nurse can ask the patient to share cultural considerations. This is correct. Each culture is unique and the nurse needs the knowledge and skills to

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

holistically care for each patient based on his or her cultural practices. This is incorrect. It is unprofessional to tell the patient that you do not have time to learn about cultural considerations that may affect his or her care. This is incorrect. Each culture is unique and the nurse needs the knowledge and skills to holistically care for each patient based on his or her cultural practices. This includes providing patients culturally appropriate dietary options.

1. 2. 3.

Feedback This is correct. The documentation states that the patient is not the primary source and is unreliable due to a cognitive impairment. This is incorrect. The docuGmReA ntDatEioSnMsO hoRuE ld.sCpO ecM ifically identify which family member and why they need to do the reporting. This is incorrect. The documentation should specifically identify if the stroke affected the patient’s speech because strokes affect different areas of the brain. Reliability is not documented. This is incorrect. Answers 2 and 3 are incorrect.

17. While performing a health history, the patient seems to be sad with a loss of interest in daily activities. The nurse wants to do a thorough assessment for depression. The nurse knows, in assessing the patient for depression, to ask which of the following questions? 1. “Is it okay if we talk about your feelings of sadness?” 2. “Many patients feel sad when they are in the hospital. Do you feel alone?” 3. “Over the past 2 weeks have you felt down, depressed, or hopeless?” 4. “You seem to be sad. Do you want me to get someone for you to talk to?” ANS: 3 Page: 38

Feedback This is incorrect. Asking permission to discuss why she is sad is good but does not

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3.

screen specifically for depression. This is incorrect. The question does not state that the patient is in the hospital and feeling alone. Nurses should not make assumptions during a health history. This is correct. Functional impairment is a sign of depression. This question will provide insight into recent signs of depression. This is a recommended question to screen specifically for depression. This is incorrect. You are acknowledging the patient seems sad, but as a nurse you should initiate further assessment questions to gather more information.

1. 2. 3. 4.

Feedback Thinking skills are assessed as part of a cognitive assessment Perception is assessed as GRADESMORE.COM part of a cognitive assessment. Memory is assessed as part of a cognitive assessment. This is the correct answer. Speech is not assessed as part of the cognitive assessment. It is assessed as part of a neurological assessment.

19. A patient’s reason for seeking health care may focus on: 1. The history of present health. 2. The history of present illness. 3. The presenting symptoms. 4. All of the above. ANS: 4 Page: 19

1. 2. 3.

Feedback Patients seek care based on their present health (such as physical examination), but also for present illness and/or presenting symptoms. Patients seek care for present illness (such as general fatigue and weakness), but also based on their present health and/or presenting symptoms. Patients seek care for present symptoms (such as cough and congestion), but also based on their present health and/or present illness.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

All are correct. Patients seek care based on their present heath (physical examination), present illness (general fatigue and weakness), and/or the presenting symptom (cough or congestion).

20. A nursing student is performing her first health assessment on a patient. The student remembers one important fact that she learned in class about health assessments is that when talking with patients: 1. Do not use medical terminology. 2. Ask closed-ended questions. 3. Allow the patient limited time. 4. Ask general questions. ANS: 1 Page: 34

1. 2. 3. 4.

Feedback This is correct. Patients must understand nurses’ questions, so it is important not to use medical terminology. This is incorrect. Open-ended questions, not close-ended questions, will invite the patient’s story. This is incorrect. The nurse needs to allow the patient time to speak and share the story about his or her health-relaGteRdAcD onEcSerMnO s.RE.COM This is incorrect. The nurse may have to explore the patient’s self-report or ask more focused questions.

1. 2. 3. 4.

Feedback This is correct. The patient’s race is considered biographical data. This is correct. The patient’s occupation is considered biographical data. This is correct. The patient’s gender is considered biographical data. This is incorrect. Medications are not biographical data, they are part of the

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

medication history. This is incorrect. The patient’s height it is not biographical data, it is part of the physical assessment.

22. A nurse is using the CAGE-AID questionnaire to assess whether a 21-year-old male patient recently admitted to the emergency department is abusing drugs or alcohol. The nurse will ask which of the following questions as part of questionnaire? Select all that apply. 1. “Do you ever feel the need to use drugs or drink in the morning as an eye-opener?” 2. “Have you ever felt guilty about your drinking or drug use?” 3. “Do you ever feel you crave alcohol or drugs?” 4. “Do you feel alcohol or drugs aid you in getting through your day?” 5. “Have you ever felt you needed to cut down on your drinking or drug use?” ANS: 1, 2, 5 Page: 28

1. 2. 3. 4. 5.

Feedback This is correct. The E in CAGE stands for Eye-opener. This is correct. The G in CAGE stands for Guilty. This is incorrect. The C in CAGE stands for Cut down (not Crave). This is incorrect. The A in CAGE stand for Annoyed (not Aid). GRADstands ESMOfor RECut .COdown. M This is correct. The C in CAGE

1. 2. 3. 4. 5.

Feedback This is incorrect. Sleeping is not considered an activity of daily living. This is correct. Meal preparation is considered an activity of daily living. This is correct. Driving is considered an activity of daily living. This is correct. Dressing is considered an activity of daily living. This is correct. Bathing is considered an activity of daily living.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

24. A patient’s family health history helps to identify the history of illness for family members. The nurse knows the family health history can more specifically identify which of the following? Select all that apply. 1. History of family education 2. Any genetic or familial tendencies for a disease 3. Family health patterns or tendencies 4. History of family eating patterns 5. History of family obesity trends ANS: 2, 3, 5 Page: 24 1. 2. 3. 4. 5.

This is incorrect. The family history section reviews the health and illness history of family members but does not include family education. This is correct. The family history section reviews the health and illness history of family members, including genetic or familial tendencies for a specific disease. This is correct. The family history section reviews the health and illness history of family members, including health patterns or tendencies. This is incorrect. The family history section reviews the health and illness history of family members but does not include family eating patterns. This is correct. The family history section reviews the health and illness history of EhSicMhOisRcEo.nsCidOeMred a diagnosis. family members who are oGbR esAeD ,w

This is correct. Assessing who lives in the home is part of the support system assessment. This is correct. Assessing the patient’s family and friends is part of the support system assessment. This is incorrect. Asking the patient if she thinks she needs to go to a rehab facility does not assess the support system.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. 5.

This is correct. Asking the patient who she thinks constitutes her support system is part of the support system assessment. This is incorrect. Asking the patient who she would like on her visitor list does not assess the support system.

26. The BATHE assessment technique serves as a tool for screening patients for anxiety, depression, and situation stress disorders. Which of the following are topics of the BATHE assessment? Select all that apply. 1. Empathy 2. Trouble 3. Background 4. Anxiety 5. Handling ANS: 1, 2, 3, 5 Page: 26

1. 2. 3. 4. 5.

Feedback Empathy is the “E” in BATHE. Trouble is the “T” in BATHE. Background is the “B” in BATHE. The “A” in the BATHE t GRADESMORE.COM not anxiety. echnique stands for affect, Handling is the “H” in BATHE.

27. Documentation in a patient’s electronic medical record should be which of the following? Select all that apply. 1. Handwritten 2. Clear 3. Concise 4. Detailed 5. General ANS: 2, 3, 4 Page: 39

1. 2. 3. 4.

Feedback This is incorrect. If it is electronic, it would not be handwritten. This is correct. Documentation in the patient’s record on a computer or other electronic device should be clear. This is correct. Documentation in the patient’s record on a computer or other electronic device should be concise. This is correct. Documentation in the patient’s record on a computer or other

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

electronic device should be detailed. This is incorrect. Documentation in the patient’s record on a computer or other electronic device should be clear, concise, and detailed.

28. Spiritual assessment is part of the overall assessment of a patient. A nurse needs to understand the difference between spirituality and religion in order to effectively assess spiritual needs of a patient. is an organized system of beliefs shared by a group of people, while is multifaceted; it is a search for a meaningful and overall purpose of life and a sense of life’s direction. ANS: Religion, spirituality Page: 33 Feedback: Religion is an organized system of beliefs shared by a group of people; there are practices, behaviors, worship, and rituals associated with that system. Spirituality is multifaceted; it is a search for a meaningful and overall purpose of life and a sense of life’s direction.

29. The nurse is performing a mental health assessment on a 42-year-old male patient. As part of the mental health assessment, the nurse needs to assess the patient’s orientation to GRADESMOR, Ean.dCOM , . ANS: person, place, time (in any order) Page: 37 Feedback: The mental health assessment is ongoing and assesses mental function, including whether a person is oriented to person (What is your name?), place (Where are you right now? What is your address?), and time (What is today’s date? What season are we in?).

30. a health history.

data are pieces of information specifically reported by the patient in

ANS: Subjective Page: 39 Feedback: Subjective data are reported by the patient and should be documented using the patient’s exact words using quotation marks.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 4: Assessing Nutrition and Anthropometric Measurements

1. A nurse is assessing an obese patient for possible malnutrition and the complications of malnutrition. The nurse understands that all of the following are possible complications of malnutrition EXCEPT: 1. Poor wound healing. 2. Shorter hospital stays. 3. Reduced quality of life. 4. Reduced immunity.

2. A nurse is caring for a patient who has recently lost weight. The nurse is concerned that the patient may be suffering from severe protein-calorie malnutrition because the patient’s weight loss is: 1. Planned and about 1 pound a week. 2. Unplanned and 5% of his total weight. 3. Unplanned and 15% of his total weight. 4. Unplanned and 25% of his total weight.

GRADESMORE.COM 3. Malnutrition is a term that can apply to those who are under- or over-nourished. The nurse knows a common cause of malnutrition is: 1. Failure to take a daily multivitamin. 2. Drinking more than two cups of coffee a day. 3. Improper absorption and distribution of foods within the body. 4. Failure to drink eight (8 oz.) glasses of water a day.

4. During the admission process, a nurse suspects that a 35-year-old single mom of three young children is malnourished. The nurse assesses for possible contributing factors, which include: 1. The patient prepares all her meals at home using only fresh produce. 2. The patient avoids processed foods. 3. The patient feeds her children first, then sits down to eat her meals. 4. The patient is low income, influencing her ability to buy food.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

preferences.” 2. “Some religious sects abstain, or are forbidden, from consuming certain foods and drinks.” 3. “Some religions restrict foods and drinks during their holy days.” 4. “Some religious sects associate dietary and food preparation practices with rituals of their faith.”

6. A 22-year-old female patient is discussing her weight with her nurse and seems to be concerned about her present weight. Which of the following questions can the nurse ask to determine the patient’s weight history? 1. “Are you happy with your weight?” 2. “What is your goal weight?” 3. “We can talk about this later if you are uncomfortable.” 4. “Have you lost or gained weight?”

7. A nurse is educating an obese patient about the importance of losing weight. The nurse is questioning the patient about food preparation in order to understand what education is needed. The nurse will ask all of the following questions EXCEPT: 1. “Do you have transportation to buy your own food?” 2. “What is your favorite restaurant to eat at?” 3. “Who prepares your meals for youG?R ” ADESMORE.COM 4. “Who do you eat your meals with?”

8. Patients who eat a well-balanced diet should receive all of the vitamins and minerals they need from their food. During the nutritional assessment it is important for the nurse to ask the patient about dietary supplements. Which of the following questions would be appropriate for the nurse to ask? 1. “Where do you buy your supplements? Are they name brands?” 2. “What time of day do you take your supplements?” 3. “Are you taking any supplements? Why do you take these supplements?” 4. “Would you consider stopping these supplements?”

9. A nutritional assessment is based on: 1. Food intake, water intake, exercises, and caloric intake. 2. Height, weight, and recent weight loss or gain. 3. Physical examination, anthropometric measurements, laboratory data, and food intake. 4. Food allergies, food availability, and height and weight.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

10. A 72-year-old female patient is admitted to the general medical/surgical floor. While the nurse is performing his physical assessment on the patient, he noted concerns with the patient’s hair, skin, teeth, and nails. He knows these are most likely related to: 1. Poor hygiene. 2. Malnutrition. 3. Too much sun. 4. Too many vitamins.

11. The purpose of measuring body mass index (BMI) is: 1. To estimate the amount of body fat. 2. To assess proper diet. 3. To assess proper amount of physical activity. 4. To estimate muscle mass.

12. The purpose of assessing the abdominal circumference is: 1. To determine how many inches the patient needs to lose from his or her waist. 2. To determine if the patient is apple- or a pear-shaped. 3. To measure abdominal fat. GRADESMORE.COM 4. To calculate BMI.

13. The purpose of assessing the waist-to-hip ratio (WHR) is: 1. To determine how many inches the patient needs to lose from his or her waist and hips. 2. To calculate BMI. 3. To measure abdominal fat. 4. To assess body size and fat distribution.

14. The purpose of assessing the mid-upper arm circumference is: 1. To assess body size and fat distribution. 2. To assess body protein stores and skeletal muscle mass. 3. To determine the patient’s baseline strength. 4. To measure the patient’s bone frame size.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

statements? 1. “I will read all food labels so I understand what I am actually eating.” 2. “I will monitor my caloric intake and be sure not to eat any high calorie foods.” 3. “I will make an effort to watch my portion sizes.” 4. “Alcohol does not count toward my calories, so I do not have to worry about the alcohol I drink.”

16. A nurse is assessing a patient’s plan for weight loss, which should include diet and exercise. The nurse knows the patient should exercise a minimum of hours per week. 1. 5 2. 7 3. 2.5 4. 10

17. Nutritional assessments are important to understanding a patient’s overall health but can be a sensitive topic to discuss with patients. When performing a nutritional assessment the nurse knows patients: 1. May not always be truthful in their report. 2. Are usually comfortable discussing their nutrition. 3. Can give an accurate 24-hour dietaGrR yA reD caEllS . MORE.COM 4. Are always compliant with a nutritional plan prescribed.

18. Obesity is a national epidemic. Causes of weight gain include all of the following EXCEPT: 1. Habitually eating too much food in excess of body needs. 2. Excess intake of carbohydrates and fats. 3. Consuming more calories than burned through daily living. 4. Eating a diet with a balance between nutrient intake and physiological requirements.

19. A nursing instructor is discussing individuals who are at risk for malnutrition with a nursing student. The instructor recognizes that the student needs further education if he indicates which of the following groups of individuals as being at risk for malnutrition? 1. Alcoholics 2. College students 3. Elderly 4. Individuals with chronic pain

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

20. A nurse is working with a 21-year-old female to provide education about weight loss. The nurse knows to discuss balancing calories as part of a weight loss plan, which includes: 1. Consuming fewer calories through food and beverage. 2. Keeping track of calories through a 24-hour recall. 3. Tracking measurements, including weight and BMI. 4. Estimating food portions; exact measurements are not necessary.

22. You are assessing an 89-year-old patient in a long-term care facility. The nursing aide reports to you that the patient states that he has no appetite and is only eating 50% of his meals. What will you document in the nursing note? 1. Patient has anorexia and is eating less than 50% of his meals. 2. Patient has anorexia and is eating only 50% of his meals. 3. Patient has ageusia and is eating only 50% of his meals. 4. Patient has dysgeusia and is eating less than 50% of his meals.

23. While the patient is eating her meal you observe her having difficulty swallowing solid food. The medical term for difficulty swallowing is: 1. Dysgeusia. 2. Dysphasia. GRADESMORE.COM 3. Dysphagia. 4. Ageusia.

24. You are performing a nutritional assessment through direct observation. The patient was given a half cup of mashed potatoes, a hamburger on a bun, and a half cup of string beans. He eats a quarter cup of the mashed potatoes, all of the hamburger, and all of the string beans. What would you document? 1. Patient ate 90% of his meal. 2. Patient ate greater than 80% of his meal. 3. Patient ate less than 75% of his meal. 4. Patient ate 50% of his meal.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. Place the tape measure around the bare abdomen several inches above the navel as the patient breathes in. 4. Place the tape measure around the bare abdomen several inches below the navel as the patient breathes out.

26. A nurse is educating a patient about the importance of good nutrition. The nurse knows the patient understands the teaching when he recognizes that the benefits of healthy eating include which of the following? Select all that apply. 1. Decreased risk of obesity 2. Decreased risk of chronic diseases 3. Increased risk for longer hospital stays 4. Decreased risk of micronutrient deficiencies 5. Increased risk for weight gain

27. A patient’s nutritional status can be influenced by many different factors including which of the following? Select all that apply. 1. Economic considerations 2. Number of fast-food restaurants 3. Available transportation GRADESMORE.COM 4. Cultural and ethnic influences 5. Lack of knowledge about good nutrition

28. A patient is having diagnostic laboratory tests drawn to assess her nutritional status. The nurse explains to the patient that there are several laboratory tests that will be used as assessment tools for nutritional status, including which of the following? Select all that apply. 1. Triglyceride level 2. Ferritin level 3. Prealbumin level 4. Calcium level 5. Sodium level

29. A nurse is discussing allergies with a patient. The nurse knows she not only has to assess for drug allergies but food allergies as well. Which of the following questions should the nurse ask to assess for possible food allergies? Select all that apply. 1. “Are there any foods you prefer not to eat?” 2. “Are you allergic to any specific types of food?” 3. “Do you have any diet intolerances?” 4. “What type of reaction do you have when you eat something you are allergic to?”

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

5. “We do not have to discuss food allergies at this time.”

30. Mr. Packard is a hospice patient. You are assessing his nutrition through direct observation. What should be assessed? Select all that apply. 1. Amount of food eaten 2. Difficulty swallowing 3. Only the amount of fluids taken 4. Ability to feed himself 5. Ability of the aide to feed him

31. Vitamin D is needed for healthy bone growth. Vitamin D can be found in which of the following? Select all that apply. 1. Vitamin D fortified foods 2. Dairy products only 3. Naturally in most foods 4. Sunlight only 5. Sunlight

GRADESMORE.COM 32. You are going to perform an anthropometric assessment. Choose your equipment. Select all that apply. 1. Computer 2. Paper tape measure 3. Tongue blade 4. Gloves 5. Stadiometer 6. Scale 7. Body mass index (BMI) chart

33. What are the basic food groups for healthy nutrition? Select all that apply. 1. Minerals 2. Dairy 3. Fruits 4. Grains 5. Protein 6. Vegetables

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

34. Mr. Mason, age 86, lives with his daughter. He has mild dementia. Mr. Mason’s daughter brings her father to the outpatient clinic because she feels that her dad is not eating well. The nurse questions Mr. Mason about his appetite and he states, “I eat when I am hungry.” Identify nutritional assessments that may be the best options to evaluate Mr. Mason’s diet and appetite. Select all that apply. 1. Indirect observation 2. Direct observation 3. A 24-hour diet recall 4. A 3-day food diary 5. A photo log of meals eaten

35. Individuals are recommended to consume from food and beverages.

cups of water per day

37. Your patient is on hospice care and you need to determine if she is losing weight. She is unable to stand on a scale, so you decide to take a mid-upper arm circumference (MUAC). Place the steps of this technique in order of sequence (1–8). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Ask the patient to allow her arm to hang by her side. 2. Remove clothing from the nondominant arm. 3. Ask the patient to bend the nondominant arm. 4. Place the patient in an upright sitting position. 5. Measure the arm at the mid-point mark. 6. Identify the mid-point of measurement and mark the arm at this point. 7. Document the measurement in centimeters. 8. Using the measuring tape, measure from the top of the shoulder to the tip of the elbow.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers 1. A nurse is assessing an obese patient for possible malnutrition and the complications of malnutrition. The nurse understands that all of the following are possible complications of malnutrition EXCEPT: 1. Poor wound healing. 2. Shorter hospital stays. 3. Reduced quality of life. 4. Reduced immunity. ANS: 2 Page: 40

1. 2. 3. 4.

Feedback Poor wound healing can be a complication related to malnutrition. This is the correct answer. Longer hospital stays, not shorter hospitals stays, are a complication of malnutrition. Reduced quality of life can be a complication related to malnutrition. Reduced immunity can be a complication related to malnutrition.

2. A nurse is caring for a patient who has recently lost weight. The nurse is concerned that the patient may be suffering from severeGpR roAteDinE-S caMloOriReEm.aC lnO utMrition because the patient’s weight loss is: 1. Planned and about 1 pound a week. 2. Unplanned and 5% of his total weight. 3. Unplanned and 15% of his total weight. 4. Unplanned and 25% of his total weight. ANS: 4 Page: 41

1. 2. 3. 4.

Feedback This is incorrect. A l pound a week weight loss indicates an intentional weight loss. This is incorrect. A 5% weight loss is an early indicator of increased risk of malnutrition. This is incorrect. A 15% weight loss indicates moderate protein-calorie malnutrition. This is correct. A 25% weight loss indicates severe protein-calorie malnutrition.

3. Malnutrition is a term that can apply to those who are under- or over-nourished. The nurse knows a common cause of malnutrition is: 1. Failure to take a daily multivitamin. 2. Drinking more than two cups of coffee a day.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. Improper absorption and distribution of foods within the body. 4. Failure to drink eight (8 oz.) glasses of water a day. ANS: 3 Page: 41-42

1. 2. 3. 4.

Feedback This is incorrect. Inadequate intake of vitamins from food can cause malnutrition, not failure to take a daily multivitamin. This is incorrect. Drinking coffee does not cause malnutrition. This is correct. One of the causes of malnutrition is improper absorption and distribution of foods within the body. This is incorrect. Eight glasses of water a day are recommended for proper hydration, but lack of water does not cause malnutrition.

GRADESMORE.COM

ANS: 4 Page: 42

1. 2. 3. 4.

Feedback This is incorrect. The use of fresh produce and home-cooked meals are not contributing factors to malnutrition. This is incorrect. Avoiding processed foods is not considered a contributing factor to malnutrition. This is incorrect. Eating meals alone is not a factor that contributes to malnutrition. This is correct. Low income, which influences the ability to buy food, is one of the factors that can contribute to malnutrition.

5. A nursing instructor is discussing religious considerations in regard to dietary practices with a student nurse. The nursing instructor understands the student nurse needs further education about religious considerations in dietary practices when she makes which of the following statements? 1. “When patients are hospitalized, we are unable to recognize their religious dietary preferences.” 2. “Some religious sects abstain, or are forbidden, from consuming certain foods and drinks.” 3. “Some religions restrict foods and drinks during their holy days.” 4. “Some religious sects associate dietary and food preparation practices with rituals of their

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

faith.” ANS: 1 Page: 44-45

1. 2. 3. 4.

Feedback This is incorrect. It is important for hospitals to recognize patients’ religious dietary practices and offer appropriate dietary preferences. This is correct. Some religious sects do abstain, or are forbidden, from consuming certain foods and drinks. This is correct. Some religions do restrict foods and drinks during their holy days. This is correct. Some religious sects do associate dietary and food preparation practices with rituals of their faith.

GRADESMORE.COM

ANS: 4 Page: 46

1. 2. 3. 4.

Feedback This is incorrect. This question does not provide any insight into the patient’s weight history. It discusses patient satisfaction with her present weight. This is incorrect. This question does not provide any insight into the patient’s weight history. It discusses a future goal. This is incorrect. The topic of weight is often difficult to discuss but it is an important part of the health history, so putting it off until later is not an option. This is correct. This question provides the nurse with information about the patient’s weight history.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 2 Page: 45-46

1. 2. 3. 4.

Feedback It is important to assess what transportation patients have in order to buy food. This is the correct answer. The patient’s restaurant choice is not part of food preparation assessment. As part of the food preparation assessment, the nurse should ask who prepares the food the patient eats. Individuals who eat by themselves are less likely to prepare meals or eat regular meals.

GRADESMORE.COM

ANS: 3 Page: 46

1. 2. 3.

Feedback This is incorrect. The nurse does not need to know where the patient purchases dietary supplements. This is incorrect. The nurse does not need to know what time of day the patient takes the dietary supplements. This is correct. The nurse needs to know if the patient is taking any dietary supplements and the names of those supplements. It is important to assess why the patient is taking specific supplements. This is incorrect. As part of the nutritional assessment, the nurse would not be suggesting stopping dietary supplements; the nurse would be asking what supplements the patient is taking.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 3 Page: 48

1. 2. 3.

Feedback This is incorrect. Food intake is part of a nutritional assessment, but water intake and exercise or caloric intake are not. This is incorrect. This is not a comprehensive nutritional assessment. This is correct. A comprehensive nutritional assessment is based on a physical examination, anthropometric measurements, laboratory data, and food intake of the patient. This is incorrect. This is not a comprehensive nutritional assessment.

GRADESMORE.COM

ANS: 2 Page: 48

1. 2. 3. 4.

Feedback This is incorrect. Poor hygiene is not related to poor condition of hair, skin, teeth, and nails. This is correct. Malnutrition can be exhibited through hair, skin, teeth, and nails in poor condition. This is incorrect. Too much sun can dry the hair, darken and dry skin, but will not cause problems with teeth and nails. This is incorrect. Vitamin deficiency will cause concerns with the hair, skin, teeth, and nails.

11. The purpose of measuring body mass index (BMI) is: 1. To estimate the amount of body fat. 2. To assess proper diet. 3. To assess proper amount of physical activity. 4. To estimate muscle mass. ANS: 1 Page: 52

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is correct. BMI is a screening tool identifying the amount of body fat based on height and weight that applies to adult men and women. This is incorrect. BMI measures amount of body fat, it does not assess diet. This is incorrect. BMI measures amount of body fat, it does not assess physical activity. This is incorrect. BMI measures amount of body fat, it does not estimate muscle mass.

2. 3. 4.

Feedback This is incorrect. The purpose of assessing abdominal circumference is to measure abdominal fat, not to determine how many inches the patient needs to lose from his or GRADESMORE.COM her waist. This is incorrect. The purpose of assessing abdominal circumference is to measure abdominal fat, not to determine the abdominal shape of the patient. This is correct. The purpose of assessing abdominal circumference is to measure abdominal fat. This is incorrect. The purpose of assessing abdominal circumference is to measure abdominal fat. This information is not needed to calculate the patient’s BMI.

Feedback This is incorrect. The purpose of assessing WHR is to assess body size and fat distribution, not to determine how many inches the patient needs to lose from his or her waist and hips.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3. 4.

This is incorrect. The purpose of assessing WHR is to assess body size and fat distribution. This information is not needed to calculate BMI. This is incorrect. The purpose of assessing WHR is to assess body size and fat distribution. Abdominal circumference measures abdominal fat. This is correct. The purpose of assessing WHR is to assess body size and fat distribution.

2. 3. 4.

Feedback This is incorrect. The purpose of assessing the mid-upper arm circumference is to assess body protein stores and skeletal muscle mass. WHR assesses body size and fat distribution. This is correct. The purpose of assessing the mid-upper arm circumference is to assess body protein stores and skG elR etA alDmEuSscMlO eR mE as.s.COM This is incorrect. The purpose of assessing the mid-upper arm circumference is to assess body protein stores and skeletal muscle mass. It does not measure strength. This is incorrect. The purpose of assessing the mid-upper arm circumference is to assess body protein stores and skeletal muscle mass. It does not measure bone frame size.

15. A nurse is working in a weight loss clinic and spends a significant amount of time educating patients. The nurse knows that education is important in helping weight loss patients be successful. She will reinforce the education if the patient makes which of the following statements? 1. “I will read all food labels so I understand what I am actually eating.” 2. “I will monitor my caloric intake and be sure not to eat any high calorie foods.” 3. “I will make an effort to watch my portion sizes.” 4. “Alcohol does not count toward my calories, so I do not have to worry about the alcohol I drink.” ANS: 4 Page: 59 Feedback

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

This is correct. Patients should read all food labels to understand the nutritional value. This is correct. Patients should monitor how many calories they eat daily and avoid high calorie foods to prevent weight gain. This is correct. Patients should watch portion sizes to maintain a healthy weight. This is incorrect and would require further teaching. Patients are encouraged to decrease alcohol consumption when trying to lose weight.

16. A nurse is assessing a patient’s plan for weight loss, which should include diet and exercise. The nurse knows the patient should exercise a minimum of hours per week. 1. 5 2. 7 3. 2.5 4. 10 ANS: 3 Page: 59

1. 2. 3. 4.

Feedback This is incorrect. A patient is recommended to exercise a minimum of 2.5 hours per week. This is incorrect. A patient is recommended to exercise a minimum of 2.5 hours per GRADESMORE.COM week. This is correct. A patient is recommended to exercise a minimum of 2.5 hours per week. This is incorrect. A patient is recommended to exercise a minimum of 2.5 hours per week.

17. Nutritional assessments are important to understanding a patient’s overall health but can be a sensitive topic to discuss with patients. When performing a nutritional assessment the nurse knows patients: 1. May not always be truthful in their report. 2. Are usually comfortable discussing their nutrition. 3. Can give an accurate 24-hour dietary recall. 4. Are always compliant with a nutritional plan prescribed. ANS: 1 Page: 40

Feedback This is correct. People do not always like to discuss what they eat, how much they eat, or foods they do not eat, even when they know that a particular food item is recommended.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3. 4.

This is incorrect. Assessing nutrition can be a sensitive topic. This is incorrect. A 24-hour recall does not provide a full nutritional assessment; it gives you information about the patient’s intake for only one day. This is incorrect. Patients are often not compliant with nutritional recommendations.

1. 2. 3. 4.

Feedback Frequent overconsumption of nutrients by eating too much food in excess can cause obesity. Frequent overconsumption of carbohydrates and fats can cause obesity. Frequent overconsumption of calories can cause obesity. This is the correct answer. Eating a balanced diet along with physical activity will not lead to obesity.

GRADESMORE.COM

1. 2. 3. 4.

Feedback This is incorrect. Alcoholics are at high risk for malnutrition because they usually do not eat healthy foods. This is correct. College students are not a population that is considered at risk for malnutrition but, rather, overnutrition. This is incorrect. The elderly are at high risk for malnutrition because they may be depressed, lonely, lack finances, or take medications that cause anorexia. This is incorrect. Individuals living with chronic pain lose their appetites and are at risk for malnutrition.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is correct. Weight loss occurs with taking in fewer calories and burning more calories through activity. This is incorrect. A 24-hour recall is helpful in tracking the last 24 hours of food but does not help with weight loss. This is incorrect. Tracking measurements is important as part of weight loss but it is not part of balancing calories. This is incorrect. Exact measurements of food are necessary when balancing calories as part of weight loss.

GRADESMORE.COM 21. While admitting a 40-year-old male patient for surgery, a nurse is performing a nutritional assessment. The nurse understands that this patient is at nutritional risk due to a history of: 1. Recent planned weight loss. 2. Recent planned weight gain. 3. Being a long-term diabetic. 4. Exercising 30 minutes, 6 days per week. ANS: 3 Page: 46

1. 2. 3. 4.

Feedback This is incorrect. Patients with a planned weight loss are not at risk for malnutrition. This is incorrect. Patients with a planned weight gain are not at risk for malnutrition. This is correct. Chronically ill individuals are at risk for malnutrition. This is incorrect. Patients who exercise 3 hours per week are not at risk for malnutrition.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. The term for loss of appetite is anorexia. The patient is not eating less than 50% of his meals. This is correct. The term for loss of appetite is anorexia. The patient is eating only 50% of his meals. This is incorrect. Ageusia is the absence of taste. This is incorrect. Dysgeusia refers to the presence of a metallic, rancid, or foul taste in the mouth.

23. While the patient is eating her meal you observe her having difficulty swallowing solid food. The medical term for difficulty swallGoR wA inD gE isS : MORE.COM 1. Dysgeusia. 2. Dysphasia. 3. Dysphagia. 4. Ageusia. ANS: 3 Page: 47

1. 2. 3. 4.

Feedback This is incorrect. Dysgeusia refers to the presence of a metallic, rancid, or foul taste in the mouth. This is incorrect. Dysphasia refers to difficulty speaking. This is correct. Dysphagia is difficulty swallowing. Individuals who have periodontal disease, few or no teeth, or poor fitting dentures have difficulty chewing food. This is incorrect. Ageusia is the absence of taste.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Patient ate 90% of his meal. 2. Patient ate greater than 80% of his meal. 3. Patient ate less than 75% of his meal. 4. Patient ate 50% of his meal. ANS: 2 Page: 52 Feedback This is incorrect. The patient ate 100% of the hamburger and string beans and only 50% of the mashed potatoes. This is 83% of his meal, not 90%. This is correct. The patient ate 100% of the hamburger (1 point) and string beans (1 point), and only 50% of the mashed potatoes (.50 point) is 2.5/3 = .83 or 83%. This is greater than 80% of his meal. This is incorrect. The patient ate 100% of the hamburger and string beans, and only 50% of the mashed potatoes. This is 83%, not less than 75% of his meal. This is incorrect. The patient ate 100% of the hamburger and string beans, and only 50% of the mashed potatoes. This is 83%, not 50% of his meal.

1. 2.

3. 4.

25. You are caring for a patient with a very large abdomen who has liver disease. The doctor has ordered abdominal circumferences to be assessed every shift. What is the correct technique to assess an abdominal circumference? GRADESMORE.COM 1. Place the tape measure around the bare abdomen at the level of the iliac crest as the patient breathes in. 2. Place the tape measure around the bare abdomen at the level of the iliac crest as the patient breathes out. 3. Place the tape measure around the bare abdomen several inches above the navel as the patient breathes in. 4. Place the tape measure around the bare abdomen several inches below the navel as the patient breathes out. ANS: 2 Page: 54

3. 4.

Feedback This is incorrect. Place the tape measure around the bare abdomen at the level of the iliac crest, which should also be close to the level of the navel after the patient normally breathes out, not breathes in. This is correct. Place the tape measure around the bare abdomen at the level of the iliac crest, which should also be close to the level of the navel after the patient normally breathes out. This is incorrect. The measurement is not taken several inches above the navel, it is taken at the level of the iliac crest. This is incorrect. The measurement is not taken several inches below the navel, it is

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

taken at the level of the iliac crest.

1. 2. 3. 4. 5.

Feedback This is correct. Good nutrition can lead to decreased risk for obesity. This is correct. Good nutrition can lead to decreased risk for chronic diseases such as type 2 diabetes, hypertension, heart disease, and certain cancers. This is incorrect. Good nutrition can lead to shorter hospital stays, not longer hospital stays. This is correct. Good nutrition can lead to decreased risk for micronutrient GRADESMORE.COM deficiencies. This is incorrect. Good nutrition can lead to weight loss, not weigh gain.

27. A patient’s nutritional status can be influenced by many different factors including which of the following? Select all that apply. 1. Economic considerations 2. Number of fast-food restaurants 3. Available transportation 4. Cultural and ethnic influences 5. Lack of knowledge about good nutrition ANS: 1, 3, 4, 5 Page: 40

1. 2. 3.

Feedback This is correct. Economic considerations including cost of food are a factor when considering influences on a patient’s diet. This is incorrect. The number of fast-food restaurants should not influence a patient’s diet. The proximity of fast-food restaurants may influence a patient’s diet. This is correct. Available transportation to go out to purchase food can influence a patient’s diet.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. 5.

This is correct. Cultural or ethnic influences affect food choice and the meaning of food. This is correct. Lack of knowledge about good nutrition may influence poor dietary intake.

1. 2. 3. 4. 5.

Feedback This is correct. Triglyceride levels are used to assess the amount of fat in the blood. This is correct. Ferritin levels are used to assess the amount of iron in the blood to identify iron deficiency anemia. This is correct. PrealbuminGlReA veDlsEaSreMuOsR edEt. oC asOseMss protein deficiency. This is incorrect. Calcium levels are not used to assess nutritional status. This is incorrect. Sodium levels are not used to assess nutritional status.

1. 2. 3.

Feedback This is incorrect. This question does not relate to assessment of allergies, but food preferences. This statement is correct. This question will identify specific food allergies. This statement is correct. This question will identify food intolerances that may be

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. 5.

related to a food allergy. This statement is correct. This question will identify allergic reactions to food. This is incorrect. It is important to assess food allergies in patients.

1. 2. 3. 4. 5.

Feedback This is correct. The purpose is to identify the amount of food a patient eats at mealtime. This is correct. During direct observation you should assess for dysphagia, difficulty swallowing. This is incorrect. You should not only assess the amount of fluids taken. ADESthe MOR E.CO This is correct. You shouldGR observe ability ofMthe patient to feed himself. This is incorrect. You are not evaluating the ability of the aide to feed the patient but whether the patient is able to eat and how much he eats and drinks.

1. 2.

Feedback This is correct. Vitamin D can be found in vitamin D fortified foods. This is incorrect. Vitamin D is found in some fortified dairy products but can also be found in vitamin D fortified foods such as cereals, milk, yogurt, margarine, cheese, and orange juice. This is incorrect. Natural foods have very little vitamin D.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is incorrect. Vitamin D is not found in sunlight only but can also be found in vitamin D fortified foods such as cereals, milk, yogurt, margarine, cheese, and orange juice. This is correct. Vitamin D is obtained through exposure to sunlight.

32. You are going to perform an anthropometric assessment. Choose your equipment. Select all that apply. 1. Computer 2. Paper tape measure 3. Tongue blade 4. Gloves 5. Stadiometer 6. Scale 7. Body mass index (BMI) chart ANS: 5, 6, 7 Page: 52-53

1. 2. 3. 4. 5. 6. 7.

Feedback This is incorrect. A computer is not needed to perform an anthropometric measurement.

GRADESMORE.COM

This is incorrect. A paper tape measure is needed for mid-upper arm circumference, abdominal circumference, or waist-to-hip ratio. This is incorrect. A tongue blade is not needed to perform an anthropometric measurement. This is incorrect. Gloves are not needed to perform an anthropometric measurement. This is correct. A stadiometer is needed to measure the height of a patient. This is correct. A scale is needed to weigh a patient. This is correct. A BMI chart is needed to calculate the BMI.

33. What are the basic food groups for healthy nutrition? Select all that apply. 1. Minerals 2. Dairy 3. Fruits 4. Grains 5. Protein 6. Vegetables ANS: 2, 3, 4, 5, 6 Page: 40 Feedback

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4. 5. 6.

This is incorrect. Minerals are not one of the basic food groups for healthy nutrition. This is correct. Dairy is one of the five basic food groups for healthy nutrition. This is correct. Fruits are one of the five basic food groups for healthy nutrition. This is correct. Grains are one of the five basic food groups for healthy nutrition. This is correct. Protein is one of the five basic food groups for healthy nutrition. This is correct. Vegetables are one of the five basic food groups for healthy nutrition.

1. 2. 3.

4. 5.

GRADESMORE.COM Feedback This is incorrect. There is no indirect observation, only direct observation for a nutritional assessment. This is correct. The daughter would directly observe what her father is eating each day and document the percentage that he eats at each meal. This is incorrect. A 24-hour recall would not be a reliable assessment. Mr. Mason, who has mild dementia, would be asked to identify what he has eaten or drank in the last 24 hours and he may not be accurate or able to remember. This is correct. A 3-day food diary would have the patient or his daughter write down all the food and beverage intake immediately after eating. This is incorrect. There is no photo log for nutritional assessment.

35. Individuals are recommended to consume from food and beverages.

cups of water per day

ANS: 9, 13 Page: 59 Feedback: The amount of water that is needed to keep our body healthy is influenced by our health, lifestyle, environment, and activity level. Individuals are recommended to consume 9 to 13 cups (1 cup equals 8 ounces) of water a day from food and beverages.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

36. The waist-to-hip ratio has been identified to be a predictor of at-risk patients for coronary heart disease. Your patient has a family history of coronary artery disease and wants to know if he is within the normal limits of a waist-to-hip ratio. Put the steps of this technique in order of sequence (1–6). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Place the tape measure around the widest point of the hips. 2. Document your findings in centimeters. 3. Record both measurements in centimeters. 4. Place the tape measure around the narrowest area of the waist between the hips and the 11th rib. 5. Take measurement after a normal breath at the end of expiration. 6. Calculate the waist-to-hip measurement by dividing the waist measurement by the hip measurement. ANS: 451362 Page: 55 Feedback: The first step is to place the tape measure around the narrowest area of the waist between the hips and the 11th rib. The second step is to take a measurement after a normal breath at the end of expiration. The third step is to place the tape measure around the widest point of the SM hips. The fourth step is to record the G mReaAsD urEem enOtsRiE n. ceCnO tiM meters. The fifth step is to calculate the waist-to-hip measurement by dividing the waist measurement by the hip measurement. The sixth step is to document your findings in centimeters.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Feedback: The first step of an MUAC is to place the patient in an upright sitting position. The second step is to remove clothing from the nondominant arm. The third step is to ask the patient to bend the nondominant arm. The fourth step is to use the measuring tape and measure from the top of the shoulder to the tip of the elbow. The fifth step is to identify the mid-point of measurement and mark the arm at this point. The sixth step is to ask the patient to allow her arm to hang by her side. The seventh step is to measure the arm at the mid-point mark. The eighth step is to document the measurement in centimeters.

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 5: Assessment Techniques

1. You are assessing an elderly man who is in isolation for a respiratory illness. He has a large abdominal dressing that needs to be changed. What will you need to wear prior to entering the room and during the assessment? Select all that apply. 1. Gown 2. Mask 3. Paper shoe covers 4. Gloves 5. Eye protector

2. What is the purpose of the assessment technique of inspection? Select all that apply. 1. To assess physical characteristics 2. To assess orientation 3. To assess posture 4. To assess appearance 5. To assess behavior

GRADESMORE.COM 3. A nurse is performing a general assessment. What is he or she assessing when performing light palpation? Select all that apply. 1. Skin textures 2. Masses 3. Tenderness 4. Abdominal organs 5. Color

4. What is the purpose of direct percussion? Select all that apply. 1. To assess for tenderness 2. To assess borders of an organ 3. To assess density of tissue 4. To assess presence of fluid 5. To assess lung sounds

5. The patient is complaining of shortness of breath and mild chest pain. You are about to start the focused assessment. What should be the nurse’s first action?

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Auscultate lung sounds. 2. Auscultate heart sounds. 3. Wash hands in front of patient. 4. Call for help immediately.

6. You are performing an admission assessment on a patient who is scheduled for open heart surgery tomorrow. He reports that he has an allergy to latex products. Which of the following measures is of highest priority? 1. Educate the patient on the signs and symptoms of the latex allergy. 2. Document the patient has a latex allergy and symptoms of the allergy. 3. Give the patient a list of latex products used in the hospital. 4. Notify the surgeon and operating room staff.

7. Which of the following is the best approach when performing a health assessment? 1. An organized approach, working from noninvasive to invasive assessments 2. A head-to-toe approach, working from the core to the extremities 3. A systems approach, working from the neurological to the musculoskeletal 4. A strict approach, depending on thGeRagAeDoEf S thMeOpR atE ie. ntCOM

8. Palpation is used to assess every system. There are two types of palpation. The part of the hands used to palpate vibrations is the: 1. Fingertips. 2. Finger pads. 3. Ball or ulnar surface of the hands. 4. Dorsal aspect of the hands.

9. You are assessing a patient’s skin and note what appears to be a small, discolored lesion on the patient’s right cheek. What would be your next nursing action? 1. Turn up the fluorescent lighting to better evaluate the lesion. 2. Document a small, discolored lesion on right cheek. 3. Continue to assess the rest of the patient’s skin. 4. Reassess using tangential lighting.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

10. A patient comes to the urgent care center stating that he feels his left leg is swollen. A fundamental assessment guideline when inspecting his left leg is which of the following? 1. Expose only the patient’s left leg and keep his other leg unexposed. 2. Compare the symmetry of body parts from one side to the other side. 3. Using the ulnar surface of your hand, feel the temperature of the skin of his left leg. 4. Measure the left leg to assess calf circumference.

11. The patient complains that he has not voided in 24 hours. You are assessing the bladder. What would be the best technique to assess a distended bladder? 1. Inspection 2. Percussion 3. Single-handed light palpation 4. Bimanual deep palpation

12. You are performing light and deep palpation on the patient’s abdomen. You know that you will press down for light palpation and for deep palpation. 1. 1 cm; 5 cm 2. 2 cm; 4 cm 3. 3 cm; 4 cm GRADESMORE.COM 4. 4 cm; 5 cm

14. The nurse enters the room of a patient and encounters a strong foul odor. This is an example of inspection.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

15. You are percussing over the posterior lobes of the lungs. The lungs are healthy and normal. The percussion sound of normal healthy lungs is called .

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers 1. You are assessing an elderly man who is in isolation for a respiratory illness. He has a large abdominal dressing that needs to be changed. What will you need to wear prior to entering the room and during the assessment? Select all that apply. 1. Gown 2. Mask 3. Paper shoe covers 4. Gloves 5. Eye protector ANS: 1, 2, 4, 5 Page: 60

2. 3. 4. 5.

Feedback This is correct. A gown is needed to protect yourself when changing the large abdominal dressing. This will be in the cart outside the room and put on prior to entering the room. This is correct. A mask is needed prior to entering the room as the patient is on isolation for a respiratory illness. This is incorrect. Paper shoe covers are not needed because there is no report of drainage on the floor and the wound is localized. This is correct. Gloves are nGeR edAeD dE duSrM inO gRthEe.wCoO unMd assessment and dressing change. Gloves can be put on prior to starting the wound assessment. This is correct. Eye protectors should always be worn to protect yourself from any drainage during the dressing change. Eye protectors should be put on prior to the wound assessment.

1. 2.

Feedback This is correct. The purpose of inspection is to look at and examine the physical aspects of the body, posture, appearance, and behavior carefully. This is incorrect. The purpose of inspection is not to assess orientation. Orientation is

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4. 5.

assessed by asking specific questions that can be validated by reliable resources. This is correct. One purpose of inspection is to assess posture. This is correct. One purpose of inspection is to assess appearance. This is correct. One purpose of inspection is to assess behavior.

3. A nurse is performing a general assessment. What is he or she assessing when performing light palpation? Select all that apply. 1. Skin textures 2. Masses 3. Tenderness 4. Abdominal organs 5. Color ANS: 1, 2, 3 Page: 63-64

1. 2. 3. 4. 5.

Feedback This is correct. Light palpation assesses skin texture and surface characteristics. This is correct. Light palpation assesses for masses. This is correct. Light palpation assesses for tenderness. This is incorrect. Light palpGaR tioAnDiE s nSoMt O deReE p. enCoO ugMh to assess abdominal organs. This is incorrect. Light palpation does not assess color. Inspection assesses color.

1. 2. 3. 4.

Feedback This is incorrect. The purpose of direct percussion is not to assess for tenderness; palpation assesses for tenderness. This is correct. The purpose of direct percussion is to assess the borders of an organ, such as the liver. This is correct. The purpose of direct percussion is to assess density of tissue. As the density increases the percussion sound becomes softer. This is correct. The purpose of direct percussion is to assess for the presence of fluid.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is incorrect. Auscultation assesses lung sounds.

5. The patient is complaining of shortness of breath and mild chest pain. You are about to start the focused assessment. What should be the nurse’s first action? 1. Auscultate lung sounds. 2. Auscultate heart sounds. 3. Wash hands in front of patient. 4. Call for help immediately. ANS: 3 Page: 61

1. 2. 3.

Feedback This is incorrect. Prior to auscultating lung sounds the nurse should wash her hands in front of the patient. This is incorrect. Prior to auscultating heart sounds the nurse should wash her hands in front of the patient. This is correct. Health care–associated infections are a major concern to patients. Always try to wash your hands in front of the patient so the patient knows that you have performed hand hygiene. This is incorrect. The patienGt RshAoD uE ldSbM eO asRseEs. seC dOfiM rst before you determine if you need help immediately.

1. 2.

Feedback This is incorrect. The patient already knows that he has a latex allergy and probably already had a reaction. This is correct. Documentation is highest priority to alert staff of the latex allergy. Even though the majority of health-care institutions are latex-free, all precautions should be taken.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

This is incorrect. The patient does not need a list of latex products used in the hospital. This is incorrect. Documentation in the chart will notify the surgeon and staff that this patient has an allergy to latex.

1. 2.

Feedback This is correct. Essential health assessment works best if you use an organized approach, working from noninvasive to invasive assessments. This is incorrect. This is not the best approach. The core of the body, such as the genitalia and rectum, would require an invasive assessment. It is best to start with noninvasive assessments. This is incorrect. This is noG t tR heAbDeEstSaM ppOrR oaEc. h.CIO f sMtarting with the neurological assessment, this would require the patient to change positions. Minimal positional changes are recommended. This is incorrect. This is not the best approach. A flexible approach would be recommended depending on the patient’s age.

1. 2. 3.

Feedback This is incorrect. Fingertips are most often used with percussion. This is incorrect. Finger pads assess fine discrimination and sensations on the surface areas such as texture, shape, consistency, pulses, and crepitus. This is correct. Balls or ulnar surfaces of the hands assess vibrations and thrills.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is incorrect. The dorsal aspect of the hands assess skin temperature.

1. 2. 3. 4.

Feedback This is incorrect. Fluorescent lights can change the color of the skin. This is incorrect. A discolored lesion is abnormal and needs further evaluation. This is incorrect. The small, discolored lesion should be further assessed and measured prior to moving on to inspect the rest of the patient’s skin. This is correct. Tangential lighting is a form of additional lighting placed at an angle in order to see more specific details for a specific assessment.

GRADESMORE.COM 10. A patient comes to the urgent care center stating that he feels his left leg is swollen. A fundamental assessment guideline when inspecting his left leg is which of the following? 1. Expose only the patient’s left leg and keep his other leg unexposed. 2. Compare the symmetry of body parts from one side to the other side. 3. Using the ulnar surface of your hand, feel the temperature of the skin of his left leg. 4. Measure the left leg to assess calf circumference. ANS: 2 Page: 62

1. 2. 3.

Feedback This is incorrect. Both lower legs should be exposed to inspect and compare the size and symmetry. This is correct. Always observe and compare the symmetry of body parts from one side to the other side. This is incorrect. The ulnar surface of the hand is not used to assess skin temperature; it is the dorsal surface of the hand that assesses skin temperature. Your priority is not to assess temperature but to inspect for swelling or edema. This is incorrect. This is not a fundamental assessment guideline. There are not standard measurements for calf circumference. If measured, both lower legs should be measured and compared.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. Inspection is not the best way to assess a distended bladder. This is incorrect. Percussion is the not the best way to assess the location of a distended bladder. This is correct. Single-handed light palpation is the best way to assess a distended bladder. This is incorrect. Bimanual palpation can also be used to stabilize a deep internal organ, such as the kidneys or spleen, but is not needed to assess the location of bladder distention that will rise up in the lower abdominal area.

GRADESMORE.COM 12. You are performing light and deep palpation on the patient’s abdomen. You know that you will press down for light palpation and for deep palpation. 1. 1 cm; 5 cm 2. 2 cm; 4 cm 3. 3 cm; 4 cm 4. 4 cm; 5 cm ANS: 1 Page: 64

1. 2. 3. 4.

Feedback This is correct. You will press down 1 cm for light palpation and 5 cm for deep palpation. This is incorrect. Palpate 1 cm for light palpation and 5 cm for deep palpation. This is incorrect. Palpate 1 cm for light palpation and 5 cm for deep palpation. This is incorrect. Palpate 1 cm for light palpation and 5 cm for deep palpation.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

13. Health assessment requires the collection of data to accurately and safely care for every patient. What is the correct sequence of assessment techniques that will provide objective assessment data (1–4)? (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Palpation 2. Auscultation 3. Inspection 4. Percussion ANS: 3142 Page: 60 Feedback: The sequence of assessment techniques which will gather the most objective data for the complete head-to-toe assessment is inspection, palpation, percussion, and auscultation, except for the abdominal assessment. The sequence for the abdominal assessment is inspection, auscultation, percussion, and palpation.

14. The nurse enters the room of a patient and encounters a strong foul odor. This is an example of inspection.

GRADESMORE.COM ANS: direct Page: 62 Feedback: Direct inspection is carefully observing and inspecting a specific area or the whole individual. This type of inspection uses three senses: seeing, hearing, and smelling. Indirect inspection is using specific equipment to improve your visualization of an area (i.e., ophthalmoscope to look at the internal structures of the eyes).

15. You are percussing over the posterior lobes of the lungs. The lungs are healthy and normal. The percussion sound of normal healthy lungs is called . ANS: resonance Page: 65 Feedback: Resonance is the percussion sound of normal healthy lungs.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 6: General Survey and Assessing Vital Signs

1. All of the following equipment is used to perform a physical health assessment EXCEPT: 1. A sphygmomanometer. 2. A watch with a second hand. 3. A stethoscope. 4. A body mass index (BMI) chart.

2. Which of the following is the correct sequence in which to perform a physical assessment? 1. General survey, temperature, pulse, respiratory rate, blood pressure 2. Respiratory rate, blood pressure, general survey, pulse, temperature 3. Respiratory rate, general survey, pulse, blood pressure, temperature 4. Blood pressure, respiratory rate, general survey, temperature, pulse

3. A nurse is performing a general survey on a patient in preparation for performing a physical examination. The nurse understands it is important to take cultural considerations into account for each individual patient because: 1. Nurses do not have to understand G diR ffA erD enEt S cuMlO tuR reE s..IC t iO sM more important to treat all patients the same. 2. It is important for the nurse to understand cultural norms for individual cultures to provide the best care. 3. Patients will tell nurses if there are any cultural considerations that need to be respected during their care. 4. Nurses have heavy workloads and their focus is on patient care. They do their best to understand cultural norms.

4. A nurse is performing a physical assessment on a patient as part of an annual physical. The nurse understands that the body temperature: 1. Varies with the time of day and the site of measurement. 2. Should not vary and variation can indicate illness. 3. Can be measured in several sites and the temperature should be the same in all sites. 4. Is not a vital sign and is not part of the physical assessment.

5. During a physical assessment of a patient, the nurse recognizes that all of the following are considered abnormal findings EXCEPT 1. unkempt grooming.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. the patient is cachectic. 3. odors of the body or breath. 4. the patient appears to be stated age.

6. A nurse is preparing a patient for a vital sign assessment. Which of the following questions should the nurse ask prior to taking the vital signs? 1. “Have you eaten any salty foods today?” 2. “Do you have any allergies, and if so, what type of reaction?” 3. “Have you had any caffeine or smoked in the past 30 minutes?” 4. “Have you exercised today?”

7. A nurse is preparing to auscultate an apical heart rate on a patient as part of a vital sign assessment. The nurse knows the proper order to assess the apical heart rate is which of the following? 1. Uncover left side of chest, place diaphragm of stethoscope over left fifth intercostal space at midclavicular line, warm stethoscope, auscultate heartbeat, count beats for 30 seconds (multiply  2), clean stethoscope with alcohol, explain technique. 2. Explain technique, place diaphragm of stethoscope over clothes over left fifth intercostal space at midclavicular line, auscultate heartbeat, count beats for 30 seconds (multiply  2). 3. Explain technique, warm stethoscoGpR e,AuDnE coSvM erOlR efE t s.idCeOoM f chest, place diaphragm of stethoscope over right fifth intercostal space at midclavicular line, count beats for 30 seconds (multiply  2), clean stethoscope with alcohol. 4. Explain technique, warm stethoscope, uncover left side of chest, place diaphragm of stethoscope over left fifth intercostal space at midclavicular line, auscultate heartbeat, count beats for 60 seconds, clean stethoscope with alcohol.

8. Blood pressure is measured routinely as part of the vital sign assessment. The best sites that a blood pressure can be taken include all of the following EXCEPT 1. the ankle. 2. the upper arm. 3. the forearms. 4. the thigh.

9. To obtain an accurate blood pressure, the blood pressure cuff needs to fit the patient properly. A nurse assessing a patient knows that a proper fitting blood pressure cuff should cover of the distance from the patient’s elbow to the shoulder. 1. two-thirds 2. one-half

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. three-fourths 4. one-third

10. The nurse is instrumental in collecting data during a health assessment. The first steps in performing a physical assessment are 1. height and weight. 2. general survey and vital signs. 3. nutritional assessment. 4. past medical history.

11. A nurse is assessing whether a patient is alert and oriented as part of assessing the patient’s level of consciousness (LOC). The nurse knows that all of the following are checked to see if a patient is alert and oriented as part of the LOC assessment EXCEPT 1. time. 2. place. 3. speech. 4. person.

GRADESMORE.COM 12. A nurse is preparing to take an oral temperature on a patient. The nurse understands that the patient needs to wait 30 minutes to take an oral temperature if the patient 1. understands and follows directions. 2. is able to breathe through the nose. 3. has an altered mental status. 4. has had hot or cold food or drink in the last 30 minutes.

13. A patient arrives for a physical assessment and is complaining of not feeling well. The nurse begins with a general survey and assessing vital signs. The nurse is concerned that the patient has orthostatic hypotension due to the patient complaining of 1. alteration in mental status and forgetfulness. 2. dizziness and feeling lightheaded with position changes. 3. gastrointestinal upset, nausea, and vomiting. 4. feeling cold, weak, and shivering.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

the following parameters? 1. Systolic greater than 180 or diastolic greater than 110 2. Systolic greater than 160 or diastolic greater than 100 3. Systolic 140 to 159 or diastolic 90 to 99 4. Systolic 120 to 139 or diastolic 80 to 89

15. When assessing a patient’s vital signs, a nurse understands that an essential principle of vital sign assessment is 1. retaking the vital signs if the first set is not within normal range. 2. comparing a patient’s baseline or prior vital signs to the current reading. 3. asking the patient if he or she remembers the last set of vital signs. 4. there is no need to compare current vital signs to previous vital signs.

16. A patient arrives for a health assessment and the nurse notes the patient has a heavy foreign accent. The nurse knows the best action is 1. to call for an interpreter to interpret for the patient. 2. use a family member as an interpreter for the patient. 3. ask the patient if he or she understands and speaks English. 4. assume the patient understands and speaks English.

GRADESMORE.COM 17. A female patient, age 48, comes to the clinic with complaints of dizziness and a frontal headache. She tells you she is under a lot of stress because her husband was recently laid off. She is 5'4" and weighs 150 lb. You take her blood pressure and it is 178/100. When you tell her the blood pressure reading she says, “This cannot be right! I usually run 100/60.” What should be your next action? 1. Tell the patient that stress can raise blood pressure. 2. Wait 2 minutes and retake the blood pressure in the other arm. 3. Call in the health-care provider to retake the blood pressure. 4. Document the blood pressure as high.

18. You are caring for a patient with traumatic brain injury. The health-care provider has ordered rectal temperatures daily. How far should you insert the rectal probe into the anal canal? 1. About 0.50 inch 2. About 0.75 inch 3. About 1.0 inch 4. About 1.5 inches

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

19. You are assessing a 78-year-old hospice patient who has end stage lung cancer. Which of the following findings would indicate an acute decline in the patient’s health status? 1. Temporal temperature 99.8°F, pulse 82, irregular, amplitude +2, RR 22 2. Temporal temperature 100.8°F, pulse 90, regular, amplitude 2+, RR 20 3. Tympanic temperature 100.1°F, pulse 60, irregular, amplitude 3+, RR 18 4. Tympanic temperature 97°F, pulse 106, irregular, amplitude 1+, RR 26

20. A 23-year-old client is being seen at the university health clinic for chest pain. The nurse has gathered the following assessment data: temperature 99.2°F (tympanic), pulse 90 (apical), regular respirations 28, blood pressure 144/84 (left arm). Which assessment data should be of greatest concern to the nurse? 1. Temperature of 99.2°F 2. Pulse 90 3. Respirations 28 4. Blood pressure 144/84

21. Mary Jane is getting a physical examination prior to starting her new job. You take her vital signs: temperature (97.8°F), radial pulse 92 reg, + 2 amplitude, respiratory rate (20), and blood DaErS pressure 150/96. What is the categorG yR ofAM y’M sO blR ooEd.pCreOsM sure? 1. Normal 2. Prehypertension 3. Stage 1 Hypertension 4. Stage 2 Hypertension

22. An 88-year-old patient had a warm sponge bath 10 minutes ago and a cup of hot tea 5 minutes ago. The nurse needs to assess her body temperature. Which temperature method should the nurse use to assess her temperature? 1. Oral 2. Rectum 3. Axillary 4. Tympanic

23. You are performing a respiratory assessment on a male patient who has smoked for the past 30 years. You are having difficulty counting his respirations. Which of the following actions would be most appropriate? 1. Place the diaphragm of the stethoscope over the trachea. 2. Place the bell of the stethoscope below the clavicle.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. Encourage the patient to take deep breaths. 4. Stand behind the patient to assess respirations.

24. You are performing the general survey as part of the physical assessment. Which of the following observations are considered part of the general survey? Select all that apply. 1. Body structure 2. Patient’s hygiene 3. Vital signs 4. Appears stated age 5. Appears healthy

25. Normal vital signs change with age, sex, weight, exercise tolerance, and medical condition. Which of the following are classified as vital signs? Select all that apply. 1. Pulse 2. Temperature 3. Heart rate 4. Respiratory rate 5. Weight

GRADESMORE.COM 26. Measuring a patient’s body temperature is part of routine essential nursing care and can be taken in several different ways. The site and measuring device is chosen based on a number of factors including which of the following? Select all that apply. 1. Patient preference 2. Age of patient 3. Mental status and cognition 4. Physical condition of patient 5. Safety and nurse’s technique with using device

27. Rectal temperatures are considered to be an accurate route for measuring core temperature. Rectal temperatures are contraindicated in which of the following patients? Select all that apply. 1. Patients who have had rectal surgery 2. Patients with cardiac disease 3. Patients with diarrhea 4. Patients who refuse a rectal temperature 5. Patients who are immobile

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

28. A nurse is assessing a radial pulse. What characteristics of the pulse must be documented? Select all that apply. 1. Time taken 2. Pulse site 3. Pulse rate 4. Pulse rhythm 5. Pulse amplitude

29. During a health assessment of a patient, a nurse is assessing vital signs, including respiratory rate. She knows that several factors can influence the respiratory rate including which of the following? Select all that apply. 1. exercise. 2. medication. 3. pain. 4. stress. 5. fever.

30. A nurse is performing a vital sign assessment on a patient and understands that he must observe the following characteristics to assess a patient’s breathing. Select all that apply. 1. Rate GRADESMORE.COM 2. Depth 3. Skin movement 4. Rhythm 5. Effort

31. Hypertension is a growing health problem in the United States. The main factors that contribute to the increase in the number of patients with hypertension include which of the following? Select all that apply. 1. The obesity epidemic 2. Population growth 3. Genetics 4. Anxiety 5. The aging population

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. Quitting cigarette smoking. 3. Limiting alcohol intake. 4. Genetic testing. 5. If overweight, losing weight.

33. A patient arrives for a health assessment and has poor hygiene, body odor, and clothes that are too big and unkempt. The nurse is concerned and considers which of the following reasons for the patient’s condition? Select all that apply. 1. Lack of resources 2. Frugality 3. Impaired mental status or cognitive dysfunction 4. Lack of finances 5. A dislike for shopping

34. You are assessing a 60-year-old patient’s blood pressure. You hear the systolic reading at 164. The Korotkoff sounds fade out at 130 and resume at 108. You hear the last Korotkoff sound at 82. This fading of sounds is called a[n] .

GRADESMORE.COM 35. You are preparing to assess the blood pressure. You start by wrapping the deflated cuff around the patient’s arm about inch(es) above the brachial artery.

36. You are assessing the radial pulse and determine that it is 92 and irregular. You auscultate the apical pulse at 104 and irregular. What is the pulse deficit? _

37. A normal resting pulse for a well-conditioned athlete is minute.

38. Normal respirations are

beats per

breaths per minute.

39. In a normotensive (normal BP) blood pressure reading, the systolic reading is less than and the diastolic reading is less than _ .

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

40. Hypertension is blood pressure reading greater than greater than .

41. The heart rate.

or the diastolic reading

pulse is the most reliable and accurate location to assess the

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers 1. All of the following equipment is used to perform a physical health assessment EXCEPT: 1. A sphygmomanometer. 2. A watch with a second hand. 3. A stethoscope. 4. A body mass index (BMI) chart. ANS: 4 Page: 69

1. 2. 3.

Feedback A sphygmomanometer is equipment used as part of the physical assessment and is used to measure blood pressure. A watch with a second hand is equipment used as part of the physical assessment and is used to count the heart rate and respiratory rate. A stethoscope is equipment used as part of the physical assessment and is used to listen to heart sounds, lung sounds, and bowel sounds. It is also used in taking a manual blood pressure. This is the correct answer. A BMI chart is used to look up BMI and is not considered equipment that is necessary for a physical assessment.

GRADESMORE.COM 2. Which of the following is the correct sequence in which to perform a physical assessment? 1. General survey, temperature, pulse, respiratory rate, blood pressure 2. Respiratory rate, blood pressure, general survey, pulse, temperature 3. Respiratory rate, general survey, pulse, blood pressure, temperature 4. Blood pressure, respiratory rate, general survey, temperature, pulse ANS: 1 Page: 69

2. 3. 4.

Feedback This is correct. The assessment begins with a general survey of the patient when you first meet and greet them, followed by taking the patient’s temperature, pulse, respiratory rate, and blood pressure. This is incorrect. This is not the proper sequence; the sequence begins with general survey. This is incorrect. This is not the proper sequence; the sequence begins with general survey. This is incorrect. This is not the proper sequence; the sequence begins with general survey.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. A nurse is performing a general survey on a patient in preparation for performing a physical examination. The nurse understands it is important to take cultural considerations into account for each individual patient because: 1. Nurses do not have to understand different cultures. It is more important to treat all patients the same. 2. It is important for the nurse to understand cultural norms for individual cultures to provide the best care. 3. Patients will tell nurses if there are any cultural considerations that need to be respected during their care. 4. Nurses have heavy workloads and their focus is on patient care. They do their best to understand cultural norms. ANS: 2 Page: 70

1. 2. 3. 4.

Feedback This is incorrect. It is important for nurses to understand cultural norms for each individual patient so as to provide the best individualized care. This is correct. It is important for nurses to understand cultural norms for each individual patient so as to provide the best individualized care. This is incorrect. It is important for nurses to understand cultural norms for each individual patient so as to provide the best individualized care. This is incorrect. It is important for nurses to understand cultural norms for each individual patient so as to G prRoA viD deEtShM eO beRstEi. ndCivOiM dualized care.

1. 2. 3. 4.

Feedback This is the correct answer. Body temperature can vary throughout the day and varies depending on the site of measurement. This is incorrect. Body temperature can vary throughout the day and variation is not always an indication of illness. This is incorrect. Body temperature can be measured in several sites, but there is variation of temperature between these different sites. This is incorrect. Measuring body temperature is a vital sign and considered part of the physical assessment.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

5. During a physical assessment of a patient, the nurse recognizes that all of the following are considered abnormal findings EXCEPT 1. unkempt grooming. 2. the patient is cachectic. 3. odors of the body or breath. 4. the patient appears to be stated age. ANS: 4 Page: 71-72

1. 2. 3. 4.

Feedback Unkempt grooming is considered an abnormal finding in a physical assessment because the patient is not caring for himself or herself. Cachexia is considered an abnormal finding in a physical assessment because it may be a sign of malnutrition. Odor of the body or breath is considered an abnormal finding in a physical assessment because it may be a sign of illness. A patient who appears his or her stated age is considered a normal finding in a physical assessment. A patient who looks older than the stated age may be exposed to chronic stress or illness.

GRADESMORE.COM

1. 2. 3. 4.

Feedback This is incorrect. Eating salty foods will not influence the vital sign assessment; longterm eating salty foods may affect blood pressure. This is incorrect. This question would be asked during the health history, not prior to taking vital signs. This is correct. Blood pressure may be affected if the patient had caffeine or cigarettes in the preceding 30 minutes. This is incorrect. Long-term effects of exercise are healthy; this will not affect the vital sign assessment.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

7. A nurse is preparing to auscultate an apical heart rate on a patient as part of a vital sign assessment. The nurse knows the proper order to assess the apical heart rate is which of the following? 1. Uncover left side of chest, place diaphragm of stethoscope over left fifth intercostal space at midclavicular line, warm stethoscope, auscultate heartbeat, count beats for 30 seconds (multiply 2), clean stethoscope with alcohol, explain technique. 2. Explain technique, place diaphragm of stethoscope over clothes over left fifth intercostal space at midclavicular line, auscultate heartbeat, count beats for 30 seconds (multiply 2). 3. Explain technique, warm stethoscope, uncover left side of chest, place diaphragm of stethoscope over right fifth intercostal space at midclavicular line, count beats for 30 seconds (multiply 2), clean stethoscope with alcohol. 4. Explain technique, warm stethoscope, uncover left side of chest, place diaphragm of stethoscope over left fifth intercostal space at midclavicular line, auscultate heartbeat, count beats for 60 seconds, clean stethoscope with alcohol. ANS: 4 Page: 80

1. 2. 3. 4.

Feedback This is incorrect. This is not the proper order for assessing an apical pulse. The technique is always explained first and not last. This is incorrect. This is nG otRthAeDpEroSpM erOtR ecEh. niC quOeMfor assessing an apical pulse. Auscultation should never be done over clothes. This is incorrect. This is not the proper order and location for assessing an apical pulse. This is correct. This is the proper order for assessing an apical pulse.

1. 2.

Feedback The ankle is not a good choice for taking a blood pressure, as it does not provide an accurate blood pressure measurement. The upper arm is a good choice for taking a blood pressure as it can provide an accurate blood pressure measurement.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

The forearm is a good choice for taking a blood pressure as it can provide an accurate blood pressure measurement. The thigh is a good choice for taking a blood pressure as it can provide an accurate blood pressure measurement.

1. 2. 3. 4.

Feedback This is correct. The blood pressure cuff should cover two-thirds of the distance from the elbow to the shoulder. This is incorrect. The blood pressure cuff should not cover one-half, but two-thirds of the distance from the elbow to the shoulder. This is incorrect. The blooG dRpA reD ssE urSeMcO ufR fE sh.oC ulO dM not cover three-fourths, but twothirds of the distance from the elbow to the shoulder. This is incorrect. The blood pressure cuff should not cover one-third, but two-thirds of the distance from the elbow to the shoulder.

1. 2. 3.

Feedback This is incorrect. The general survey and assessment of vital signs are the first steps in performing a physical assessment, not assessing the patient’s height and weight. This is correct. The general survey and assessment of vital signs are the first steps in performing a physical assessment. This is incorrect. The general survey and assessment of vital signs are the first steps in

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

performing a physical assessment, not performing a nutritional assessment. This is incorrect. The general survey and assessment of vital signs are the first steps in performing a physical assessment, not assessing the patient’s past medical history. This is done in the health history prior to the physical assessment.

1. 2. 3.

Feedback Orientation to time assesses level of consciousness and is a correct statement. Orientation to place assesses level of consciousness and is a correct statement. Speech is checked as part of the LOC and neurological assessment but not to see if the patient is alert and oriented. Person, place, and time are checked three times to see if a patient is alert and orientedG.RADESMORE.COM Orientation to person assesses level of consciousness and is a correct statement.

12. A nurse is preparing to take an oral temperature on a patient. The nurse understands that the patient needs to wait 30 minutes to take an oral temperature if the patient 1. understands and follows directions. 2. is able to breathe through the nose. 3. has an altered mental status. 4. has had hot or cold food or drink in the last 30 minutes. ANS: 4 Page: 75

1. 2. 3.

Feedback This is incorrect. It is not necessary to wait to perform an oral temperature on a patient who is able to understand and follow directions. This is incorrect. It is not necessary to wait to perform an oral temperature on a patient who is able to breathe through the nose. This is incorrect. It is not necessary to wait to perform an oral temperature on a patient who has an abnormal normal mental status; however, you may choose a different route to take the temperature.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is correct. If a patient has consumed or drank hot or cold foods or beverages, it is important to wait 30 minutes to take an oral temperature in order to obtain an accurate temperature reading.

Feedback This is incorrect. With orthostatic hypotension, the patient presents with dizziness and lightheadedness with position changes. Orthostatic hypotension can occur with hypovolemia or dehydration, may be a side effect of medications, or may be a sign of a medical condition. This is correct. With orthostatic hypotension, the patient presents with dizziness and RrEth.oC lightheadedness with positGioRnAcD haEnS geMsO .O stO atM ic hypotension can occur with hypovolemia or dehydration, may be a side effect of medications, or may be a sign of a medical condition. This is incorrect. With orthostatic hypotension, the patient presents with dizziness and lightheadedness with position changes. Orthostatic hypotension can occur with hypovolemia or dehydration, may be a side effect of medications, or may be a sign of a medical condition. This is incorrect. With orthostatic hypotension, the patient presents with dizziness and lightheadedness with position changes. Orthostatic hypotension can occur with hypovolemia or dehydration, may be a side effect of medications, or may be a sign of a medical condition.

14. A patient arrives at the clinic complaining of a severe headache and nausea. The nurse begins with the general survey and assesses the vital signs. The nurse understands that the patient is in hypertensive crisis, which is a medical emergency, because his blood pressure is within which of the following parameters? 1. Systolic greater than 180 or diastolic greater than 110 2. Systolic greater than 160 or diastolic greater than 100 3. Systolic 140 to 159 or diastolic 90 to 99 4. Systolic 120 to 139 or diastolic 80 to 89

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 1 Page: 86

1. 2. 3. 4.

Feedback This is correct. Hypertensive crisis is defined as systolic blood pressure greater than 180 or diastolic greater than 110. This is incorrect. Hypertension, stage 2, is defined as systolic blood pressure greater than 160 or diastolic greater than 100. This is incorrect. Hypertension, stage 1, is defined as systolic blood pressure 140≠159 or diastolic 90 to 99. This is incorrect. Prehypertension is defined as systolic blood pressure 120 to 139 or diastolic 80 to 89.

2. 3.

GRADESMORE.COM Feedback This is incorrect. It is recommended that vital signs are retaken if not within normal range; however, the essential principal for assessing vital signs is always reviewing and comparing a patient’s baseline or prior vital signs to the current readings. This is correct. An essential principal for assessing vital signs is always reviewing and comparing a patient’s baseline or prior vital signs to the current readings. This is incorrect. Asking a patient if he or she remembers the last set of vital signs is not objective data. An essential principal for assessing vital signs is always reviewing and comparing a patient’s baseline or prior vital signs to the current readings. This is incorrect. There is an absolute need to compare to previous vital signs. An essential principal for assessing vital signs is always reviewing and comparing a patient’s baseline or prior vital signs to the current readings.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 3 Page: 70

3. 4.

Feedback This is incorrect. The patient has a heavy foreign accent, but it does not mean the patient does not understand the English language. The first step in assessing comprehension of the English language is to ask the patient if he or she understands the question and can repeat back information. This is incorrect. A family member should not be used as an interpreter. The first step in assessing comprehension of the English language is to ask the patient if he or she understands the question and can repeat back information. This is correct. The first step in assessing comprehension of the English language is to ask the patient if he or she understands the question and can repeat back information. This is incorrect. A nurse should never assume the patient understands English. The first step in assessing comprehension of the English language is to ask the patient if he or she understands the question and can repeat back information.

17. A female patient, age 48, comes to the clinic with complaints of dizziness and a frontal headache. She tells you she is under a lot of stress because her husband was recently laid off. She is 5'4" and weighs 150 lb. You take her blood pressure and it is 178/100. When you tell her the blood pressure reading she says, “ThG isRcA anDnE otSbMeOriR ghEt. ! ICuOsuMally run 100/60.” What should be your next action? 1. Tell the patient that stress can raise blood pressure. 2. Wait 2 minutes and retake the blood pressure in the other arm. 3. Call in the health-care provider to retake the blood pressure. 4. Document the blood pressure as high. ANS: 2 Page: 85

1. 2.

Feedback This is incorrect. This blood pressure reading may be related to stress, but it must be validated by a second reading. This is correct. If the blood pressure reading is high, wait for about 2 minutes and retake the blood pressure in the opposite arm. Document the higher of the two blood pressure readings. This is incorrect. The nurse has the responsibility to make sure the blood pressure reading is accurate. The health-care provider should not have to be called in to assess a second reading at this time. This is incorrect. This is a high blood pressure and needs to be confirmed as accurate.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. Inserting the probe 0.50 inch may result in an inaccurate rectal temperature because it may not be in the anal canal. This is incorrect. Inserting the probe 0.75 inch may result in an inaccurate rectal temperature because it may not be in the anal canal. This is correct. Gently insert the tip of the thermometer into the rectum about 1 inch to obtain an accurate rectal temperature reading. This is incorrect. Inserting the probe 1.5 inches may be too far and cause harm to the patient.

19. You are assessing a 78-year-old hospice patient who has end stage lung cancer. Which of the following findings would indicate anGaR cuAtD eE deSclMinOeRinEt.hC eO paMtient’s health status? 1. Temporal temperature 99.8°F, pulse 82, irregular, amplitude +2, RR 22 2. Temporal temperature 100.8°F, pulse 90, regular, amplitude 2+, RR 20 3. Tympanic temperature 100.1°F, pulse 60, irregular, amplitude 3+, RR 18 4. Tympanic temperature 97°F, pulse 106, irregular, amplitude 1+, RR 26 ANS: 4 Page: 76, 79, 81-82

2. 3.

Feedback This is incorrect. The temperature is slightly elevated, pulse is normal rate and amplitude. Respiratory rate is slightly greater than 20 breaths per minute. These vital signs do not indicate an acute decline. This is incorrect. The patient has a fever; pulse and respiratory rate are within normal limits. This is incorrect. Patient has a low-grade fever, pulse rate is normal but irregular; this may be normal for a 78-year-old patient. The amplitude is 3+, which is indicative of a bounding pulse due to increased cardiac output; the respiratory rate is normal. This is correct. The temperature is less than 98°F; the pulse is high, irregular, weak and thready. There is an increased respiratory rate. The low temperature, increased pulse, with a 1+ amplitude and increased respiratory rate shows signs of acute decline.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3.

Feedback This is incorrect. This is a normal finding because tympanic temperature range is between 98.2°F to 100°F. This is incorrect. This is a normal finding because normal pulse range is between 60 to 100 bpm. This is correct. The elevated respiratory rate is of greatest concern because changes in respiratory function are increasingly recognized as the most sensitive indicator of patient deterioration. This is incorrect. Both systolic and diastolic are slightly elevated but not of the GRADESMORE.COM greatest concern.

21. Mary Jane is getting a physical examination prior to starting her new job. You take her vital signs: temperature (97.8°F), radial pulse 92 reg, + 2 amplitude, respiratory rate (20), and blood pressure 150/96. What is the category of Mary’s blood pressure? 1. Normal 2. Prehypertension 3. Stage 1 Hypertension 4. Stage 2 Hypertension ANS: 3 Page: 86

1. 2. 3. 4.

Feedback This is incorrect. This is not normal blood pressure. Normal blood pressure is systolic less than 120 and diastolic less than 80. This is incorrect. This is not prehypertension. Prehypertension is systolic 120 to 139 and diastolic 80 to 89. This is correct. Blood pressure of 150/96 falls in the Stage I category. Systolic blood pressure range is 140 to 159 and diastolic blood pressure range is 90 to 99. This is incorrect. Blood pressure of 150/96 does not fall in the Stage II category.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Systolic blood pressure is 160 or higher and diastolic is 100 or higher.

2. 3. 4.

Feedback This is incorrect. The patient just had some hot tea and should not have an oral temperature taken. An oral temperature should not be taken until 30 minutes after drinking a hot beverage. This is incorrect. Rectal temperature is not needed because there are other methods. A physician order is usually required for a rectal temperature. This is incorrect. Axillary body temperature measurement is not recommended as an assessment of core body temperature in adults. .C This is correct. Tympanic wGoR ulAdDbE eS thM eO beRsE tm etO hoMd to assess the body temperature.

1. 2. 3. 4.

Feedback This is correct. If you are having difficulty assessing respirations, place the diaphragm of the stethoscope over the trachea and auscultate for breath sounds. This is incorrect. Lung sounds are assessed using the diaphragm of the stethoscope, not the bell of the stethoscope, which is used for low-pitched sounds. This is incorrect. Telling the patient to take deep breaths is not going to help you to count his respirations, which should be done when the patient is resting quietly. This is incorrect. A posterior approach to assess the rise and fall of the chest area will

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

not assess the rise and fall of the thoracic cage.

1. 2. 3. 4. 5.

Feedback This is correct. The patient’s body structure is considered part of his or her physical appearance. This is correct. The patient’s body hygiene is considered part of his or her physical appearance. This is incorrect. The patient’s vital signs are not considered part of his or her physical appearance. This is correct. The patient’s appearance as his or her stated age is considered part of his or her physical appearaGnR ceA. DESMORE.COM This is correct. The patient’s general appearance of being healthy is considered part of his or her physical appearance.

1. 2. 3. 4. 5.

Feedback This is correct. Pulse is considered a vital sign. This is correct. Temperature is considered a vital sign. This is correct. Heart rate is considered a vital sign. This is correct. Respiratory rate is considered a vital sign. This is incorrect. Weight is not considered a vital sign but is part of the physical

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

assessment.

26. Measuring a patient’s body temperature is part of routine essential nursing care and can be taken in several different ways. The site and measuring device is chosen based on a number of factors including which of the following? Select all that apply. 1. Patient preference 2. Age of patient 3. Mental status and cognition 4. Physical condition of patient 5. Safety and nurse’s technique with using device ANS: 2, 3, 4, 5 Page: 74

1. 2. 3. 4. 5.

Feedback This is incorrect. Patient preference is not a factor to determine the site and type of measuring device. Nurses use available devices. This is correct. The patient’s age is one of the factors that needs to be taken into consideration when choosing a temperature device. This is correct. The patient’s mental status and cognition is one of the factors that needs to be taken into consideration when choosing a temperature device. This is correct. The physicGalRcAoD ndEitSioMnOoR fE th. eC paOtiMent is one of the factors that needs to be taken into consideration when choosing a temperature device. This is correct. The safety and nurse’s technique with using the device is one of the factors that needs to be taken into consideration when choosing a temperature device.

1. 2.

Feedback This is correct. Patients who have had rectal surgery should not have a rectal temperature because the rectum was the surgical site. This is correct. Patients who have cardiac disease should not have a rectal temperature because it could stimulate the vagus nerve and can cause a cardiac arrhythmia.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is correct. Patients who have diarrhea should not have a rectal temperature because the reading may not be accurate and stimulate the patient to have a diarrhea episode. This is incorrect. A patient’s refusal of a rectal temperature is not a contraindication for taking a rectal temperature. However, a patient has the right to refuse and ask for an alternate site. This is incorrect. Immobility is not a contraindication for a rectal temperature.

28. A nurse is assessing a radial pulse. What characteristics of the pulse must be documented? Select all that apply. 1. Time taken 2. Pulse site 3. Pulse rate 4. Pulse rhythm 5. Pulse amplitude ANS: 3, 4, 5 Page: 79

1. 2. 3. 4. 5.

Feedback This is incorrect. A characteristic of the pulse is not the time taken. This is incorrect. DocumenGtR atA ioD n EoS f aMpOuR lsE e. siC teOisMnot a characteristic of a pulse but documents pulse location. This is correct. Documentation of a pulse includes the pulse rate. This is correct. Documentation of a pulse includes the pulse rhythm. This is correct. Documentation of a pulse includes the pulse amplitude.

1. 2.

Feedback This is correct. Exercise is a muscular activity and increases the respiratory rate. This is correct. Some medications can increase or decrease the respiratory rate.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4. 5.

This is correct. Pain causes an increase in respiratory rate and decreases the depth of respirations. This is correct. Stress is the result of sympathetic stimulations and increases the respiratory rate. This is correct. Fever increases the respiratory rate.

30. A nurse is performing a vital sign assessment on a patient and understands that he must observe the following characteristics to assess a patient’s breathing. Select all that apply. 1. Rate 2. Depth 3. Skin movement 4. Rhythm 5. Effort ANS: 1, 2, 4, 5 Page: 81

1. 2. 3. 4. 5.

Feedback This is correct. Assessing respiratory rate assesses a patient’s breathing. Less than 12 breaths and more than 18 breaths per minute are abnormal findings. This is correct. Assessing the depth of respirations assesses a patient’s breathing. Deep or shallow breaths are abnG orRmAaD l fEinSdM inO gsR. E.COM This is incorrect. This is a vague answer. The nurse should be assessing chest movement, not skin movement. This is correct. Assessing the rhythm of respirations should be assessed for an irregular rhythm, which is an abnormal finding. This is correct. Respiratory effort is a characteristic of a patient’s breathing. The nurse should assess for use of accessory muscles.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4. 5.

This is correct. The epidemic of obesity is a contributing factor to the increase in the number of patients with hypertension. This is correct. The growth in population is a contributing factor to the increase in the number of patients with hypertension. This is incorrect. Genetics is not a contributing factor to the increase in the number of patients with hypertension. This is incorrect. Anxiety is not a contributing factor to the increase in the number of patients with hypertension. This is correct. The aging population is a contributing factor to the increase in the number of patients with hypertension.

32. High blood pressure is a modifiable risk factor for heart disease and stroke. Nurses are responsible for educating patients about lifestyle modifications for high blood pressure, which include which of the following? Select all that apply. 1. Reducing sodium, saturated fats, and cholesterol. 2. Quitting cigarette smoking. 3. Limiting alcohol intake. 4. Genetic testing. 5. If overweight, losing weight. ANS: 1, 2, 3, 5 Page: 90

1. 2. 3. 4. 5.

GRADESMORE.COM

Feedback This is correct. Reducing sodium, saturated fats, and cholesterol is a modifiable risk factor that will help to decrease blood pressure. This is correct. Quitting cigarette smoking is a modifiable risk factor that will help to decrease blood pressure. This is correct. Limiting alcohol intake is a modifiable risk factor that will help to decrease blood pressure. This is incorrect. Genetic testing is not a modifiable risk factor. This is correct. Losing weight, if overweight, is a modifiable risk factor that will help to decrease blood pressure.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 1, 3, 4 Page: 71

1. 2. 3. 4. 5.

Feedback This is correct. A patient who has a lack of resources may be unable to purchase appropriate clothes and may not have a place to perform personal hygiene. This is incorrect. A patient who is frugal may not have the best fitting, nicest clothes, but personal hygiene and body odor would not be a problem due to frugality. This is correct. A patient with impaired mental status or cognitive dysfunction can present with poor hygiene, body odor, and ill-fitting clothing. This is correct. A patient with a lack of finances can present with poor hygiene, body odor, and ill-fitting clothing. This is incorrect. A patient who does not like to shop may not have the best clothing, but personal hygiene and body would not be a problem.

GRADESMORE.COM

Feedback: An auscultatory gap, also called a silent gap, is the interval of pressure where Korotkoff sounds indicating true systolic pressure fade away and reappear at a lower pressure point during the manual measurement of blood pressure.

35. You are preparing to assess the blood pressure. You start by wrapping the deflated cuff around the patient’s arm about inch(es) above the brachial artery. ANS: 1, one Page: 86 Feedback: Wrap the deflated cuff around the patient’s arm about 2.5 cm (1 inch) above the brachial artery.

36. You are assessing the radial pulse and determine that it is 92 and irregular. You auscultate the apical pulse at 104 and irregular. What is the pulse deficit? _ ANS: 12, twelve

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Page: 80 Feedback: A pulse deficit is a difference in beats between the apical and radial pulse. This may be a sign of a cardiac arrhythmia.

37. A normal resting pulse for a well-conditioned athlete is minute.

beats per

ANS: 40, 60 Page: 79 Feedback: A normal resting pulse for well-conditioned athletes is 40 to 60 beats per minute.

38. Normal respirations are

breaths per minute.

ANS: 12; 18 Page: 81 Feedback: Respiratory rate equals one inhalation and exhalation of breath. A normal respiratory rate is 12 to 20 breaths per minute; pG atR teA rnDiE sS evMenO;RrhEy.thCmOiMs regular.

39. In a normotensive (normal BP) blood pressure reading, the systolic reading is less than and the diastolic reading is less than _ . ANS: 120; 80 Page: 85 Feedback: Normotensive (normal BP); systolic reading is less than 120; diastolic reading is less than 80.

40. Hypertension is blood pressure reading greater than greater than .

or the diastolic reading

ANS: 140; 90 Page: 85 Feedback: Hypertension is blood pressure greater than or equal to 140 systolic or greater than or equal to 90 diastolic. This is an abnormal finding.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

41. The heart rate.

pulse is the most reliable and accurate location to assess the

ANS: apical Page: 78 Feedback: The apical pulse is the most reliable because you are auscultating the heart rate at the apex of the heart.

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 7: Assessing Pain

1. The nurse is assessing an alert patient who just had surgery several hours ago. He is awake and complaining of pain. What is the nurse’s next action? 1. Ask the patient what pain medication he prefers. 2. Assess the patient’s self-report of pain. 3. Administer pain medication as ordered. 4. Use distraction therapy to alleviate pain.

2. The nurse is admitting a patient who states that she has been experiencing achy pain in her lower back for the past 6 months. Which term does the nurse use to describe this pain? 1. Acute 2. Chronic 3. Intractable 4. Intermittent

3. A diabetic patient states the pain “feels like needles and stings my feet. I also have numbness and tingling sensations.” The nurse wGoRuA ldDdE esScM ribOeRtE hi. sC asO: M 1. Neuropathic pain. 2. Somatic pain. 3. Visceral pain. 4. Colicky pain.

4. Which question or statement will provide the nurse with the most information about the patient’s pain? 1. “Are you in pain?” 2. “Have you ever had pain?” 3. “What is your level of pain on the numerical scale?” 4. “Describe the pain you are experiencing.”

5. Pain impulses are initiated by activation of free nerve endings. These free nerve endings are pain receptors called: 1. Gelatinosa cells. 2. A-delta fibers. 3. Nociceptors. 4. Pain stimulus.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

6. A patient fell off a ladder while painting his ceiling and hurt his lower back. He is now complaining of a burning, aching pain that is shooting down his leg. The nurse documents this as which type of pain? 1. Phantom limb syndrome 2. Psychogenic pain 3. Radiating pain 4. Referred pain

7. Which culture is unlikely to display pain and/or physical discomfort? 1. Amish culture 2. Jewish culture 3. Puerto Rican culture 4. Chinese Americans

8. Which pain scale would be most appropriate to use for a patient who is unable to communicate pain? 1. PAINAD assessment GRADESMORE.COM 2. Wong-Baker scale 3. Numerical scale 4. Verbal descriptor scale

9. The patient’s family reports to the staff nurse that the patient is having a lot of pain. What is the nurse’s best action? 1. Medicate the patient for pain per the physician’s order. 2. Go to the patient’s room and assess the patient’s pain. 3. Access the electronic medical record and determine when the patient last had pain medication. 4. Tell the family you will reevaluate the patient when pain medications are due.

10. A mother of a 4-year-old boy brings her son to the pediatrician’s office with stomach pain. Which pain scale would be best to use on an alert 4-year-old child? 1. PAINAD assessment 2. Wong-Baker scale 3. Numerical scale 4. Verbal descriptor scale

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

11. You are caring for a patient who is a nonverbal critically ill adult. What is the best pain rating scale to assess pain? 1. PAINAD assessment 2. Wong-Baker scale 3. Numerical scale 4. Nonverbal descriptor scale

12. What are the two physiological processes that the pain experience involves? 1. Interpretation and response 2. Location and damage 3. Detection and location 4. Detection and interpretation

13. The nurse understands the gate control theory of pain management when which statement is made? 1. “The pain medications close the gate and block the pain perception.” 2. “The pain impulses can be influenced by many factors, including a person’s emotions.” ADpain ESMreceptors.” ORE.COM 3. “The gate blocks the transmissionGofRall 4. “This theory is still in the developmental stages at the time.”

14. A 7-year-old child fractured his left leg riding his bicycle. The nurse uses the Wong-Baker scale to assess the child’s pain. The child points to the face that has a 10 rating. The nurse knows that a 10 rating based on the Wong-Baker scale would indicate what type of pain? 1. Minimal to none 2. A little bit to minimal 3. Hurts a lot 4. Hurts the worst

15. The nurse is assessing a patient who states she has a pain level of “8.” The patient is laughing and talking on the phone. What should the nurse do next? 1. Reassess the level of pain to obtain a pain score that matches the patient’s actions. 2. Do nothing as this is an acceptable level of pain for this patient. 3. Medicate the patient per health-care provider orders, if time appropriate. 4. Notify the health-care provider of the patient’s pain level.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

16. What does the abbreviation OPQRST mean? 1. Onset, pain, quality, relieving, starting, treatment 2. Original, particular, qualify, resting, standing, total 3. Onset, provocation, quality, radiation, severity, timing 4. Onset, pulsing, quota, realization, sensorium, temperature

17. Which question would you ask a patient to assess the “P” (provocation of pain) in the OPQRST method of pain assessment?” 1. “What causes the pain?” 2. “What does the pain feel like?” 3. “What symptoms do you have with the pain?” 4. “Where do you feel the pain?”

18. Which statement is true regarding pain assessments? 1. Only one type of pain assessment is best to use with the patient to prevent confusion. 2. The patient’s self-report of pain is the only valid pain assessment. 3. Combining pain assessment validations is more reliable than just using one type of assessment. 4. Teaching the nurse one pain scale G toRcAaD reEfoSrMpO atR ieEnt.s CisOtM he most essential.

19. The 1. thalamus 2. cortex 3. pituitary 4. cerebellum

of the brain interprets the sensation of pain.

20. The patient was in a motor vehicle accident and suffered trauma to his back and legs. He had extensive injuries to his legs and has nerve damage. What type of pain is caused by injury or damage to the nerves? 1. Cutaneous 2. Somatic 3. Visceral 4. Neuropathic

21. Which are factors that can affect the pain experience? Select all that apply.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Age of patient 2. Gender 3. Cultural background 4. Birth order 5. Previous pain experience

22. You are starting the health history on a patient who states he has right hip pain. Which are examples of nonverbal body language indicative of pain that you may observe during the interview? Select all that apply. 1. Rating pain a 7 out of 10 2. Facial grimacing 3. Moaning 4. Protective guarding 5. Rapid breathing

23. Which of the following physical changes would the nurse find on assessment in an adult with chronic pain? Select all that apply. 1. Dilated pupils 2. Increased restlessness GRADESMORE.COM 3. Absence of nausea 4. Dry skin 5. Increased pulse rate

24. The American Society for Pain Management addresses populations that may not be able to self-report pain. Which of the following populations do they address? Select all that apply. 1. Unconscious patients 2. Patients at end of life 3. Patients receiving opioid medications 4. Patients with visual deficits 5. Older adults

25. Which are considered emotional effects of chronic pain? Select all that apply. 1. Inability to work 2. Anger 3. Anxiety 4. Disability 5. Depression

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

26. The patient has chronic pain from rheumatoid arthritis. Which are functional effects of chronic pain? Select all that apply. 1. Inability to work 2. Anger 3. Inability to perform activities of daily living (ADLs) 4. Disability 5. Anxiety

27. The patient has sharp and localized somatic pain. This type of pain most often originates in which of the following? Select all that apply. 1. Lungs 2. Organs 3. Muscle 4. Joints 5. Bones

28. You are using the PAINAD assessment to assess pain in a dementia patient. What will you ADEapply. SMORE.COM be assessing using this scale? Select G allRthat 1. Body language 2. Temperature 3. Breathing 4. Negative vocalizations 5. Facial expression 6. Consolability

29. Phantom limb pain (PLP) is a poorly understood type of felt in a body part that has been removed.

pain that is

30. There are two main types of nerve fibers that transport the pain signals to the central nervous system. Pain fibers travel slowly through the nervous system. The pain fibers initiate a pain sensation that will feel diffuse, dull, burning, or achy.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers 1. The nurse is assessing an alert patient who just had surgery several hours ago. He is awake and complaining of pain. What is the nurse’s next action? 1. Ask the patient what pain medication he prefers. 2. Assess the patient’s self-report of pain. 3. Administer pain medication as ordered. 4. Use distraction therapy to alleviate pain. ANS: 2 Page: 97

1. 2. 3. 4.

Feedback This is incorrect. The patient’s preferred pain medication will not provide assessment data needed to treat the patient’s pain. This is correct. The patient’s self-report of pain is the “gold standard” for assessing the patient’s pain. This is incorrect. Assessing the patient’s pain would occur first, followed by administering the patient’s pain medication. This is incorrect. Distraction therapy is an excellent technique to alleviate pain; however, you must first assess the patient’s pain in order to determine if distraction therapy will be effective.

GRADESMORE.COM 2. The nurse is admitting a patient who states that she has been experiencing achy pain in her lower back for the past 6 months. Which term does the nurse use to describe this pain? 1. Acute 2. Chronic 3. Intractable 4. Intermittent ANS: 2 Page: 94

1. 2. 3. 4.

Feedback This is incorrect. Acute pain begins suddenly and is usually sharp in quality, of short duration, and protective in nature. This is correct. Chronic pain continues longer than 3 months or past the time of normal tissue healing. This is incorrect. Intractable pain is constant, resistant to treatment, or incurable. It continues even with intervention that attempts to alleviate the pain. This is incorrect. Intermittent pain comes and goes.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. A diabetic patient states the pain “feels like needles and stings my feet. I also have numbness and tingling sensations.” The nurse would describe this as: 1. Neuropathic pain. 2. Somatic pain. 3. Visceral pain. 4. Colicky pain. ANS: 1 Page: 96

Feedback This is correct. Neuropathic pain is caused by injury or damage to nerves. This pain feels sharp, stings, burns, and the patient may experience numbness and tingling sensations. This is incorrect. Somatic pain is diffuse, sharp, and well localized. It can often be reproduced by touching or moving the area or tissue involved; arises from tissues such as skin, muscle, joints, bones, and ligaments; and is often known as musculoskeletal pain. This is incorrect. Visceral pain is vague or poorly localized and usually originates from internal organs. It feels achy and crampy, and is caused by compression in and around the organs, ischemia, inflammation, or stretching of the abdominal cavity. This is incorrect. Colicky pain fluctuates in intensity from severe to mild and most often occurs in waves. It is usually related to spasms in the intestines.

GRADESMORE.COM

1. 2. 3. 4.

Feedback This is incorrect. This is a closed-ended question and will not obtain the most information from the patient regarding his or her pain. This is incorrect. This is a closed-ended question and will not obtain the most information from the patient regarding his or her pain. This is incorrect. This is a closed-ended question and will not obtain the most information from the patient regarding his or her pain. This is correct. This is an open-ended statement to encourage the patient to describe his or her pain.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

5. Pain impulses are initiated by activation of free nerve endings. These free nerve endings are pain receptors called: 1. Gelatinosa cells. 2. A-delta fibers. 3. Nociceptors. 4. Pain stimulus. ANS: 3 Page: 92

1. 2. 3. 4.

Feedback This is incorrect. Gelatinosa cells act as “gates” to regulate the flow of impulses to the spinal cord. This is incorrect. A-delta fibers are large, thick nerve fibers that travel quickly through the nervous system. This is correct. Nociceptor is another term for pain receptors that initiate pain impulses. This is incorrect. Pain stimulus is transmitted though the peripheral nerves through the dorsal horn of the spinal cord.

GRADESMORE.COM 6. A patient fell off a ladder while painting his ceiling and hurt his lower back. He is now complaining of a burning, aching pain that is shooting down his leg. The nurse documents this as which type of pain? 1. Phantom limb syndrome 2. Psychogenic pain 3. Radiating pain 4. Referred pain ANS: 3 Page: 96

3. 4.

Feedback This is incorrect. Phantom limb syndrome is a poorly understood type of neuropathic pain that is felt in a body part that has been removed. The brain still gets pain messages from the nerves that originally carried impulses from the missing limb. This is incorrect. Psychogenic pain has no organic or structural cause. The main mechanism proposed for the development of this condition is psychological trauma and suppression of the painful emotions. This is correct. Radiating pain starts in one area and spreads out to another part of the body. This is incorrect. Referred pain is felt in an area away from the actual source of the pain (e.g., gallbladder pain may be felt in the shoulder).

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

7. Which culture is unlikely to display pain and/or physical discomfort? 1. Amish culture 2. Jewish culture 3. Puerto Rican culture 4. Chinese Americans ANS: 1 Page: 94

1. 2. 3. 4.

Feedback This is correct. Individuals from the Amish culture are unlikely to display pain and physical discomfort. This is incorrect. Jewish culture views verbalization of pain as acceptable. This is incorrect. Individuals from the Puerto Rican culture tend to be loud and outspoken in expressing pain. This is incorrect. Chinese American culture expresses pain in terms of more diverse body symptoms.

GRADESMORE.COM 8. Which pain scale would be most appropriate to use for a patient who is unable to communicate pain? 1. PAINAD assessment 2. Wong-Baker scale 3. Numerical scale 4. Verbal descriptor scale ANS: 1 Page: 101

2. 3. 4.

Feedback This is correct. The PAINAD assessment can be used to assess pain in patients who are cognitively impaired, noncommunicative, or suffering from dementia and unable to use self-report methods to describe pain. This is incorrect. The Wong-Baker scale is used with patients age 3 years and older who are able to understand the instructions and point or report a pain level. This is incorrect. The numerical scale asks the patient to verbally estimate his or her pain based on a 1 to 10 scale. This is incorrect. The verbal descriptor scale is for patients who are able to describe pain as mild, moderate, or severe.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

Feedback This is incorrect. Proxy reporting can be obtained from a family member who knows the patient well. In this case, the relationship is not established, so it is best for the nurse to assess the level of pain. This is correct. The most reliable method for assessing pain is to have the patient describe the pain in his or her own words. It is best for the nurse to assess the patient’s self-report of pain. This is incorrect. This is not an accurate or safe method to determine if the patient is having a lot of pain. This is incorrect. Telling the family you will be there when pain medications are due omits the step of assessing the patient’s level of pain.

GRADESMORE.COM 10. A mother of a 4-year-old boy brings her son to the pediatrician’s office with stomach pain. Which pain scale would be best to use on an alert 4-year-old child? 1. PAINAD assessment 2. Wong-Baker scale 3. Numerical scale 4. Verbal descriptor scale ANS: 2 Page: 99

3. 4.

Feedback This is incorrect. The PAINAD assessment is used to assess pain in patients who are cognitively impaired, noncommunicative, and unable to use self-report methods to describe pain. An alert 4-year-old will be able to self-report pain. This is correct. The Wong-Baker scale uses faces for the patient to look at and either point or verbally state his or her pain level. This would be best for a 4-year-old child who is able to understand instructions. This is incorrect. The numerical scale asks the patient to verbally estimate his or her pain based on a numbers scale. This function is above that of a 4-year-old child. This is incorrect. The verbal descriptor scale is for a patient who is able to describe

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

pain using words such as mild, moderate, or severe. The vocabulary is above that of a 4-year-old child.

2. 3. 4.

Feedback This is correct. The PAINAD assessment is used to assess pain in patients who are cognitively impaired, noncommunicative, and unable to use self-report methods to describe pain. This would be best to use for a nonverbal critically ill adult. This is incorrect. The Wong-Baker scale uses faces for the patient to look at and either point at or verbally state his or her pain level. This is incorrect. The numerical scale asks the patient to verbally estimate his or her pain based on a numbers sG caRleA. D TE hiS sM paOtiR enEt.isCnOoM nverbal. This is incorrect. There is no nonverbal descriptor scale. The verbal descriptor scale is for a patient who is able to describe pain using words such as mild, moderate, or severe.

12. What are the two physiological processes that the pain experience involves? 1. Interpretation and response 2. Location and damage 3. Detection and location 4. Detection and interpretation ANS: 4 Page: 92

1. 2. 3.

Feedback This is incorrect. Detection and interpretation are the two processes that are involved in the pain experience. The patient must be able to detect and interpret the pain. This is incorrect. Detection and interpretation are the two processes that are involved in the pain experience. The patient must be able to detect and interpret the pain. This is incorrect. Detection and interpretation are the two processes that are involved in the pain experience. The patient must be able to detect and interpret the pain.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is correct. Detection and interpretation are the two processes that are involved in the pain experience. The patient must be able to detect and interpret the pain.

13. The nurse understands the gate control theory of pain management when which statement is made? 1. “The pain medications close the gate and block the pain perception.” 2. “The pain impulses can be influenced by many factors, including a person’s emotions.” 3. “The gate blocks the transmission of all pain receptors.” 4. “This theory is still in the developmental stages at the time.” ANS: 2 Page: 92

1. 2. 3. 4.

Feedback This is incorrect. Pain medication is not a component of the gate control theory. This is correct. The gate control theory theorizes that pain impulses can be influenced by many factors, including a person’s emotions and mind. This is incorrect. The gate does not block the transmission of all pain receptors. Pain receptors are not a component of the gate control theory. This is incorrect. This theory was developed in 1965.

GRADESMORE.COM 14. A 7-year-old child fractured his left leg riding his bicycle. The nurse uses the Wong-Baker scale to assess the child’s pain. The child points to the face that has a 10 rating. The nurse knows that a 10 rating based on the Wong-Baker scale would indicate what type of pain? 1. Minimal to none 2. A little bit to minimal 3. Hurts a lot 4. Hurts the worst ANS: 4 Page: 99

1. 2. 3. 4.

Feedback This is incorrect. Minimal to none would indicate a pain level of 0 to 1. This is incorrect. A little bit to minimal would indicate a pain level of 2 to 4. This is incorrect. Hurts a lot would indicate a pain level of 8. This is correct. Hurts the worst would indicate a pain level of 10.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. There is no need to reassess the pain as pain is what the patient states it is. All people respond differently to pain. This is incorrect. An “8” is not an acceptable level of pain for any patient. This patient is self-reporting. This is correct. Medicating the patient per health-care provider orders is the nurse’s next action. The nurse is not to judge if the patient is in pain or not. This is incorrect. There is no reason to notify the health-care provider unless this is a new onset of increased pain.

16. What does the abbreviation OPQRST mean? MeOnRt E.COM 1. Onset, pain, quality, relieving, starGtiR ngA, D trE eaStm 2. Original, particular, qualify, resting, standing, total 3. Onset, provocation, quality, radiation, severity, timing 4. Onset, pulsing, quota, realization, sensorium, temperature ANS: 3 Page: 98-99

1. 2. 3. 4.

Feedback This is incorrect. OPQRST is an acronym for onset of pain, provocation of pain, quality of pain, radiation of pain, severity of pain, and timing of pain. This is incorrect. OPQRST is an acronym for onset of pain, provocation of pain, quality of pain, radiation of pain, severity of pain, and timing of pain. This is correct. OPQRST is an acronym for onset of pain, provocation of pain, quality of pain, radiation of pain, severity of pain, and timing of pain. This is incorrect. OPQRST is an acronym for onset of pain, provocation of pain, quality of pain, radiation of pain, severity of pain, and timing of pain.

17. Which question would you ask a patient to assess the “P” (provocation of pain) in the OPQRST method of pain assessment?” 1. “What causes the pain?”

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. “What does the pain feel like?” 3. “What symptoms do you have with the pain?” 4. “Where do you feel the pain?” ANS: 1 Page: 98

1. 2. 3. 4.

Feedback This is correct. Provocation of pain can best be assessed by the questions “What causes the pain?” and “What makes the pain worse?” This is incorrect. “What does the pain feel like?” would assess the quality of the pain. This is incorrect. “What symptoms do you have with the pain?” would best be used with the OLDCART for aggravating factors. This is incorrect. “Where do you feel the pain?” would best assess the location of the pain.

18. Which statement is true regarding pain assessments? 1. Only one type of pain assessment is best to use with the patient to prevent confusion. 2. The patient’s self-report of pain is the only valid pain assessment. 3. Combining pain assessment validations is more reliable than just using one type of assessment. GRADESMORE.COM 4. Teaching the nurse one pain scale to care for patients is the most essential. ANS: 3 Page: 98

1. 2. 3. 4.

Feedback This is incorrect. More than one type of pain assessment should be used for the best results. This is incorrect. The patient’s self-report of pain is an excellent source but should be combined with additional pain assessments for the best results. This is correct. Combining the patient’s pain assessment with an additional pain assessment is more reliable. This is incorrect. The nurse must be aware of all pain scales currently in use.

19. The 1. thalamus 2. cortex 3. pituitary 4. cerebellum

of the brain interprets the sensation of pain.

ANS: 2

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Page: 93

1. 2. 3. 4.

Feedback This is incorrect. The thalamus is the part of the brain that receives the pain information from the spinal cord. This is correct. The cortex of the brain interprets the sensation of pain. This is incorrect. The pituitary is a gland that is responsible for hormone levels. This is incorrect. The cerebellum functions to coordinate and regulate muscular activity.

GRADESMORE.COM

1. 2. 3. 4.

Feedback This is incorrect. Cutaneous pain originates from the skin and subcutaneous tissue. It is superficial pain. This is incorrect. Somatic pain arises from tissues such as skin, muscle, joints, bones, and ligaments. This is incorrect. Visceral pain originates from internal organs. This is correct. Neuropathic pain is caused by injury or damage to the nerves.

21. Which are factors that can affect the pain experience? Select all that apply. 1. Age of patient 2. Gender 3. Cultural background 4. Birth order 5. Previous pain experience ANS: 1, 2, 3, 5 Page: 91

Feedback This is correct. The age of the patient is a factor that can affect the pain experience.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4. 5.

This is correct. The gender of the patient is a factor that can affect the pain experience. Men and women react differently to the pain experience and research has documented that women have a lower pain threshold. This is correct. Cultural background is a factor that can affect the pain experience. This is incorrect. Birth order is not identified as a factor affecting the pain experience. This is correct. Previous experience with pain is a factor that can affect the pain experience.

GRADESMORE.COM

This is incorrect. Rating of pain is a verbal communication. This is correct. Facial grimacing is a form of nonverbal communication. This is correct. Moaning is a form of nonverbal communication. This is correct. Protective guarding is a form of nonverbal communication. This is correct. Rapid breathing is a form of nonverbal communication.

23. Which of the following physical changes would the nurse find on assessment in an adult with chronic pain? Select all that apply. 1. Dilated pupils 2. Increased restlessness 3. Absence of nausea 4. Dry skin 5. Increased pulse rate ANS: 3, 4 Page: 95

1. 2. 3.

Feedback This is incorrect. Dilated pupils are seen with acute pain, not chronic pain. This is incorrect. Increased restlessness is seen with acute pain, not chronic pain. This is correct. Absence of nausea or no nausea is seen with chronic pain.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. 5.

This is correct. Dry skin is seen with chronic pain. Patients with acute pain are diaphoretic. This is incorrect. Increased pulse rate is seen with acute pain. Pulse rate remains normal with chronic pain.

1. 2. 3. 4. 5.

Feedback This is correct. The unconscious/critically ill patient has been identified as one of the five populations of patients who may be unable to self-report pain. This is correct. Patients at the end of life have been identified as one of the five populations of patients who may be unable to self-report pain. This is incorrect. Patients G reR ceAivDinEgSoMpO ioR idEs . arCeOnM ot identified as a population of patients who may be unable to self-report pain. This is incorrect. Patients with visual deficits are not identified as a population of patients who may be unable to self-report pain. This is incorrect. Older adults with dementia have been identified as a population of patients who may be unable to self-report pain, not just older adults.

25. Which are considered emotional effects of chronic pain? Select all that apply. 1. Inability to work 2. Anger 3. Anxiety 4. Disability 5. Depression ANS: 2, 3, 5 Page: 95

1. 2. 3.

Feedback This is incorrect. Inability to work is a functional effect of pain. This is correct. Anger is an emotional effect of chronic pain. This is correct. Anxiety is an emotional effect of chronic pain.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. 5.

This is incorrect. Disability is a functional effect of chronic pain. This is correct. Depression is an emotional effect of chronic pain.

1. 2. 3. 4. 5.

Feedback This is correct. Inability to work is a functional effect of chronic pain. This is incorrect. Anger is an emotional effect of chronic pain. This is correct. Inability to perform ADLs is a functional effect of chronic pain. This is correct. Disability is a functional effect of chronic pain. This is incorrect. Anxiety is an emotional effect of chronic pain.

GRADESMORE.COM 27. The patient has sharp and localized somatic pain. This type of pain most often originates in which of the following? Select all that apply. 1. Lungs 2. Organs 3. Muscle 4. Joints 5. Bones ANS: 3, 4, 5 Page: 95-96

1. 2. 3. 4. 5.

Feedback This is incorrect. Somatic pain does not originate in the lungs; it is most commonly a musculoskeletal pain. This is incorrect. Visceral pain originates in the organs; somatic pain originates in the musculoskeletal system. This is correct. Somatic pain originates in muscles; it is musculoskeletal pain. This is correct. Somatic pain originates in joints; it is musculoskeletal pain. This is correct. Somatic pain originates in bones; it is musculoskeletal pain.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

28. You are using the PAINAD assessment to assess pain in a dementia patient. What will you be assessing using this scale? Select all that apply. 1. Body language 2. Temperature 3. Breathing 4. Negative vocalizations 5. Facial expression 6. Consolability ANS: 1, 3, 4, 5, 6 Page: 103

1. 2. 3. 4. 5. 6.

Feedback This is correct. The patient’s body language is assessed in the PAINAD assessment. This is incorrect. Body temperature is not assessed in the PAINAD assessment. This is correct. Breathing is assessed in the PAINAD assessment. This is correct. Negative vocalizations are assessed in the PAINAD assessment. This is correct. Facial expression is assessed in the PAINAD assessment. This is correct. Consolability is assessed in the PAINAD assessment.

GRADESMORE.COM 29. Phantom limb pain (PLP) is a poorly understood type of felt in a body part that has been removed.

pain that is

ANS: neuropathic Page: 96 Feedback: PLP varies in character from neuropathic-type descriptors such as sharp, shooting, or electrical-like, to more nociceptive-specific adjectives such as dull, squeezing, and cramping. It can be localized to the entire limb or just one region of the missing limb.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Feedback: C fibers are smaller, thinner, unmyelinated nerve fibers that travel slowly through the nervous system; pain will feel diffuse, dull, burning, or achy.

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 8: Assessing the Skin, Hair, and Nails

1. The layer of the skin that adds strength and elasticity, and gives individuals the ability to feel is the: 1. Epidermis. 2. Dermis. 3. Subcutaneous. 4. Stratum corneum.

2. A decrease in the number of functioning melanocytes results in: 1. Melanomas. 2. Thinning of the skin. 3. Graying of hair. 4. Darkening of the skin.

3. The pink color of the nail beds is dGuR eA toD: ESMORE.COM 1. Pigment from melanocytes. 2. Vascularity of epithelial cells. 3. Genetic predisposition. 4. Inflammation of the epidermis.

4. Apocrine sweat glands differ from eccrine sweat glands in that they: 1. Produce body odor when reacting to bacterial decomposition. 2. Decrease in response to emotional stress. 3. Maintain body temperature. 4. Are located only on the palms, soles, and forehead.

5. During your assessment of a 17-year-old female, you determine that she uses tanning beds on a regular basis. You should inform her that: 1. Tanning beds should not be used by persons under 18 years of age. 2. Tanning beds increase the risk of melanoma by 75%. 3. Tanning beds are less dangerous than sun exposure. 4. 1 and 2

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

5. 1, 2, and 3

6. Keloid formation is commonly seen in: 1. Overexposure to the sun. 2. Allergic reactions. 3. Dark-skinned individuals. 4. Individuals with poor skin hygiene.

7. The nurse pinches the patient’s skin over the clavicle between two fingers and lets it go. The skin remains tented and slowly returns to the flat position. The nurse knows this is a sign of: 1. Dehydration. 2. A large amount of recent weight gain. 3. Inflammation. 4. Poor peripheral circulation.

8. The nurse assesses excessive moisG tuRreAoDfEthSeMsO kiR n,Ec. alC leOdMhyperhidrosis, which can indicate a(n): 1. Cardiac condition. 2. Endocrine disorder. 3. Renal disorder. 4. Neurological condition.

9. A bruise caused by bleeding under the skin or mucous membranes after a local trauma is called: 1. Ecchymosis. 2. Hematoma. 3. Purpura. 4. Petechiae.

10. The most common form of cutaneous malignancy is: 1. Malignant melanoma. 2. Squamous cell carcinoma. 3. Basal cell carcinoma.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Skin cancer.

11. If lice are found during an inspection of the hair, the best way to pick them up is with a: 1. Hemostat. 2. Tongue blade. 3. Piece of clear tape. 4. Gloved hand.

12. An inflammation of a hair follicle with white pustules is called: 1. Alopecia. 2. Folliculitis. 3. Seborrhea dermatitis. 4. Tinea capitis.

13. While assessing the patient’s fingernails, the nurse notices a thickening, yellow discoloration and scaling of the nail bed. The nurseGw spOeR ctE : .COM RoAuDldEsSuM 1. Onychomycosis. 2. Paronychia. 3. Spoon nails. 4. Pitting.

14. The nurse is assessing a wound on a patient’s buttocks. The wound depth would be measured with a: 1. Tape measure. 2. Sterile cotton-tipped applicator. 3. Gloved finger. 4. Sterile hemostat.

15. While assessing a pressure ulcer, the nurse notes that the exudate is light red or pink in color. The term for correct documentation of this exudate is: 1. Serous. 2. Serosanguineous. 3. Sanguinous.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Purulent.

16. When changing a dressing on a pressure ulcer, the nurse notes maceration around the area and teaches the patient and his family that this is caused by a dressing that is: 1. Dry. 2. Left on too long. 3. Not covering the wound adequately. 4. Taped too tightly.

17. A patient comes to the health-care provider’s office complaining of a red, raised rash. The nurse assesses lesions distributed over the entire body and documents this distribution as: 1. Localized. 2. Scattered. 3. Regional. 4. Diffuse/generalized.

GRADESMORE.COM

18. During an assessment, the nurse notices a lesion on the patient’s leg that is round with central clearing. This would be documented as a(n): 1. Discrete lesion. 2. Confluent lesion. 3. Iris lesion. 4. Circular lesion.

19. Moles (nevi) are examples of which type of lesion pattern? 1. Round/oval 2. Discrete 3. Linear 4. Reticula

20. The patient in the emergency room is assessed as having scrapes of the superficial layers of the skin of his arms and legs following a motorcycle accident. This would be documented as: 1. Contusions. 2. Lacerations.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. Abscesses. 4. Abrasions.

21. A child presents at the urgent care center after falling through a glass window. A large shard of glass is still lodged in his leg. This type of wound would be documented as a: 1. Puncture wound. 2. Penetrating wound. 3. Tunnel wound. 4. Crushing wound.

22. Upon admission, the patient is assessed using the Braden Scale for Predicting Pressure Sore Risk. The patient responds to verbal commands, but cannot communicate discomfort or the need to be turned. His skin is moist, requiring extra linen changes daily. His ability to walk is severely limited and he must be assisted into a wheelchair. He requires maximum assistance in moving and frequently slides down in bed. When in bed, he makes occasional slight changes in body or extremity positions. He eats over half of most meals, including at least four servings of meat and dairy products. His Braden Scale Score is 14 and translates to: 1. No risk. GRADESMORE.COM 2. Low risk. 3. Moderate risk. 4. High risk.

23. The nurse would implement the pressure ulcer prevention protocol if he or she assesses a Braden Scale for Predicting Pressure Sore Risk of: 1. 24 or less. 2. 20 or less. 3. 18 or less. 4. 16 or less.

24. The nurse assesses a patient with a chronic skin disorder that causes the skin to be scaly, itchy, inflamed, and irritated. The patient states that her mother and sister have the same condition. The nurse recognizes this as: 1. Acne. 2. Eczema. 3. Psoriasis.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Seborrhea dermatitis.

25. During an assessment, the nurse notices smooth white patches all over the skin. She documents this as possible: 1. Hypopigmentation. 2. Albinism. 3. Hyperpigmentation. 4. Vitiligo.

26. In the recovery room, the nurse assesses a bluish discoloration of the patient’s oral mucosa and conjunctiva of the eyes, lips, and tongue. These changes in color could indicate: 1. Jaundice. 2. Pallor. 3. Peripheral cyanosis. 4. Central cyanosis.

GRADESMORE.COM 27. While changing a surgical dressing, the nurse explains to the patient that the pink skin color surrounding his wound indicates: 1. Infection. 2. Increased blood flow. 3. Delayed healing. 4. Imminent wound separation.

28. Yellowing of the skin without yellowing of the sclera of the eye might indicate: 1. Jaundice. 2. Hyperpigmentation. 3. Carotenemia. 4. Erythema.

29. A patient presents with concern about yellowing of her skin. The nurse assesses that there is no yellowing of the sclera of the eye and inquires about the patient’s: 1. Exposure to the sun. 2. Dietary intake.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. Exposure to chemicals. 4. Allergies.

30. The patient presents with redness, swelling, and spider-like blood vessels on the middle of the face. The nurse suspects this is a condition called: 1. Rosacea. 2. Acne vulgaris. 3. Eczema. 4. Erythema.

31. You are performing a skin assessment on a patient’s face and inspect many freckles on both sides. A freckle is a: 1. Macule. 2. Papule. 3. Vesicle. 4. Nodule.

GRADESMORE.COM 32. A patient comes to the clinic to have an elevated brown mole removed. You measure the mole and it is 0.9 mm. The nurse knows that this is a: 1. Macule. 2. Papule. 3. Vesicle. 4. Nodule.

33. The nurse assesses a skin lesion that is elevated, encapsulated, and filled with fluid. The nurse knows that this is a: 1. Nodule. 2. Wheal. 3. Cyst. 4. Pustule.

34. The dried collection of blood, serum, or pus that is part of the normal healing process is called a:

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Fissure. 2. Scar. 3. Scale. 4. Crust.

35. A postoperative patient exhibits thick and raised tissue extending beyond the original boundaries of the incision. The nurse recognizes this as: 1. A scar. 2. Erosion. 3. A keloid. 4. Excoriation.

36. Dysplastic nevi or Clark’s nevi, which have a greater potential for developing into melanoma, are characterized by: 1. Irregular, poorly defined borders. 2. No variations in color. 3. Being smaller in size than typical nevi. 4. Maintaining a consistent size. GRADESMORE.COM

37. The nurse is assessing and staging a pressure ulcer. She determines that there is full thickness loss involving subcutaneous tissue. The ulcer extends to but not through fascia. A deep crater undermines adjacent tissues. The nurse assesses this pressure ulcer to be: 1. Stage 1. 2. Stage 2. 3. Stage 3. 4. Stage 4. 5. Unstageable.

38. Nail growth can be affected by which of the following? Select all that apply. 1. Seasons 2. Stress 3. Disease 4. Hormone deficiency 5. Weight

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

39. The integumentary system comprises skin, hair, and nails but also includes which of the following? Select all that apply. 1. Glands 2. Tendons 3. Mucous membranes 4. Capillaries 5. Cartilage

40. The nurse explains to the patient’s family that persons at risk for developing pressure ulcers include which of the following? Select all that apply. 1. Those who are immobile or have decreased mobility 2. Those who have poor nutrition 3. Those who are confined to a bed or wheelchair 4. Those who have decreased blood circulation 5. Those who are hydrated

GRADESMORE.COM 41. Which skin diseases tend to be familial? Select all that apply. 1. Basal cell carcinoma 2. Eczema 3. Psoriasis 4. Herpes simplex 5. HPV

42. Using the Braden Scale for Predicting Pressure Sore Risk, the nurse assesses several factors. Select all that apply. 1. Sensory perception 2. Moisture 3. Activity 4. Mobility 5. Nutrition 6. Friction and shear

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

43. In assessing a pressure ulcer, the nurse notes areas of eschar and areas of slough. Which of the following statements are true of these findings? Select all that apply. 1. Eschar is dry, leathery, indurated, and black. 2. Slough is yellow, moist, and stringy. 3. Eschar is hydrated necrotic tissue. 4. Slough is dehydrated necrotic tissue.

44. The skin assessment indicates a mole on the patient’s back. The nurse will assess it for which of the following? Select all that apply. 1. Asymmetry 2. Border 3. Color 4. Diameter 5. Evolving characteristics

45. In assessing for cyanosis, the nurse would inspect which of the following? Select all that apply. 1. Lips GRADESMORE.COM 2. Oral mucosa 3. Extremities 4. Sclera of the eyes 5. Neck

46. Intertriginous areas trap moisture and can easily become infected. These areas include which of the following? Select all that apply. 1. Under the breasts 2. Under the arms 3. Under stomach folds of obese individuals 4. Groin areas 5. Behind the ears

47. To protect the skin from sun damage, what does the nurse teach about sunblock? Select all that apply. 1. It should have an SPF of at least 15. 2. It should be water resistant.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. It should be reapplied after the user has been in the water. 4. It should be applied immediately before sun exposure. 5. It should be applied once a day.

48. The skin is involved in several functions of the body, including which of the following? Select all that apply. 1. Sensation and perception 2. Thermoregulation 3. Fluid balance 4. Synthesis of vitamin K 5. Excretion 6. Immunity

49. Sebum is secreted through hair follicles in which areas of the body? Select all that apply. 1. Soles of the feet 2. Palms of the hand 3. Axilla 4. Face GRADESMORE.COM

50. Your adult patient presents with a severe, red rash over both arms and hands. There are no other symptoms. In taking a health history you would assess which of the following? Select all that apply. 1. Onset of the rash 2. Associated or alleviating factors 3. History/family history of skin disorders 4. Effects on body image 5. Age of patient

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

52. A college student comes to Student Health Services stating that he thinks he is having an allergic reaction. He states that these lesions are itchy and getting worse. You inspect his skin and see the skin lesion in the accompanying figure. This lesion is called a .

53. The patient reports that he has been under a lot of stress since he lost his job last month. He wants the health-care provider to look at the above lesions that are on his bottom lip. The configuration of the lesions in the picture is .

GRADESMORE.COM

55. You are inspecting and palpating a patient’s fingernails. The patient has chronic obstructive pulmonary disease related to smoking for the past 30 years. You look at his nails and note an increased nail base angle. You know that the normal nail base angle is degrees.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers

1. The layer of the skin that adds strength and elasticity, and gives individuals the ability to feel is the: 1. Epidermis. 2. Dermis. 3. Subcutaneous. 4. Stratum corneum. ANS: 2 Page: 104

1. 2. 3. 4.

Feedback This is incorrect. The epidermis contains keratinocytes and melanocytes that give the skin color. This is correct. The dermis contains connective tissue, sensory nerve fibers, capillaries, collagen, and elastin. This is incorrect. The subcutaneous layer is composed of adipose and fat. This is incorrect. The stratum corneum is a thin layer of dead skin that changes in thickness depending on its location.

GRADESMORE.COM 2. A decrease in the number of functioning melanocytes results in: 1. Melanomas. 2. Thinning of the skin. 3. Graying of hair. 4. Darkening of the skin. ANS: 3 Page: 105

1. 2. 3. 4.

Feedback This is incorrect. Decreasing melanocytes does not result in melanomas. This is incorrect. Decreasing melanocytes does not result in thinning of the skin. This is correct. Gray hair occurs due to a decrease in the number of functioning melanocytes. This is incorrect. Pigmentation is determined by the number, size, and distribution of melanosomes.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. The pink color of the nail beds is due to: 1. Pigment from melanocytes. 2. Vascularity of epithelial cells. 3. Genetic predisposition. 4. Inflammation of the epidermis. ANS: 2 Page: 106

1. 2. 3. 4.

Feedback This is incorrect. The pink color of the nail beds is not related to skin color. This is correct. The pink color of the nail beds is due to highly vascular epithelial cells. This is incorrect. Genetics are not related to vascularity. This is incorrect. The pink color of the nail beds is not related to inflammation.

1. 2. 3. 4.

Feedback This is correct. Apocrine sweat glands produce body odor in reaction to bacterial decomposition. This is incorrect. Eccrine sweat glands increase in response to emotional stress. This is incorrect. Eccrine sweat glands maintain body temperature. This is incorrect. Eccrine sweat glands are located on the palms, soles, and forehead.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 4 Page: 107

1. 2. 3. 4. 5.

Feedback Tanning beds should not be used by persons under 18 years of age due to the hazards of ultraviolet radiation. Tanning beds increase the risk of melanoma by 75%. This is incorrect. Tanning beds are not less dangerous than sun exposure. This is correct. Both 1 and 2 are correct answers. This is incorrect. Answer 3 is incorrect.

6. Keloid formation is commonly seen in: 1. Overexposure to the sun. 2. Allergic reactions. 3. Dark-skinned individuals. 4. Individuals with poor skin hygiene. ANS: 3 Page: 109

GRADESMORE.COM 1. 2. 3. 4.

Feedback This is incorrect. Keloids are not related to sun exposure. This is incorrect. Keloids are not related to allergy. This is correct. Keloid formation is overgrowth of connective tissue commonly seen in dark-skinned individuals. This is incorrect. Keloids are not related to poor skin hygiene.

Feedback This is correct. Poor turgor can indicate dehydration.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3. 4.

This is incorrect. Poor turgor can indicate recent weight loss, not weight gain. This is incorrect. Poor turgor is not a sign of inflammation. This is incorrect. Poor turgor is not a sign of poor peripheral circulation.

8. The nurse assesses excessive moisture of the skin, called hyperhidrosis, which can indicate a(n): 1. Cardiac condition. 2. Endocrine disorder. 3. Renal disorder. 4. Neurological condition. ANS: 2 Page: 118

1. 2. 3. 4.

Feedback This is incorrect. Hyperhidrosis is excessive sweating and does not indicate a cardiac condition. This is correct. Hyperhidrosis is excessive sweating and can indicate an endocrine disorder. This is incorrect. Hyperhidrosis G isReA xcDeE ssS ivMe Osw ReEa. tinCgOaMnd does not indicate a renal disorder. This is incorrect. Hyperhidrosis is excessive sweating and does not indicate a neurological disorder.

9. A bruise caused by bleeding under the skin or mucous membranes after a local trauma is called: 1. Ecchymosis. 2. Hematoma. 3. Purpura. 4. Petechiae. ANS: 1 Page: 125

1. 2.

Feedback This is correct. Ecchymosis is a bruise caused by bleeding under the skin or mucous membranes. It occurs as a result of local trauma. This is incorrect. Hematoma is an elevated collection of usually clotted blood within the tissue caused by a break in a blood vessel.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

This is incorrect. Purpura is a hemorrhagic red or purple rash that is flat and does not blanch, measures 3 to 10 mm, and is usually associated with coagulation disorders. This is incorrect. Petechiae are tiny, pinpoint hemorrhages caused by superficial bleeding from the capillaries of the skin, measure less than 3 mm, and may be related to platelet deficiencies.

10. The most common form of cutaneous malignancy is: 1. Malignant melanoma. 2. Squamous cell carcinoma. 3. Basal cell carcinoma. 4. Skin cancer. ANS: 3 Page: 125

1. 2. 3. 4.

Feedback: This is incorrect. Basal cell carcinoma is the most common form of cutaneous malignancy. This is incorrect. Basal cell carcinoma is the most common form of cutaneous OoMst common. malignancy. Squamous cell carcG inRoA mD aE isSthMeOsR ecEo. ndCm This is correct. Basal cell carcinoma is the most common form of cutaneous malignancy. This is incorrect. Skin cancer is a general term. There are specific types of skin cancer.

11. If lice are found during an inspection of the hair, the best way to pick them up is with a: 1. Hemostat. 2. Tongue blade. 3. Piece of clear tape. 4. Gloved hand. ANS: 3 Page: 126

1. 2. 3. 4.

Feedback This is incorrect. If nits or lice are found, use clear tape to pick them up. This is incorrect. If nits or lice are found, use clear tape to pick them up. This is correct. If nits or lice are found, use clear tape to pick them up. This is incorrect. If nits or lice are found, use clear tape to pick them up.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

12. An inflammation of a hair follicle with white pustules is called: 1. Alopecia. 2. Folliculitis. 3. Seborrhea dermatitis. 4. Tinea capitis. ANS: 2 Page: 127

1. 2. 3. 4.

Feedback This is incorrect. Alopecia, defined as hair loss, may be due to nutritional deficiencies, medications, illness, endocrine disorders, radiation, or the physiological changes of aging. This is correct. Folliculitis is inflammation of a hair follicle developing on the face, arms, legs, or buttocks; white pustules appear around the hair follicle. This is incorrect. Seborrhea dermatitis, also called cradle cap in infants, is a chronic, greasy scale that accumulates and thickens on the scalp with or without redness. This is incorrect. Tinea capitis, also called scalp ringworm, is a fungal infection of the scalp causing round, patchy hair loss, pustules, and scale on the skin.

GRADESMORE.COM 13. While assessing the patient’s fingernails, the nurse notices a thickening, yellow discoloration and scaling of the nail bed. The nurse would suspect: 1. Onychomycosis. 2. Paronychia. 3. Spoon nails. 4. Pitting. ANS: 1 Page: 128

1. 2. 3.

Feedback This is correct. Onychomycosis is thickening, yellow discoloration and scaling of the nail bed due to a fungal infection. It is more common in diabetics and older individuals. This is incorrect. Paronychia is a skin infection around the nail causing erythema, swelling, and tenderness at the nail fold. This is incorrect. Spoon nails are flat or concave; outer edges flare out; dips or waves are visible on the surface of the nail. This may be hereditary or related to a nutritional or systemic disease. This is incorrect. Pitting of nails is a sign of psoriasis; affects both fingernails and toenails; appears as indentations in different sizes, shapes, and depths; nails can disintegrate easily.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

14. The nurse is assessing a wound on a patient’s buttocks. The wound depth would be measured with a: 1. Tape measure. 2. Sterile cotton-tipped applicator. 3. Gloved finger. 4. Sterile hemostat. ANS: 2 Page: 130

Feedback This is incorrect. Using a sterile cotton-tipped applicator, gently insert the applicator into the deepest area. Measure by placing your fingers on the applicator next to the wound edge. Position the applicator next to a tape measure. This is correct. Using a sterile cotton-tipped applicator, gently insert the applicator into the deepest area. Measure by placing your fingers on the applicator next to the wound edge. Position the applicator next to a tape measure. This is incorrect. Using a sterile cotton-tipped applicator, gently insert the applicator into the deepest area. Measure by plaGciRnA gD yoEuSr M fiO ngReE rs.oC nO thMe applicator next to the wound edge. Position the applicator next to a tape measure. This is incorrect. A sterile hemostat is not used to measure wound depth. Using a sterile cotton-tipped applicator, gently insert the applicator into the deepest area. Measure by placing your fingers on the applicator next to the wound edge. Position the applicator next to a tape measure.

1. 2.

Feedback This is incorrect. Serous is clear to straw colored. This is correct. Serosanguineous is light red or pink in color.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

This is incorrect. Sanguineous is red to dark red in color. This is incorrect. Purulent is yellow or green in color, indicating infection.

Feedback This is incorrect. Wound maceration is not caused by a dry dressing. Wound maceration is caused by excessive moisture from pooled drainage or a moist dressing that is inappropriately applied, left on too long, or overlaps healthy skin. This is correct. Wound maceration is caused by excessive moisture from pooled drainage or a moist dressing that is inappropriately applied, left on too long, or overlaps healthy skin. GRADESMORE.COM This is incorrect. Wound maceration is not caused by a dressing that does not cover the wound adequately. Wound maceration is caused by excessive moisture from pooled drainage or a moist dressing that is inappropriately applied, left on too long, or overlaps healthy skin. This is incorrect. Wound maceration is not caused by a dressing that is taped too tightly. Wound maceration is caused by excessive moisture from pooled drainage or a moist dressing that is inappropriately applied, left on too long, or overlaps healthy skin.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

This is incorrect. Localized indicates lesions in a very limited, discrete area. This is incorrect. Scattered indicates lesions that are sparsely distributed. This is incorrect. Regional indicates lesions confined to a specific body area. This is correct. Diffuse/generalized lesions are distributed over the entire body.

1. 2. 3. 4.

Feedback This is incorrect. Discrete lesions remain separate and apart. They are common in many skin disorders. This is incorrect. Confluent lesions run together. This is correct. An iris lesion is aGbRuAllD ’sE -eSyM eO leR siE on.oCrOroMund lesion with central clearing. This is incorrect. Circular lesions are ring-shaped.

19. Moles (nevi) are examples of which type of lesion pattern? 1. Round/oval 2. Discrete 3. Linear 4. Reticula ANS: 2 Page: 121

1. 2. 3. 4.

Feedback This is incorrect. This is a shape of a lesion. This is correct. This is a pattern of a lesion. Discrete lesions remain separate and apart. This is incorrect. This is a pattern not commonly seen with nevi. Linear lesions are arranged in lines. This is incorrect. This is a pattern not commonly seen with nevi. Reticular lesions form a mesh-like pattern.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. A contusion is a closed wound caused by blunt trauma. This is incorrect. A laceration occurs when the skin or mucous membranes are torn open, resulting in a wound with jagged margins. This is incorrect. An abscess is a localized collection of pus resulting from invasion from a pyogenic bacterium or other pathogen. This is correct. An abrasion is a scrape of superficial layers of the skin.

GRADESMORE.COM 21. A child presents at the urgent care center after falling through a glass window. A large shard of glass is still lodged in his leg. This type of wound would be documented as a: 1. Puncture wound. 2. Penetrating wound. 3. Tunnel wound. 4. Crushing wound. ANS: 2 Page: 129

1. 2. 3. 4.

Feedback This is incorrect. A puncture wound is an open wound caused by a sharp object. This is correct. A penetrating wound is an open wound in which the agent causing the wound lodges in body tissue. This is incorrect. A tunnel wound is a wound with an entrance and exit site. This is incorrect. A crushing wound is caused by force, leading to compression or disruption of tissues.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

22. Upon admission, the patient is assessed using the Braden Scale for Predicting Pressure Sore Risk. The patient responds to verbal commands, but cannot communicate discomfort or the need to be turned. His skin is moist, requiring extra linen changes daily. His ability to walk is severely limited and he must be assisted into a wheelchair. He requires maximum assistance in moving and frequently slides down in bed. When in bed, he makes occasional slight changes in body or extremity positions. He eats over half of most meals, including at least four servings of meat and dairy products. His Braden Scale Score is 14 and translates to: 1. No risk. 2. Low risk. 3. Moderate risk. 4. High risk. ANS: 3 Page: 135

1. 2. 3. 4.

Feedback This is incorrect. The patient has difficulty walking and requires maximum assistance. He is at risk for skin breakdown. This is incorrect. A Braden score of 15 to 16 = low risk. This is correct. A Braden score of 13 to 14 = moderate risk. This is incorrect. A Braden score of 12 or less = high risk.

GRADESMORE.COM 23. The nurse would implement the pressure ulcer prevention protocol if he or she assesses a Braden Scale for Predicting Pressure Sore Risk of: 1. 24 or less. 2. 20 or less. 3. 18 or less. 4. 16 or less. ANS: 4 Page: 136

1. 2. 3. 4.

Feedback This is incorrect. When the Braden scale score is 16 or less, implement pressure ulcer prevention protocols. This is incorrect. When the Braden scale score is 16 or less, implement pressure ulcer prevention protocols. This is incorrect. When the Braden scale score is 16 or less, implement pressure ulcer prevention protocols. This is correct. When the Braden scale score is 16 or less, implement pressure ulcer prevention protocols.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. Acne is an inflammatory disease of the sebaceous follicles of the skin, marked by comedones, papules, and pustules. This is correct. Eczema is a chronic skin disorder that causes the skin to become scaly, itchy, inflamed, and irritated. This skin disorder has familial tendencies. This is incorrect. Psoriasis is a chronic immune disorder that causes the skin to develop slivery, scaly plaques. This is incorrect. Seborrhea derm s iEs S anMiOnR flaEm.m GaRtiAtiD CaOtoMry skin condition causing a flaky, yellow scale to form on the scalp, ears, and face.

25. During an assessment, the nurse notices smooth white patches all over the skin. She documents this as possible: 1. Hypopigmentation. 2. Albinism. 3. Hyperpigmentation. 4. Vitiligo. ANS: 4 Page: 109

1. 2. 3. 4.

Feedback This is incorrect. Hypopigmentation is lighter skin color. This is incorrect. Albinism is an inherited disorder caused by the total or partial absence of an enzyme that produces melanin. This is incorrect. Hyperpigmentation is darker skin color. This is correct. Vitiligo is an autoimmune disorder that causes smooth, white patches of skin all over the body.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3.

Feedback This is incorrect. Jaundice is yellowing of the skin due to excessive levels of bilirubin in the blood. This is incorrect. Pallor is pale skin seen in anemia, a decrease in circulating red blood cells or blood flow, or absence of oxygenated blood. This is incorrect. Peripheral cyanosis is a blue, gray, slate, or dark purple discoloration of the skin or mucous membranes caused by deoxygenated or reduced hemoglobin in the blood. It may occur with decreased cardiac output. This is correct. Central cyanosisGisRbAluDisEhSdMisO coRlE or. atC ioOnMto the skin related to decreased circulating oxygen. It is best assessed in the oral mucosa and conjunctiva of the eyes, lips, and tongue.

27. While changing a surgical dressing, the nurse explains to the patient that the pink skin color surrounding his wound indicates: 1. Infection. 2. Increased blood flow. 3. Delayed healing. 4. Imminent wound separation. ANS: 2 Page: 108

1. 2. 3.

Feedback This is incorrect. Erythema is red-pink skin color that may indicate infection with inflammation. This is correct. Pink skin color indicates increased blood flow to the wound. This is incorrect. Pink skin color does not indicate delayed healing; edges may be pale or bright red.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is incorrect. Edges of the wound would not be approximated; bright red edges may indicate infection.

28. Yellowing of the skin without yellowing of the sclera of the eye might indicate: 1. Jaundice. 2. Hyperpigmentation. 3. Carotenemia. 4. Erythema. ANS: 3 Page: 108

1. 2. 3.

Feedback This is incorrect. Jaundice is yellowing of the skin due to excessive levels of bilirubin in the blood. This is incorrect. Hyperpigmentation is darker skin color. This is correct. Carotenemia is a yellowing of the skin due to increased dietary intake of carotene in the diet from foods such as carrots, sweet potatoes, pumpkin, corn, yams, spinach, and beans. The sclera of the eye does not become yellow. This is incorrect. Erythema is reG d-R piAnD kE skSinMcOoR loEr . thC atOm May indicate inflammation, fever, or increased blood flow.

1. 2.

3. 4.

Feedback This is incorrect. Exposure to the sun does not cause yellowing of the skin. This is correct. Carotenemia is a yellowing of the skin due to increased dietary intake of carotene in the diet from foods such as carrots, sweet potatoes, pumpkin, corn, yams, spinach, and beans. The sclera of the eye does not become yellow. This is incorrect. Exposure to chemicals does not cause yellowing of the skin. This is incorrect. Allergies do not cause yellowing of the skin.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is correct. Rosacea is an inflammatory skin condition causing redness, swelling, and spider-like blood vessels to develop on the middle of the face. This is incorrect. Acne vulgaris is a skin condition originating from sebaceous glands that can cause blemishes, cysts, bumps, pustules, and inflammation of the skin. This is incorrect. Eczema causes chronic inflammation of the skin and itchy, dry, scaly patches of skin. This is incorrect. Erythema is red-pink skin color that may indicate inflammation, fever, or increased blood flow. GRADESMORE.COM

31. You are performing a skin assessment on a patient’s face and inspect many freckles on both sides. A freckle is a: 1. Macule. 2. Papule. 3. Vesicle. 4. Nodule. ANS: 1 Page: 111

2. 3.

Feedback This is correct. A macule is a circular, small, flat spot less than 1 mm to 1 cm in diameter. Macules are red, brown, or white in color, and the color is not the same as that of nearby skin. They present in different shapes. This is incorrect. A papule is a solid, elevated spot that appears rough in texture and measures less than 1 cm in diameter. Papules are pink, red, or brown in color. This is incorrect. A vesicle is raised, round, or oval with a thin mass filled with serous blood or clear fluid measuring less than 0.5 cm in diameter.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is incorrect. A nodule is solid, elevated, and palpable, measuring greater than 2 cm in diameter.

32. A patient comes to the clinic to have an elevated brown mole removed. You measure the mole and it is 0.9 mm. The nurse knows that this is a: 1. Macule. 2. Papule. 3. Vesicle. 4. Nodule. ANS: 2 Page: 111

2. 3. 4.

Feedback This is incorrect. A macule is a circular, small, flat spot less than 1 mm to 1 cm in diameter. Macules are red, brown, or white in color, and the color is not the same as that of nearby skin. They present in different shapes. This is correct. A papule is a solid, elevated spot that appears rough in texture and measures less than 1 cm in diameter. Papules are pink, red, or brown in color. This is incorrect. A vesicle is raiG seRdA , rDoE unSdM , oOrRoE va.l C wOitM h a thin mass filled with serous blood or clear fluid measuring less than 0.5 cm in diameter. This is incorrect. A nodule is solid, elevated, and palpable, measuring greater than 2 cm in diameter.

33. The nurse assesses a skin lesion that is elevated, encapsulated, and filled with fluid. The nurse knows that this is a: 1. Nodule. 2. Wheal. 3. Cyst. 4. Pustule. ANS: 3 Page: 113

1. 2.

Feedback This is incorrect. A nodule is solid, elevated, and palpable, measuring greater than 2 cm in diameter. This is incorrect. A wheal is raised swelling with itchy skin. Wheals are red in color and are usually caused by an allergic reaction.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

This is correct. A cyst is elevated, encapsulated, and filled with fluid, measuring 1 cm or larger. This is incorrect. A pustule is a raised vesicle filled with pus. Infection is the primary cause.

34. The dried collection of blood, serum, or pus that is part of the normal healing process is called a: 1. Fissure. 2. Scar. 3. Scale. 4. Crust. ANS: 4 Page: 113

1. 2. 3. 4.

Feedback This is incorrect. A fissure is a linear break in the skin that involves the epidermal and dermal layers. This is incorrect. A scar is discolored fibrous tissue that appears over healed surgical incisions and wounds. GRADESMORE.COM This is incorrect. Scale is a dry build-up of dead skin cells that usually flakes off the surface of the skin. This is correct. Crust is a dried collection of blood, serum, or pus and is part of the normal healing process.

1. 2.

Feedback This is incorrect. A scar is discolored fibrous tissue that appears over healed surgical incisions and wounds. Scars can be red, blue, white, or silver in color. This is incorrect. Erosion is a depressed area that is moist and shiny with loss of

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

superficial epidermis. This is correct. A keloid is created by excessive collagen production extending beyond the original boundaries of a wound or incision. They are thick and raised. This is incorrect. Excoriation is a hollow, crusted area with loss of the epidermis and an exposed dermis; may be caused by scratching the area.

Feedback This is correct. Atypical moles are called dysplastic nevi or Clark’s nevi. They are larger with irregular, poorly defined borders. Color varies between shades of brown, tan, and pink. They have a greater potentG iaR l fAoD rE deSvM elO opRinEg.iC ntO o Mmelanoma. This is incorrect. Atypical moles are called dysplastic nevi or Clark’s nevi. They are larger with irregular, poorly defined borders. Color varies between shades of brown, tan, and pink. They have a greater potential for developing into melanoma. This is incorrect. Atypical moles are called dysplastic nevi or Clark’s nevi. They are larger with irregular, poorly defined borders. Color varies between shades of brown, tan, and pink. They have a greater potential for developing into melanoma. This is incorrect. Atypical moles are called dysplastic nevi or Clark’s nevi. They are larger with irregular, poorly defined borders. Color varies between shades of brown, tan, and pink. They have a greater potential for developing into melanoma.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 3 Page: 134

1. 2. 3. 4.

Feedback This is incorrect. Stage 1: Nonblanchable erythema of intact skin. This is incorrect. Stage 2: Partial thickness loss involving both epidermis and dermis. The ulcer is still superficial and appears as a blister, abrasion, or very shallow crater. This is correct. Stage 3: Full thickness loss involving subcutaneous tissue. The ulcer may extend to but not through fascia. It is a deep crater that may undermine adjacent tissues. This is incorrect. Stage 4: Full thickness loss with extensive involvement of muscle or bone, or supporting structures. This deep ulcer may involve undermining and sinus tracts of adjacent tissues. This is incorrect. When eschar or slough covers an ulcer completely, the wound bed is obscured and cannot be assessed; the ulcer is then documented as unstageable. Until the slough and eschar are removed, the wound will not heal. The slough and eschar will have to be removed for healing to take place and for the true depth of the wound to be measured.

38. Nail growth can be affected by which of the following? Select all that apply. 1. Seasons GRADESMORE.COM 2. Stress 3. Disease 4. Hormone deficiency 5. Weight ANS: 1, 3, 4 Page: 106 Feedback 1. 2. 3. 4. 5.

This is correct. Nail growth is affected by seasons. Nails grow slower in the summer than in the winter. This is incorrect. Nail growth is not affected by stress. This is correct. Nail growth is also affected by certain diseases. This is correct. Nail growth is also affected by hormone deficiency. This is incorrect. Nail growth is not affected by a person’s weight.

39. The integumentary system comprises skin, hair, and nails but also includes which of the following? Select all that apply. 1. Glands

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. Tendons 3. Mucous membranes 4. Capillaries 5. Cartilage ANS: 1, 3 Page: 104

1. 2. 3. 4. 5.

Feedback This is correct. The skin, hair, nails, glands, and mucous membranes comprise the integumentary system. This is incorrect. Tendons are part of the musculoskeletal system. This is correct. The skin, hair, nails, glands, and mucous membranes comprise the integumentary system. This is incorrect. Capillaries are part of the circulatory system. This is incorrect. Cartilage is part of the musculoskeletal system.

40. The nurse explains to the patient’s family that persons at risk for developing pressure ulcers include which of the following? Select all that apply. 1. Those who are immobile or have decreased mobility GRADESMORE.COM 2. Those who have poor nutrition 3. Those who are confined to a bed or wheelchair 4. Those who have decreased blood circulation 5. Those who are hydrated ANS: 1, 2, 3, 4 Page: 133

1. 2. 3. 4. 5.

Feedback This is correct. Those most at risk for pressure ulcers include those who are immobile or have decreased mobility. This is correct. Those most at risk for pressure ulcers include those who have poor nutrition. This is correct. Those most at risk for pressure ulcers include those who are confined to a bed or wheelchair. This is correct. Those most at risk for pressure ulcers include those who have decreased blood circulation. This is incorrect. Those who stay hydrated are less likely to develop pressure ulcers.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

41. Which skin diseases tend to be familial? Select all that apply. 1. Basal cell carcinoma 2. Eczema 3. Psoriasis 4. Herpes simplex 5. HPV ANS: 2, 3 Page: 107

2. 3. 4. 5.

Feedback This is incorrect. Basal cell carcinoma develops most often on sun-exposed areas of the skin and does not have a familial tendency. Melanoma is the type of skin cancer that has a familial tendency. This is correct. Eczema is familial. This is correct. Psoriasis is familial. This is incorrect. Herpes is not familial but infectious. This is incorrect. HPV is not familial but infectious.

42. Using the Braden Scale for PrediG ctR inA gDPE reS ssMuO reRSEo. reCROisMk, the nurse assesses several factors. Select all that apply. 1. Sensory perception 2. Moisture 3. Activity 4. Mobility 5. Nutrition 6. Friction and shear ANS: 1, 2, 3, 4, 5, 6 Page: 135-136

1. 2. 3. 4. 5. 6.

Feedback This is correct. Sensory perception is part of the Braden scale. This is correct. Moisture is part of the Braden scale. This is correct. Activity is part of the Braden scale. This is correct. Mobility is part of the Braden scale. This is correct. Nutrition is part of the Braden scale. This is correct. Friction and shear are part of the Braden scale.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is correct. Eschar looks dry, leathery, and indurated, causing a black discoloration. This is correct. Slough is yellow, moist, and stringy. This is incorrect. Eschar is dehydrated necrotic tissue. This is incorrect. Slough is hydrated necrotic tissue.

44. The skin assessment indicates a mole on the patient’s back. The nurse will assess it for which of the following? Select all that apply. 1. Asymmetry 2. Border GRADESMORE.COM 3. Color 4. Diameter 5. Evolving characteristics ANS: 1, 2, 3, 4, 5 Page: 123

1. 2. 3. 4. 5.

Feedback This is correct. Asymmetry of the sides is assessed. Assess moles using the ABCDE mnemonic: Asymmetry, Border, Color, Diameter, Evolving. This is correct. Regular or irregular borders are assessed. Assess moles using the ABCDE mnemonic: Asymmetry, Border, Color, Diameter, Evolving. This is correct. Uniform or shades of color are assessed. Assess moles using the ABCDE mnemonic: Asymmetry, Border, Color, Diameter, Evolving. This is correct. Diameter of the mole needs to be measured. Assess moles using the ABCDE mnemonic: Asymmetry, Border, Color, Diameter, Evolving. This is correct. Evolving characteristics of the mole need to be assessed. Assess moles using the ABCDE mnemonic: Asymmetry, Border, Color, Diameter, Evolving.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

45. In assessing for cyanosis, the nurse would inspect which of the following? Select all that apply. 1. Lips 2. Oral mucosa 3. Extremities 4. Sclera of the eyes 5. Neck ANS: 1, 2, 3 Page: 118

1. 2. 3. 4. 5.

Feedback This is correct. Assess cyanosis in the lips. This is correct. Assess cyanosis in the oral mucosa. This is correct. Assess cyanosis in the extremities. This is incorrect. The sclera is not assessed for cyanosis but most commonly for jaundice. This is incorrect. The neck is not assessed for cyanosis.

46. Intertriginous areas trap moisture and can easily become infected. These areas include which of the following? Select all that applG y.RADESMORE.COM 1. Under the breasts 2. Under the arms 3. Under stomach folds of obese individuals 4. Groin areas 5. Behind the ears ANS: 1, 2, 3, 4 Page: 117

1. 2. 3. 4. 5.

Feedback This is correct. Under the breasts is an area where skin folds trap moisture and need inspection. This is correct. Under the arms is an area where skin folds trap moisture and need inspection. This is correct. Under the stomach folds of obese individuals is an area where skin folds trap moisture and need inspection. This is correct. The groin area has skin folds trapping moisture and needs inspection. This is incorrect. The ears do not have skin folds that trap moisture.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

47. To protect the skin from sun damage, what does the nurse teach about sunblock? Select all that apply. 1. It should have an SPF of at least 15. 2. It should be water resistant. 3. It should be reapplied after the user has been in the water. 4. It should be applied immediately before sun exposure. ANS: 2, 3 Page: 107

1. 2. 3. 4. 5.

Feedback This is incorrect. Sunblock should have an SPF of greater than 30. This is correct. Sunblock should be water resistant. This is correct. Sunblock should be reapplied after the user has been in the water. This is incorrect. Sunblock should be applied at least 15 minutes before sun exposure. This is incorrect. Sunblock should be applied prior to sun exposure and at least every 2 hours; sooner if the user has been in water.

48. The skin is involved in several functions of the body, including which of the following? Select all that apply. GRADESMORE.COM 1. Sensation and perception 2. Thermoregulation 3. Fluid balance 4. Synthesis of vitamin K 5. Excretion 6. Immunity ANS: 1, 2, 3, 5, 6 Page: 104

1. 2. 3. 4. 5. 6.

Feedback This is correct. The skins functions in sensation and perception. This is correct. The skin functions in thermoregulation. This is correct. The skin functions in fluid balance. This is incorrect. The skin synthesizes vitamin D, not vitamin K. This is correct. The skin functions in excretion. This is correct. The skin functions in immunity.

49. Sebum is secreted through hair follicles in which areas of the body? Select all that apply.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Soles of the feet 2. Palms of the hand 3. Axilla 4. Face ANS: 3, 4 Page: 106

1. 2. 3. 4.

Findings This is incorrect. Sebaceous glands do not produce and secrete sebum in the soles of the feet. This is incorrect. Sebaceous glands do not produce and secrete sebum in the palms of the hands. This is correct. Sebaceous glands produce and secrete a protective oil through the hair follicles in the axilla. This is correct. Sebaceous glands produce and secrete a protective oil through the hair follicles on the face.

50. Your adult patient presents with a severe, red rash over both arms and hands. There are no other symptoms. In taking a health history you would assess which of the following? Select all GRADESMORE.COM that apply. 1. Onset of the rash 2. Associated or alleviating factors 3. History/family history of skin disorders 4. Effects on body image 5. Age of patient ANS: 1, 2, 3, 4 Page: 106

1. 2. 3. 4. 5.

Feedback This is correct. Using the OLDCARTS mnemonic, onset of rash should be assessed. This is correct. Using the OLDCARTS mnemonic, associated and alleviating factors should be assessed. This is correct. A family history of skin disorders should be assessed. Skin disorders have familial tendencies. This is correct. Rashes can affect an individual’s body image, especially if it is exposed and seen by others. This is incorrect. The age of the patient is not relevant to the development of a rash.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

51. The nurse is staging the patient’s pressure ulcer and determines full thickness loss with extensive involvement of muscle. This ulcer is almost completely covered in eschar. The nurse determines this ulcer to be . ANS: unstageable Page: 134 Feedback: When eschar or slough covers an ulcer completely, the wound bed is obscured and cannot be assessed. The ulcer is then documented as unstageable.

GRADESMORE.COM

ANS: wheal Page: 112

Feedback: A wheal is defined by raised swelling and itchy skin. Wheals are red in color and are usually caused by an allergic reaction.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

54. A patient is at his dermatologist’s office to have a skin lesion on his face evaluated. The healthcare provider tells that patient that she is going to do a biopsy to rule out cell carcinoma, a malignant cutaneous malignancy arising from keratinocytes of the skin. ANS: squamous Page: 125 Feedback: Squamous cell carcinoma is a cutaneous malignancy arising from keratinocytes of the skin or mucosal surfaces. The tumor is soft, freely movable, and may be inflamed at the base. This is the second most common type of skin cancer.

GRADESMORE.COM 55. You are inspecting and palpating a patient’s fingernails. The patient has chronic obstructive pulmonary disease related to smoking for the past 30 years. You look at his nails and note an increased nail base angle. You know that the normal nail base angle is degrees. ANS: 160 Page: 128 Feedback: A normal nail base angle is 160 degrees.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 9: Assessing the Head, Face, Mouth, and Neck

1. What is the purpose of assessing the patency of the nose? 1. To assess for nasal passageway occlusion 2. To assess for tenderness, inflammation, or deviation 3. To assess appearance and symmetry 4. To assess for normal size and shape

2. The patient is diagnosed with a neurological disorder. During the assessment of this patient’s head, what abnormal assessment findings would the nurse expect to find? 1. Tenderness and swelling of the head 2. Tremors, tics, or jerking movements of the head 3. A mass or lesions on the skull 4. Depression of the skull

3. The patient reports that she is feeling tired all the time and has been gaining weight. She thinks that her face is “puffy.” You assess the thyroid gland and find it to be enlarged. The health-care RoEu.eCxO provider suspects the patient has hypG otRhA yrD oiEdS isM mO .Y peMct that the health-care provider will order which of the following blood work to assess the thyroid gland? 1. Triiodothyronine (T3) 2. Thyroid-stimulating hormone (TSH) only 3. Thyroid-stimulating hormone (TSH) and free thyroxine (Free T4) 4. Thyroid-stimulating hormone (TSH), free thyroxine (Free T4), and triiodothyronine (T3)

4. The nasal labial folds and the palpebral fissures of the face are measured to assess for: 1. Appearance of the face. 2. Symmetry of the face. 3. Edema of the face. 4. Involuntary movements of the face.

5. A patient comes to the urgent care center with a nosebleed. During the focused health history, the patient states that this is the first time she has ever had a nosebleed and is scared. You assess her nose and observe blood coming from the right nostril. What should the nurse do to try to stop the bleeding? 1. Have the patient apply pressure with an ice pack and tilt her head back. 2. Hold pressure on the nares by pinching the nostrils tightly for 10 minutes.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. Have the patient lean forward and press on the bridge of the nose for 5 minutes. 4. Instruct the patient to sit up, lean forward, and pinch the nostrils for 10 to 15 minutes.

6. The student nurse is explaining the technique of palpating the face to the instructor. The instructor identifies that further teaching is necessary when the student nurse makes which of the following statements? 1. Using the finger pads of both hands, gently palpate the face for tenderness and swelling. 2. Place your fingers in back of the earlobes and below the eyes and palpate the temporal arteries simultaneously by each ear. 3. Place your fingertips in front of each ear at the zygomatic arch and ask the patient to open and close his or her mouth. 4. Assess for any clicking sounds or decreased range of motion (ROM) of the jaw, including temporomandibular joint (TMJ) disorder .

7. The aide reports to the nurse that the patient coughs when he drinks liquids and appears to be having difficulty swallowing solid foods. The medical term for difficulty swallowing is: 1. Xerostomia. 2. Dysphasia. 3. Dysphagia. GRADESMORE.COM 4. Bruxism.

8. The patient states that she has frequent headaches. The patient explains that the headaches are stabbing pain on one side of the face or sometimes occur behind one eye. The headaches occur most often in the early morning. What type of headache is this patient describing? 1. Migraine 2. Cluster 3. Sinus 4. Tension

9. Cancers of the larynx and pharynx are most common in which racial or ethnic groups? 1. Latinos and Asians 2. Asians and Italians 3. Caucasians and African Americans 4. African Americans and Latinos

10. Which bone of the face is considered the largest and strongest bone?

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Frontal bone 2. Cranial bone 3. Cranial vault 4. Mandible

11. Which of the following statements is true concerning the anatomy and physiology of the mouth? 1. Stensen ducts are located in the lower oral cavity and drain saliva. 2. The hard palate is the largest and strongest bone of the face. 3. The soft palate is responsible for closing off the nasal passages during the act of swallowing. 4. Gingiva is the mucous membrane epithelium lining inside of the mouth.

12. The nurse has inspected and palpated the nose during the patient’s assessment. What documentation indicates normal findings? 1. Nose symmetrical without tenderness 2. Skin color red with nasal congestion 3. Nose tender and bruised 4. Nose symmetrical with deviated septum

GRADESMORE.COM

13. What are you assessing in the picture above? 1. Sphenoid sinuses 2. Frontal sinuses 3. Maxillary sinuses 4. Ethmoid sinuses

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. X-ray of the sinuses 3. Nasal culture of sinus drainage 4. Computed tomography (CT) scan of the sinuses

15. When inspecting and palpating the nose, the nurse assesses for which of the following? 1. Symmetry, septum alignment, color, swelling, and tenderness 2. Symmetry, color, moisture, lesions, and pain 3. Symmetry, movable, pain, lesions, and septum alignment 4. Symmetry, pain, bleeding, moisture, lesions, and tenderness

16. A patient comes to the emergency room stating that he woke up this morning with swollen lips. He reports that he has just started a new medication for his allergies. What is the name of this GRADESMORE.COM condition? 1. Anaphylaxis 2. Angioedema 3. Herpes simplex 4. Angular cheilitis

17. What statement is true concerning the sinuses of the patient? 1. Frontal sinuses are between the eyes, deeper in the skull, and not visible for examination. 2. Ethmoid sinuses are behind the nasal cavity, deeper in the skull, and not visible for examination. 3. Sphenoid sinuses are above the eyes in the center of the forehead. 4. Maxillary sinuses are the largest and located in the cheekbones below the eyes.

18. You are inspecting the buccal mucosa of a 70-year-old male patient. Which of the following instructions should you give to this patient? 1. “Hold your mouth open until I tell you that I am finished.” 2. “Please remove your dentures so that I can assess the gums of your mouth.” 3. “Let me know if you have xerostomia and I will give you a cup of water to drink.” 4. “I will be using a penlight to look in your mouth.”

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

19. Which statement best describes the function of the neck? 1. The neck is formed by seven cervical vertebrae, muscles, and ligaments to support the head. 2. The major muscles supporting the neck are the sternocleidomastoid and trapezius muscles. 3. The neck protects the nerves that carry sensory and motor impulses from the brain to the body. 4. The neck protects the thyroid gland in the anterior portion of the neck.

20. You are assessing a 32-year-old man’s mouth. Using a penlight, you inspect the mouth and note that the he has red, bleeding gums. What is the name of this abnormal finding? 1. Aphthous stomatitis 2. Gingivitis 3. Gingival hyperplasia 4. Periodontal disease

21. A patient comes to the outpatient clinic complaining of jaw pain and asks the nurse what might be some causes. The nurse explains to the patient that jaw pain is related to: 1. Temporomandibular joint (TMJ) disorder, teeth grinding, or temporal arteritis. 2. TMJ disorder, xerostomia, allergieGs,RoAr D goEiS teM r. ORE.COM 3. TMJ disorder, rhinorrhea, sinusitis, or epistaxis. 4. TMJ disorder, teeth grinding, or cardiac conditions.

22. You are assessing the mouth of this patient. What technique are you performing? 1. Inspecting the upper dentition 2. Inspecting and palpating the dorsal surface of the tongue 3. Palpating the soft and hard palates 4. Inspecting and palpating the soft palate only

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

23. You are performing a mouth assessment. What are you assessing in this picture? 1. Mouth range of motion 2. Jaw range of motion 3. Dorsal surface of the tongue 4. Ventral surface of the tongue

24. What cranial nerve assesses the position of the tongue? 1. Cranial nerve I 2. Cranial nerve III 3. Cranial nerve X GRADESMORE.COM 4. Cranial nerve XII

25. You are performing a mouth assessment and are going to inspect and palpate the tongue. What equipment will you need? 1. Gown and gloves 2. Gloves and sterile gauze 3. Goggles and penlight 4. Penlight and gloves

26. You are assessing a patient and note that he has an enlarged head and face, hands, and feet. This syndrome is called: 1. Acromegaly. 2. Macrocephaly. 3. Microcephaly. 4. Parkinson’s syndrome.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

27. You are assessing this patient’s tongue and note that patches on the tongue are missing papillae. What is the name of this condition? 1. Atrophic glossitis 2. Hairy tongue 3. Geographic tongue 4. Leukoplakia

28. A 37-year-old female presents to the community health clinic complaining of a severe sore throat and swollen glands. You have already inspected the rising of the soft palate and uvula. Prior to using the tongue depressor to assess the oropharynx, which of the following should the nurse do first? 1. Ask the patient to open her mouth real wide. 2. Moisten the tongue blade with warm water. 3. Ask the patient to say “ahh.” GRADESMORE.COM 4. Assess for swollen glands.

29. A college student goes to the on-campus health clinic complaining of a severe sore throat and difficulty swallowing. You put on gloves and with the aid of a penlight assess her pharynx. You see that her throat is very red, her tonsils have white purulent spots, and the tonsils are almost touching her uvula. What objective data would you document? 1. Throat is red, tonsils are enlarged 2. Throat is red, tonsils are 3+ with multiple white spots 3. Reports painful sore throat, swollen glands, and dysphagia 4. Painful sore throat, white spots on tonsils, enlarged tonsils 3+

30. You are inspecting the trachea. Where will you place your right index finger to start the assessment for tracheal deviation? 1. Below the cricoid cartilage 2. Below the thyroid isthmus 3. In the sternal notch 4. To the right and left of the trachea

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

31. The purpose of inspecting the thyroid gland is to assess: 1. Tenderness and size. 2. Size and mobility. 3. Position within the neck and nodules. 4. Mobility and tenderness.

32. You are using the posterior approach to palpate the thyroid gland. Where will you place your finger pads? 1. At the level of the thyroid isthmus 2. Below the thyroid isthmus 3. Above the cricoid cartilage 4. Below the cricoid cartilage

33. You are preparing to assess the head, face, mouth, and neck of a patient. Choose your equipment. Select all that apply. 1. Face shield 2. Goggles 3. Gloves GRADESMORE.COM 4. Gauze 5. Penlight 6. Stethoscope 7. Tongue blade 8. Cup of water

34. The nurse is inspecting and palpating the patient’s head. What is the nurse specifically assessing? Select all that apply. 1. Voluntary movement of the tongue 2. Size and shape of the head 3. Configuration 4. Range of motion 5. Movement 6. Palpating for masses or depressions 7. Palpating the head for moisture

35. You are inspecting and assessing a patient’s teeth. What will you be assessing? Select all that apply. 1. Buccal mucosa

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. Color of teeth 3. Tooth decay 4. Malocclusion 5. Tongue

36. The patient is complaining of a sinus headache and nasal congestion. What technique is used to assess the sinuses? Select all that apply. 1. Inspection 2. Palpation 3. Percussion 4. Auscultation

37. The nurse assesses the patient’s face. What documentation indicates normal findings of this assessment? Select all that apply. 1. Face square 2. Asymmetry of the face structures 3. Nasolabial folds and palpebral fissures equal 4. Flat affect 5. No involuntary muscle movement GRADESMORE.COM 6. Skin smooth and clear 7. No edema 8. Masklike facial appearance

38. You are assessing a patient who has swelling of the face. Which of the following are normal findings when palpating the face? Select all that apply. 1. No tenderness 2. Temporal artery nontender 3. Temporomandibular joint (TMJ) has limited range of motion (ROM) 4. TMJ has no clicking sounds 5. Mouth opens on the average of 1 to 2 cm 6. Mouth moves laterally 3 to 6 cm

39. The nose is located centrally on the face and is composed of bone and cartilage. What structures are considered part of the anatomy of the nose? Select all that apply. 1. Septum 2. Turbinates 3. Nares 4. Adenoids

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

5. Tonsils 6. Epiglottis 7. Hyoid bone

40. The patient reports a chronic sore throat, chronic hoarseness, and dysphagia. What diagnostic tests would you expect the health-care provider to order for further evaluation? Select all that apply. 1. Computed tomography (CT) scan 2. Swallowing evaluation 3. Throat culture 4. Fiberoptic endoscopic evaluation of swallowing (FEES) 5. Magnetic resonance imaging (MRI) 6. Modified barium swallow (MBS) study

41. The patient is experiencing xerostomia. Identify the factors that may cause xerostomia. Select all that apply. 1. Medications 2. Pain 3. Systemic disease GRADESMORE.COM 4. Radiation therapy 5. Anxiety 6. Smoking 7. Gastroesophageal reflux 8. Dehydration

42. You are inspecting the neck of an older adult. What is the purpose of this assessment technique? Select all that apply. 1. To assess symmetry 2. To assess for tenderness 3. To assess for lumps 4. To assess range of motion 5. To assess for swelling

43. You are using the anterior approach to palpate the thyroid gland. The purpose of palpating this gland is to assess which of the following? Select all that apply. 1. Smoothness 2. Swelling 3. Nodules

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Tenderness 5. Size

44. You are using the anterior approach to palpating the thyroid gland. What are normal findings? Select all that apply. 1. Variations of firmness 2. Palpable lobes 3. Nonpalpable lobes 4. Small nodules 5. Nontender

45. You are providing patient education on dental health. The patient states that he has been using the same toothbrush for the past year and has not seen a dentist in 2 years. The nurse should educate the patient with which of the following statements? Select all that apply. 1. Toothbrushes should be replaced every 6 months. 2. Have a dental examination twice per year. 3. Brush all tooth surfaces for at least 60 seconds. 4. Place your toothbrush at a 90-degree angle to the gums. 5. Floss at least once a day, preferably more often. 6. Brush your tongue to remove bactG erR iaA . DESMORE.COM

47. The adult skull is made up of

bones and

cranial bones.

48. The major artery of the head that branches from within the external carotid artery and has a palpable pulse superior to the zygomatic arch is called the artery.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

49.49. The nurse in the photo is auscultating the left lobe of the thyroid gland for a

50. The purpose of inspecting and palpating the head is to assess the and of the head.

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers 1. What is the purpose of assessing the patency of the nose? 1. To assess for nasal passageway occlusion 2. To assess for tenderness, inflammation, or deviation 3. To assess appearance and symmetry 4. To assess for normal size and shape ANS: 1 Page: 155

1. 2. 3. 4.

Feedback This is correct. The purpose of assessing the patency of the nose is to assess for nasal passage occlusion. This is incorrect. The purpose of inspecting and palpating the nose is to assess for tenderness, inflammation, or deviation. This is incorrect. The purpose of inspecting the face is to assess facial appearance and symmetry. This is incorrect. The purpose of inspecting and palpating the head is to assess for normal size and shape.

GRADESMORE.COM 2. The patient is diagnosed with a neurological disorder. During the assessment of this patient’s head, what abnormal assessment findings would the nurse expect to find? 1. Tenderness and swelling of the head 2. Tremors, tics, or jerking movements of the head 3. A mass or lesions on the skull 4. Depression of the skull ANS: 2 Page: 151

1. 2. 3. 4.

Feedback This is incorrect. Tenderness and swelling of the head is not a sign or symptom of a neurological disorder. This is correct. Neurological disorders cause involuntary movements such as tremors, tics, or jerking movements of the head. This is incorrect. A mass or lesions of the skull is not a sign or symptom of a neurological disorder. This is incorrect. Depression of the skull is not a sign of a neurological disorder.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. The patient reports that she is feeling tired all the time and has been gaining weight. She thinks that her face is “puffy.” You assess the thyroid gland and find it to be enlarged. The health-care provider suspects the patient has hypothyroidism. You expect that the health-care provider will order which of the following blood work to assess the thyroid gland? 1. Triiodothyronine (T3) 2. Thyroid-stimulating hormone (TSH) only 3. Thyroid-stimulating hormone (TSH) and free thyroxine (Free T4) 4. Thyroid-stimulating hormone (TSH), free thyroxine (Free T4), and triiodothyronine (T3) ANS: 4 Page: 145-146

Feedback This is incorrect. This test is ordered for hyperthyroidism. Triiodothyronine (T3) is a blood test that is used with the TSH and T4 blood tests to diagnose an overactive thyroid gland. This hormone is converted from the T4 hormone in the tissues rather than directly from the thyroid gland. This is incorrect. The thyroid-stimulating hormone (TSH) would not be ordered by itself. The TSH would be ordered with the triiodothyronine (T3) and free thyroxine (Free T4).

This is incorrect. All three thyroid tests would be ordered—thyroid-stimulating hormone (TSH), free thyroGxR inA eD (FEreSeMTO4)R, E an.dCtrOiiM odothyronine (T3)—to differentiate thyroid malfunction.

This is correct. Thyroid-stimulating hormone (TSH), free thyroxine (Free T4), and triiodothyronine (T3) tests are used to differentiate thyroid malfunction.

Feedback This is incorrect. The nasal labial folds and the palpebral fissures are measured to assess for the symmetry of the face (cranial nerve VII). Assessing for appearance involves identifying round, square, or oval shape of the face. This is correct. The nasal labial folds and the palpebral fissures are measured to

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

assess for the symmetry of the face (cranial nerve VII). This is incorrect. The nasal labial folds and the palpebral fissures are measured to assess for the symmetry of the face (cranial nerve VII). This is incorrect. The nasal labial folds and the palpebral fissures are measured to assess for the symmetry of the face (cranial nerve VII). Involuntary movements of the face involve the muscles of the face.

3. 4.

Feedback This is incorrect. This is thGeRwAroDnEgSpM osOitR ioE n..IC f yOoMu have the patient tilt her head back, the blood will drip down the pharynx. The patient should sit up, lean forward, and pinch the nostrils for 10 to 15 minutes. This is incorrect. This answer is missing the position to instruct the patient to be in while she holds pressure to the nares. The patient should sit up, lean forward, and pinch the nostrils for 10 to 15 minutes. This is incorrect. The nostrils that are highly vascular should be pinched, not the bridge of the nose. This is correct. Instruct the patient to sit up, lean forward, and pinch the nostrils for 10 to 15 minutes.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Assess for any clicking sounds or decreased range of motion (ROM) of the jaw, including temporomandibular joint (TMJ) disorder . ANS: 2 Page: 154

1. 2.

3. 4.

Feedback Using the finger pads of both hands, gently palpate the face for tenderness and swelling is an appropriate technique of palpating the face. This is the correct answer. The correct technique is placing your fingers in front of the earlobes and corners of the eyes and palpating the temporal arteries simultaneously in front of each ear. Place your fingertips in front of each ear at the zygomatic arch and ask the patient to open and close his or her mouth is an appropriate technique of palpating the face. Assess for any clicking sounds or decreased ROM of the jaw, including TMJ disorder, is an appropriate technique of palpating the face.

7. The aide reports to the nurse that the patient coughs when he drinks liquids and appears to be having difficulty swallowing solid foods. The medical term for difficulty swallowing is: 1. Xerostomia. GRADESMORE.COM 2. Dysphasia. 3. Dysphagia. 4. Bruxism. ANS: 3 Page: 144

Feedback This is incorrect. Xerostomia is a dry mouth.

2. 3. 4.

This is incorrect. Dysphasia is difficulty speaking. This is correct. Dysphagia is difficulty swallowing. This is incorrect. Bruxism is grinding of teeth.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Tension ANS: 2 Page: 147

Feedback This is incorrect. Migraine headaches are characterized by unilateral or bilateral, throbbing, intense pain lasting from hours to 3 days. They cause nausea or vomiting, are made worse with activity, typically occur one to three times per month, and cause sensitivity to light. This is correct. Cluster headaches are characterized by stabbing pain on one side of the face or behind one eye or at the temple near the forehead. Pain is constant and occurs in “clusters” or periods of time. Cluster headaches occur at predictable times, most commonly in the very early morning between midnight and 0300.

This is incorrect. Sinus headaches are characterized by throbbing pain in front of the face and are accompanied by upper respiratory symptoms.

This is incorrect. Tension or stress headaches are characterized by feelings of pressure in the front of the head or both sides of the head or neck. They feel like a band is tightening around the head and may be related to stress or poor posture.

GRADESMORE.COM 9. Cancers of the larynx and pharynx are most common in which racial or ethnic groups? 1. Latinos and Asians 2. Asians and Italians 3. Caucasians and African Americans 4. African Americans and Latinos ANS: 3 Page: 149

1. 2. 3. 4.

Feedback This is incorrect. Latinos and Asians are not the racial/ethnic group at the highest risk for cancers of the larynx and pharynx. This is incorrect. Asians and Italians are not the racial/ethnic group at the highest risk for cancers of the larynx and pharynx. This is correct. Caucasians and African Americans are at the highest risk for cancers of the larynx and pharynx. This is incorrect. Italians are not the racial/ethnic group at the highest risk for cancers of the larynx and pharynx.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

10. Which bone of the face is considered the largest and strongest bone? 1. Frontal bone 2. Cranial bone 3. Cranial vault 4. Mandible ANS: 4 PAGE: 143

Feedback This is incorrect. The frontal bone is the most important and forms the forehead above the eyeballs, giving each person’s facial appearance.

This is incorrect. The cranial bones are bones of the skull and meet at meshed immovable joints called sutures. The major sutures are the sagittal, coronal, and lambdoidal.

This is incorrect. The cranial vault is the large part of the skull that protects the brain from injury and acts like a helmet to the brain.

This is correct. The jaw bone (mandible) is the largest and strongest bone of the face.

GRADESMORE.COM

Feedback This is incorrect. The Wharton’s ducts are located on each side of the lower oral cavity and drain saliva from the submandibular and sublingual glands. The Stensen ducts (parotid glands) are located in the upper buccal mucosa. This is the route saliva flows from the parotid gland into the mouth. This is incorrect. The jawbone (mandible) is the largest and strongest bone of the face. The hard palate is a thin, horizontal plate of the skull located in the roof of the

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

mouth. It is covered with stratified squamous epithelium. 3.

This is correct. The soft palate is composed of muscle and connective tissue, and is responsible for closing off the nasal passages during the act of swallowing.

This is incorrect. The oral mucosa is the mucous membrane epithelium lining inside the mouth. The gingiva (gums) are covered by mucous membranes; tough insoluble protein mucosa; area around the root of a tooth; attaches to the surface area of the tooth root (cementum) and the alveolar bone; thickened ridge of bone that contains the tooth socket.

GRADESMORE.COM 1. 2. 3. 4.

Feedback This is correct. Nose symmetrical and nontender is a normal finding. This is incorrect. Skin color same as face with no nasal congestion is a normal finding. This is incorrect. Nose tender and bruised is an abnormal finding. This is incorrect. Nose symmetrical with septum straight and midline is a normal finding.

13. What are you assessing in the picture above?

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Sphenoid sinuses 2. Frontal sinuses 3. Maxillary sinuses 4. Ethmoid sinuses ANS: 2 Page: 156

1. 2. 3. 4.

Feedback This is incorrect. Sphenoid sinuses are behind the nasal cavity and deeper in the skull. These sinuses cannot be palpated. This is correct. The frontal sinuses are located above the eyes toward the center of the forehead. This is incorrect. Maxillary sinuses are the largest sinuses and are located in the cheekbones below the eyes. This is incorrect. The ethmoid sinuses cannot be percussed or palpated.

14. The patient has a history of chronic sinus infections for the past 2 years. What diagnostic test would you expect the health-care provider to order to provide detailed imaging of the sinuses? 1. X-ray of the face GRADESMORE.COM 2. X-ray of the sinuses 3. Nasal culture of sinus drainage 4. Computed tomography (CT) scan of the sinuses ANS: 4 Page: 141

Feedback This is incorrect. X-ray of the face would not be the best diagnostic test. X-rays will show deformity of the bones but not create detailed pictures of the air-filled spaces. The preferred diagnostic test is the CT scan.

This is incorrect. X-ray of the sinuses would not be the best diagnostic test. X-rays will show detailed pictures of the air-filled spaces. The preferred diagnostic test is the CT scan.

This is incorrect. The patient is not reporting sinus drainage. A nasal culture would not be ordered.

This is correct. CT scan of the sinuses is an imaging test that uses x-rays with or without contrast dye to create detailed pictures of the air-filled spaces inside the face (sinuses). This scan may help to diagnose infection, nasal polyps, birth defects, or

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

abnormalities of the sinuses.

1. 2.

Feedback This is correct. When inspecting and palpating the nose, the nurse assesses for symmetry, septum alignment, color, swelling, and tenderness. This is incorrect. When inspecting and palpating the nose, the nurse assesses for symmetry, septum alignment, color, swelling, and tenderness. Pain and moisture are not usually assessed. This is incorrect. When inspecting and palpating the nose, the nurse assesses for symmetry, septum alignment, color, swelling, and tenderness. The ability to move GRADEassessed. SMORE.COM the nose and pain are not usually This is incorrect. When inspecting and palpating the nose, the nurse assesses for symmetry, septum alignment, color, swelling, and tenderness. Pain, bleeding, and moisture are not normally assessed.

16. A patient comes to the emergency room stating that he woke up this morning with swollen lips. He reports that he has just started a new medication for his allergies. What is the name of this condition? 1. Anaphylaxis 2. Angioedema 3. Herpes simplex 4. Angular cheilitis ANS: 2

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Page: 157

1. 2. 3. 4.

Feedback This is incorrect. Anaphylaxis is a general term for severe allergic reaction. The picture specifically shows swollen lips, which is angioedema. This is correct. Angioedema is edema of the lips, usually related to an allergic reaction. This is incorrect. Herpes simplex virus manifests with cold sores or blisters on the lips. This is incorrect. Angular cheilitis is sore, cracked corners of the lips, commonly caused by yeast infections, dry mouth, or vitamin deficiency.

GRADESMORE.COM

Feedback This is incorrect. Frontal sinuses are above the eyes in the center of the forehead.

This is incorrect. Ethmoid sinuses are between the eyes, deeper in the skull, and not visible for examination.

This is incorrect. Sphenoid sinuses are behind the nasal cavity, deeper in the skull, and not visible for examination.

This is correct. Maxillary sinuses are the largest and are located in the cheekbones below the eyes.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 2 Page: 158

Feedback This is incorrect. The patient should be told to let you know if he is uncomfortable holding open his mouth during this assessment.

This is correct. If the patient has full or partial dentures, have him remove the dentures for inspection and palpation of gum area.

This is incorrect. You should not use medical terminology when giving instructions to a patient because he may not understand the term xerostomia.

This is incorrect. You are explaining what you will be doing. This is not giving instructions to the patient.

19. Which statement best describes the function of the neck? 1. The neck is formed by seven cervical vertebrae, muscles, and ligaments to support the head. 2. The major muscles supporting the neck are the sternocleidomastoid and trapezius muscles. 3. The neck protects the nerves that cGaR rryAD seE nsSoM ryOaRnE d. mCoO toM r impulses from the brain to the body. 4. The neck protects the thyroid gland in the anterior portion of the neck. ANS: 3 Page: 144

3. 4.

Feedback This is incorrect. This does not identify the function of the neck. The function of the neck is to protect the nerves that carry sensory and motor impulses from the brain to the body. This is incorrect. The major muscles of the neck do not identify the function. The function of the neck is to protect the nerves that carry sensory and motor impulses from the brain to the body. This is correct. The function of the neck is to protect the nerves that carry sensory and motor impulses from the brain to the body. This is incorrect. The thyroid gland is located within the neck. The function of the neck is to protect the nerves that carry sensory and motor impulses from the brain to the body.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. Aphthous stomatitis is a canker sore. This is correct. Gingivitis is the mildest type of periodontal disease. The patient’s gums will be red, swollen, and bleeding. This is incorrect. Gingival hyperplasia is an enlargement or overgrowth of the gum tissue. The gums do not bleed. This is incorrect. Periodontal disease is a chronic infection of the gums and is caused by bacteria. The gums pull away from the teeth and form deep pockets around the teeth, causing damage to the teeth, gums, and underlying bone.

GRADESMORE.COM 21. A patient comes to the outpatient clinic complaining of jaw pain and asks the nurse what might be some causes. The nurse explains to the patient that jaw pain is related to: 1. Temporomandibular joint (TMJ) disorder, teeth grinding, or temporal arteritis. 2. TMJ disorder, xerostomia, allergies, or goiter. 3. TMJ disorder, rhinorrhea, sinusitis, or epistaxis. 4. TMJ disorder, teeth grinding, or cardiac conditions. ANS: 4 Page: 149

Feedback This is incorrect. TMJ and teeth grinding promote jaw pain. Temporal arteritis is an inflammation of the temporal arteries and blood vessels that supply blood to the head and does not promote jaw pain. This is incorrect. TMJ promotes jaw pain. Xerostomia is a dry mouth and allergies are sneezing and nasal congestion with watery nasal drainage. Goiter is an enlargement of the thyroid gland. None of these conditions promote jaw pain. This is incorrect. TMJ promotes jaw pain. Rhinorrhea is a thin, watery discharge from the nose; sinusitis is an inflammation or infection of the sinuses and nasal passages; and epistaxis is a nosebleed. None of these conditions promote jaw pain. This is correct. Jaw pain may be related to TMJ disorder, teeth grinding, or cardiac

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

conditions.

GRADESMORE.COM

This is incorrect. You are not inspecting the upper dentition, you are wearing gloves and palpating the soft and hard palate. This is incorrect. You are not inspecting and palpating the dorsal surface of the tongue, you are using your index finger to gently palpate the soft and hard palates. This is correct. You are using your index finger to gently palpate the soft and hard palates. This is incorrect. You are not inspecting in this picture. You are using your index finger to gently palpate the soft and hard palates.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

23. You are performing a mouth assessment. What are you assessing in this picture? 1. Mouth range of motion 2. Jaw range of motion 3. Dorsal surface of the tongue 4. Ventral surface of the tongue ANS: 3 Page: 160

1. 2. 3. 4.

Feedback This is incorrect. You are not assessing the range of motion of the mouth. The GRADEtoSassess MOREthe .Cdorsal OM surface of the tongue. patient is sticking out her tongue This is incorrect. You are not assessing the range of motion of the jaw. The patient is sticking out her tongue to assess the dorsal surface of the tongue. This is correct. The patient is sticking out her tongue to assess the dorsal surface of the tongue. This is incorrect. This is not the ventral surface of the tongue. The patient is sticking out her tongue to assess the dorsal surface of the tongue.

24. What cranial nerve assesses the position of the tongue? 1. Cranial nerve I 2. Cranial nerve III 3. Cranial nerve X 4. Cranial nerve XII ANS: 4 Page: 160

Feedback This is incorrect. Olfactory nerve is cranial nerve I, which controls the sense of

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3. 4.

smell. Cranial nerve XII innervates the muscles of the tongue. This is incorrect. Oculomotor nerve is cranial nerve III, which controls eye movement. Cranial nerve XII innervates the muscles of the tongue. This is incorrect. Vagus nerve is cranial nerve X, which supplies the heart, lungs, and gastrointestinal tract. Cranial nerve XII innervates the muscles of the tongue. This is correct. Hypoglossal nerve is cranial nerve XII, which controls the position of the tongue.

1. 2. 3. 4.

Feedback This is incorrect. A gown dGoReA s nDoEt S neMeO dR toEb.eCwOoM rn to inspect and palpate the tongue. The correct answer is gloves and sterile gauze. This is correct. Gloves and sterile gauze are needed to inspect and palpate the tongue. This is incorrect. Goggles and a penlight are not needed to inspect and palpate the tongue. The correct answer is gloves and sterile gauze. This is incorrect. A penlight is not needed to inspect the tongue because the patient will be sticking his or her tongue out. Gloves are needed to palpate the tongue. The correct answer is gloves and sterile gauze.

26. You are assessing a patient and note that he has an enlarged head and face, hands, and feet. This syndrome is called: 1. Acromegaly. 2. Macrocephaly. 3. Microcephaly. 4. Parkinson’s syndrome. ANS: 1 Page: 152

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Feedback 1.

2. 3. 4.

This is correct. Acromegaly is a syndrome of growth hormone excess by the pituitary gland and is characterized by enlargement of the bones of the hands, feet, and face. This is incorrect. Macrocephaly is an abnormally large head size. This is incorrect. Microcephaly is a birth defect of an abnormally small head size. This is incorrect. Parkinson’s syndrome does not have an abnormal head size but a “masklike” facial appearance.

This is incorrect. Atrophic glossitis is a smooth red or pink tongue and may indicate nutritional deficiencies. This is incorrect. Hairy tongue is a white plaque to a dark, hairy surface that may indicate systemic immune suppression. This is correct. Geographic tongue is a harmless condition. The tongue is usually covered with tiny, pinkish-white bumps (papillae), but with this condition patches on the tongue are missing papillae and the tongue appears as a smooth, red “island,” often with slightly raised borders. This is incorrect. Leukoplakia are patches on the tongue (usually white or gray), which progresses to cancer 19% of the time.

28. A 37-year-old female presents to the community health clinic complaining of a severe sore throat and swollen glands. You have already inspected the rising of the soft palate and uvula.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Prior to using the tongue depressor to assess the oropharynx, which of the following should the nurse do first? 1. Ask the patient to open her mouth real wide. 2. Moisten the tongue blade with warm water. 3. Ask the patient to say “ahh.” 4. Assess for swollen glands. ANS: 2 Page: 161 Feedback 1.

2. 3.

This is incorrect. Prior to using the tongue blade the nurse should moisten it with warm water to decrease the chances of the patient gagging. The patient has already opened her mouth wide when you inspected the rising of the soft palate and uvula. This is correct. Moisten a tongue blade with warm water. A moistened tongue blade may help to decrease the chances of the patient gagging. This is incorrect. The patient will have to say “ahh” but first the nurse should moisten the tongue blade with warm water to decrease the chances of the patient gagging. This is incorrect. The nurse will assess for swollen glands after she inspects the oropharynx. Prior to using the tongue blade the nurse should moisten it with warm water to decrease the chanG ceRs AoD f tE heSpMaOtiR enEt . gaCgO giMng.

This is incorrect. The data is objective but needs to be more specific with the grading of the tonsils and identification of the white spots on the tonsils. This is correct. This is objective data documenting what the nurse assesses. This is incorrect. This is subjective data. The patient is reporting the symptoms of sore throat, swollen glands, and dysphagia.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is incorrect. The question asks for objective data only. Painful sore throat is subjective data; the white spots and grading of tonsils are objective data.

This is incorrect. You will inspect the trachea below the thyroid isthmus and gently place your right index finger in the sternal notch. This is incorrect. You will inspect the trachea below the cricoid cartilage and thyroid isthmus and gently place your right index finger in the sternal notch. This is correct. You will gently place your right index finger in the sternal notch and then slip your finger off to each side, noting distance from the sternomastoid GRADESMORE.COM muscle. This is incorrect. This is a vague answer. You will gently place your right index finger in the sternal notch and then slip your finger off to each side, noting distance from the sternomastoid muscle.

31. The purpose of inspecting the thyroid gland is to assess: 1. Tenderness and size. 2. Size and mobility. 3. Position within the neck and nodules. 4. Mobility and tenderness. ANS: 2 Page: 164 Feedback 1. 2. 3.

This is incorrect. The nurse would palpate for tenderness, not inspect. The nurse would inspect the size of the thyroid for signs of enlargement. This is correct. The nurse would inspect the thyroid for size and mobility as the patient swallows. This is incorrect. The nurse would palpate for the position of the thyroid and for

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

nodules. This is incorrect. The nurse inspects for mobility but palpates for tenderness.

This is incorrect. The nurse will place her fingers below the cricoid cartilage, not at the level of thyroid isthmus, to properly palpate the thyroid gland. This is incorrect. The nurse will place her fingers below the cricoid cartilage, not below the thyroid isthmus, to properly palpate the thyroid gland. This is incorrect. The nurse will place her fingers below the cricoid cartilage, not above the cricoid cartilage, to properly palpate the thyroid gland. GRADESMORE.COM This is correct. The nurse will place her fingers below the cricoid cartilage to properly palpate the thyroid gland.

33. You are preparing to assess the head, face, mouth, and neck of a patient. Choose your equipment. Select all that apply. 1. Face shield 2. Goggles 3. Gloves 4. Gauze 5. Penlight 6. Stethoscope 7. Tongue blade 8. Cup of water ANS: 3, 4, 5, 6, 7, 8 Page: 150

Feedback This is incorrect. You do not need to wear a face shield to assess the head, face,

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3. 4. 5. 6. 7. 8.

mouth, and neck. This is incorrect. You do not need to wear goggles to assess the head, face, mouth, and neck. This is correct. You do need to wear gloves to assess the head and mouth during this assessment. This is correct. You do need to use gauze to inspect the ventral and dorsal surfaces of the tongue during this assessment. This is correct. You do need to use a penlight to inspect the mouth during this assessment. This is correct. You do need a stethoscope to assess for carotid bruits in the neck area. This is correct. You do need to use a tongue blade to inspect the oropharynx during this assessment. This is correct. You do need to have a cup of water to assess the thyroid.

34. The nurse is inspecting and palpating the patient’s head. What is the nurse specifically assessing? Select all that apply. 1. Voluntary movement of the tongue 2. Size and shape of the head 3. Configuration 4. Range of motion GRADESMORE.COM 5. Movement 6. Palpating for masses or depressions 7. Palpating the head for moisture ANS: 2, 3, 5, 6 Page: 150

1. 2. 3. 4. 5. 6. 7.

Feedback This is incorrect. Inspecting for voluntary movements of the tongue is not part of the head assessment but done during the mouth assessment. This is correct. Inspecting for size and shape is done when assessing the head. This is correct. Inspecting for configuration is done when assessing the head. This is incorrect. Full range of motion is not assessed during inspection of the head. Range of motion of the head is assessed when assessing the neck. This is correct. Inspecting for any involuntary movement is done when assessing the head. This is correct. Palpating the head is done to assess for any masses or depressions. This is incorrect. Palpating the head for moisture is not part of the head assessment as moisture is assessed in the extremities.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

35. You are inspecting and assessing a patient’s teeth. What will you be assessing? Select all that apply. 1. Buccal mucosa 2. Color of teeth 3. Tooth decay 4. Malocclusion 5. Tongue ANS: 2, 3, 4 Page: 158

2. 3. 4. 5.

Feedback This is incorrect. This is not part of inspecting the teeth. You will inspect the buccal mucosa when inspecting and palpating the buccal mucosa during the mouth assessment. This is correct. You will be inspecting the color of the teeth. This is correct. You will be inspecting for tooth decay or rotted teeth. This is correct. You will be inspecting for malocclusion or malposition of teeth. This is incorrect. You will not be inspecting the tongue at this time because you are only inspecting the teeth during this assessment.

GRADESMORE.COM 36. The patient is complaining of a sinus headache and nasal congestion. What technique is used to assess the sinuses? Select all that apply. 1. Inspection 2. Palpation 3. Percussion 4. Auscultation ANS: 2, 3 Page: 156

1. 2. 3. 4.

Feedback This is incorrect. Inspection does not assess the maxillary and frontal sinuses; palpation or percussion assesses for sinus tenderness. This is correct. Palpating the maxillary or frontal sinuses assesses if there is sinus tenderness. This is correct. Percussing the maxillary or frontal sinuses assesses if there is sinus tenderness. This is incorrect. You cannot auscultate for sinus tenderness. Palpating or percussing are the techniques that assess the sinuses.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

37. The nurse assesses the patient’s face. What documentation indicates normal findings of this assessment? Select all that apply. 1. Face square 2. Asymmetry of the face structures 3. Nasolabial folds and palpebral fissures equal 4. Flat affect 5. No involuntary muscle movement 6. Skin smooth and clear 7. No edema 8. Masklike facial appearance ANS: 1, 3, 5, 6, 7 Page: 152

1. 2.

3. 4.

Feedback This is correct. Face round, square, or oval are normal findings of an assessment of the face. This is incorrect. Symmetrical facial structures are normal findings of an assessment of the face. Asymmetry of the face may be related to abscess, infection, enlargement of parotid gland, or neurological disorders. This is correct. Nasolabial folds and palpebral fissures equal are normal findings of an assessment of the face. GRADESMORE.COM This is incorrect. Expression relaxed is a normal finding of an assessment of the face. Flat affect indicates depression or chronic pain.

This is correct. No involuntary muscle movements are normal findings of an assessment of the face.

This is correct. Skin smooth and clear is a normal finding of an assessment of the face. This is correct. No edema is a normal finding of an assessment of the face. This is incorrect. Expression relaxed is a normal finding of an assessment of the face. Masklike facial appearance is seen in patients with Parkinson’s disease.

7. 8.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 1, 2, 4 Page: 155

1. 2.

Feedback This is correct. No tenderness is a normal finding. This is correct. Temporal artery nontender is a normal finding.

3. 4. 5. 6.

This is incorrect. TMJ has no limited ROM would be a normal finding. This is correct. TMJ has no clicking sounds is a normal finding. This is incorrect. Mouth opens on the average of 3 to 6 cm. This is incorrect. Mouth moves laterally 1 to 2 cm.

Feedback This is correct. The nasal septum is midline and is made up of cartilage and many blood vessels (Kiesselbach area). It divides the nose into equal halves. Receptors for cranial nerve I (olfactory) are located in the upper part of the septum and nasal cavity.

This is correct. Turbinates (superior, middle, inferior) are bony lobes on the lateral walls of the nasal cavity that comprise most of the mucosal area and increase the surface area. They are enriched with airflow pressure and temperature-sensing nerve receptors.

This is correct. Two nostrils (nares) are lined with mucous membranes and make up the anatomy of the nose.

This is incorrect. Adenoids are clusters of lymphatic tissue behind the nose and are part of the immune system.

This is incorrect. Tonsils are masses of lymphoid tissue located in the back of the pharynx and are part of the body’s immune system.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is incorrect. The epiglottis is the flap that separates the trachea from the esophagus and prevents aspiration of food and fluids.

This is incorrect. The hyoid bone is a horseshoe-shaped bone between the chin and the thyroid cartilage, anchored only by muscles in the floor of the mouth. The base of the tongue rests on this bone and aids in tongue movement and swallowing.

GRADESMORE.COM 1.

Feedback This is incorrect. CT scan is a noninvasive test that combines special x-ray equipment with sophisticated computers to produce multiple images or pictures of the inside of the body. CT scan is not usually used for a throat evaluation.

This is correct. Swallowing evaluation is usually initiated when difficulty swallowing foods or fluids is observed or reported. A speech pathologist will observe the patient closely while she or he eats and drinks to assess for dysphagia, which is difficulty swallowing.

This is correct. Throat culture is commonly done to identify the organism causing a bacterial, viral, or fungal infection. This is correct. FEES requires a small, flexible endoscope to be passed through the nose into the pharynx. The physician is able to assess the structures of the throat and assess swallowing.

This is incorrect. MRI is a noninvasive test that uses a powerful magnetic field, radio frequency pulses, and a computer to produce detailed pictures of organs, soft tissues, bone, and virtually all other internal body structures. An MRI is not usually used for a throat evaluation.

This is correct. MBS study is a radiologic procedure that assesses swallowing using a fluoroscope, an instrument used for viewing x-ray images on a screen. The mouth,

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

throat, and esophagus are assessed.

41. The patient is experiencing xerostomia. Identify the factors that may cause xerostomia. Select all that apply. 1. Medications 2. Pain 3. Systemic disease 4. Radiation therapy 5. Anxiety 6. Smoking 7. Gastroesophageal reflux 8. Dehydration ANS: 1, 3, 4, 5, 8 PAGE: 148

1. 2. 3. 4. 5. 6. 7.

Feedback This is correct. Certain medications promote a dry mouth. This is incorrect. Pain doeG s nRoAt D usEuS alM lyOpRroEm.oCteOaMdry mouth. This is correct. Certain systemic diseases promote a dry mouth. This is correct. Radiation therapy promotes a dry mouth. This is correct. Anxiety promotes a dry mouth. This is incorrect. Smoking does not promote a dry mouth. This is incorrect. Gastroesophageal reflux does not promote a dry mouth.

This is correct. Dehydration promotes a dry mouth.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4. 5.

Feedback This is correct. The purpose is to inspect the symmetry of the neck. This is incorrect. You palpate for tenderness, not inspect for tenderness. This is incorrect. You palpate for lumps, not inspect for lumps. This is correct. You inspect for range of motion and movement of the neck. This is correct. You inspect for swelling or edema of the neck.

1. 2. 3. 4. 5.

Feedback This is correct. The purposGeRoA f pDaE lpSaM tinOgRtE he.tC hyOrM oid gland is to assess smoothness. This is correct. The purpose of palpating the thyroid gland is to assess for swelling. This is correct. The purpose of palpating the thyroid gland is to assess for nodules or lumps. This is correct. The purpose of palpating the thyroid gland is to assess for tenderness. This is correct. The purpose of palpating the thyroid gland is to assess size, such as enlargement.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2.

4. 5.

This is incorrect. This is an abnormal finding. There should not be variations of firmness, which may be indicative of disease. This is correct. This is a normal finding. The thyroid gland lateral lobes may or may not be palpable. The thyroid gland is small with the length of the lobes only measuring 4 to 6 cm. This is correct. This is a normal finding. The thyroid gland lateral lobes may or may not be palpable. The thyroid gland is small with the length of the lobes only measuring 4 to 6 cm. This is incorrect. This is an abnormal finding. Small nodules may be a sign of disease. This is correct. This is a normal finding. The thyroid gland should be nontender.

GRADESMORE.COM

6. Brush your tongue to remove bacteria. ANS: 2, 5, 6 Page: 167-168

1. 2. 3. 4.

Feedback This is incorrect. All toothbrushes should be dry before storing and toothbrushes should be replaced every 3 to 4 months or sooner if the bristles are frayed. This is correct. The American Dental Association (2016) recommends dental examinations twice per year. This is incorrect. The American Dental Association (2016) recommends brushing all tooth surfaces for at least 90 seconds, not 60 seconds. This is incorrect. The American Dental Association (2016) recommends placing your toothbrush at a 45-degree angle, not a 90-degree angle to the gums.

This is correct. The American Dental Association (2016) recommends flossing at least once a day, preferably more often.

This is correct. The American Dental Association (2016) recommends brushing your tongue to remove bacteria.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

46. The nurse is preparing to begin the physical assessment on a young adult starting with assessing the head, face, and neck. Order the following in the correct sequence (1–5). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Auscultation 2. Inspection 3. Palpation 4. Explain procedure 5. Document findings ANS: 42315 Page: 150 Feedback: The nurse explains the procedure to the patient, assesses by inspection, then palpation, and then auscultation. Findings are documented last.

47. The adult skull is made up of ANS: 22; 8 Page: 141

bones and

cranial bones.

GRADESMORE.COM

Feedback: The adult skull is made up of 22 bones and 8 cranial bones.

48. The major artery of the head that branches from within the external carotid artery and has a palpable pulse superior to the zygomatic arch is called the artery. ANS: temporal Page: 142 Feedback: The temporal artery is the major artery of the head that branches from within the external carotid artery, has a palpable pulse superior to the zygomatic arch, and is palpable in front of each ear.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

49.49. The nurse in the photo is auscultating the left lobe of the thyroid gland for a

ANS: bruit Page: 167 Feedback: A bruit is a vascular sound heard with the presence of turbulent blood flow. It is usually heard in the presence of hyperthyroidism.

50. The purpose of inspecting and palpating the head is to assess the and of the head. ANS: size; shape (in any order) Page: 150

GRADESMORE.COM

Feedback: The purpose of inspecting and palpating the head is to assess the size and shape of the head for any abnormalities.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 10: Assessing the Ears

1. Routine health assessment is dependent on a person’s ability to hear the health interview questions. During the first encounter the nurse should note whether is intact while asking questions. 1. Conversational hearing 2. Conductive hearing 3. Sensorineural hearing 4. The cranial nerve

2. The nurse asks the patient if he or she has been exposed to loud noises. Why is this question important? 1. Hearing loss may be inherited or could be caused by ototoxic drugs. 2. Hearing loss can have an economic impact on everyday health. 3. Prolonged exposure to loud noise may cause wear and tear on the hairs or nerves. 4. Prolonged exposure to loud noise can cause tinnitus.

3. On assessment of a 56-year-old mG anRtA heDnEuSrsMe OdR iscEo.vC erO sM he is complaining of “ringing in the ears.” The nurse recalls that the medical term for this is: 1. Presbycusis. 2. Vertigo. 3. Tinnitus. 4. Tophi.

4. The nurse has finished her focused health history and is preparing to do an assessment of the ears. Which position should the patient be placed in? 1. Supine 2. Prone 3. Semi-Fowler’s 4. Comfortable sitting position

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

5. What is the nurse assessing for in the photo? 1. Tenderness 2. Hearing loss 3. Visual deformities 4. Color

6. You are assessing an ear and see this deviation. What is the name of the assessment finding shown in the photo? GRADESMORE.COM 1. Cyst 2. Darwin tubercle 3. Tophi 4. Tragus

7. This part of the ear is responsible for transmitting sound waves through the auditory nerve (cranial nerve VIII). 1. Inner 2. Middle 3. Auricle 4. Ear canal

8. After inspecting the ears of a 76-year-old male the nurse documents: “Patient presents with abnormally large ears.” The nurse recalls that the medical term for this is: 1. Vertigo. 2. Cauliflower ear. 3. Microtia. 4. Macrotia.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

9. In performing the Weber test to assess for sensorineural hearing loss, where is the tuning fork placed on the patient? 1. Place the base of the tuning fork on the midline of the top of the patient’s head. 2. Place the tuning fork in front of the ear on the mastoid bone. 3. Place the tines of the tuning fork perpendicular to the patient’s ear canal. 4. Place the tines of the tuning fork on the midline of the top of the patient’s head.

10. The nurse has documented in the chart: “Patient exhibits a cauliflower ear.” What is a cauliflower ear? 1. A blood clot that forms under the skin causing damage to the cartilage. 2. A congenital deformity that causes an incompletely formed ear. 3. Abnormally large ears that are greater than 4 cm in height in adults. 4. A hard whitish or cream-colored deposit of uric acid crystals.

11. A 58-year-old male has come in for a routine visit at the physician’s office. During the health history he states, “I have been having some hearing loss lately. My wife thinks I am ignoring her, but I just do not hear her. The doctor says I have cerumen in my ears.” This type of hearing loss is called: GRADESMORE.COM 1. Conductive hearing loss. 2. Sensorineural hearing loss. 3. Mixed hearing loss. 4. Complete hearing loss.

12. An 88-year-old female has come in for her annual physical visit. During the review of systems she states that your voice sounds “muffled and unclear.” This type of hearing loss is called: 1. Conductive hearing loss. 2. Sensorineural hearing loss. 3. Hearing loss related to aging. 4. Complete hearing loss.

13. Which of the following two tests should be performed to correctly assess sensorineural hearing loss? 1. Weber and Whisper tests 2. Weber and Rinne tests 3. Rinne and Whisper tests

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Audiogram and Weber tests

14. You are assessing for unilateral hearing loss and functioning of the cochlear nerve. Identify the assessment technique. 1. Weber test 2. Rinne test 3. Whisper test 4. Audiogram

GRADESMORE.COM 15. You are performing a hearing assessment. You place the tuning fork on the mastoid bone and then place the tines perpendicular to the ears. What is the name of this hearing assessment? 1. Weber test 2. Rinne test 3. Whisper test 4. Audiogram

16. Which of the following findings would indicate a negative Rinne test? 1. Bone conduction is heard longer than air conduction. 2. Air conduction is heard longer than bone conduction. 3. Air and bone conduction are heard at the same length of time. 4. Only air conduction is heard.

17. The nurse has completed her inspection and palpation assessment of the ear. He is now going to use the otoscope. What is the purpose of assessing an ear using an otoscope? 1. To inspect the auricle for presence of water 2. To inspect the external auditory canal, middle ear, and eardrum 3. To assure you can see the light in the inferior quadrant at the 7 o’clock location in the left ear 4. To practice the use of the otoscope, as nurses do not regularly use an otoscope

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

18. The nurse is using an otoscope to assess the inner right ear and notes an excessive amount of a dark brown substance in the external ear canal. What would the nurse document in the electronic health record? 1. Right ear: excess cerumen present 2. Right ear: signs of otitis media present 3. Right ear: no abnormalities noted 4. Right ear: effusion present

19. Identify the ear condition: inflammation of the outer ear, yellow discharge in the external ear canal, and ear pain. 1. Cerumen 2. Otitis externa 3. Otitis media 4. Normal findings

20. One of the most common complaints for which individuals seek medical care for their ears GRADESMORE.COM is: 1. Hearing loss. 2. Tinnitus. 3. Vertigo. 4. Otalgia.

21. You are performing an inner ear assessment. What is your assessment finding based on the photo above? 1. Normal finding 2. Otitis media 3. Ruptured tympanic membrane 4. Cerumen buildup

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

22. The patient comes to urgent care complaining of ear pain. You assess the ear using an otoscope. What is your assessment finding? 1. Otitis media 2. Normal finding 3. Ruptured tympanic membrane 4. Cerumen

23. You note that while you are interviewing the patient he turns his right ear toward you. Which of the following questions are the BEST questions to ask about the patient’s ability to hear? Select all that apply. 1. “Do you have difficulty hearing words when an individual is talking?” 2. “Do you have hearing loss? When did it start?” 3. “Do you have presbycusis?” 4. “Do you have difficulty watching television?” 5. “Do you yell a lot?” GRADESMORE.COM

24. During the palpation assessment of the ear, which structures are gently palpated in each ear? Select all that apply. 1. Tragus 2. Earlobes 3. Auricles 4. Mastoid process 5. Eardrum 6. Ossicles

25. You are inspecting the ears of a 32-year-old male who is complaining of right ear tenderness and swelling. Which of the following would the nurse document as normal findings? Select all that apply. 1. Firm consistency 2. Color darker than facial skin 3. Equal size and symmetrical 4. Tender on palpation 5. Angle of attachment is greater than 10 degrees

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers 1. Routine health assessment is dependent on a person’s ability to hear the health interview questions. During the first encounter the nurse should note whether is intact while asking questions. 1. Conversational hearing 2. Conductive hearing 3. Sensorineural hearing 4. The cranial nerve ANS: 1 Page: 169

Feedback This is correct. During the first encounter the nurses notes whether the patient has hearing through conversational hearing. Conversational hearing is the ability to participate in a conversation without difficulty and comprehending and answering the question without asking for questions to be repeated. This is incorrect. Conductive hearing is considered middle ear hearing loss and is when sound is not conducted through the outer ear canal to the eardrum. This is assessed by the Rinne test. This is incorrect. Sensorineural hearing loss occurs when there is damage to the inner ear or to the nerve pathways from the inner ear to the brain. This is assessed by the GRADESMORE.COM Weber test. This is incorrect. It is a vague answer. Specifically, cranial nerve VIII brings sound and information to the brain.

1. 2. 3.

Feedback This is incorrect. This answer does not integrate with the question asking about exposure to loud noises. This is incorrect. This question is not referring to economic impact on everyday health. This is correct. Prolonged exposure to loud noise may cause wear and tear on the hairs and nerve cells in the cochlea that send sound signals to the brain. When these

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

hairs or nerve cells are damaged or missing, electrical signals are not transmitted as efficiently and hearing loss occurs. This is incorrect. Tinnitus is not known to be caused by prolonged exposure to loud noise. It could be a symptom of an inner ear disorder.

3. On assessment of a 56-year-old man the nurse discovers he is complaining of “ringing in the ears.” The nurse recalls that the medical term for this is: 1. Presbycusis. 2. Vertigo. 3. Tinnitus. 4. Tophi. ANS: 3 Page: 172

1. 2. 3.

Feedback This is incorrect. Presbycusis is a natural process of hearing loss related to sensorineural hearing loss from death of cochlear hair cells. This is incorrect. Vertigo is a feeling of lightheadedness, which may lead to feeling faint. This is correct. Tinnitus is the perception of sound when no actual external noise is present. It is commonly refeG rrR edAtD oE asS“MriOnR giE ng.iCnOthMe ears” and can manifest many different perceptions of sound. This is incorrect. Tophi are hard, whitish, or cream-colored nontender deposits of uric acid crystals indicative of gout.

1. 2. 3.

Feedback This is incorrect. Supine position, lying flat on the back, is not the position for the ear assessment. This is incorrect. Prone position, lying flat on the stomach, is not the position for the ear assessment. This is incorrect. Semi-Fowler’s position, sitting upright at 30 to 40 degrees in bed, is

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

not the position for the ear assessment. Feet need to be dangling to allow the practitioner to stand in front of the patient. This is correct. The patient should be in a sitting position, allowing the practitioner to stand in front of the patient to assess both ears.

5. What is the nurse assessing for in the photo? 1. Tenderness 2. Hearing loss 3. Visual deformities 4. Color ANS: 1 Page: 174 Feedback 1. 2. 3. 4.

GRADESMORE.COM

This is correct. This is the assessment, gently palpating ears, which is used to assess for tenderness. This is incorrect. This assessment does not assess for hearing loss. This is incorrect. Palpating the ears is not a visual assessment for deformities. This is incorrect. Color would be assessed by inspecting.

6. You are assessing an ear and see this deviation. What is the name of the assessment finding shown in the photo? 1. Cyst 2. Darwin tubercle 3. Tophi 4. Tragus ANS: 2

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Page: 173

1. 2. 3. 4.

Feedback This is incorrect. A cyst is a fluid-filled sac. This is correct. Darwin tubercle is a congenital deviation that is a small cartilaginous protuberance of the helix of the ear. This is incorrect. Tophi are hard, whitish, or cream-colored nontender deposits of uric acid crystals. This is incorrect. Tragus is the protuberance anterior to the auditory canal. This is an anatomical feature of the ear.

7. This part of the ear is responsible for transmitting sound waves through the auditory nerve (cranial nerve VIII). 1. Inner 2. Middle 3. Auricle 4. Ear canal ANS: 1 Page: 170

1. 2. 3. 4.

GRADESMORE.COM Feedback This is correct. The inner ear or labyrinth is responsible for transmitting sound waves through the auditory nerve (cranial nerve VIII) to the brain. This is incorrect. The middle ear transmits sound waves from the eardrum to the inner ear and the Eustachian tubes. This is incorrect. The auricle is the outer visible portion of the ear. This is incorrect. The ear canal is the outer ear that transmits sound waves to the eardrum.

Feedback This is incorrect. Vertigo is dizziness or a feeling of lightheadedness. This may lead to

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3. 4.

fainting, a feeling that the environment is spinning. This is incorrect. Cauliflower ear results from repeated trauma or hitting the ear. This is incorrect. Microtia is a congenital deformity that involves an incompletely formed or small ear. This is correct. Macrotia is abnormally large ears which are greater than 10 cm (approximately 4 inches) in vertical height in adults.

2. 3. 4.

Feedback This is correct. To perform a Weber test hold the tuning fork with one hand without touching the tines. Strike the tines on the back of your other hand to initiate the tines to vibrate. Place the base of the tuning fork on the midline of the top of the patient’s GRADESMORE.COM head. This is incorrect. This is not the correct way to perform the Weber test. The mastoid bone is not in front of the ear, it is in the back of the ear. This is incorrect. This is not the correct way to perform the Weber test. The Rinne test is where you would place the tuning tines perpendicular to the ear. This is incorrect. This is not the correct way to perform the Weber test. You would not place the tines of the tuning fork on top of the patient’s head.

Feedback This is correct. Cauliflower ear occurs from repeated trauma or hitting the ear. A blood clot forms under the skin or there is damage to the cartilage causing a change in

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3. 4.

shape and structure of the ear. Wrestlers or people who play contact sports are at risk for developing cauliflower ear. This is incorrect. Microtia is a congenital deformity that is an incompletely formed or small ear. This is incorrect. Macrotia are abnormally large ears. This is incorrect. Tophi are a hard, whitish or cream-colored nontender deposits of uric acid crystals.

11. A 58-year-old male has come in for a routine visit at the physician’s office. During the health history he states, “I have been having some hearing loss lately. My wife thinks I am ignoring her, but I just do not hear her. The doctor says I have cerumen in my ears.” This type of hearing loss is called: 1. Conductive hearing loss. 2. Sensorineural hearing loss. 3. Mixed hearing loss. 4. Complete hearing loss. ANS: 1 Page: 175 Feedback 1.

2. 3. 4.

GRADESMORE.COM

This is correct. Conductive hearing loss is considered middle ear hearing loss, when sound is not conducted through the outer ear canal to the eardrum and the tiny bones of the middle ear. Wax impaction is the most common cause of conductive hearing loss. This is incorrect. Sensorineural hearing loss is considered inner ear hearing loss, where speech may sound unclear or muffled. This is incorrect. Mixed hearing loss includes both sensorineural and conductive hearing loss. This is incorrect. Complete hearing loss is absence of hearing.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

Feedback This is incorrect. Conductive hearing loss is when sound is not conducted through the outer ear to the eardrum. This involves a reduction in sound level or the ability to hear faint sounds. The nurse is not speaking quietly and the patient cannot hear the normal tone of her voice. This is correct. Sensorineural hearing loss, which is also considered inner ear hearing loss, occurs when there is damage to the inner ear (cochlea) or to the nerve pathways from the inner ear to the brain. Speech may sound unclear or muffled. This is the most common type of permanent hearing loss. This is incorrect. This is not the specific type of hearing loss. Presbycusis is the term related to hearing loss related to aging, which is caused by sensorineural hearing loss. This is incorrect. Complete hearing loss is the absence of hearing.

13. Which of the following two tests should be performed to correctly assess sensorineural hearing loss? 1. Weber and Whisper tests 2. Weber and Rinne tests 3. Rinne and Whisper tests 4. Audiogram and Weber tests ANS: 2 Page: 176

2. 3.

GRADESMORE.COM

Feedback This is incorrect. These are not the two best tests to assess for sensorineural hearing loss. The Weber test assesses unilateral sensorineural hearing loss but the Whisper test assesses high frequency hearing loss. This is correct. The Weber test should always be accompanied by the Rinne test to assess for sensorineural hearing loss. This is incorrect. The Rinne and Whisper tests are not the best hearing tests to confirm sensorineural hearing loss. The Whisper test is for high frequency hearing loss. This is incorrect. The Audiometric testing (audiogram) is a hearing evaluation to assess the sensitivity of a person’s sense of hearing at different high and low frequencies.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

14. You are assessing for unilateral hearing loss and functioning of the cochlear nerve. Identify the assessment technique. 1. Weber test 2. Rinne test 3. Whisper test 4. Audiogram ANS: 1 Page: 176

2. 3. 4.

Feedback This is correct. This assessment is conducting the Weber test. The purpose of the Weber test is to assess unilaG teR raA l hDeEarSinMgOlR osE s. anCdOfM unction of the cochlear nerve. Place the base of the tuning fork on the midline of the top of the individual’s head. This is incorrect. This assessment is conducting the Weber test. The purpose of the Rinne test is to assess hearing by bone conduction versus air conduction. This is incorrect. This assessment is conducting the Weber test. The Whisper test is to assess for impaired or high frequency hearing loss. This is incorrect. This assessment is conducting the Weber test. The audiogram is a hearing evaluation to assess the sensitivity of a person’s sense of hearing at different high and low frequencies.

15. You are performing a hearing assessment. You place the tuning fork on the mastoid bone and then place the tines perpendicular to the ears. What is the name of this hearing assessment? 1. Weber test 2. Rinne test 3. Whisper test 4. Audiogram ANS: 2 Page: 177 Feedback

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

This is incorrect. This is not the Weber test. A tuning fork is used to assess sounds vibrating through the bones only. This is correct. This is the Rinne test. It assesses bone conduction versus air conduction. This is incorrect. This is not the Whisper test. The Whisper test involves whispering words into the patient’s ear. This is incorrect. This is not an audiogram. An audiogram is a hearing evaluation to assess the sensitivity of a person’s sense of hearing at different high and low frequencies.

1. 2. 3. 4.

Feedback This is correct. A negative Rinne test is when bone conduction is heard longer than GRADESMORE.COM air conduction. This is incorrect. This is a positive Rinne test. Air conduction is heard longer than bone conduction. This is incorrect. This is neither a positive or negative Rinne test. This is incorrect. This is not a negative Rinne test. A Rinne test assesses both air and bone conduction.

1. 2.

Feedback This is incorrect. You do not need an otoscope to inspect the auricle. This is correct. The purpose of assessing an ear using an otoscope is to inspect the external auditory canal, middle ear, and eardrum.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

This is incorrect. This is an assessment of the ear, not a purpose. This is incorrect. This is not the purpose of using an otoscope.

1. 2.

3. 4.

Feedback This is correct. Earwax (cerumen) is a moist or dry, waxy substance that acts to protect the skin of the external ear canal. This is incorrect. Otitis media is an inflammation of the inner ear. On assessment the inner ear would be inflamed and have a buildup of fluid. The eardrum would appear red and bulging. This is incorrect. Nurses should document that a dark brown substance was noted in GRADESMORE.COM the ear canal. This is incorrect. There is no effusion to be noted on assessment of the inner ear, only the outer ear. Effusion is a collection of fluid.

19. Identify the ear condition: inflammation of the outer ear, yellow discharge in the external ear canal, and ear pain. 1. Cerumen 2. Otitis externa 3. Otitis media 4. Normal findings ANS: 2 Page: 179

1. 2. 3. 4.

Feedback This is incorrect. Cerumen is a moist or dry, waxy substance found in the inner ear, not outer ear. This is correct. Otitis externa is an inflammation of the outer ear. It appears as redness, inflammation, discharge, and pain. This is incorrect. Otitis media is an inflammation of the inner ear, not outer ear. This is incorrect. A normal finding is no inflammation or discharge and a small

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

amount of cerumen present.

20. One of the most common complaints for which individuals seek medical care for their ears is: 1. Hearing loss. 2. Tinnitus. 3. Vertigo. 4. Otalgia. ANS: 4 Page: 179

1. 2. 3. 4.

Feedback This is incorrect. Hearing loss is not a frequent or common complaint. Hearing loss is usually gradual and occurs over time. This is incorrect. Tinnitus is the perception of sound (“ringing in the ears”) and is not the most common complaint. This is incorrect. This is not the most common complaint. Vertigo is a feeling that the environment is moving and is not the most common complaint. This is correct. Ear pain (otalgia) and ear drainage (otorrhea) are the most common complaints for which individuals seek medical care for their ears.

GRADESMORE.COM

21. You are performing an inner ear assessment. What is your assessment finding based on the photo above? 1. Normal finding 2. Otitis media 3. Ruptured tympanic membrane 4. Cerumen buildup ANS: 2 Page: 179

Feedback This is incorrect. This is not a normal finding. The ear should appear without inflammation or discharge.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3. 4.

This is correct. Otitis media is an inflammation of the inner ear, causing inflammation, a buildup of fluid, and a bright red bulging eardrum. This is incorrect. This is not a picture of a ruptured tympanic membrane. A ruptured tympanic membrane appears as a dark oval hole. This is incorrect. This is not a picture of earwax. Cerumen is a waxy colored substance.

GRADESMORE.COM

ANS: 3 Page: 179

2. 3. 4.

Feedback This is incorrect. Otitis media is an inflammation of the inner ear. On assessment the inner ear would be inflamed, have a buildup of fluid, and the eardrum would appear red and bulging. This is incorrect. This is not a normal finding. The tympanic membrane should appear intact. This is correct. This is a ruptured tympanic membrane The membrane is a dark oval and a hole is present. This is incorrect. Cerumen appears as a waxy substance.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 1, 2, 4 Page: 171

1. 2.

3. 4. 5.

Feedback This is correct. Difficulty hearing words when an individual is talking indicates that the spoken word may be mumbled and the individual may have difficulty hearing. This is correct. These are direct questions. Patients should be able to tell the nurse if they have difficulty hearing and approximately how long they have had problems with their hearing. This is incorrect. You should not ask a patient a question using medical terminology. Patients may not know what presbycusis means. This is correct. Patients with hearing loss have difficulty watching television because they cannot hear the television. This is incorrect. Patients with hearing loss may speak louder, but asking the patient if they “yell a lot” is not helpful.

24. During the palpation assessment of the ear, which structures are gently palpated in each ear? Select all that apply. 1. Tragus 2. Earlobes GRADESMORE.COM 3. Auricles 4. Mastoid process 5. Eardrum 6. Ossicles ANS: 1, 2, 3, 4 Page: 174

1. 2. 3. 4. 5. 6.

Feedback This is correct. The tragus is the outer part of the ear that is palpated. This is correct. The earlobes are the outer parts of the ears that are palpated. This is correct. The auricles are the outer parts of the ears that are palpated. This is correct. The mastoid process is behind the ear that is palpated. This is incorrect. The eardrum can only be assessed using an otoscope. This is incorrect. The ossicles are the tiny bones of the middle ear that can only be assessed using an otoscope.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. Color darker than facial skin 3. Equal size and symmetrical 4. Tender on palpation 5. Angle of attachment is greater than 10 degrees ANS: 1, 3 Page: 174

1. 2. 3. 4. 5.

Feedback This is correct. Firm consistency is a normal finding when palpating the ear. This is incorrect. Color darker than facial skin is an abnormal finding when inspecting the ears. The color should be the same as facial skin. This is correct. Equal size and symmetrical is a normal finding when inspecting the ears. This is incorrect. Tender on palpation is an abnormal finding when palpating the ears. This is incorrect. Angle of attachment should not be greater than 10 degrees. The normal angle of attachment is less than 10 degrees.

26. You are assessing the patient’s hearing. Place the following steps in order (1–6) to conduct the sequence of the Whispered Voice test. (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. ExGaR mA plD e:E1S2M 34O.)RE.COM 1. Document your findings. 2. Ask the individual to cover the left ear that you are not testing. 3. Whisper three random words, letters, or numbers toward the right ear. 4. Repeat on the opposite side. 5. Have the individual repeat what you whispered. 6. Stand behind the person to his or her right side about 2 feet away. ANS: 623541 Page: 175 Feedback: This is the sequence for assessing the patient for impaired or high frequency hearing loss: First, stand behind the person to his or her right side about 2 feet away so you cannot be seen. Second, ask the individual to cover the left ear that you are not testing. Third, whisper three random words, letters, or numbers toward the right ear. Fourth, have the individual repeat what you whispered. Fifth, repeat each step on the left side. Finally, document your findings.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 11: Assessing the Eyes

1. Which of the following cranial nerves are responsible for the activity of the eye? Select all that apply. 1. Cranial nerve III 2. Cranial nerve IV 3. Cranial nerve I 4. Cranial nerve VI 5. Cranial nerve X

2. The nursing instructor is teaching a group of students about the Healthy People 2020 goals related to improving vision health. Which objectives should the nursing student be prepared to include in future patient education? Select all that apply. 1. Have routine eye examinations performed. 2. Rest your eyes. 3. Wear protective eyewear. 4. Increase protein in diet. 5. Take B12 vitamins daily.

GRADESMORE.COM 3. The extraocular structures of the eye include which of the following? Select all that apply. 1. Sclera 2. Conjunctiva 3. Optic nerve 4. Lacrimal glands 5. Iris

4. A patient is diagnosed with glaucoma. The nurse reviews the patient’s medical record, expecting to note which of the following? Select all that apply. 1. Medications for intraocular pressure 2. Decreased visual acuity 3. Loss of peripheral vision 4. Redness of the conjunctiva 5. Swelling of the eyes

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

5. An older patient is diagnosed with macular degeneration and asks the nurse to explain this condition. The nurse includes which information in her response to the patient? Select all that apply. 1. “It may be an age-related problem.” 2. “It is a breakdown of cells in the macula of the retina.” 3. “It is caused by a gradual blockage of the arteries and veins in your eye.” 4. “It is a result of deterioration of the area that controls peripheral vision.” 5. “Treatment aims to help maximize remaining vision.”

6. You are assessing a patient’s eyes. You start by inspecting the anterior eye structures. Normal findings would include which of the following? Select all that apply. 1. Eyelashes equally distributed 2. Yellow drainage from lacrimal ducts 3. Eyes symmetrical 4. Cornea with white opacities 5. Sclera white 6. No abnormal involuntary movement

7. You are assessing a patient’s eye using the Confrontation Test for Visual Field Testing. At what angles should the field of visionGbReAaD ssEeS ssM edO?RSE el. ecCt O alMl that apply. 1. Temporal 2. Nasal 3. Posteriorly 4. Superiorly 5. Inferiorly

8. You are performing an eye assessment on a patient in the intensive care unit who suffered a head injury. Which of the following are normal findings? Select all that apply. 1. The left pupil measures 7 mm and the right pupil measures 6 mm. 2. The eyes are symmetrical. 3. There is a drooping eyelid and constricted right pupil. 4. The pupils dilate in response to light.

9. You are assessing the internal structures of the eye. Normal findings of the optic disc include which of the following? Select all that apply. 1. Color is red or dark orange 2. Shape is round or oval 3. Disc outline is sharp or cloudy

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Central physiologic cup (if present) is a dark gray color

10. You are assessing for color blindness. What are the most common colors affected when you have color blindness? Select all that apply. 1. White 2. Red 3. Blue 4. Brown 5. Green

11. A patient has fallen off a small cliff and hit his head. He reports blurry vision. What is the purpose of inspecting this patient’s pupil size and consensual pupil response? Select all that apply. 1. To assess the integrity of the optic pathways 2. To assess the accommodation reflex 3. To assess the pupillary light reflex 4. To assess the functioning of the ocular muscles

GRADESMORE.COM 12. You are assessing a patient’s eyes and note that the left eyelid is drooping. What assessment should you perform next? 1. Assess the nasolacrimal folds. 2. Assess the conjunctiva for drainage. 3. Assess the palpebral fissures. 4. Assess the pupil reaction.

13. The nurse is preparing a patient for a dilated eye examination using mydriatic eye drops. Which areas of the eye will be examined? 1. Eyebrows, conjunctiva, and optic disc 2. Conjunctiva, optic disc, and eyelids 3. Pupils, sclera, and lacrimal glands 4. Fundus, macula, and optic disc

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. “You should follow up with the doctor in a week.” 4. “You may feel a numbing sensation for several hours.”

15. An elderly African American man reports that he has been diagnosed with open-angle glaucoma. He has a past medical history of being a type 2 diabetic and states that he takes pills for his diabetes. He does not know what he did wrong to have this eye condition and asks if you can help him to understand why he has glaucoma. How should the nurse respond? 1. “Open-angle glaucoma is more common in diabetics and African Americans.” 2. “You should not have glaucoma at your age, but sometimes it just develops.” 3. “Open-angle glaucoma occurs more often when you do not get regular eye examinations.” 4. “Open-angle glaucoma occurs most often among all family members.”

16. A patient comes to the community health clinic complaining of blurry vision. She reports that her vision has been blurry for the last couple of months. Which statement by the patient may require further evaluation? 1. “My mother has diabetes and takes insulin every day.” 2. “My father had decreased circulation in his legs.” 3. “I wear dark sunglasses when I’m outside.” 4. “I had my last eye examination 2 years ago.”

GRADESMORE.COM 17. You are starting to perform an internal eye assessment. Using the ophthalmoscope, you have tried several times to find the red reflex but are unable to see it. What should be your next action? 1. Ask the patient if he or she has any eye pain. 2. Call the health-care provider immediately. 3. Ask the patient if he or she has an artificial eye or cataracts. 4. Continue on with your internal eye examination.

18. The patient’s daughter reports that her mother has red, crusty, and greasy eyelid lashes every morning and throughout the day. The nurse knows that this condition is called: 1. Conjunctivitis. 2. Hordeolum. 3. Blocked lacrimal duct. 4. Blepharitis.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

19. You are assessing the vision of a patient who wears glasses. What instructions will you give this patient? 1. “Read each line from right to left on the Snellen chart until you cannot read one letter correctly.” 2. “Read each line on the Snellen chart until you cannot read all the letters.” 3. “You may keep your glasses on, cover your left eye, and start reading each line from left to right.” 4. “Remove your glasses, cover your right eye, and start reading the lines from top to bottom.”

20. The nurse is conducting the Snellen test on a patient in a clinic. The findings are recorded as 20/40 in both eyes. Which is the correct interpretation of this finding? 1. The patient can read from 20 feet what someone with 20/20 vision can read at 40 feet. 2. The patient is farsighted and needs correction to see more clearly. 3. The patient can read from 40 feet what someone with 20/40 vision can read at 20 feet. 4. The patient is suffering from presbyopia and needs to be rescreened.

21. You are assessing the eyes for PERRLA. What equipment will the nurse need? 1. Blood pressure cuff 2. Stethoscope GRADESMORE.COM 3. Reflex hammer 4. Penlight

22. You are assessing consensual pupil reaction. What is a normal finding? 1. Shine light into the left eye pupil and assess the left eye; left eye should constrict. 2. Shine light into the left eye pupil and assess the right eye; right eye should constrict. 3. Both eyes should dilate in response to bright light. 4. Both eyes should constrict when the lights are turned on.

23. A patient presents to the clinic complaining of blurred vision and feeling like he needs to clean his glasses all the time, which does not improve his blurry vision. The patient denies eye pain. Based on this patient’s report, which eye disorder would the nurse suspect? 1. Ectropion 2. Conjunctivitis 3. Diabetic retinopathy 4. Cataracts

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

24. The patient reports that he is legally blind. The definition of legal blindness is: 1. Visual acuity of 20/40 or more. 2. Visual acuity of 20/50 or more. 3. Visual acuity of 20/100 or more. 4. Visual acuity of 20/200 or more.

25. Which statement illustrates proper use of the standard ophthalmoscope? 1. Hold the instrument in your right hand to examine the patient’s right eye. 2. Focus the lens from a position of about 12 to 15 inches away from the patient. 3. Ask the patient to look directly into the light beam. 4. No adjustments to the diopter are needed to see the red reflex.

26. A patient comes to the urgent care center stating that while mowing his lawn, his eyes brushed against a hanging tree limb. He reports that his “eyes hurt and feel gritty.” Which external structures should the nurse inspect? 1. Conjunctiva 2. Macula 3. Retina 4. Pupil size

GRADESMORE.COM 27. A patient comes to the emergency room complaining that he has sudden left eye pain with blurry vision. He states, “I am also seeing flashing lights in my left eye.” What eye condition does the nurse suspect? 1. Cataract blindness 2. Acute glaucoma 3. Detached retina 4. Macular degeneration

28. The 60-year-old patient is complaining of seeing tiny floating spots in his line of vision, especially when he wakes up in the morning. The nurse knows that these symptoms are the result of which pathological process? 1. Clouding of the lens 2. Myopia 3. Hyperopia 4. Vitreous floaters

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

29. The nurse asks a patient to read a paragraph in a newspaper. He is able to read the paragraph without difficulty. She asks the patient to read the bottom line of a Snellen chart and he is unable to read all the letters correctly. Which visual disorder would the nurse suspect? 1. Hyperopia 2. Legal blindness 3. Myopia 4. Presbyopia

30. The nurse is preparing to assess a patient’s central vision. Which chart will the nurse use to assess central vision? 1. Snellen 2. Tumbling 5 3. Amsler grid 4. Ishihara plate

31. The nurse is assessing a patient’s extraocular muscles for motor nerve activity. When documenting the findings, what should the nurse include regarding which cranial nerves were assessed? 1. II, IV, V GRADESMORE.COM 2. III, IV, V 3. II, III, VI 4. III, IV, VI

32. The nurse is testing the patient’s peripheral vision. Which test will the nurse perform or use? 1. Amsler grid 2. PERRLA 3. Confrontation 4. Snellen chart

33. The nurse is examining a 48-year-old patient’s eyes and notices the patient moving the handheld vision card to arm’s length. Which visual disorder would the nurse suspect? 1. Hyperopia 2. Blindness 3. Myopia 4. Presbyopia

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

34. You are performing an eye assessment and inspecting the conjunctiva. What instructions should you give to the patient? 1. Ask the patient to look up. 2. Ask the patient to look down. 3. Ask the patient to look at a focal point on the wall. 4. Ask the patient to look straight ahead.

35. The patient covers one eye. You place your hand with extended fingers behind the patient’s field of vision and move your fingers toward the patient’s field of vision. What assessment technique are you performing? 1. Consensual response 2. Confrontation test 3. Test for accommodation GRADESMORE.COM 4. Ocular mobility test

36. You are assessing the accommodation reflex of the eye. How far away should you hold the object from the eye for the patient to focus on it? 1. 6 inches 2. 12 inches 3. 14 inches 4. 16 inches

37. You are assessing the accommodation reflex of the eye. Which is a normal finding? 1. Pupils constrict and both eyes converge simultaneously. 2. Pupils constrict and both eyes diverge simultaneously. 3. Pupils dilate and both eyes converge simultaneously. 4. The right eye dilates and the left eye constricts with accommodation.

38. You are assessing the six cardinal positions of gaze. While performing this assessment, what should the nurse do to make sure involuntary movements of the eye are not missed?

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Slowly move the object to six different positions. 2. Tell the patient to move his or her head to follow the pattern. 3. Pause before changing each of the six different positions. 4. Hold the patient’s head in place and look directly into the eyes.

39. A patient arrives in the emergency room after falling down a cliff. He is lethargic. You are assessing his pupils and note the right pupil measurement is 10 mm and the left pupil measurement is 6 mm. This is called: 1. Diplopia. 2. Anisocoria. 3. Miosis. 4. Mydriasis.

40. A diabetic patient has come in for his annual physical examination. He reports that he has been a diabetic for more than 40 years and takes insulin. You take his vital signs: blood pressure 170/92, pulse 82, respiratory rate 18, and temperature 97.8°F (tympanic). The patient reports that his blood pressure is always high. You assess the eyes with an ophthalmoscope and see puffy, white patches on the retina. What are you seeing? 1. Drusen bodies GRADESMORE.COM 2. Diabetic retinopathy 3. Papilledema 4. Cotton wool spots

41. You are performing an eye assessment. The part(s) of the eye you are palpating in this picture is/are the _ .

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers 1. Which of the following cranial nerves are responsible for the activity of the eye? Select all that apply. 1. Cranial nerve III 2. Cranial nerve IV 3. Cranial nerve I 4. Cranial nerve VI 5. Cranial nerve X ANS: 1, 2, 4 Page: 181

Feedback This is correct. Cranial nerve III (oculomotor), cranial nerve IV (trochlear), and cranial nerve VI (abducens) are the three cranial nerves responsible for the motor nerve activity of the eye. This is correct. Cranial nerve III (oculomotor), cranial nerve IV (trochlear), and cranial nerve VI (abducens) are the three cranial nerves responsible for the motor nerve activity of the eye. This is incorrect. Cranial nerve I is the olfactory nerve and controls the sense of smell. Cranial nerve III (oculomotor), cranial nerve IV (trochlear), and cranial nerve VI (abducens) are the three cranial nerves responsible for the motor nerve activity of the GRADESMORE.COM eye. This is correct. Cranial nerve III (oculomotor), cranial nerve IV (trochlear), and cranial nerve VI (abducens) are the three cranial nerves responsible for the motor nerve activity of the eye. This is incorrect. Cranial nerve X is the vagus nerve. Cranial nerve III (oculomotor), cranial nerve IV (trochlear), and cranial nerve VI (abducens) are the three cranial nerves responsible for the motor nerve activity of the eye.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. 5.

This is correct. Healthy People 2020 objectives include interventions to preserve sight and prevent blindness. These include: encouraging a comprehensive eye examination, giving eyes rest, and wearing protective eyewear. Eating right to protect sight includes a diet rich in fruits and vegetables and omega-3. This is correct. Healthy People 2020 objectives include interventions to preserve sight and prevent blindness. These include: encouraging a comprehensive eye examination, giving eyes rest, and wearing protective eyewear. Eating right to protect sight includes a diet rich in fruits and vegetables and omega-3. This is correct. Healthy People 2020 objectives include interventions to preserve sight and prevent blindness. These include: encouraging a comprehensive eye examination, giving eyes rest, and wearing protective eyewear. Eating right to protect sight includes a diet rich in fruits and vegetables and omega-3. This is incorrect. Eating more protein will not improve eyesight. Protein helps your body repair cells. This is incorrect. Vitamin B12 helps with normal functioning of the brain and nervous system.

3. The extraocular structures of the eye include which of the following? Select all that apply. 1. Sclera 2. Conjunctiva 3. Optic nerve GRADESMORE.COM 4. Lacrimal glands 5. Iris ANS: 2, 4 Page: 182

1. 2. 3. 4.

Feedback This is incorrect. The sclera is an intraocular structure. This is correct. The conjunctiva, a thin membrane covering the front of the eye (bulbar conjunctiva) and inner eyelids (palpebral conjunctiva), is an extraocular structure. This is incorrect. The optic nerve is an intraocular structure. This is correct. Lacrimal glands are the tear ducts that continually release tears and protective fluids to clean, lubricate, and moisten the eyes. These glands are extraocular structures. This is incorrect. The iris is an intraocular structure.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Redness of the conjunctiva 5. Swelling of the eyes ANS: 1, 2, 3 Page: 184, 188

1. 2. 3. 4. 5.

Feedback This is correct. Patients with glaucoma will be placed on eye drops. Glaucoma is a buildup of intraocular pressure that damages the eye’s optic nerve. This is correct. Glaucoma causes decreased visual acuity secondary to loss of peripheral vision. This is correct. Glaucoma causes loss of peripheral vision. This is incorrect. Glaucoma does not cause redness of the conjunctiva; conjunctivitis causes redness of the conjunctiva. This is correct. Glaucoma affects the internal structures of the eyes and does not cause swelling of the eyes.

5. An older patient is diagnosed with macular degeneration and asks the nurse to explain this condition. The nurse includes which information in her response to the patient? Select all that apply. 1. “It may be an age-related problem.” 2. “It is a breakdown of cells in the mGaRcuAlD aE ofSthMeOrR etE in.a.C ” OM 3. “It is caused by a gradual blockage of the arteries and veins in your eye.” 4. “It is a result of deterioration of the area that controls peripheral vision.” 5. “Treatment aims to help maximize remaining vision.” ANS: 1, 2, 5 Page: 184, 193

1. 2. 3. 4.

Feedback This is correct. Macular degeneration is a deterioration of the macula, the area of central vision. It can be related to deterioration of the macula related to the aging process. This is correct. Macular degeneration is a breakdown of cells in the macula of the retina, causing loss of central vision. This is incorrect. Macular degeneration is a deterioration of the macula and a blockage in the capillaries of the blood vessels, not the arteries and veins. This is incorrect. Macular degeneration is a deterioration of the macula, the area of central vision. This deterioration does not cause loss of peripheral vision but central vision. This is correct. Macular degeneration is a deterioration of the macula, the area of central vision. Treatment is aimed at maintaining and maximizing vision.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4. 5. 6.

Feedback This is correct. Eyelashes equally distributed is a normal finding. This is incorrect. Yellow drainage from lacrimal ducts is an abnormal finding and can be a sign of infection. This is correct. Eyes are symmetrical is a normal finding. This is incorrect. Cornea with white opacities is an abnormal finding and a sign of cataracts. This is correct. Sclera is white is a normal finding. This is correct. No abnormal involuntary movement is a normal finding.

GRADESMORE.COM 7. You are assessing a patient’s eye using the Confrontation Test for Visual Field Testing. At what angles should the field of vision be assessed? Select all that apply. 1. Temporal 2. Nasal 3. Posteriorly 4. Superiorly 5. Inferiorly ANS: 1, 2, 4, 5 Page: 194

1. 2. 3. 4. 5.

Feedback This is correct. The temporal angle is one of the four angles to assess the field of vision. This is correct. The nasal angle is one of the four angles to assess the field of vision. This is incorrect. The posterior angle is not one of the four angles to assess the field of vision. This is correct. The superior angle is one of the four angles to assess the field of vision. This is correct. The inferior angle is one of the four angles to assess the field of vision.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is correct. A normal pupil diameter range is 2 to 8 mm. This is correct. A normal finding would be that the eyes are symmetrical. This is incorrect. This is an abnormal finding. Drooping eyelid and constricted right pupil may indicate Horner syndrome. This is incorrect. This is an abnormal finding. Pupils constrict in response to light.

1. 2. 3. 4.

Feedback This is incorrect. The color of the optic disc is yellow/orange to creamy pink. This is correct. The optic disc shape is round or oval. This is correct. The optic disc outline is sharp or cloudy. This is incorrect. The central physiologic cup (if present) is a brighter yellowish, white color.

10. You are assessing for color blindness. What are the most common colors affected when you have color blindness? Select all that apply. 1. White 2. Red 3. Blue 4. Brown 5. Green

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 2, 3, 5 Page: 192

Feedback This is correct. The purpose of inspecting pupil size and consensual pupil response is to assess the pupillary light reflex that controls the diameter of the pupil and the integrity of the optic pathways (consensual pupil response). This is incorrect. Inspecting pupil size and consensual pupil response does not assess the accommodation reflex. Testing for Accommodation (CN III) assesses the accommodation reflex. This is correct. The purpose of inspecting pupil size and consensual pupil response is to assess the pupillary light reflex that controls the diameter of the pupil and the integrity of the optic pathways (consensual pupil response). This is incorrect. Inspecting pupil size and consensual pupil response does not assess the functioning of the ocular muscles. Testing for Ocular Motility: Six Cardinal Positions of Gaze assesses the functioning of the optic pathways.

11. A patient has fallen off a small cliff and hit his head. He reports blurry vision. What is the purpose of inspecting this patient’s pupil size and consensual pupil response? Select all that apply. 1. To assess the integrity of the optic pathways 2. To assess the accommodation refleGxRADESMORE.COM 3. To assess the pupillary light reflex 4. To assess the functioning of the ocular muscles ANS: 1, 3 Page: 196

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

12. You are assessing a patient’s eyes and note that the left eyelid is drooping. What assessment should you perform next? 1. Assess the nasolacrimal folds. 2. Assess the conjunctiva for drainage. 3. Assess the palpebral fissures. 4. Assess the pupil reaction. ANS: 3 Page: 190

1. 2. 3. 4.

Feedback This is incorrect. Nasolabial folds measure from the tip of the nose to the tip of the mouth. The priority assessment is the eyelid. This is incorrect. The priority assessment is the drooping eyelid. Palpebral fissures should be measured. This is correct. Because the patient has a drooping eyelid, you should assess and measure the palpebral fissures for symmetry. This is incorrect. Pupil reaction should be assessed after the palpebral fissures are assessed for symmetry and measurement.

13. The nurse is preparing a patient for a dilated eye examination using mydriatic eye drops. Which areas of the eye will be examiGnR edA?DESMORE.COM 1. Eyebrows, conjunctiva, and optic disc 2. Conjunctiva, optic disc, and eyelids 3. Pupils, sclera, and lacrimal glands 4. Fundus, macula, and optic disc ANS: 4 Page: 184

Feedback This is incorrect. A dilated eye examination using mydriatic drops is used to examine the internal structures of the eye, which include the fundus, macula, and optic disc. The eyebrows and conjunctiva are not part of the internal eye structures. This is incorrect. A dilated eye examination using mydriatic drops is used to examine the internal structures of the eye, which include the fundus, macula, and optic disc. The conjunctiva and eyelids are not part of the internal eye structures. This is incorrect. A dilated eye examination using mydriatic drops is used to examine the internal structures of the eye, which include the fundus, macula, and optic disc. The lacrimal glands are not part of the internal eye structure. This is correct. A dilated eye examination using mydriatic drops is used to examine the internal structures of the eye, which include the fundus, macula, and optic disc.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

14. The nurse is preparing a patient for a dilated eye examination using mydriatic eye drops. What post-procedure education should be provided to the patient? 1. “You should not drive for 1 to 2 hours.” 2. “You will need to remain on bedrest today.” 3. “You should follow up with the doctor in a week.” 4. “You may feel a numbing sensation for several hours.” ANS: 1 Page: 184

2. 3. 4.

Feedback This is correct. A dilated eye examination using mydriatic drops is used to examine the internal structures of the eye. The drops cause blurry vision and sensitivity to light. As a result, patients should be educated not to drive for 1 to 2 hours after administration. This is incorrect. The patient does not need to be on bedrest after having mydriatic eye drops. This is incorrect. A patient does not need to have a follow-up after having mydriatic eye drops for a routine eye examination. This is incorrect. The patient will not have a numbing sensation. The patient may have blurry vision and sensitivity to light.

GRADESMORE.COM 15. An elderly African American man reports that he has been diagnosed with open-angle glaucoma. He has a past medical history of being a type 2 diabetic and states that he takes pills for his diabetes. He does not know what he did wrong to have this eye condition and asks if you can help him to understand why he has glaucoma. How should the nurse respond? 1. “Open-angle glaucoma is more common in diabetics and African Americans.” 2. “You should not have glaucoma at your age, but sometimes it just develops.” 3. “Open-angle glaucoma occurs more often when you do not get regular eye examinations.” 4. “Open-angle glaucoma occurs most often among all family members.” ANS: 1 Page: 184

2. 3. 4.

Feedback This is correct. Open-angle glaucoma affects African Americans three to six times more often than whites. It is six times more likely to cause blindness in African Americans than in whites. Diabetics are 40% more likely to develop glaucoma. This is incorrect. This answer does not answer the patient’s question. This is incorrect. Open-angle glaucoma is detected by a comprehensive eye examination. It does not occur because the patient did not get regular eye check-ups. This is incorrect. Open-angle glaucoma runs in families and places the patient at risk, but it does not occur most often among all family members.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3. 4.

Feedback This is correct. Patients who have family members with a history of diabetes are at greater risk of getting diabetes, and patients with diabetes are at greater risk for retinopathy and blindness. This is incorrect. The patient’s father has decreased circulation to his leg, which is not related to blurry vision. This is incorrect. This is good practice to protect the eyes from the ultraviolet rays. This is incorrect. Even though the patient should have an eye examination every year, this is not most concerning or related to the patient’s symptom.

3. 4.

Feedback This is incorrect. If you cannot find the red reflex you would reposition the ophthalmoscope and ask if the patient has an artificial eye or cataracts. Patients with diabetes are 60% more likely to develop cataracts. This is incorrect. Prior to calling the health-care provider ask the patient if he or she has an artificial eye or cataracts. Patients with diabetes are 60% more likely to develop cataracts. This is correct. You should ask the patient if he or she has an artificial eye or cataracts. Patients with diabetes are 60% more likely to develop cataracts. This is incorrect. It could be a medical emergency if you are unable to see the red reflex.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

The nurse should reposition the ophthalmoscope and ask the patient if he or she has an artificial eye or cataracts. Patients with diabetes are 60% more likely to develop cataracts.

1. 2. 3. 4.

Feedback This is incorrect. Conjunctivitis is a bacterial or viral infection causing erythema of the sclera and yellow-green drainage of the conjunctiva. This is incorrect. Hordeolum is an inflammation of a follicle of an eyelash that causes redness, inflammation, and a lump at the site. This is incorrect. Blocked lacrimal duct causes excessive tearing because tears cannot drain properly. GRADESMORE.COM This is correct. Blepharitis is an inflammation and infection of the eyelid margins. The eyelid margin becomes red, crusty, and greasy due to too much oil being produced by the eye glands.

Feedback This is incorrect. These directions are not detailed enough. If the patient has glasses, he or she can wear the glasses, then cover one eye and read each line from top to bottom and from left to right, not right to left. This is incorrect. These directions are not detailed enough. If the patient has glasses, he

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

or she can wear the glasses, then cover one eye and read each line until they read up to two letters incorrectly. This is correct. If the patient wears glasses or contact lenses, they should be worn during the vision assessment. The patient should cover one eye and start reading the lines from top to bottom and left to right. This is incorrect. The patient should not remove the glasses. If the patient has glasses, he or she can wear the glasses, then cover one eye and read each line from top to bottom.

3. 4.

Feedback This is correct. The results of the Snellen test are recorded using two numbers. The top number is the distance that theGpRatAieDnE t iS sM stO anRdE in.gCfrOoM m the chart. The lower number indicates the distance at which an individual with normal eyesight (20/20) could read the same line that the patient correctly reads. This is incorrect. This patient has nearsightedness. Nearsightedness, known as myopia, is poor visual acuity. Distant objects appear blurred because the images are focused in front of the retina rather than on it. The denominator is greater than 20. This is incorrect. The numbers are reversed. It should state the patient can read from 20 feet what someone with 20/20 vision can read at 40 feet. This is incorrect. Presbyopia is the inability to focus clearly on near objects. The patient holds the print farther away to focus and magnifying glasses are used to read.

21. You are assessing the eyes for PERRLA. What equipment will the nurse need? 1. Blood pressure cuff 2. Stethoscope 3. Reflex hammer 4. Penlight ANS: 4 Page: 196 Feedback

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is incorrect. A blood pressure cuff is not needed to assess for PERRLA. PERRLA stands for pupils are equal, round, react to light, and accommodate. In order to test reaction to light, the nurse will need a penlight. The other tools listed are not needed during eye assessment. This is incorrect. A stethoscope is not needed to assess for PERRLA. PERRLA stands for pupils are equal, round, react to light, and accommodate. In order to test reaction to light, the nurse will need a penlight. The other tools listed are not needed during eye assessment. This is incorrect. A reflex hammer is not needed to assess for PERRLA. PERRLA stands for pupils are equal, round, react to light, and accommodate. In order to test reaction to light, the nurse will need a penlight. The other tools listed are not needed during eye assessment. This is correct. A penlight is needed to assess pupil reaction. PERRLA stands for pupils are equal, round, react to light, and accommodate. In order to test reaction to light, the nurse will need a penlight. The other tools listed are not needed during eye assessment.

GRADESMORE.COM

ANS: 2 Page: 197

1. 2.

3. 4.

Feedback This is incorrect. This is testing for direct response, not consensual response. This is correct. To assess consensual reaction, start by putting your nondominant hand between the patient’s two eyes. Shine light into the left eye pupil and assess the right eye. The right eye should constrict and have a consensual response. This is incorrect. This is a general statement that is wrong. It is also not testing for consensual response. Bright light causes constriction of pupils. This is incorrect. This answer is not specific to consensual response. It is true that both eyes should constrict with bright light. To assess consensual reaction, start by putting your nondominant hand between the patient’s two eyes. Shine light into the left eye pupil and assess the right eye. The right eye should constrict and have a consensual response.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. Conjunctivitis 3. Diabetic retinopathy 4. Cataracts ANS: 4 Page: 184

1. 2.

Feedback This is incorrect. Ectropion is an everted eyelid (turns outward). Cataracts is a clouding of the lens that causes blurry, decreased, or lost vision. This is incorrect. Conjunctivitis is a bacterial or viral infection causing erythema of the sclera and yellow-green drainage of the conjunctiva. Cataracts is a clouding of the lens that causes blurry, decreased, or lost vision. This is incorrect. There is no mention that the patient is a diabetic. Diabetic retinopathy is the leading cause of blindness in diabetics. A cataract is a clouding of the lens that causes blurry, decreased, or lost vision. This is correct. A cataract is a clouding of the lens that causes blurry, decreased, or lost vision.

24. The patient reports that he is legally blind. The definition of legal blindness is: 1. Visual acuity of 20/40 or more. 2. Visual acuity of 20/50 or more. GRADESMORE.COM 3. Visual acuity of 20/100 or more. 4. Visual acuity of 20/200 or more. ANS: 4 Page: 192

1. 2. 3. 4.

Feedback This is incorrect. This is nearsightedness. The lower denominator is greater than 20. This is incorrect. This is nearsightedness. The lower denominator is greater than 20. This is incorrect. This is nearsightedness. The lower denominator is greater than 20. This is correct. The definition of legal blindness is visual acuity of 20/200 or more. This means that the patient standing at 20 feet can see what a normal patient can see at 200 feet.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 1 Page: 198

3. 4.

Feedback This is correct. The correct technique is to hold the ophthalmoscope in your right hand and use your right eye to examine the patient’s right eye and left to left to facilitate better viewing while keeping the nose out of the way. This is incorrect. The statement is wrong because the ophthalmoscope should be positioned only 12 inches away and from a 15-degree lateral angle to the patient’s line of vision. This is incorrect. The patient should be instructed to look at a distant object or focal point over your shoulder and not look directly into the light beam. This is incorrect. Everyone has different vision. A diopter is a unit of measurement of the optical power of the lens to converge or diverge light. Use your index finger to control the wheel to change the setting of the diopter to adjust your focus to find the red reflex.

1. 2. 3. 4.

Feedback This is correct. As part of the external portion of the eye assessment the conjunctiva should be assessed for signs of trauma. This is incorrect. The macula is not an external structure of the eye but an internal structure. This is incorrect. The retina is not an external structure of the eye but an internal structure. This is incorrect. The pupil is not an external structure of the eye but an intraocular structure.

27. A patient comes to the emergency room complaining that he has sudden left eye pain with blurry vision. He states, “I am also seeing flashing lights in my left eye.” What eye condition does the nurse suspect? 1. Cataract blindness

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. Acute glaucoma 3. Detached retina 4. Macular degeneration ANS: 3 Page: 188

1. 2. 3. 4.

Feedback This is incorrect. Cataracts are a clouding of the lens that causes blurry, decreased, or lost vision. This is incorrect. Glaucoma is a buildup of intraocular pressure that damages the eye’s optic nerve, causing a loss of peripheral vision. This is correct. Flashing lights may be a sign of an oncoming ocular migraine headache or could be as serious as a detached retina. This is incorrect. Macular degeneration is the loss of central vision.

1. 2. 3. 4.

Feedback This is incorrect. Cataracts are the clouding of the lens that causes blurry or decreased vision. This is incorrect. Myopia is known as nearsightedness and is the blurring of distant objects. This is incorrect. Hyperopia is known as farsightedness and is difficulty in focusing on near objects. This is correct. These symptoms indicate vitreous floaters, tiny spots or flecks in the field of vision, that are a normal part of aging.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. Myopia 4. Presbyopia ANS: 3 Page: 185

1. 2. 3. 4.

Feedback This is incorrect. Hyperopia is the inability to see things up close. The patient was able to read the newspaper. This is incorrect. Legal blindness is a visual acuity of 20/200. This is correct. Because the patient is unable to read at a distance, the nurse would suspect that the patient has myopia, the inability to see things at a distance. This is incorrect. Presbyopia is the inability to focus clearly on near objects. The patient holds the print farther away to focus and magnifying glasses are used to read.

30. The nurse is preparing to assess a patient’s central vision. Which chart will the nurse use to assess central vision? 1. Snellen 2. Tumbling 5 3. Amsler grid 4. Ishihara plate

GRADESMORE.COM

ANS: 3 Page: 193

1. 2. 3. 4.

Feedback This is incorrect. The Snellen chart is used to measure a patient’s vision to see details at far distances. This is incorrect. The Tumbling 5 chart has the capital letter “5” facing in different directions and is used if the patient cannot recognize letters on the Snellen chart. This is correct. The Amsler grid is used to assess central vision. This is incorrect. The Ishihara plate is used to assess for color blindness.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Page: 181

Feedback This is incorrect. Cranial nerve II (optic nerve) and cranial nerve IV (trochlear nerve) control movement of the eyeball, and cranial nerve V (trigeminal nerve) controls opening and closing of the mouth and sensation. Cranial nerves II and V are incorrect. This is incorrect. Cranial nerve III (oculomotor nerve) assesses motor activity of the eye, cranial nerve IV (trochlear nerve) controls movement of the eyeball, not the muscles, and cranial nerve V (trigeminal nerve) controls movement of the mouth. Only cranial nerves III and IV are correct. This is incorrect. Cranial nerve II (optic nerve) innervates the retina for vision and does not control eye movement, cranial nerve III (oculomotor nerve) assesses motor activity of the eye, and cranial nerve VI is the abducens nerve, which does control movement of the eyeball. The extraocular muscles are innervated by cranial nerves III, IV, and VI. This is correct. The extraocular muscles are innervated by cranial nerves III, IV, and VI.

32. The nurse is testing the patient’s peripheral vision. Which test will the nurse perform or use? 1. Amsler grid 2. PERRLA 3. Confrontation 4. Snellen chart

GRADESMORE.COM

ANS: 3 Page: 194

1. 2. 3. 4.

Feedback This is incorrect. The Amsler grid is used to assess central vision. This is incorrect. PERRLA is a mnemonic that stands for pupils are equal, round, react to light, and accommodation. This is correct. The confrontation test assesses peripheral vision and visual fields. This is incorrect. The Snellen chart is the most commonly used in vision examinations.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. Hyperopia is the inability to see things up close. This is incorrect. Legal blindness is a visual acuity of 20/200. This is incorrect. Myopia, or nearsightedness, is the inability to see things at a distance. This is correct. Presbyopia is the inability to focus clearly on near objects. The patient holds the print farther away to focus and magnifying glasses are used to read.

1. 2. 3. 4.

Feedback This is correct. Use your thumbs to slide the bottom eyelids down to assess the mucosa of the lower conjunctiva. Ask the patient to look up to inspect the color of the mucosa. This is incorrect. The nurse should ask the patient to look up so that the lower GRADESMORE.COM conjunctiva is inspected. This is incorrect. The patient should not look at a focal point but look up so that the lower conjunctiva is inspected. This is incorrect. The patient should not look straight ahead but look up so that the lower conjunctiva is inspected.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Ocular mobility test ANS: 2 Page: 194

Feedback This is incorrect. The consensual response test assesses the pupillary light reflex that controls the diameter of the pupil. This assessment is testing peripheral and overall field of vision. This is correct. The confrontation test for visual field testing assesses peripheral vision, overall field of vision, and blind spots by placing your hand with extended fingers behind the patient’s field of vision and moving your fingers toward the patient’s field of vision. The patient says “now” when he or she can see your fingers. This is incorrect. The test for accommodation assesses the accommodation reflex of the eye. The nurse holds a penlight or finger in front of the patient’s eyes, about 14 inches in front of his or her nose, and instructs the patient to focus on the finger or object for 30 seconds. The patient follows the finger or object as it is moved toward his or her nose. This is incorrect. This is not assessing ocular motility. The ocular motility test has the nurse moving an object in six different positions using a wide “H” or “star” pattern to assess the six cardinal positions.

36. You are assessing the accommodG atR ioAnDreEfS leM xO ofRtE he.eCyO e.MHow far away should you hold the object from the eye for the patient to focus on it? 1. 6 inches 2. 12 inches 3. 14 inches 4. 16 inches ANS: 3 Page: 196

1. 2. 3. 4.

Feedback This is incorrect. This is too short. The object or your finger should be held 14 inches in front of the patient’s nose. This is incorrect. This is too short. The object or your finger should be held 14 inches in front of the patient’s nose. This is correct. Hold a penlight or your finger in front of the patient’s eyes about 14 inches in front of his or her nose. This is incorrect. This is too far away. The object or your finger should be held 14 inches in front of the patient’s nose.

37. You are assessing the accommodation reflex of the eye. Which is a normal finding?

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Pupils constrict and both eyes converge simultaneously. 2. Pupils constrict and both eyes diverge simultaneously. 3. Pupils dilate and both eyes converge simultaneously. 4. The right eye dilates and the left eye constricts with accommodation. ANS: 1 Page: 196

1. 2. 3. 4.

Feedback This is correct. A normal finding is pupils constrict (accommodation) and both eyes converge simultaneously to focus on a near object. This is incorrect. Pupils do constrict but do not diverge simultaneously, they converge simultaneously. This is incorrect. The pupils do not dilate but constrict as a normal response. This is incorrect. One pupil does not dilate while the other pupil constricts. Both pupils will constrict and converge simultaneously.

38. You are assessing the six cardinal positions of gaze. While performing this assessment, what should the nurse do to make sure involuntary movements of the eye are not missed? 1. Slowly move the object to six different positions. 2. Tell the patient to move his or her head to follow the pattern. 3. Pause before changing each of theGsR ixAdD ifE feS reMnO t pRoE si. tioCnOs.M 4. Hold the patient’s head in place and look directly into the eyes. ANS: 3 Page: 195

2. 3. 4.

Feedback This is incorrect. Slowly moving the object to six different positions will not help you to see involuntary movements. Pausing in between changing positions allows you to watch for any involuntary movements of the eye. This is incorrect. The patient should not move his or her head to follow the pattern but should be instructed to follow your finger or the object with just the eyes. This is correct. Pausing in between changing positions allows you to watch for any involuntary movements of the eye. This is incorrect. The nurse should not hold the patient’s head in place and look directly into the eyes during this assessment. Pausing in between changing positions allows you to watch for any involuntary movements of the eye.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Diplopia. 2. Anisocoria. 3. Miosis. 4. Mydriasis. ANS: 2 Page: 197

1. 2. 3. 4.

Feedback This is incorrect. Diplopia is double vision. The pupils would not be unequal in size. This is correct. Anisocoria is unequal size of the pupils, which may be caused by genetics, medications, or be related to a neurological disorder. This is incorrect. Miosis is an abnormal constriction of the pupils. This is incorrect. Mydriasis is bilateral dilated and fixed pupils.

Feedback This is incorrect. Drusen bodies are yellow deposits of normal cell metabolic byproducts in the eye. This patient has cotton wool spots seen as puffy, white patches on the retina. This is incorrect. Diabetic retinopathy causes damage to the blood vessels of the retina. New vessels develop resulting from ischemia, lack of oxygen, and circulation. This is a common complication of diabetes, which eventually may lead to blindness. This patient has cotton wool spots that present as puffy, white patches on the retina. This is incorrect. Papilledema optic disc swelling is caused by increased intracranial pressure along the optic nerve. During assessment, the optic disc appears swollen and loses its distinctive shape. This patient has cotton wool spots that present as puffy, white patches on the retina. This is correct. This patient is a diabetic and has long-term hypertension. Cotton wool spots look like puffy, white patches on the retina. They are caused by swelling of the surface of the retina, ischemia, and damaging nerve fibers. This is commonly seen in diabetic and hypertensive patients.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

41. You are performing an eye assessment. The part(s) of the eye you are palpating in this picture is/are the . ANS: lacrimal ducts Page: 190 Feedback: Wearing gloves, the nurse should inspect and palpate the lacrimal duct for any swelling or excessive tearing.

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 12: Assessing the Respiratory System

1. The major function of the lungs is gas exchange and the delivery of oxygen to all parts of the body. The other body systems that maintain the respiratory system include which of the following? Select all that apply. 1. Circulatory system 2. Musculoskeletal system 3. Neurological system 4. Gastrointestinal system

2. During inhalation the nasal cavity performs which of the following functions? Select all that apply. 1. Warms air 2. Humidifies air 3. Filters air 4. Concentrates oxygen

3. The patient presents at the urgent cGaR reAcDenEtS erMwOitRhEsh.oCrtO nM ess of breath. Which questions would be appropriate to ask this patient? Select all that apply. 1. “How far can you walk without becoming short of breath?” 2. “Do you use oxygen? How often? How much?” 3. “Does a certain position relieve your shortness of breath?” 4. “How would you rate your shortness of breath on a scale of 1 to 10?”

4. Ethnic differences in asthma prevalence, morbidity, and mortality are highly correlated with which of the following? Select all that apply. 1. Poverty 2. Urban air quality 3. Indoor allergens 4. Lack of patient education 5. Inadequate medical care

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. Compare findings on the same level on each side as each assessment technique is performed. 4. To maintain modesty, the nurse should keep the anterior chest covered until the anterior lungs are assessed.

6. The nurse teaches her patient ways to promote respiratory health and includes which of the following? Select all that apply. 1. Do not smoke. 2. Avoid exposure to secondhand smoke, air pollutants, and chemicals. 3. Perform good hand and oral hygiene to prevent infection. 4. Get vaccinated every 5 years against influenza.

7. The nurse uses a peak flow meter during a respiratory assessment. She instructs the patient to do which of the following? Select all that apply. 1. Take a deep breath and hold it. 2. Place the meter in the mouth with the tongue under the mouthpiece. 3. Close the lips tightly around the mouthpiece. 4. Blow slowly until as much air as possible is exhaled.

GRADESMORE.COM 8. When doing a respiratory assessment on an adult the nurse remembers which of the following is true? Select all that apply. 1. The normal respiratory rate is 15 to 25 breaths per minute. 2. The normal inspiratory-to-expiratory ratio is 1:2. 3. The chest is a conical shape: larger at the top and narrows at the bottom. 4. The chest movement is symmetrical.

9. When assessing a patient’s history of respiratory problems it would be important to ask about which of the following? Select all that apply. 1. Asthma 2. Chronic obstructive pulmonary disease (COPD) 3. Cystic fibrosis 4. Bronchitis 5. Pneumonia

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. It is a waste product of oxygen metabolism. 2. It is released from the lungs at the alveoli tissue level. 3. It influences the respiratory center of the brain to increase or decrease respiratory rate. 4. It helps maintain acid/base balance.

11. The alveoli in the lungs secrete surfactant, which serves to do which of the following? Select all that apply. 1. Increase oxygen transfer. 2. Reduce surface tension in the alveoli. 3. Keep alveoli moist. 4. Control blood acid-base balance.

12. You are inspecting the thoracic cage of a middle-aged male. He does not have a history of smoking or chronic pulmonary disease. Identify the normal findings. Select all that apply. 1. AP-to-lateral ratio approximately 1:2 2. AP-to-lateral ratio approximately 1:1 3. Costal angle greater than 90 degrees 4. Conical shape 5. Accessory muscle retractions GRADESMORE.COM 6. Symmetrical 7. Color uniform

13. You are performing the respiratory assessment technique of tactile fremitus. The purpose of this technique is to: 1. Palpate voice sound vibrations through the bronchi. 2. Palpate tissue density in the upper lobes. 3. Auscultate breath sounds as they travel down the larger bronchi. 4. Percuss for adventitious sounds in the upper bronchi.

14. During a respiratory assessment, the purpose of palpating the thorax is to assess for: 1. Skeletal deformities and color. 2. Respiratory distress and abnormal sounds. 3. Surface characteristics and tenderness. 4. Color of skin and tissue density.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

15. A patient comes to the health clinic complaining of cough, wheezing, and chest tightness. You are going to assess for posterior symmetrical expansion. Where will you place your hands? 1. Thoracic 5 or 6 2. Thoracic 7 or 8 3. Thoracic 9 or 10 4. Thoracic 11 or 12

16. You are performing a respiratory assessment and palpating for tactile fremitus on an older patient. The patient has a past medical history of pneumonia. If the patient has pneumonia again, what will be the findings? 1. Equal palpable vibrations 2. Unequal palpable vibrations 3. Decreased fremitus 4. Increased fremitus

17. A patient comes to the health-care provider’s office stating she has been short of breath for the past 2 days. She rates her shortness of breath a 6/10. The patient has a past medical history of asthma. You are percussing the lungs and will do all of the following EXCEPT: 1. Percuss the intercostal spaces, moving from the apex to the base using direct percussion. 2. Percuss the intercostal spaces, movGiR ngAoDnEeSacMhOsR idEe.oC f tO heManterior lung fields. 3. Percuss the intercostal spaces, moving on each side of the posterior lung fields. 4. Percuss each side of the lateral lung fields using the direct percussion technique.

18. You are auscultating the mid-chest anterior intercostal spaces of a middle-aged adult. What are the medium-pitched sounds? 1. Vesicular 2. Bronchovesicular 3. Tracheal 4. Bronchial

19. During the assessment, the nurse explains to the patient that the structure that has roles in speech, breathing, and prevention of aspiration is the: 1. Nasopharynx. 2. Oropharynx. 3. Bronchi. 4. Trachea.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

20. The serous membrane that lines and adheres to the thoracic wall and produces pleural fluid is the: 1. Surfactant. 2. Parietal pleura. 3. Visceral pleura. 4. Pulmonary pleura.

21. The percent of arterial hemoglobin saturated with oxygen is tested at the bedside with: 1. Arterial blood gases. 2. Pulse oximeter. 3. Thoracentesis. 4. Bronchoscopy.

22. The nurse asks the patient about his smoking history. He has smoked one-half pack of cigarettes daily for the past 20 years. You document his pack-year smoking history as: 1. 5 pack-year. 2. 10 pack-year. 3. 15 pack-year. GRADESMORE.COM 4. 20 pack-year.

23. The highest concentrations of carcinogens are found in: 1. Smoke exhaled by the smoker. 2. Sidestream smoke. 3. Secondhand smoke. 4. All forms are equally carcinogenic.

24. The nurse assesses a patient with chronic obstructive pulmonary disease. The patient reports difficulty breathing sometimes accompanied by wheezing. The nurse knows that this is indicative of: 1. Cardiac dyspnea. 2. Expiratory dyspnea. 3. Orthopnea. 4. Paroxysmal nocturnal dyspnea.

25. The nurse assesses that the patient is frequently coughing up sputum and documents this as a:

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Hacking cough. 2. Chronic cough. 3. Productive cough. 4. Dry cough.

26. The nurse uses the proper sequence of assessment of the lungs, which is: 1. Inspection, palpation, percussion, auscultation. 2. Palpation, percussion, auscultation, inspection. 3. Percussion, auscultation, inspection, palpation. 4. Auscultation, inspection, palpation, percussion.

27. When percussing the lungs the nurse hears a soft muffled sound over an area normally filled with air and recognizes that this indicates: 1. An area of consolidation. 2. Overinflation of the lungs. 3. Pneumothorax. 4. Crepitus.

GRADESMORE.COM 28. The nurse uses a peak flow meter to measure the patient’s ability to push air out of the lungs and repeats the test three times. When documenting the results, the nurse notes: 1. The highest number obtained. 2. The lowest number obtained. 3. The average result of all attempts. 4. The results of all attempts.

29. The patient uses the peak flow meter with results in the yellow zone. The nurse interprets this to mean that the patient: 1. Can go about his usual activities. 2. May begin to have shortness of breath. 3. Should get help right away. 4. Should be able to sleep without trouble.

30. The nurse is assessing a 67-year-old male patient. During the respiratory assessment the nurse asks: 1. “Have you received the pneumonia vaccine yet?” 2. “Have you had your annual pneumonia vaccination?”

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. “Why haven’t you received your pneumonia shot?” 4. “Considering your age and health, why haven’t you gotten your Pneumovax shot?”

31. In mapping the thoracic cage, the right midclavicular line, midsternal line, and left midclavicular line are references for the: 1. Anterior thorax. 2. Posterior thorax. 3. Left lateral thorax. 4. Right lateral thorax.

32. During the assessment, patients in respiratory distress may assume which position? 1. Sitting on the side of the examining table 2. Lying supine 3. Assuming the tripod position 4. Standing and leaning on a chair for support

33. The nurse assesses the anterior-posterior to lateral ratio as 1:1 and the costal angle is greater Mn as: than 90 degrees. This assessment indG icRatAesDaEcSoM ndOiR tioEn.kCnO ow 1. Pectus excavatum. 2. Pigeon breast. 3. Barrel chest. 4. Pectus carinatum.

34. If the nurse palpates decreased fremitus in the lungs in the left lower lobe, it might indicate: 1. Pleural effusion. 2. Increased density of lung tissue. 3. Lung mass. 4. Pneumonia.

35. The adventitious breath sound that indicates upper airway obstruction and is a medical emergency is: 1. Wheeze. 2. Rhonchi. 3. Stridor. 4. Rales.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

36. Arrange the assessment techniques of the chest in the proper sequence (1–4). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Palpation 2. Inspection 3. Auscultation 4. Percussion

GRADESMORE.COM 38. The low-pitched, clear, hollow sound that is percussed over healthy, air-filled lung fields is called .

39. Breath sounds that are not normally heard in the chest are called breath sounds.

40. A respiratory rate of less than 10 breaths per minute is called

41. Gradual increase in depth of respirations, followed by gradual decrease and then a period of apnea, is called respirations.

42. The nurse assesses the patient’s skin color to have a bluish hue. This is called

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers 1. The major function of the lungs is gas exchange and the delivery of oxygen to all parts of the body. The other body systems that maintain the respiratory system include which of the following? Select all that apply. 1. Circulatory system 2. Musculoskeletal system 3. Neurological system 4. Gastrointestinal system ANS: 1, 2, 3 Page: 202 Feedback 1. This is correct. The circulatory system works to maintain the respiratory system. 2. This is correct. The musculoskeletal system works to maintain the respiratory system. 3. This is correct. The neurological system works to maintain the respiratory system. 4. This is incorrect. The gastrointestinal system does not work to maintain the respiratory system.

2. During inhalation the nasal cavity G pR erA foDrm EsSw MhOicRhEo.f CthOeMfollowing functions? Select all that apply. 1. Warms air 2. Humidifies air 3. Filters air 4. Concentrates oxygen ANS: 1, 2, 3 Page: 202

1. 2. 3. 4.

Feedback This is correct. Air moves through the nasal cavity where it warms air. This is correct. Air moves through the nasal cavity where it humidifies air. This is correct. Air moves through the nasal cavity where it filters air. This is incorrect. The nasal cavity does not concentrate oxygen as air moves through it.

3. The patient presents at the urgent care center with shortness of breath. Which questions would be appropriate to ask this patient? Select all that apply. 1. “How far can you walk without becoming short of breath?” 2. “Do you use oxygen? How often? How much?” 3. “Does a certain position relieve your shortness of breath?” 4. “How would you rate your shortness of breath on a scale of 1 to 10?”

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 1, 2, 3, 4 Page: 207

1. 2. 3. 4.

Feedback This is correct. This question will help to identify the distance that he or she can walk when first feeling short of breath. This is correct. It is important to identify if supplemental oxygen is needed to relieve the shortness of breath. This is correct. This question identifies whether a change in position alleviates the shortness of breath. This is correct. This question identifies the severity of the shortness of breath.

GRADESMORE.COM

ANS: 1, 2, 3, 4, 5 Page: 208

1, 2. 3. 4. 5.

Feedback This is correct. Ethnic differences in asthma prevalence, morbidity, and mortality are highly correlated with poverty. This is correct. Ethnic differences in asthma prevalence, morbidity, and mortality are highly correlated with urban air quality. This is correct. Ethnic differences in asthma prevalence, morbidity, and mortality are highly correlated with indoor allergens. This is correct. Ethnic differences in asthma prevalence, morbidity, and mortality are highly correlated with lack of patient education. This is correct. Ethnic differences in asthma prevalence, morbidity, and mortality are highly correlated with inadequate medical care.

5. In preparation for assessment of the chest the nurse would do which of the following? Select all that apply. 1. Instruct the patient to lie supine on the examining table. 2. Advise the patient to breathe normally. 3. Compare findings on the same level on each side as each assessment technique is performed.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. To maintain modesty, the nurse should keep the anterior chest covered until the anterior lungs are assessed. ANS: 2, 3, 4 Page: 208

1. 2. 3. 4.

Feedback This is incorrect. The patient is not assessed in the supine position. Instruct the patient to sit on the side of the examining table. This is correct. Advise the patient to breathe normally. This is correct. Always compare findings at the same level on each side as each assessment technique is performed. This is correct. Keep the anterior chest covered until the anterior lungs are assessed. It is important to maintain modesty for all patients.

GRADESMORE.COM

ANS: 1, 2, 3 Page: 220

3. 4.

Feedback This is correct. Do not smoke. Cigarette smoking is the major cause of pulmonary disease and lung cancer. Cigarette smoke destroys lung tissue and may trigger changes that grow into cancer. This is correct. Avoid exposure to pollutants that can damage your lungs. Secondhand smoke, outdoor air pollution, chemicals in the home and workplace, and radon can all cause or worsen lung disease. This is correct. Prevent infection. Good hand and oral hygiene can protect you from the germs in your mouth that lead to infections. This is incorrect. Get vaccinated every year against influenza.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 1, 2, 3 Page: 219

1. 2. 3. 4.

Feedback This is correct. Instruct the patient to take in a deep breath and hold it. This is correct. Place the peak flow meter in the mouth with the tongue under the mouthpiece. This is correct. Instruct the patient to close the lips tightly around the mouthpiece. This is incorrect. Do not instruct the patient to blow out slowly. The patient should blow out as hard and fast as possible.

8. When doing a respiratory assessment on an adult the nurse remembers which of the following is true? Select all that apply. 1. The normal respiratory rate is 15 to 25 breaths per minute. 2. The normal inspiratory-to-expiratory ratio is 1:2. 3. The chest is a conical shape: larger at the top and narrows at the bottom. 4. The chest movement is symmetrical. ANS: 2, 4 Page: 210

1. 2. 3. 4.

GRADESMORE.COM

Feedback This is incorrect. Normal adult respiratory rate (eupnea) is 12 to 20 breaths per minute, not 15 to 25 per minute. This is correct. Normal inspiratory-to-expiratory ratio (I: E) is 1:2. The expiratory phase is longer than the inspiratory phase. This is incorrect. Conical shape: smaller at the top and widens at the bottom. This is correct. Chest movement is symmetrical.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4. 5.

This is correct. Asthma is a reactive airway disease causing inflammation, increased mucus production, and narrowing of the bronchi. Symptoms include cough, congestion, shortness of breath, and wheezing. This is correct. COPD is an obstructive and progressive lung disease causing inflammation and destruction of the lung tissue. Symptoms include shortness of breath and congestion. Smoking is the leading cause of COPD. This is correct. Cystic fibrosis is a hereditary disease of the exocrine glands. The body produces abnormally thick and sticky mucus that obstructs the lungs and digestive organs. This is correct. Bronchitis is a viral or bacterial infection causing inflammation of the bronchi. The most common symptoms are fever, cough, and lung congestion. This is correct. Pneumonia is a viral, bacterial, or fungal infection of the lung causing inflammation and congestion in the alveoli of the lung. Symptoms include fever, cough, congestion, and shortness of breath.

10. In the lungs, gases move across systemic capillaries and an exchange of oxygen and carbon dioxide occurs at the cellular level. Which of the following is true regarding carbon dioxide? Select all that apply. 1. It is a waste product of oxygen metabolism. 2. It is released from the lungs at the alveoli tissue level. 3. It influences the respiratory center of the brain to increase or decrease respiratory rate. 4. It helps maintain acid/base balance.

GRADESMORE.COM

ANS: 1, 2, 3, 4 Page: 203

1. 2. 3. 4.

Feedback This is correct. Carbon dioxide is a waste product of oxygen metabolism. This is correct. Oxygen and carbon dioxide are exchanged at the alveoli tissue level. This is correct. Changes in carbon dioxide influence the respiratory center in the brain by increasing or decreasing the respiratory rate. This is correct. Changes in carbon dioxide influence the respiratory center in the brain by increasing or decreasing the respiratory rate to maintain the acid-base balance.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. Alveoli do not increase oxygen transfer but exchange oxygen and carbon dioxide. This is correct. Alveoli secrete a surfactant, a substance that reduces the surface tension. This is correct. Alveoli secrete a surfactant, a substance that keeps the alveoli moist. This is incorrect. Alveoli do not control the blood’s acid-base balance.

1. 2. 3. 4. 5. 6. 7.

GRADESMORE.COM Feedback This is correct. Transverse diameter is approximately twice the anteroposterior (AP) diameter; AP-to-lateral ratio is approximately 1:2. This is incorrect. Barrel chest: anterior posterior-to-lateral ratio is 1:1; most commonly seen in patients with chronic pulmonary disease. This is incorrect. The costal angle is less than 90 degrees, not greater than 90 degrees. This is correct. Conical shape: smaller at the top and widens at the bottom. This is incorrect. Accessory muscle contractions would be seen in a patient who is having difficulty breathing. This is correct. Symmetrical: sternum is symmetrical; clavicles and scapula are the same height; chest movement is symmetrical. This is correct. Skin color is uniform and intact.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Page: 213

1. 2. 3. 4.

Feedback This is correct. The purpose of tactile fremitus is to palpate voice sound vibrations through the bronchi. This is incorrect. Tactile fremitus does not palpate tissue density but palpates voice sound vibrations that can assess changes in tissue density. This is incorrect. Tactile fremitus is not auscultated. This is correct. Adventitious sounds are auscultated, not percussed.

This is incorrect. You wG ouRldAiDnE spSecMtOfoRrEsk.eC leOtaMl deformities and color, not palpate. This is incorrect. You would auscultate for respiratory distress and abnormal sounds, not palpate. This is correct. You would palpate for surface characteristics and tenderness. This is incorrect. You would inspect the color of skin and percuss for tissue density, not palpate.

This is incorrect. Thoracic 5 or 6 is too high to correctly assess symmetrical expansion. This is incorrect. Thoracic 7 or 8 is too high to correctly assess symmetrical

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

expansion. This is correct. Thoracic 9 or 10 is the correct location to assess symmetrical expansion. This is incorrect. Thoracic 11 or 12 is too low to assess symmetrical expansion.

This is incorrect. Equal palpable vibrations is a normal finding found in healthy lungs. This is incorrect. Unequal palpable vibrations is an abnormal finding but not specific to pneumonia. GRADESMORE.COM This is incorrect. Decreased fremitus may indicate the vibrations are obstructed with fluid (pleural effusion), decreased air movement, obesity, or increased musculature. This is correct. Increased fremitus may indicate increased density of the lung tissue. This may be related to fluid or pathology in the lung that is changing the density or compressing the lung tissue, such as pneumonia.

17. A patient comes to the health-care provider’s office stating she has been short of breath for the past 2 days. She rates her shortness of breath a 6/10. The patient has a past medical history of asthma. You are percussing the lungs and will do all of the following EXCEPT: 1. Percuss the intercostal spaces, moving from the apex to the base using direct percussion. 2. Percuss the intercostal spaces, moving on each side of the anterior lung fields. 3. Percuss the intercostal spaces, moving on each side of the posterior lung fields. 4. Percuss each side of the lateral lung fields using the direct percussion technique. ANS: 4 Page: 214 Feedback 1.

You should percuss the intercostal spaces moving from the apex to the base, on each side of the anterior lung fields and on each side of the posterior lung fields.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

You should percuss the intercostal spaces moving from the apex to the base, on each side of the anterior lung fields and on each side of the posterior lung fields. You should percuss the intercostal spaces moving from the apex to the base, on each side of the anterior lung fields and on each side of the posterior lung fields. This is the correct answer. You should not percuss each side of the lateral lung fields using the direct percussion technique. You should percuss the intercostal spaces moving from the apex to the base, on each side of the anterior lung fields and on each side of the posterior lung fields.

3. 4.

18. You are auscultating the mid-chest anterior intercostal spaces of a middle-aged adult. What are the medium-pitched sounds? 1. Vesicular 2. Bronchovesicular 3. Tracheal 4. Bronchial ANS: 2 Page: 216 Feedback 1. This is incorrect. Vesicular sounG dsRaAreDhEeS arM dOthRroEu.gC hoOuM t the periphery of the lungs. The inspiration sound is longer and louder than the expiration sound. They are soft, lowpitched, rustling sounds. 2. This is correct. Bronchovesicular sounds are heard anteriorly over the mid-chest anterior intercostal spaces and between the scapula posteriorly. These are medium-pitched sounds. 3. This is incorrect. Tracheal sounds are heard only over the trachea. Expiration is slightly longer than inspiration. They are loud, harsh-like sounds because the airways are larger. 4. This is incorrect. Bronchial breath sounds are heard over the larynx, trachea, and posterior nape of the neck. Expiratory sounds are louder and last longer than inspiratory sounds and have a pause between them. They are high-pitched, hollow, tubular breath sounds.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Feedback 1. This is incorrect. The nasopharynx warms, humidifies, and filters air. 2. This is correct. The oropharynx has major roles in speech, breathing, and the ability to talk. Its closing mechanism prevents aspiration of liquids and solids during swallowing. 3. This is incorrect. The bronchi warms and moistens air as it moves in and out of the respiratory tract. 4. This is incorrect. The trachea functions to allow air flow to the bronchi.

20. The serous membrane that lines and adheres to the thoracic wall and produces pleural fluid is the: 1. Surfactant. 2. Parietal pleura. 3. Visceral pleura. 4. Pulmonary pleura. ANS: 2 Page: 203

1. 2. 3 4.

Feedback This is incorrect. Alveoli secrete a surfactant, a substance that reduces the surface tension and keeps the alveoli moist. GRADESMORE.COM This is correct. Parietal pleura lines and adheres to the thoracic wall and produces a serous fluid known as pleural fluid. This is incorrect. Visceral pleura covers the outer surface of the lungs and produces a serous fluid known as pleural fluid. This is incorrect. There is no pulmonary pleura.

21. The percent of arterial hemoglobin saturated with oxygen is tested at the bedside with: 1. Arterial blood gases. 2. Pulse oximeter. 3. Thoracentesis. 4. Bronchoscopy. ANS: 2 Page: 205 Feedback 1. This is incorrect. Measuring arterial blood gases means measuring the levels of oxygen and carbon dioxide in the blood. Sites are the radial, brachial, or femoral artery. 2. This is correct. Pulse oximeter measures the oxygen saturation. This is the percent of arterial hemoglobin saturated with oxygen. A pulse oximeter reading should normally be higher than 95%.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. This is incorrect. Thoracentesis is insertion of a needle into the thoracic cavity. The test is performed for analysis or removal of fluid from the pleural space for diagnostic or therapeutic purposes. 4. This is incorrect. Bronchoscopy is a diagnostic or therapeutic procedure that provides direct visualization of the larynx, trachea, and bronchial tree. A fiberoptic bronchoscope with a light is inserted through the patient’s nose or mouth into the trachea or bronchi.

1. 2.

3. 4.

Feedback This is incorrect. To calculate pack-year smoking history multiply the number of packs of cigarettes smoked each day times the number of years. This is correct. To calculate packG-R yeAaD r sEmSoM kiOnR gE hi. stC orOyMmultiply the number of packs of cigarettes smoked each day times the number of years (0.5 packs x 20 years is 10 packyears). This is incorrect. To calculate pack-year smoking history multiply the number of packs of cigarettes smoked each day times the number of years. This is incorrect. To calculate pack-year smoking history multiply the number of packs of cigarettes smoked each day times the number of years.

23. The highest concentrations of carcinogens are found in: 1. Smoke exhaled by the smoker. 2. Sidestream smoke. 3. Secondhand smoke. 4. All forms are equally carcinogenic. ANS: 2 Page: 207 Feedback 1. This is incorrect. Sidestream smoke has higher concentrations of cancer-causing agents (carcinogens) than mainstream smoke. 2. This is correct. Sidestream smoke has higher concentrations of cancer-causing agents

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

(carcinogens) than mainstream smoke. 3. This is incorrect. Sidestream smoke has higher concentrations of cancer-causing agents (carcinogens) than mainstream smoke. 4. This is incorrect. Sidestream smoke has higher concentrations of cancer-causing agents (carcinogens) than mainstream smoke.

1. 2. 3. 4.

Feedback This is incorrect. Cardiac dyspnea is difficulty breathing related to an inadequate cardiac output. This is correct. Expiratory dyspnea is difficulty breathing associated with chronic obstructive lung disease. WheeziGnR gA isDuE suSaM llyOpRrE es.enCtO .M This is incorrect. Orthopnea is difficulty breathing while lying in the supine position. This is incorrect. Paroxysmal nocturnal dyspnea is shortness of breath when the patient is asleep in bed and sits upright to attempt to relieve the shortness of breath. This is a symptom of left ventricular heart failure.

25. The nurse assesses that the patient is frequently coughing up sputum and documents this as a: 1. Hacking cough. 2. Chronic cough. 3. Productive cough. 4. Dry cough. ANS: 3 Page: 207

1. 2. 3. 4.

Feedback This is incorrect. Hacking cough is a series of repeated efforts, as in many respiratory infections. This is incorrect. Chronic cough occurs daily for a minimum of 3 weeks. This is correct. Productive cough produces mucus and is expectorated. This is incorrect. Nonproductive or dry cough has no sputum production.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is correct. Sequence of assessment: inspection, palpation, percussion, auscultation. This is incorrect. Sequence of assessment: inspection, palpation, percussion, auscultation. This is incorrect. Sequence of assessment: inspection, palpation, percussion, auscultation. This is incorrect. Sequence of assessment: inspection, palpation, percussion, auscultation.

27. When percussing the lungs the nurse hears a soft muffled sound over an area normally filled with air and recognizes that this indicates: 1. An area of consolidation. GRADESMORE.COM 2. Overinflation of the lungs. 3. Pneumothorax. 4. Crepitus. ANS: 1 Page: 215

2. 3.

Feedback This is correct. Dullness sounds are soft and muffled and heard over areas of increased density. They may be heard over solid mass or areas of increased consolidation, such as pneumonia or pleural effusion. This is incorrect. Hyper-resonance is a low-pitched, drum-like, accentuated percussion sound heard in the lungs when the bronchi and alveoli are overinflated. This is incorrect. Tympany is a high-pitched hollow sound heard when there is excess air in the chest. This may be associated with air leaking into the space between the lungs and chest wall (pneumothorax). This is incorrect. Crepitus is a light crackling or popping feeling under the skin caused by leakage of air into the subcutaneous tissue. It is not percussed but palpated.

28. The nurse uses a peak flow meter to measure the patient’s ability to push air out of the lungs and repeats the test three times. When documenting the results, the nurse notes:

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. The highest number obtained. 2. The lowest number obtained. 3. The average result of all attempts. 4. The results of all attempts. ANS: 1 Page: 219

1. 2. 3. 4.

Feedback This is correct. Record the highest number obtained. This is incorrect. The lowest number is not recorded. Record the highest number obtained. This is incorrect. Do not average the numbers. Record the highest number obtained. This is incorrect. Do not record all of the attempts. Record the highest number obtained.

GRADESMORE.COM

ANS: 2 Page: 220

Feedback This is incorrect. The green zone (80% to 100% of your personal best) is the zone you should be in every day. Measurements in this zone signal that air moves well through the large airways and that you can do your usual activities and go to sleep without trouble. This is correct. Yellow is the caution or slow down zone (50% to 80% of your personal best). Measurements in this zone are a clue that the large airways are starting to narrow. You may begin to have mild symptoms such as coughing, feeling tired, feeling short of breath, or feeling like your chest is tightening. This is incorrect. The red zone (less than 50% of your personal best) is the stop zone. Readings in this zone mean severe narrowing of the large airways has occurred. This is a medical emergency and you should get help right away. This is incorrect. The green zone (80% to 100% of your personal best) is the zone you should be in every day. Measurements in this zone signal that air moves well through the large airways and that you can do your usual activities and go to sleep without trouble.

30. The nurse is assessing a 67-year-old male patient. During the respiratory assessment the nurse asks: 1. “Have you received the pneumonia vaccine yet?”

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. “Have you had your annual pneumonia vaccination?” 3. “Why haven’t you received your pneumonia shot?” 4. “Considering your age and health, why haven’t you gotten your Pneumovax shot?” ANS: 1 Page: 207

1. 2. 3. 4.

Feedback This is correct. The pneumococcal polysaccharide vaccination (PPSV23) is recommended for all adults age 65 years and older. This is incorrect. You do not receive the pneumonia vaccine annually. This is incorrect. This is a judgmental question. It does not utilize therapeutic communication techniques. This is incorrect. This is a judgmental question with the use of medical terminology that the patient may not understand.

1. 2. 3. 4.

Feedback This is correct. Anterior reference lines are the right midclavicular line, midsternal line, and left midclavicular line. This is incorrect. Posterior reference lines are the right scapular line, midvertebral line, and left scapular line. This is incorrect. Lateral reference lines are the anterior axillary line, midaxillary line, and posterior axillary line. This is incorrect. Right lateral thorax reference lines are the anterior axillary line, midaxillary line, and posterior axillary line.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 3 Page: 209

1. 2. 3. 4.

Feedback This is incorrect. Sitting on the side of the examining table does not facilitate expansion of the lungs. This is incorrect. Lying supine does not facilitate the expansion of the lungs. This is correct. Patients in respiratory distress may assume the tripod position to facilitate expansion of the lungs. This is incorrect. Standing and leaning on a chair for support does not facilitate expansion of the lungs. This is also an unsafe position.

33. The nurse assesses the anterior-posterior to lateral ratio as 1:1 and the costal angle is greater than 90 degrees. This assessment indicates a condition known as: 1. Pectus excavatum. 2. Pigeon breast. 3. Barrel chest. 4. Pectus carinatum. ANS: 3 Page: 210

GRADESMORE.COM

Feedback 1. This is incorrect. Pectus excavatum is a congenital condition where the sternum is abnormally depressed or sunken into the chest. 2. This is incorrect. Pectus carinatum (pigeon breast) is where the sternum protrudes out from the chest. 3. This is correct. A barrel chest is indicated by an anterior posterior-to-lateral ratio of 1:1 and the costal angle greater than 90 degrees. An increase in the costal angle may be a sign of chronic obstructive pulmonary disease. 4. This is incorrect. Pectus carinatum (pigeon breast) is where the sternum protrudes out from the chest.

34. If the nurse palpates decreased fremitus in the lungs in the left lower lobe, it might indicate: 1. Pleural effusion. 2. Increased density of lung tissue. 3. Lung mass. 4. Pneumonia. ANS: 1 Page: 214

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is correct. Decreased fremitus may indicate the vibrations are obstructed with fluid, as in pleural effusion. This is incorrect. Increased density of lung tissue would cause increased fremitus. This is incorrect. Increased fremitus may indicate increased lung tissue, as heard with a lung mass. This is incorrect. Increased fremitus may indicate increased density of lung tissue, as heard in pneumonia.

35. The adventitious breath sound that indicates upper airway obstruction and is a medical emergency is: 1. Wheeze. 2. Rhonchi. 3. Stridor. 4. Rales. ANS: 3 Page: 216

3. 4.

Feedback This is incorrect. A wheeze is caused by narrowed passageways in the trachea-bronchial RADESMOR COM body. It is a high-pitched, tree by secretions, inflammation,Gobstruction, orEa.foreign whistling or musical sound. This is incorrect. Rhonchi are louder, deeper, lower-pitched wheezes occurring in the upper bronchi. This may be related to obstruction of the larger airways and is commonly heard during exhalation. It sounds like snoring. This is correct. Stridor indicates upper airway narrowing or obstruction, is a sign of respiratory distress, and is a medical emergency. This is incorrect. Rales (crackles) are soft high-pitched sounds produced by air passing over secretions. They are usually heard at the end of inspiration and may be cleared by coughing.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Feedback: Inspection is the first assessment technique in a respiratory assessment, followed by palpation, percussion, and auscultation.

37. You are performing a respiratory assessment on a patient with complaints of wheezing and productive cough. Arrange the steps in assessing symmetrical expansion of the thoracic cage in proper sequence (1–7). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Observe chest expansion and the expansion of your hands and thumbs. 2. Repeat on the anterior thorax. 3. Pinch up a small fold of skin between your fingers. 4. Document your findings. 5. Place the patient in the sitting position. 6. Place your warmed hands on the posterior chest wall with thumbs at level T (thoracic) 9 or T10. 7. Instruct the patient to inhale deeply through the nose and to exhale through the mouth. ANS: 5637124 Page: 212-213 Feedback: First, observe chest expansion and the expansion of your hands and thumbs. Second, place your warmed hands on the posterior chest wall with thumbs at level T9 or T10. Third, pinch up a small fold of skin betweenGyRoAuD r fEinSgM erOs.RFEo. urCthO, M instruct the patient to inhale deeply through the nose and to exhale through the mouth. Fifth, place the patient in the sitting position. Sixth, repeat on anterior thorax. Finally, document your findings.

38. The low-pitched, clear, hollow sound that is percussed over healthy, air-filled lung fields is called . ANS: resonance Page: 214 Feedback: Resonance is the low-pitched, clear, hollow sound that is percussed over healthy, airfilled lung fields.

39. Breath sounds that are not normally heard in the chest are called breath sounds. ANS: adventitious Page: 216

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Feedback: Adventitious breath sounds are sounds not normally heard in a chest. Examples of adventitious sounds are rales, wheezes, rhonchi, pleural friction rub, and stridor.

40. A respiratory rate of less than 10 breaths per minute is called

ANS: bradypnea Page: 212 Feedback: Bradypnea is respirations less than 10 breaths per minute. This is an abnormal respiratory rate.

41. Gradual increase in depth of respirations, followed by gradual decrease and then a period of apnea, is called respirations. ANS: Cheyne-Stokes Page: 211 Feedback: Cheyne-Stokes respirations are a gradual increase in depth of respirations, followed by gradual decrease and then a period of apnea.

GRADESMORE.COM 42. The nurse assesses the patient’s skin color to have a bluish hue. This is called ANS: cyanosis Page: 211 Feedback: Cyanosis presents as a bluish hue skin color due to lack of oxygen in the blood, respiratory infections, or airway obstruction.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 13: Assessing the Cardiovascular System

1. Which of the following clients would be considered at risk for the development of cardiovascular disease? 1. The 65-year-old male who consumes one alcoholic drink a day 2. The 50-year-old female who consumes 25 grams of fiber per day 3. The 40-year-old male who consumes 300 mg of saturated fats and cholesterol a day 4. The 30-year-old female who walks every day for 35 minutes

2. The physician would like to assess the patient for the cause of a heart murmur. Which test would the nurse anticipate the physician ordering? 1. Holter monitor 2. Echocardiogram 3. Exercise stress test 4. Electrocardiogram (EKG)

3. What is the layer of the heart that is the thick, middle layer? GRADESMORE.COM 1. Epicardium 2. Myocardium 3. Endocardium 4. Pericardium

4. What areas of the heart do the semilunar valves separate? 1. The right atrium from the right ventricle 2. The left atrium from the left ventricle 3. The ventricles from the pulmonary and systemic circulation 4. The right ventricle from the pulmonary artery

5. When auscultating heart sounds S1 and S2, the nurse should do which of the following? 1. Instruct the client to breathe deeply. 2. Clip the hair of the male hairy chest. 3. Use the diaphragm of the stethoscope. 4. Listen at the left sternal border, 2nd intercostal space.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

7. The nurse is assessing the patient’s heart sounds and hears a sound that has a thud-like quality that occurs directly before the S1 heart sound. How does the nurse document this sound? 1. S4 2. S3 3. Murmur 4. Pericardial friction rub

8. The patient has had some blood work done. The results show cardiac tissue damage due to decreased oxygenation. The laboratory values were elevated levels 7 days after cardiac tissue damage. Which laboratory test did the patient have? 1. Creatine kinase-MB 2. Troponin level GRADESMORE.COM 3. Total cholesterol level 4. High density lipoprotein (HDL-C)

9. To auscultate the aortic area, where would the nurse place the stethoscope? 1. Right sternal border, 2nd intercostal space 2. Left sternal border, 2nd intercostal space 3. Left sternal border, 4th intercostal space 4. Left sternal border, 5th intercostal space

10. The patient sees a cardiologist every 6 months for a grade V heart murmur. What is the characteristic of a grade V heart murmur? 1. Faint but can be identified immediately 2. Moderately loud 3. Loud and associated with a palpable thrill 4. Loud with palpable thrill heard with only the rim of the stethoscope touching the skin

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

11. The nurse suspects the patient has a pericardial friction rub. What would the nurse expect to find when assessing the patient? 1. A high-pitched sound heard after the S1 sound 2. A muffled, grating sound heard at the apex of the heart 3. A swishing or unusually prolonged sound heard during diastole 4. A low-pitched sound that occurs at the end of diastole

12. The nurse knows that the patient understands teaching about a Holter monitor when the patient states which of the following? 1. “This test will use high-frequency sound waves to help diagnose cardiovascular disorders.” 2. “This test will last 24 hours and will record cardiac electrical activity.” 3. “This test will take place while I walk on a treadmill.” 4. “This test will help visualize the size and shape of my heart.”

13. At what age does the U.S. Preventive Services Task Force (USPSTF) recommend screening for men who are at increased risk for coronary artery disease for lipid disorders? 1. 20 to 35 2. 20 to 45 3. 35 and older GRADESMORE.COM 4. 45

14. What is the most reported symptom of the cardiac system? 1. Shortness of breath 2. Palpitations 3. Angina 4. Edema of the lower extremities

15. The nurse is completing a teaching plan for the patient regarding prevention of coronary artery disease. What should the nurse include in the teaching plan? 1. “Drink one beer a week to help increase the high-density lipoproteins (HDLs).” 2. “If you smoke, you should quit smoking.” 3. “Drink a glass of red wine each night to help decrease your cholesterol levels.” 4. “Intake of alcohol has no relation to heart disease.”

16. What statement made by the patient would lead the nurse to suspect a heart attack? 1. “I have a burning pain in my epigastric area.”

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. “I am hot and sweaty.” 3. “I have a headache and sore muscles.” 4. “I have pressure in the center of my chest.”

17. When assessing the patient for an S3 heart sound, the nurse uses which of the following information to provide care for the patient? 1. The S3 heart sound occurs directly after the S1 heart sound. 2. S3 is indicative of rapid ventricular filling. 3. S3 is considered abnormal in physically active young adults. 4. S3 may be due to scar tissue of hypertensive heart disease or coronary artery disease.

18. The nurse is auscultating the patient’s heart and hears an ejection click. What does the nurse suspect the patient may have? 1. Turbulent blood flow 2. Pericarditis 3. Hypertension 4. Mitral valve prolapse

GRADESMORE.COM 19. While assessing the patient, the nurse hears an S4 heart sound. What can the nurse interpret from this finding? 1. The patient may have aortic valve regurgitation. 2. The patient may have hypertension. 3. The patient has a pulse deficit. 4. The patient may have a valve with a defective leaflet.

20. The nurse auscultates a thrill at the left sternal border, 4th intercostal space. The nurse knows that this may indicate which of the following? 1. Aortic stenosis 2. Pulmonic stenosis 3. Aortic aneurysm 4. Ventricular enlargement

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. The patient’s father had a heart attack at age 70. 4. The patient’s total cholesterol is 180 mg/dL.

22. Compared to white adults, which of the following statements about cultural groups is true regarding heart disease? 1. African Americans have a higher rate of high blood pressure than white adults. 2. Asian Americans have a higher rate of high blood pressure than white adults. 3. Hispanic Americans are more likely than non-Hispanic white adults to have coronary heart disease. 4. Asian Americans are more likely than whites to be obese, causing heart disease.

23. You are palpating the apical pulse on a slightly overweight male patient but cannot feel the pulsation of the apical pulse. What will be your next step? 1. Ask the patient to sit up straight and lean forward. 2. Ask the patient to turn slightly on his left side. 3. Ask the patient to turn slightly on his right side. 4. Ask the patient to take a deep breath and hold it.

GRADESMORE.COM 24. An 86-year-old female patient comes to the emergency room complaining of chest pain, heart palpitations, and shortness of breath. You take her vital signs: blood pressure 160/100, apical pulse 92, carotid pulse 104, respiratory rate 24, tympanic temperature 100.4°F. What is the pulse deficit? 1. 196 2. 60 3. 12 4. 8

25. While interpreting heart sounds it is essential to understand from which part of the cardiac cycle heart sounds are being generated. Which technique will assist you to interpret the cardiac cycle as you auscultate heart sounds? 1. Use the bell of the stethoscope at each of the five cardiac landmarks. 2. Use the diaphragm of the stethoscope at each of the five landmarks. 3. Listen with your eyes closed as you auscultate the heart sounds. 4. Palpate the carotid artery simultaneously while auscultating the heart.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

26. You are auscultating heart sounds using the bell of the stethoscope. You hear a “swooshing” sound at Erb’s point. Identify the area where you hear this heart murmur. 1. A 2. B 3. C 4. D 5. E

27. Place the following steps to assess the anterior chest for a cardiovascular assessment in order (1–7). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Adjust the head of the examining table so that the patient is supine with head and chest elevated at 30 degrees. 2. Document your findings. GRADESMORE.COM 3. Drape the patient so only the chest area is exposed. 4. Palpate the precordium for vibrations. 5. Palpate the apical pulse. 6. Inspect the symmetry of the chest. 7. Auscultate heart sounds

28. Electrical impulses are initiated in the right atrium. Put the route that the impulses travel from the base of the heart to the apex of the heart in the correct sequence (1–4). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Bundle of His 2. Sinoatrial node 3. Purkinje fibers 4. Atrioventricular node

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. The right ventricle does most of the work of the heart. 5. The left ventricle pumps oxygenated blood.

30. The nurse is assessing the patient and suspects that the patient has developed congestive heart failure. What signs or symptoms help to validate the nurse’s suspicions? Select all that apply. 1. A faint, low-pitched S3 heart sound is heard upon auscultation. 2. Closing of the atrioventricular valves is heard upon auscultation. 3. The patient reports use of two to three pillows to sleep comfortably at night. 4. The peripheral edema is 3+ bilaterally.

31. The nurse is attempting to assess the patient’s apical pulse and cannot palpate it. In which of the following patients would it be difficult to palpate the patient’s apical pulse? Select all that apply. 1. The female patient with small breasts 2. The male patient with enlarged pectoral muscles 3. The patient who has chronic obstructive pulmonary disease 4. The patient who is underweight 5. The patient who has fluid around the heart

GRADESMORE.COM 32. The nurse is teaching the patient about modifiable risk factors for coronary artery disease. Which factors would the nurse include in the teaching plan? Select all that apply. 1. Uncontrolled high blood pressure 2. Family history 3. Diabetes 4. Smoking 5. Gender

33. Which of the following is true regarding heart murmurs? Select all that apply. 1. Murmurs produce a swishing sound. 2. Murmurs are caused by pericarditis. 3. Murmurs occur during systole only. 4. Murmurs can be innocent. 5. Babies are born with murmurs.

34. Which of the following is typically a cause of a heart murmur? Select all that apply.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Increased blood flow through a normal valve 2. Blood flow into a dilated chamber 3. Heart failure 4. Blood flow through a dilated valve 5. Regurgitation of blood through an incompetent valve

35. The nurse suspects the patient has an aortic valve murmur. How would the nurse assess the patient? Select all that apply. 1. Instruct the patient to sit up and lean forward. 2. Use the bell of the stethoscope. 3. Place the stethoscope on the 2nd right intercostal space (ICS). 4. Take the patient’s pulse while auscultating the heart. 5. Instruct the patient to breath normally.

36. You are performing a cardiac assessment and inspecting the anterior chest. The purpose of inspecting the anterior chest is to assess for which of the following? Select all that apply. 1. Symmetry 2. Murmurs 3. Pulsations GRADESMORE.COM 4. Heaves 5. Vibrations

37. You are auscultating a patient’s heart sounds at the 2nd left intercostal space. You hear a split S2 [dub] sound. This is a normal heart sound that is affected by .

38. You are performing a cardiovascular assessment and are palpating the precordium. Using the surface of your right hand, you will gently palpate the five landmarks.

39. is an electrical current moving from cell to cell that produces a positively charged wave through the myocardium. The interior of the cell becomes positively charged and initiates a contraction of the resting myocytes.

40. Identify the configuration of the following heart murmur: and then gradually fades away.

GRADESMORE.COM .

starts loud

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers 1. Which of the following clients would be considered at risk for the development of cardiovascular disease? 1. The 65-year-old male who consumes one alcoholic drink a day 2. The 50-year-old female who consumes 25 grams of fiber per day 3. The 40-year-old male who consumes 300 mg of saturated fats and cholesterol a day 4. The 30-year-old female who walks every day for 35 minutes ANS: 3 Page: 240

1. 2. 3. 4.

Feedback This is incorrect. Moderation in alcohol consumption is recommended. Men are limited to two drinks per day, so this male is not at risk. This is incorrect. It is recommended that women eat 25 grams of fiber per day, so this female is not at risk. This is correct. It is recommended that both men and women limit fats and cholesterol to 200 mg per day, so this male is at risk. This is incorrect. It is recommended that both men and women increase physical activity to 35 minutes per day, 7 days per week, so this female is not at risk.

GRADESMORE.COM 2. The physician would like to assess the patient for the cause of a heart murmur. Which test would the nurse anticipate the physician ordering? 1. Holter monitor 2. Echocardiogram 3. Exercise stress test 4. Electrocardiogram (EKG) ANS: 2 Page: 228

1. 2.

Feedback This is incorrect. A Holter monitor is a 24-hour ambulatory test that records the cardiac electrical impulses. This is correct. An echocardiogram is a noninvasive ultrasound that uses highfrequency sound waves of various intensities to help diagnose cardiovascular disorders. This is the standard for establishing the cause of a heart murmur. This is incorrect. An exercise stress test monitors the heart function and rhythm while the patient is walking and running on a treadmill. Aspects of heart function, such as heart rate, breathing, blood pressure, EKG, and how tired the patient becomes when exercising can be checked. This is incorrect. An EKG provides vital information about the heart’s electrical conduction system; records the electrical activity of the heart; and helps diagnose

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

abnormal heart beats, heart rhythm, and tissue ischemia.

3. What is the layer of the heart that is the thick, middle layer? 1. Epicardium 2. Myocardium 3. Endocardium 4. Pericardium ANS: 2 Page: 221

1. 2. 3. 4.

Feedback This is incorrect. The epicardium is the thin, outer layer of the heart. This is correct. The myocardium is the thick, middle, muscular layer of the heart. This is incorrect. The endocardium is the thin inner layer of the heart. This is incorrect. The pericardium is the fluid-filled fibrous sac that surrounds the heart.

4. What areas of the heart do the semilunar valves separate? GRADESMORE.COM 1. The right atrium from the right ventricle 2. The left atrium from the left ventricle 3. The ventricles from the pulmonary and systemic circulation 4. The right ventricle from the pulmonary artery ANS: 3 Page: 222

1. 2. 3. 4.

Feedback This is incorrect. The tricuspid valve separates the right atrium from the right ventricle. This is incorrect. The mitral valve separates the left atrium from the left ventricle. This is correct. The semilunar valves separate the pulmonary and systemic circulation. This is incorrect. The pulmonic valve separates the right ventricle from the pulmonary artery.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Listen at the left sternal border, 2nd intercostal space. ANS: 3 Page: 213

1. 2.

3. 4.

Feedback This is incorrect. The patient should be instructed to breathe normally as the nurse listens to heart sounds. This is incorrect. If the patient has a hairy chest, the nurse should wet the patient’s chest hair with a little warm water to decrease the sounds caused by friction of hair against a stethoscope. This is correct. The diaphragm of the stethoscope is used to auscultate S1 and S2 heart sounds (high-pitched heart sounds). This is incorrect. Although S1 is heard loudest at the apex of the heart and S2 is heard loudest at the base of the heart, the nurse should auscultate S1 and S2 at the five landmark locations of the precordium.

6. The new graduate nurse is auscultating the patient’s heart sounds. The nurse preceptor should intervene when the new nurse places the patient in which of the following positions? 1. Semi-Fowler’s 2. Fowler’s GRADESMORE.COM 3. Right-sided lying position 4. Supine ANS: 3 Page: 224 Feedback 1. This is incorrect. Semi-Fowler’s is one of the positions used to auscultate heart sounds. The nurse preceptor would not intervene. 2. This is incorrect. Fowler’s is one of the positions used to auscultate heart sounds. The nurse preceptor would not intervene. 3. This is correct. Left-sided, not right-sided lying position is one of the positions used to auscultate heart sounds. In this case, the nurse preceptor would intervene. 4. This is incorrect. Supine is one of the positions used to auscultate heart sounds. The nurse preceptor would not intervene. CON: Assessment

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. Murmur 4. Pericardial friction rub ANS: 1 Page: 225

1. 2. 3. 4.

Feedback This is correct. S4 occurs directly before the S1 heart sound and has a thud-like quality sound. This is incorrect. S3 occurs directly after the S2 heart sound. This is incorrect. Murmurs have a swishing or unusually prolonged sound and can occur anywhere in the cardiac cycle. This is incorrect. Pericardial friction rubs have a high-pitched, muffled, grating, and leather sound.

8. The patient has had some blood work done. The results show cardiac tissue damage due to decreased oxygenation. The laboratory values were elevated levels 7 days after cardiac tissue damage. Which laboratory test did the patient have? 1. Creatine kinase-MB 2. Troponin level 3. Total cholesterol level GRADESMORE.COM 4. High density lipoprotein (HDL-C) ANS: 2 Page: 228

2. 3.

Feedback This is incorrect. Although creatine kinase-MB levels increase when cardiac tissue is damaged due to decreased oxygenation, levels usually elevate 3 to 4 hours after cardiac tissue damage. This is correct. Troponin levels rise when lack of oxygen in the heart occurs and are detectable a few hours to 7 days after the onset of symptoms of myocardial damage. This is incorrect. Total cholesterol levels measure cholesterol, which is composed of lipoproteins, which are composed of fat and proteins. This measurement indicates a risk factor for coronary artery disease, not cardiac tissue damage. This is incorrect. High-density lipoproteins (HDLs) transport cholesterol from tissues back to the liver where it is then broken down and eliminated from the body. This is the “good” cholesterol.

9. To auscultate the aortic area, where would the nurse place the stethoscope? 1. Right sternal border, 2nd intercostal space 2. Left sternal border, 2nd intercostal space

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. Left sternal border, 4th intercostal space 4. Left sternal border, 5th intercostal space ANS: 1 Page: 233

1. 2. 3. 4.

Feedback This is correct. The nurse would place the stethoscope at the right sternal border (RSB), 2nd intercostal space (aortic area). This is incorrect. The left sternal border, 2nd intercostal space is the pulmonic area. This is incorrect. The left sternal border, 4th intercostal space is the tricuspid valve area. This is incorrect. The left sternal border, 5th intercostal space is the mitral valve area.

10. The patient sees a cardiologist every 6 months for a grade V heart murmur. What is the characteristic of a grade V heart murmur? 1. Faint but can be identified immediately 2. Moderately loud 3. Loud and associated with a palpable thrill 4. Loud with palpable thrill heard wiG thRoAnD lyEthSeMrO imRoEf.thCeOsM tethoscope touching the skin ANS: 4 Page: 226

1. 2. 3. 4.

Feedback This is incorrect. A grade II murmur can be identified immediately. This is incorrect. A grade III murmur is moderately loud. This is incorrect. A grade IV murmur is loud and associated with a palpable thrill. This is correct. A grade V murmur is a loud murmur with palpable thrill that can be heard with the rim of the stethoscope touching the chest.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. An ejection sound (click) is a high-pitched sound heard after S1. This is correct. A pericardial friction rub is a high-pitched, muffled, grating, and leather sound auscultated at the apex and left sternal border. This is incorrect. This is what a murmur sounds like, but may be heard anywhere in the cardiac cycle. This is incorrect. An S4 is a low-pitched sound that occurs at the end of diastole.

1. 2. 3. 4.

Feedback This is incorrect. An echocardiogram uses high-frequency sound waves of GRAdiagnose DESMOcardiovascular RE.COM disorders. various intensities to help This is correct. A Holter monitor is an ambulatory 24-hour test where the patient wears a monitor that records the cardiac electrical impulses. This is incorrect. An exercise stress test monitors the heart function and rhythm while the patient is walking and running on a treadmill. This is incorrect. An echocardiogram is a noninvasive ultrasound that allows visualization of the size, shape, position, thickness, and movement of the cardiac structures.

Feedback This is correct. The USPSTF recommends screening men aged 20 to 35 for lipid

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3.

disorders if they are at increased risk for coronary heart disease. This is incorrect. The USPSTF recommends screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease. This is incorrect. The USPSTF strongly recommends screening men aged 35 and older for lipid disorders, but recommends a younger age (20 to 35) for men who are at increased risk for coronary heart disease. This is incorrect. The USPSTF strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease.

14. What is the most reported symptom of the cardiac system? 1. Shortness of breath 2. Palpitations 3. Angina 4. Edema of the lower extremities ANS: 3 Page: 231

1. 2. 3.

Feedback This is incorrect. Angina is the most reported symptom of the cardiac system. This is incorrect. Angina is the most reported symptom of the cardiac system. RADES(sudden MORE.pain COMbeneath the sternum, often This is correct. AnginaGpectoris radiating to the left shoulder and arm) is the most reported symptom of the cardiac system. This is incorrect. Angina is the most reported symptom of the cardiac system.

Feedback This is incorrect. Although it is true that alcohol may have some health benefits, the best-known effect is that it produces a small increase in HDL cholesterol. The American Heart Association does not recommend drinking wine or any other form of alcohol to gain this potential benefit. This is correct. Smoking is a major cause of atherosclerosis, a buildup of fatty

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

substances in the arteries. This is incorrect. Although it is true that alcohol may have some health benefits, the best-known effect is that it produces a small increase in HDL cholesterol. The American Heart Association does not recommend drinking wine or any other form of alcohol to gain this potential benefit. This is incorrect. Used in excess, alcohol could lead to heart failure, high blood pressure, and alcohol-related diseases such as cirrhosis of the liver.

16. What statement made by the patient would lead the nurse to suspect a heart attack? 1. “I have a burning pain in my epigastric area.” 2. “I am hot and sweaty.” 3. “I have a headache and sore muscles.” 4. “I have pressure in the center of my chest.” ANS: 4 Page: 231

1. 2. 3. 4.

Feedback This is incorrect. A burning pain in the epigastric area is a symptom of heartburn. This is incorrect. A common symptom of a heart attack is a cold sweat, not hot GRADESMORE.COM and sweaty. This is incorrect. A headache and sore muscles are not symptoms of a heart attack. This is correct. A common symptom of a heart attack is an uncomfortable pressure, squeezing, fullness, or pain in the center of the chest.

1. 2.

Feedback This is incorrect. The S3 heart sound occurs directly after the S2 heart sound. S4 occurs directly after the S1 heart sound. This is correct. S3 is indicative of rapid ventricular filling and may signal volume overload to the ventricle in patients older than 40 years.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

This is incorrect. S3 is considered normal in physically active young adults. This is incorrect. S4 may be due to scar tissue or hypertensive heart disease or coronary artery disease. S3 signals volume overload to the ventricles and is associated with heart failure.

1. 2. 3.

Feedback This is incorrect. A murmur may be an indication of turbulent blood flow. This is incorrect. A pericardial friction rub may be indicative of pericardial sac inflammation (pericarditis). This is incorrect. An S4 heart sound may be indicative of thickening (hypertrophy) of the left ventricle, hypertension, aortic stenosis, or be heard after a myocardial GRADESMORE.COM infarction. This is correct. An ejection click may be heard at valves with defective leaflets, such as in mitral valve prolapse.

19. While assessing the patient, the nurse hears an S4 heart sound. What can the nurse interpret from this finding? 1. The patient may have aortic valve regurgitation. 2. The patient may have hypertension. 3. The patient has a pulse deficit. 4. The patient may have a valve with a defective leaflet. ANS: 2 Page: 239

1. 2.

3. 4.

Feedback This is incorrect. A heart murmur would be heard with aortic valve regurgitation. This is correct. An S4 heart sound may be indicative of thickening (hypertrophy) of the left ventricle, hypertension, aortic stenosis, or be heard after a myocardial infarction. This is incorrect. A pulse deficit may be indicative of atrial fibrillation. This is incorrect. An ejection click may be heard at valves with defective leaflets,

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

such as in mitral valve prolapse.

1. 2. 3. 4

Feedback This is incorrect. A thrill at the right sternal border, 2nd intercostal space may be indicative of aortic stenosis. This is incorrect. A thrill at the left sternal border, 2nd intercostal space may be indicative of pulmonic stenosis. This is incorrect. A pulsation at the right sternal border, 2nd intercostal space may be indicative of aortic aneurysm. This is correct. A thrill at the left sternal border, 4th intercostal space may be indicative of ventricular enlargement and defects.

GRADESMORE.COM

21. The nurse is reviewing the patient’s chart. Which information in the chart would concern the nurse the most? 1. The patient has a low-density lipoprotein (LDL) of 190 mg/dL. 2. The patient stated that he sleeps with one pillow at night. 3. The patient’s father had a heart attack at age 70. 4. The patient’s total cholesterol is 180 mg/dL. ANS: 1 Page: 228

2. 3. 4.

Feedback This is correct. African American adults of both genders are 40% more likely to have high blood pressure than their white counterparts and 10% less likely than their white counterparts to have their blood pressure under control. This is incorrect. Asian Americans have lower rates of hypertension. This is incorrect. Hispanic American adults are 20% less likely than non-Hispanic white adults to have coronary heart disease. This is incorrect. Asian Americans have lower rates of being overweight or obese.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3. 4.

GRADESMORE.COM 23. You are palpating the apical pulse on a slightly overweight male patient but cannot feel the pulsation of the apical pulse. What will be your next step? 1. Ask the patient to sit up straight and lean forward. 2. Ask the patient to turn slightly on his left side. 3. Ask the patient to turn slightly on his right side. 4. Ask the patient to take a deep breath and hold it. ANS: 2 Page: 236

1. 2. 3. 4.

Feedback This is incorrect. Sitting up and leaning forward helps to auscultate heart murmurs. This is correct. The left lateral position will push the apex beat further outward as the heart has a degree of mobility in the chest. This is incorrect. Asking the patient to turn to his right side will push the apex of the heart further inward. This is incorrect. Patients should breathe normally when you are palpating the apical beat.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

24. An 86-year-old female patient comes to the emergency room complaining of chest pain, heart palpitations, and shortness of breath. You take her vital signs: blood pressure 160/100, apical pulse 92, carotid pulse 104, respiratory rate 24, tympanic temperature 100.4°F. What is the pulse deficit? 1. 196 2. 60 3. 12 4. 8 ANS: 3 Page: 236

2. 3.

Feedback This is incorrect. Pulse deficit is the difference between the simultaneously counted apical heart rate and the peripheral or carotid pulse rate. You do not add the carotid and apical pulses. This is incorrect. Pulse deficit is the difference between the simultaneously counted apical heart rate and the peripheral or carotid pulse rate. This is correct. Pulse deficit is the difference between the simultaneously counted apical heart rate and the peripheral or carotid pulse rate and may be indicative of atrial fibrillation. Apical pulse is 92, carotid pulse is 104, so 104 – 92 = 12. This is incorrect. Pulse deficit is the difference between the simultaneously counted apical heart rate and the peripheral or carotid pulse rate.

GRADESMORE.COM

1. 2. 3. 4.

Feedback This is incorrect. Using the bell of the stethoscope will help you to identify lowpitched heart sounds. This is incorrect. Using the diaphragm of the stethoscope will help you to identify high-pitched heart sounds. This is incorrect. Listening with your eyes closed will help you to concentrate on the sounds but does not help with interpreting the cardiac cycle.. This is correct. Palpating the carotid artery simultaneously will help you to interpret the cardiac cycle. The carotid upstroke corresponds to ventricular systole.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4. 5.

GRADESMORE.COM Feedback This is incorrect. Right sternal border (RSB), 2nd intercostal space (ICS) is the aortic area. This is incorrect. Left sternal border (LSB), 2nd intercostal space (ICS) is the pulmonic area. This is correct. Left sternal border (LSB), 3rd intercostal space (ICS) is Erb’s point. This is incorrect. Left sternal border (LSB), 4th intercostal space (ICS) is the tricuspid valve. This is incorrect. Left sternal border (LSB), 5th intercostal space (ICS) is the mitral valve.

27. Place the following steps to assess the anterior chest for a cardiovascular assessment in order (1–7). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Adjust the head of the examining table so that the patient is supine with head and chest elevated at 30 degrees. 2. Document your findings. 3. Drape the patient so only the chest area is exposed. 4. Palpate the precordium for vibrations. 5. Palpate the apical pulse.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

6. Inspect the symmetry of the chest. 7. Auscultate heart sounds ANS: 1364572 Page: 234-235 Feedback: When assessing the anterior chest in a cardiovascular assessment, first, adjust the head of the examining table so that the patient is supine with head and chest elevated at 30 degrees. Second, drape the patient so only the chest area is exposed. Third, inspect the symmetry of the chest. Fourth, palpate the precordium for vibrations. Fifth, palpate the apical pulse. Sixth, auscultate heart sounds. Finally, document your findings.

GRADESMORE.COM

Feedback: Electrical impulses are initiated in the heart from the sinoatrial node, also known as the pacemaker of the heart, in the right atrium. The impulses then travel through the right atrium to the atrioventricular node located on the septum, then to the bundle of His in the septum, and then to the Purkinje fiber system (located in the ventricles).

29. Which of the following statements is true about the chambers of the heart? Select all that apply. 1. The left atria pumps blood to the left ventricle. 2. The right atria pumps deoxygenated blood. 3. The left ventricle pumps blood out to the aorta. 4. The right ventricle does most of the work of the heart. 5. The left ventricle pumps oxygenated blood. ANS: 2, 3, 5 Page: 222

Feedback This is incorrect. The left atria pumps blood to the right ventricle (deoxygenated blood).

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3. 4. 5.

This is correct. The right atria pumps deoxygenated blood to the right ventricle. This is correct. The left ventricle pumps blood out to the aorta (oxygenated). This is incorrect. The left ventricle does most of the work of the heart. This is correct. The left ventricle pumps blood out to the aorta (oxygenated blood).

2. 3.

Feedback This is correct. The S3 heart sound is a faint, low-pitched extra heart sound. An S3 may indicate congestive heart failure, aortic valve regurgitation, and be present after a myocardial infarction. This is incorrect. The closing of atrioventricular valves causes the first heart sound (S1), which is a normal finding. GRAofDbreath ESMORE.COM This is correct. Shortness (dyspnea) is a symptom of congestive heart failure caused by an increased fluid accumulation in the lungs. Sleeping with two to three pillows at night may be an indication of shortness of breath when lying in the supine position. This is correct. A symptom of congestive heart failure is edema of the lower extremities caused by blood backing up into the peripheral system causing edema in the dependent areas.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4. 5.

This is incorrect. An apical pulse may not be palpable in a patient with a thick chest wall or breast tissue, not small breasts. This is correct. An apical pulse may not be palpable in a patient with a thick chest wall, such as enlarged pectoral muscles. This is correct. An apical pulse may not be palpable in a patient with chronic obstructive pulmonary disease due to a barrel chest. This is incorrect. An apical pulse may not be palpable in a patient who is obese, not underweight. This is correct. An apical pulse may not be palpable in a patient who has fluid around the heart.

32. The nurse is teaching the patient about modifiable risk factors for coronary artery disease. Which factors would the nurse include in the teaching plan? Select all that apply. 1. Uncontrolled high blood pressure 2. Family history 3. Diabetes 4. Smoking 5. Gender ANS: 1, 3, 4 Page: 230

1. 2. 3. 4. 5.

GRADESMORE.COM Feedback This is correct. Uncontrolled high blood pressure increases risk for coronary artery disease. This is incorrect. Family history is a nonmodifiable risk factor for coronary artery disease. This is correct. Diabetes and prediabetes are contributing modifiable risk factors for coronary artery disease. This is correct. Smoking is a major cause of coronary artery disease as a modifiable risk factor. This is incorrect. Gender is a nonmodifiable risk factor for coronary artery disease. The incidence is greater in men than in women until women reach menopause.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Page: 225

1. 2. 3. 4.

Feedback This is correct. Heart murmurs produce a swishing or unusually prolonged sounds. This is incorrect. A pericardial friction rub may be caused by pericardial sac inflammation (pericarditis). This is incorrect. Murmurs may occur anywhere in the cardiac cycle. This is correct. There are two types of murmurs. An innocent or physiological heart murmur is not caused by a heart problem and the patient does not have symptoms. An abnormal or pathological murmur is caused by heart problems such as diseased heart valves. The patient may have cardiac symptoms such as heart palpitations or shortness of breath. This is correct. Babies are born with heart murmurs or murmurs can develop sometime during a patient’s lifetime.

34. Which of the following is typically a cause of a heart murmur? Select all that apply. 1. Increased blood flow through a normal valve 2. Blood flow into a dilated chamber 3. Heart failure 4. Blood flow through a dilated valve 5. Regurgitation of blood through an incompetent valve

GRADESMORE.COM

ANS: 1, 2, 5 Page: 225

1. 2. 3. 4. 5.

Feedback This is correct. A cause of heart murmurs is increased blood flow through a normal valve. This is correct. A cause of heart murmurs is blood flow into a dilated chamber. This is incorrect. Heart murmurs are not caused by heart failure. This is incorrect. A cause of heart murmurs is blood flow through a constricted, not dilated, valve. This is correct. A cause of heart murmurs is backflow (regurgitant flow) through an incompetent valve.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 1, 3 Page: 238 Feedback This is correct. Aortic valve murmurs are best heard when the patient is sitting up and leaning forward. This is incorrect. Aortic valve murmurs should be auscultated with the diaphragm This is correct. Aortic valve murmurs should be auscultated at the 2nd right ICS. This is incorrect. Taking the patient’s pulse while auscultating the heart will help to reveal a pulse deficit and may be indicative of atrial fibrillation, not an aortic valve murmur. This is incorrect. The patient should be instructed to inhale, then exhale and hold his or her breath.

1. 2. 3. 4.

1. 2. 3. 4. 5.

Feedback This is correct. The purpose is to assess for symmetry and compare the right and left sides of the anterior chest. This is incorrect. Murmurs are auscultated, not inspected. This is correct. The purpose is to assess for pulsations. An apical pulsation may or may not be visible at the left 5th midclavicular line. This is correct. The purpose is to assess for lifts or heaves, a sustained, forceful, outward thrusting of the ventricle secondary to increased workload. This is incorrect. Vibrations are palpated, not inspected.

37. You are auscultating a patient’s heart sounds at the 2nd left intercostal space. You hear a split S2 [dub] sound. This is a normal heart sound that is affected by . ANS: respirations Page: 239

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Feedback: Split S2 [dub] sound is a normal heart sound that is affected by respirations. During inspiration, the pulmonic valve closure is delayed due to increased venous return to the right side of the heart. Toward the end of inspiration, the aortic valve closes 0.06 seconds earlier than the pulmonic valve, causing the S2 sound to physiologically split. This sound is heard at the pulmonic valve.

38. You are performing a cardiovascular assessment and are palpating the precordium. Using the surface of your right hand, you will gently palpate the five landmarks. ANS: palmar Page: 235 Feedback: The palmar surface of the hand is used for palpating the precordium.

GRADESMORE.COM

Feedback: The cardiac cells (myocytes) are electrically polarized in their resting state. The inside of the cell is negatively charged. Depolarization is an electrical current moving from cell to cell that produces a positively charged wave through the myocardium.

40. Identify the configuration of the following heart murmur: and then gradually fades away.

starts loud

ANS: Decrescendo Page: 226 Feedback: Decrescendo starts loud and then gradually fades away. Crescendo starts soft and gets louder. Crescendo and decrescendo starts soft, gets louder toward the peak, and then gradually fades away. In plateau-shaped the sound is the same from the beginning to the end of the murmur.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 14: Assessing the Abdomen

1. You are performing an abdominal assessment and know that solid abdominal viscera include which of the following? Select all that apply. 1. Gallbladder 2. Adrenal glands 3. Kidneys 4. Liver 5. Ovaries

2. The liver plays a key role in which of the following? Select all that apply. 1. Metabolizing carbohydrates, proteins, fats, and drugs 2. Producing bile 3. Detoxifying harmful chemicals 4. Producing vitamin B12

3. Characteristics of bilirubin include which of the following? Select all that apply. RB AC D)EcSatMabOoRliEsm ..COM 1. It is a by-product of red blood cellG(R 2. It deposits yellow pigment in the skin and sclera at elevated levels. 3. A decrease is known as icterus. 4. It is produced by the liver, spleen, and bone marrow.

4. The gallbladder and biliary system perform which of the following functions? Select all that apply. 1. Produce bile. 2. Collect and store bile. 3. Concentrate bile. 4. Transport bile to the intestine to aid in digestion.

5. The spleen performs which of the following functions? Select all that apply. 1. Filters blood 2. Manufactures lymphocytes, monocytes, and macrophages 3. Stores erythrocytes and platelets 4. Produces white blood cells during bone marrow depression

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

6. Characteristics of fecal occult blood (FOB) include which of the following? Select all that apply. 1. It can originate from any part of the digestive tract. 2. It is not observed by the patient. 3. The test for it is an invasive test. 4. The test for it is done twice a year on adults. 5. It may be a warning sign of colorectal cancer.

7. You are doing an assessment on a patient who has diabetes and chronic kidney disease. What tests may the health-care provider order to assess kidney function? Select all that apply. 1. Blood urea nitrogen (BUN) 2. Creatinine 3. Glomerular filtration rate (GFR) 4. Bladder scan

8. You auscultate the abdominal vasculature. What arteries will you auscultate for the presence of bruits? 1. Popliteal arteries GRADESMORE.COM 2. Renal arteries 3. Femoral arteries 4. Iliac arteries 5. Aorta

10. A patient reports that he has recently traveled outside the country and is feeling ill. Suspecting hepatitis, the nurse should ask about which of the following symptoms? Select all that apply. 1. Back pain 2. Nausea 3. Fatigue 4. Poor appetite

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

11. The nurse is auscultating bowel sounds. Which of the following steps are correct? Select all that apply. 1. Place the diaphragm of the stethoscope on the abdomen at the right upper quadrant. 2. Assess intensity, pitch, and frequency of bowel sounds. 3. Auscultate in all four abdominal quadrants. 4. Auscultate for a full minute before documenting that there are no bowel sounds.

12. When palpating the bladder, the nurse knows that which of the following is true? Select all that apply. 1. An empty bladder is not palpable. 2. A partially filled bladder will feel firm and hard like a tennis ball. 3. A distended bladder will extend as far up as the umbilicus. 4. Tenderness or pain during palpation may indicate bladder infection.

13. Patient education for prevention of colon cancer should include which of the following? Select all that apply. GRADESMORE.COM 1. Maintaining a healthy weight 2. Eating a diet high in protein and grains 3. No limits on alcohol intake 4. Increasing the intensity of any exercise regimen

14. Screening for colorectal cancer can include which of the following? Select all that apply. 1. Sigmoidoscopy 2. Double-contrast barium enema 3. Stool DNA test 4. Yearly fecal occult blood test after age 50

15. The patient reports that he has not had a bowel movement in several days. You auscultate the abdomen for bowel sounds. What characteristics are you assessing? Select all that apply. 1. Quality 2. Frequency 3. Amplitude 4. Absence of bowel sounds

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

16. The endothelial serous membrane that covers the walls of the abdominal cavity is the: 1. Abdominal peritoneum. 2. Peritoneal cavity. 3. Parietal peritoneum. 4. Visceral peritoneum.

17. The double-layer membranous tissue containing blood vessels and nerves that supply the intestinal wall is the: 1. Peritoneum. 2. Mesentery. 3. Adrenals. 4. Viscera.

18. A rise in levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) can indicate: 1. Injury or damage to the liver. 2. Pancreatic insufficiency. 3. Excess bile production. GRADESMORE.COM 4. Nutritional deficiency.

19. You are a nurse assessing a patient with a pancreatic disorder. You know that the pancreas produces: 1. Bile and hydrochloric acid. 2. Hydrochloric acid and creatinine. 3. Insulin, amylase, and lipase. 4. Ammonia and amylase only.

20. You are assessing a patient who has chronic complaints of diarrhea alternating with periods of constipation. As a nurse, you know that the primary function of the large intestine is: 1. Propulsion of chyme. 2. Production of digestive enzymes. 3. Absorption of water and electrolytes. 4. Digestion and absorption of nutrients.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

21. An examination that uses a flexible fiberoptic scope to visualize the mucosa of the lower third of the large intestine is called a: 1. Colonoscopy. 2. Sigmoidoscopy. 3. Esophagogastroduodenoscopy. 4. Barium enema.

22. Lactose intolerance in adulthood is most prevalent in: 1. African Americans 2. Hispanics 3. East Asians 4. Scandinavians

25. A vague feeling of fullness and chest discomfort, indigestion, or burning in the chest or upper abdomen, especially after eating is called: 1. Pyrosis. 2. Hematemesis. 3. Dyspepsia. 4. Gastroesophageal reflux.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

26. The nurse assesses the patient’s pain as a dull, gnawing, cramping, or burning pain that is poorly localized. The nurse suspects that the pain is: 1. Visceral. 2. Parietal. 3. Peritoneal. 4. Referred.

27. During the history of present illness, the patient reports narrowing of stools or pencil-like stools. The nurse knows that this may indicate: 1. Constipation. 2. Intestinal obstruction. 3. Hemorrhoids. 4. Intestinal parasites.

28. During the chief complaint, the patient reports blood and mucous in the stool. The nurse remembers that this is associated with: 1. Iron supplements. 2. Hepatitis. 3. Rectal bleeding. 4. Inflammatory bowel disorders. GRADESMORE.COM

29. You are inspecting the abdomen. Where will you stand to do a full inspection of the abdomen? 1. Stand at the head of the examining table and at the patient’s feet. 2. Stoop down on the left and right sides of the patient. 3. Stoop down at the patient’s side and stand at the patient’s feet. 4. Stoop down at the patient’s head and stand at the patient’s feet.

30. The nurse is performing an abdominal assessment and starts with inspecting the abdomen. The nurse notes a ripple-like movement over the abdomen and remembers that this may indicate a(n): 1. Hernia. 2. Ascites. 3. Diastasis recti. 4. Intestinal obstruction. 5. Aortic aneurysm.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

31. You are auscultating bowel sounds. How many clicks or gurgles per minute are considered normal bowel sounds? 1. 1 to 5 2. 5 to 34 3. 20 to 37 4. 29 to 50

32. You are auscultating arterial sounds in the abdomen. Turbulent, blowing sounds heard over a partially or totally obstructed artery are called: 1. Friction rubs. 2. Venous hums. 3. Vascular sounds. 4. Bruits.

33. A patient presents with complaints of feeling bloated. You percuss all four quadrants of the abdomen. A high-pitched, hollow-quality, drum-like sound that is heard over air-filled viscera is called: 1. Tympany. GRADESMORE.COM 2. Dullness. 3. Hyper-resonance. 4. Distention.

34. A nurse should be able to mentally visualize the organs in the abdomen for abdominal mapping. In assessing the abdomen, the nurse knows organs in the midline are the: 1. Gallbladder, liver, and duodenum. 2. Stomach, spleen, and pancreas. 3. Aorta, uterus, and bladder. 4. Appendix, ascending colon, and ovary. 5. Descending colon, ureter, and spermatic cord.

35. Patients who have diarrhea, laxative use, gastroenteritis, or early intestinal obstruction will have: 1. Normal bowel sounds. 2. Hyperactive bowel sounds. 3. Hypoactive bowel sounds. 4. Absent bowel sounds.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

36. If ascites is assessed and the patient is experiencing respiratory distress, a procedure for removing fluid from the peritoneal cavity is called: 1. Paracentesis. 2. Thoracentesis. 3. Chest tubes. 4. Gastrointestinal suction.

38. You are assessing a patient who is complaining of “feeling bloated and short of breath.” The patient is lying in the supine position. Your assessment findings are: inspection: skin is shiny and taut, protuberant abdomen with spider veins noted at the umbilical area; auscultation: hypoactive low-pitched bowel soundG s,R1A 0D clEicSkM s pOeRr E m. inCuO teM ; abdominal vasculature, no bruits; percussion: tympany at hypogastric and umbilical area; dull sounds on lateral dependent quadrants; palpation: firm, nontender, unable to palpate organs. What assessment should you perform next? 1. Cardiac assessment 2. Testing for fluid waves 3. Respiratory assessment 4. Edema of the extremities

39. The sequence of an abdominal assessment is different from other assessments so that peristalsis is not stimulated. Put the sequence for the abdominal assessment in order (1–4). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Palpation 2. Inspection 3. Auscultation 4. Indirect percussion

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

40. The patient has a history of alcoholism with liver disease. The diagnostic test you would expect the health-care provider to order in relation to a liver that is compromised is level.

41. The patient is complaining of sharp lower right quadrant pain with nausea and vomiting that started 20 hours ago. She states that she is extremely uncomfortable and rates the pain a 10/10. You will perform an assessment for rebound tenderness at point.

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers 1. You are performing an abdominal assessment and know that solid abdominal viscera include which of the following? Select all that apply. 1. Gallbladder 2. Adrenal glands 3. Kidneys 4. Liver 5. Ovaries ANS: 2, 3, 4, 5 Page: 241

1. 2. 3. 4. 5.

Feedback This is incorrect. The hollow viscera are the gallbladder, small intestine, stomach, colon, and bladder. This is correct. The solid viscera of the abdomen includes the adrenal glands. This is correct. The solid viscera of the abdomen includes the kidneys. This is correct. The solid viscera of the abdomen includes the liver. This is correct. The solid viscera of the abdomen includes the ovaries.

2. The liver plays a key role in whichGoRfAthDeEfoSlM loO wR inEg. ?C SeOleMct all that apply. 1. Metabolizing carbohydrates, proteins, fats, and drugs 2. Producing bile 3. Detoxifying harmful chemicals 4. Producing vitamin B12 ANS: 1, 2, 3 Page: 242

1. 2. 3. 4.

Feedback This is correct. The liver plays a key role in metabolizing carbohydrates, proteins, fats, and drugs. This is correct. The liver plays a key role in producing bile. This is correct. The liver plays a key role in detoxifying harmful chemicals. This is incorrect. The liver does not produce vitamin B12 but produces clotting factors.

3. Characteristics of bilirubin include which of the following? Select all that apply. 1. It is a by-product of red blood cell (RBC) catabolism. 2. It deposits yellow pigment in the skin and sclera at elevated levels. 3. A decrease is known as icterus. 4. It is produced by the liver, spleen, and bone marrow.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 1, 2, 4 Page: 242 Feedback 1. This is correct. Bilirubin is a by-product of heme catabolism from aged RBCs. 2. This is correct. An increase in bilirubin levels deposits a yellow pigment in the skin and sclera. 3. This is incorrect. An increase, not decrease, in bilirubin is called jaundice or icterus. 4. This is correct. It is primarily produced in the liver, spleen, and bone marrow.

1. 2. 3. 4.

GRADESMORE.COM Feedback This is incorrect. Bile is produced by the liver. This is correct. The gallbladder and biliary system collect and store bile. This is correct. The gallbladder and biliary system concentrate bile. This is correct. The gallbladder and biliary system transport bile to the intestines to aid in digestion.

1. 2. 3. 4.

Feedback This is correct. The spleen filters blood. This is correct. The spleen manufactures lymphocytes, monocytes, and macrophages. This is correct. The spleen stores erythrocytes and platelets. This is incorrect. The spleen does not produce white blood cells during bone marrow

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

depression. The spleen produces erythrocytes during bone marrow depression.

1. 2. 3. 4. 5.

Feedback This is correct. FOB may come from any part of the digestive tract. This is correct. FOB is not seen by the patient. This is incorrect. The FOB test is not an invasive test. This is incorrect. The FOB test is done annually on adults, not twice a year. This is correct. FOB could be the first warning sign of colorectal cancer.

GRADESMORE.COM 7. You are doing an assessment on a patient who has diabetes and chronic kidney disease. What tests may the health-care provider order to assess kidney function? Select all that apply. 1. Blood urea nitrogen (BUN) 2. Creatinine 3. Glomerular filtration rate (GFR) 4. Bladder scan ANS: 1, 2, 3 Page: 245-246 Feedback 1. This is correct. BUN is a nonprotein nitrogen compound formed in the liver from ammonia as an end product of protein metabolism. The compound is excreted by the kidneys. It is a reflection of the amount of urea produced and excreted. This value may be used to evaluate liver and renal function. If the kidneys are not working properly, the BUN level rises. 2. This is correct. Creatinine is the end product of muscle metabolism. This chemical waste is transported through the bloodstream and out of the body through the kidneys. If the waste products are accumulating and are not excreted by the kidneys, the creatinine level rises. This level is a reliable indicator that the kidneys are functioning properly. 3. This is correct. GFR assesses kidney functioning. This test estimates how much blood passes through the glomeruli of the kidneys in 1 minute and assesses whether a patient has

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

renal disease, renal insufficiency, or renal failure. 4. This is incorrect. Bladder scan is a portable ultrasound instrument used to identify how much urine is in the bladder. The scan is most often used to measure post-void residual volume, which is urine retained in the bladder after voiding.

8. You auscultate the abdominal vasculature. What arteries will you auscultate for the presence of bruits? 1. Popliteal arteries 2. Renal arteries 3. Femoral arteries 4. Iliac arteries 5. Aorta ANS: 2, 3, 4, 5 Page: 255

1. 2. 3. 4. 5.

Feedback This is incorrect. The popliteal arteries are located in the legs and are assessed as part of the peripheral vascular assessment. This is correct. While auscultating abdominal vasculature, the renal arteries are assessed for bruits.

GRADESMORE.COM

This is correct. While auscultating abdominal vasculature, the femoral arteries are assessed for bruits. This is correct. While auscultating abdominal vasculature, the iliac arteries are assessed for bruits. This is correct. While auscultating abdominal vasculature, the aorta is assessed for bruits.

9. You are assessing a focused health history on a patient who is reporting excessive flatulence. The nurse will inquire about which of the following? Select all that apply. 1. Air swallowing with eating 2. Intestinal disorders such as irritable bowel syndrome 3. Ingestion of all meats and vegetables 4. Feeling of being bloated ANS: 1, 2, 4 Page: 249 Feedback 1. This is correct. Flatulence and bloating can be influenced by how much air is swallowed. 2. This is correct. Flatulence and bloating can be influenced by some intestinal disorders such as irritable bowel syndrome. 3. This is incorrect. Ingestion of all meats and vegetables is too general. Common foods that

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

cause gas include beans, peas, lentils, cabbage, onions, high-fiber cereals, bananas, raisins, apricots, and milk products. 4. This is correct. Patients with excessive flatulence may feel bloated.

1. 2. 3. 4.

Feedback This is incorrect. Hepatitis A, B, and C are caused by a specific virus causing infection and inflammation of the liver. Symptoms may include abdominal pain, not back pain. This is correct. Hepatitis A, B, and C are caused by a specific virus causing infection and inflammation of the liver. Symptoms may include nausea. This is correct. Hepatitis A, B, and C are caused by a specific virus causing infection and inflammation of the liver. SymptGoR mA sD mE aySiMnO clR udEe.faCtiOgM ue. This is correct. Hepatitis A, B, and C are caused by a specific virus causing infection and inflammation of the liver. Symptoms may include poor appetite.

1. 2. 3. 4.

Feedback This is incorrect. Auscultate bowel sounds by placing the diaphragm of the stethoscope on the abdomen at the ileocecal valve (RLQ) where bowel sounds are usually always present. This is correct. Assess the intensity, pitch, and frequency of the bowel sounds. This is correct. Auscultate in all four abdominal quadrants (RLQ, RUQ, LUQ, LLQ). This is incorrect. Listen for 5 minutes before documenting that there are no bowel sounds.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is correct. An empty bladder is not palpable. This is incorrect. A partially filled bladder will feel firm and smooth, not hard. This is correct. A distended bladder will extend as far up as the umbilicus. This is correct. Tenderness or pain during palpation may indicate bladder infection.

13. Patient education for prevention of colon cancer should include which of the following? Select all that apply. 1. Maintaining a healthy weight GRADESMORE.COM 2. Eating a diet high in protein and grains 3. No limits on alcohol intake 4. Increasing the intensity of any exercise regimen ANS: 1, 4 Page: 261

1. 2. 3. 4.

Feedback This is correct. Maintain a healthy weight. Obesity increases the risk for colon cancer. This is incorrect. Eat a healthy diet high in vegetables, fruits, and whole grains; low in red and processed meats. This is incorrect. Alcohol should be limited. This is correct. Increase the intensity of any exercise regimen. Participate in moderate-tovigorous exercise for 30 minutes, 5 or more days per week.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 1, 2, 3, 4 Page: 261

Feedback This is correct. The American Cancer Society (2015) recommends that beginning at age 50, both men and women follow one of these testing schedules. If flexible sigmoidoscopy is chosen, it should be done every 5 years. This is correct. The American Cancer Society (2015) recommends that beginning at age 50, both men and women follow one of these testing schedules. If double-contrast barium enema is chosen, it should be done every 5 years. This is correct. The American Cancer Society (2015) recommends that beginning at age 50, both men and women follow one of these testing schedules. If stool DNA testing is chosen, it should be done every 5 years. This is correct. The American Cancer Society (2015) recommends that beginning at age 50, both men and women follow one of these testing schedules. Yearly fecal occult blood test may be started at age 50 if there is no history of colon cancer in the family.

1. 2. 3. 4.

Feedback This is correct. Assess the quality of the bowel sounds: loud or soft. This is correct. Assess the frequency of bowel sounds: 5 to 34 clicks per minute is normal. This is incorrect. You do not assess amplitude; pulses are assessed for amplitude. This is correct. Assess for the absence of bowel sounds.

16. The endothelial serous membrane that covers the walls of the abdominal cavity is the: 1. Abdominal peritoneum. 2. Peritoneal cavity. 3. Parietal peritoneum. 4. Visceral peritoneum. ANS: 3 Page: 241

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. Abdominal peritoneum pertains to both parietal and visceral peritoneum. This is incorrect. Peritoneal cavity is the space between the parietal and visceral peritoneum. This is correct. Parietal peritoneum covers the walls of the abdominal cavity. This is incorrect. Visceral peritoneum covers the organs.

17. The double-layer membranous tissue containing blood vessels and nerves that supply the intestinal wall is the: 1. Peritoneum. 2. Mesentery. 3. Adrenals. 4. Viscera. ANS: 2 Page: 241

1. 2. 3. 4.

Feedback This is incorrect. Peritoneum is an endothelial serous membrane lining covering the abdominal cavity and abdominal organs. This is correct. Mesentery is a double-layer membranous tissue containing blood vessels GRAwall. DESMORE.COM and nerves that supply the intestinal This is incorrect. Adrenals are glands. This is incorrect. Viscera are abdominal organs.

1. 2. 3. 4.

Feedback This is correct. If damage to the liver occurs due to injury or pathology, there is a rise in these enzymes. This is incorrect. The pancreatic enzymes of lipase and amylase would be affected. This is incorrect. An increase in the bilirubin level increases bile production. This is incorrect. Changes in AST and ALT are not related to nutritional deficiency.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. The liver produces bile. This is incorrect. The stomach produces hydrochloric acid and the kidneys produce creatinine. This is correct. The pancreas produces insulin and the pancreatic enzymes of amylase and lipase. This is incorrect. Ammonia comes from two sources: removal of amino acids during protein metabolism and degradation of proteins by colon bacteria. Amylase is a pancreatic enzyme.

GRADESMORE.COM 20. You are assessing a patient who has chronic complaints of diarrhea alternating with periods of constipation. As a nurse, you know that the primary function of the large intestine is: 1. Propulsion of chyme. 2. Production of digestive enzymes. 3. Absorption of water and electrolytes. 4. Digestion and absorption of nutrients. ANS: 3 Page: 244

1. 2. 3. 4.

Feedback This is incorrect. The propulsion of chyme is not the key function of the large intestine. This is incorrect. The stomach and pancreas produce digestive enzymes. This is correct. The primary function of the large intestine is the absorption of water and electrolytes. This is incorrect. The primary function of the small intestine is digestion and absorption of nutrients.

21. An examination that uses a flexible fiberoptic scope to visualize the mucosa of the lower third of the large intestine is called a:

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Colonoscopy. 2. Sigmoidoscopy. 3. Esophagogastroduodenoscopy. 4. Barium enema. ANS: 2 Page: 245 Feedback 1. This is incorrect. Colonoscopy uses a flexible tube with a camera to inspect the inner lining of the mucosa of the large intestine, ileocecal valve, and terminal ileum for abnormalities. This procedure allows for tissue samples to be biopsied and polyps (abnormal growths) to be removed. 2. This is correct. Sigmoidoscopy uses a flexible fiberoptic scope to visualize the mucosa of the lower third of the large intestine. This noninvasive procedure is able to screen for colon cancer and polyps (abnormal growths) in the rectum and sigmoid colon. 3. This is incorrect. Esophagogastroduodenoscopy is also known as an upper gastrointestinal (GI) endoscopy. A lighted, flexible scope or video scope is inserted through the patient’s mouth and is passed through the esophagus and stomach to the duodenum of the small intestine. The procedure is done to assess the mucosa of the upper GI tract, to remove foreign bodies or polyps, and to aid in diagnosis of symptoms. 4. This is incorrect. Barium enema is a radiological examination and fluoroscopy with air or barium contrast. A rectal tube is inserted into the rectum to instill the barium. The patient holds the barium while a series oGf R x-AraDyE sS arM eO taR keEn.. C ThOiM s test is useful to identify several different pathologies such as diverticula, tumors, polyps, rectal bleeding, or complaints of abdominal pain.

22. Lactose intolerance in adulthood is most prevalent in: 1. African Americans 2. Hispanics 3. East Asians 4. Scandinavians ANS: 3 Page: 247

1. 2. 3. 4.

Feedback This is incorrect. Lactose intolerance in adulthood is most prevalent in people of East Asian descent, affecting more than 90% of adults in some of these communities. This is incorrect. Lactose intolerance in adulthood is most prevalent in people of East Asian descent, affecting more than 90% of adults in some of these communities. This is correct. Lactose intolerance in adulthood is most prevalent in people of East Asian descent, affecting more than 90% of adults in some of these communities. This is incorrect. Lactose intolerance in adulthood is most prevalent in people of East

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Asian descent, affecting more than 90% of adults in some of these communities.

23. A patient comes to the emergency room complaining that he has been vomiting for the past 24 hours with black vomitus/emesis. You know that black vomitus may indicate: 1. A biliary obstruction. 2. Blood acted on by gastric digestion. 3. Intestinal obstruction. 4. Gastritis or food poisoning. ANS: 2 Page: 248 Feedback 1. This is incorrect. Green-yellow bile is related to a biliary obstruction. 2. This is correct. Black vomitus contains blood acted on by gastric digestion. 3. This is incorrect. Coffee-ground vomitus may have blood mixed in with the vomitus. A fecal odor may indicate fecal material related to an intestinal obstruction. 4. This is incorrect. Digested or undigested food may be related to gastritis or food poisoning.

GRADESMORE.COM 24. A patient reports that he has been severely vomiting for the last 24 hours. He states that the vomiting is very strong and he describes it as projectile. Projectile vomiting without nausea is a sign of: 1. Food poisoning. 2. Intestinal obstruction. 3. Brain pathology or head trauma. 4. Gastric hemorrhage. ANS: 3 Page: 248 Feedback 1. This is incorrect. Projectile vomiting is not a sign of food poisoning. 2. This is incorrect. Projectile vomiting without nausea is a not a sign of intestinal obstruction. Vomiting of fecal material is a sign of intestinal obstruction. 3. This is correct. Projectile vomiting without nausea is a sign of central stimulation of the medulla and could be a sign of brain pathology or head trauma. 4. This is incorrect. Projectile vomiting without nausea is a not a sign of gastric hemorrhage, as blood would be visible in the vomitus.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3.

Feedback This is incorrect. Pyrosis is indigestion/heartburn usually described as a “burning sensation” in the epigastric area radiating up to the throat. This is incorrect. Hematemesis is vomiting of blood related to gastrointestinal bleeding. This is correct. Dyspepsia is a term that is used to describe a vague feeling of fullness and chest discomfort, indigestion, or burning in the chest or upper abdomen, especially after eating. This is incorrect. Gastroesophageal reflux disease (GERD) is a motility disorder characterized by heartburn and reflux of gastric content into the lower esophagus.

26. The nurse assesses the patient’s pain as a dull, gnawing, cramping, or burning pain that is poorly localized. The nurse suspects G thRaA t tD heEpSaM inOiR s:E.COM 1. Visceral. 2. Parietal. 3. Peritoneal. 4. Referred. ANS: 1 Page: 248

1. 2. 3. 4.

Feedback This is correct. Visceral pain is dull, gnawing, cramping, or burning; poorly localized; and originates in the abdominal organs. This is incorrect. Parietal pain is steady, sharp, localized, and intensifies with movement. It is usually caused by inflammation in the parietal peritoneum. This is incorrect. Peritoneal pain caused by peritoneal inflammation produces localized, sharp, or generalized abdominal tenderness. This is incorrect. Referred pain arises in one part of the abdomen but is perceived by the sensory cortex via nerve fibers remote from the site.

27. During the history of present illness, the patient reports narrowing of stools or pencil-like stools. The nurse knows that this may indicate:

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Constipation. 2. Intestinal obstruction. 3. Hemorrhoids. 4. Intestinal parasites. ANS: 2 Page: 249 Feedback 1. This is incorrect. Constipation is difficulty passing stools or a change in pattern in bowel movements. 2. This is correct. Narrowing of stools or pencil-like stools may indicate some type of intestinal obstruction. 3. This is incorrect. Hemorrhoids are a protrusion of veins in the rectal area. 4. This is incorrect. Intestinal parasites are organisms that may produce the symptom of diarrhea.

28. During the chief complaint, the patient reports blood and mucous in the stool. The nurse remembers that this is associated with: 1. Iron supplements. 2. Hepatitis. GRADESMORE.COM 3. Rectal bleeding. 4. Inflammatory bowel disorders. ANS: 4 Page: 249

1. 2. 3. 4.

Feedback This is incorrect. Dark, non-tarry stools are commonly seen in patients taking iron supplements. This is incorrect. Gray stools or clay-colored stools are common with hepatitis. This is incorrect. Bright red stools indicate gastrointestinal bleeding or rectal bleeding. This is correct. Blood and mucous in stools are associated with inflammatory bowel disorders.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 3 Page: 252-253

2. 3. 4.

Feedback This is incorrect. Inspection of the abdomen is not done standing at the head of the examining table. Inspection is done stooping at the patient’s side and standing at the patient’s feet. This is incorrect. Inspection of the abdomen is not done stooping down on the right and left side; it is done on one side and standing at the patient’s feet. This is correct. Inspection of the abdomen should be done in two positions: at the patient’s side and standing at the patient’s feet. This is incorrect. Inspection of the abdomen is not done stooping down at the patient’s head but stooping down at the patient’s side and standing at the patient’s feet.

1. 2. 3.

4. 5.

Feedback This is incorrect. Hernia is a bulge that may appear only when the patient raises the head or coughs. This is incorrect. Ascites is an abnormal accumulation of fluid in the peritoneal cavity. This is incorrect. Diastasis recti is a bulging area in the abdomen occurring with the separation of the two halves of the rectus abdominis muscles in the midline at the linea alba. This is correct. Increased peristaltic waves (ripple-like movement from left upper quadrant to right lower quadrant) are seen with intestinal obstruction. This is incorrect. Pulsations are increased with the presence of aortic aneurysm.

31. You are auscultating bowel sounds. How many clicks or gurgles per minute are considered normal bowel sounds? 1. 1 to 5 2. 5 to 34 3. 20 to 37

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. 29 to 50 ANS: 2 Page: 254

1. 2. 3. 4.

Feedback This is incorrect. 5 to 34 clicks or gurgles per minute is normal. This is correct. 5 to 34 clicks or gurgles per minute is normal. This is incorrect. 5 to 34 clicks or gurgles per minute is normal. This is incorrect. 5 to 34 clicks or gurgles per minute is normal.

2. 3. 4.

GRADESMORE.COM Feedback This is incorrect. Friction rub is a grating sound heard over inflamed organs with serous surfaces; most commonly heard in the right upper quadrant (liver) or left upper quadrant (spleen). This is incorrect. Venous hum is a continuous medium-pitched sound caused by turbulent blood flow in a large vascular organ. This is incorrect. Pattern of blood flow is the abdominal vasculature. This is correct. Bruits are turbulent, blowing sounds heard over a partially or totally obstructed artery. Bruits are most commonly caused by a buildup of plaque in the artery.

33. A patient presents with complaints of feeling bloated. You percuss all four quadrants of the abdomen. A high-pitched, hollow-quality, drum-like sound that is heard over air-filled viscera is called: 1. Tympany. 2. Dullness. 3. Hyper-resonance. 4. Distention. ANS: 1 Page: 256

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is correct. Tympany is a high-pitched, hollow-quality, drum-like sound that is heard over air-filled viscera. This is incorrect. Dullness is a low-amplitude sound heard over fluid, organs, adipose tissue, or a distended bladder. This is incorrect. Hyper-resonance are high-pitched tympanic sounds between tympany and resonance that occur with air or gas in the intestine. This is incorrect. Excessive, high-pitched tympanic sounds may indicate distention.

GRADESMORE.COM

1. This is incorrect. The right upper quadrant contains the duodenum of the small intestine, gallbladder, liver, head of the pancreas, right kidney, right adrenal gland, hepatic flexure of the colon, and part of the ascending and transverse colon. 2. This is incorrect. The left upper quadrant contains the left lobe of the liver, stomach, spleen, body of the pancreas, left kidney, left adrenal, splenic flexure of the colon, and part of the transverse and descending colon. 3. This is correct. The midline contains the aorta, uterus, and bladder. 4. This is incorrect. The right lower quadrant contains the cecum, appendix, part of the ascending colon, right ovary and tube, right ureter, and right spermatic cord. This is incorrect. The left lower quadrant contains part of the descending colon, sigmoid colon, left ovary and tube, left ureter, and left spermatic cord.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. Normal bowel sounds are known as borborygmus and are loud gurgling or rumbling sounds made by the movement of gas through the intestines. This is correct. Hyperactive bowel sounds are loud, high-pitched sounds heard in patients with diarrhea, laxative use, gastroenteritis, and early intestinal obstruction. This is incorrect. Hypoactive bowel sounds are slow, decreased sounds heard in patients with constipation, obstruction, and paralytic ileus. This is incorrect. When bowel sounds are absent, no sounds are heard. This may indicate a paralytic ileus after surgery, bowel obstruction, and peritonitis.

2. 3. 4.

GRADESMORE.COM Feedback This is correct. Paracentesis is the procedure to remove fluid from the peritoneal cavity by inserting a needle into the cavity. This procedure is usually done when the patient is experiencing respiratory distress or abdominal pain. This is incorrect. Thoracentesis removes fluid from the chest cavity. This is incorrect. Chest tubes remove fluid and air from the chest cavity. This is incorrect. Gastrointestinal suction removes fluid from the gastrointestinal tract.

37. You are inspecting a patient’s abdomen and suspect the patient may have a diastasis recti separation. To confirm your suspicion, you will ask the patient to: 1. Turn to either side. 2. Breathe deeply. 3. Lie supine. 4. Cough. ANS: 4 Page: 253 Feedback 1. This is incorrect. The bulge appears with intra-abdominal pressure and will not appear if the patient just turns to either side. Have the patient raise his or her head or cough.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. This is incorrect. The bulge appears with intra-abdominal pressure and will not appear with just deep breathing. Have the patient raise his or her head or cough. 3. This is incorrect. The bulge will not always appear by just lying supine. Have the patient raise his or her head or cough. 4. This is correct. The bulge may appear only when the patient raises his or her head or coughs.

38. You are assessing a patient who is complaining of “feeling bloated and short of breath.” The patient is lying in the supine position. Your assessment findings are: inspection: skin is shiny and taut, protuberant abdomen with spider veins noted at the umbilical area; auscultation: hypoactive low-pitched bowel sounds, 10 clicks per minute; abdominal vasculature, no bruits; percussion: tympany at hypogastric and umbilical area; dull sounds on lateral dependent quadrants; palpation: firm, nontender, unable to palpate organs. What assessment should you perform next? 1. Cardiac assessment 2. Testing for fluid waves 3. Respiratory assessment 4. Edema of the extremities ANS: 2 Page: 253

1. 2. 3. 4.

GRADESMORE.COM

Feedback This is incorrect. You are performing an abdominal assessment and have abnormal findings. A cardiac assessment should not be performed next. This is correct. The findings reveal a protuberant abdomen with percussion sounds indicative of ascites. You should test for ascites by doing a test for fluid waves. This is incorrect. The patient’s abdomen is distended with abnormal percussion sounds. The patient needs to be assessed for fluid waves, not a respiratory assessment. This is incorrect. Assessing the peripheral extremities is not the next assessment because there are abnormal abdominal assessment findings. An advanced assessment for ascites should be performed.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 2341 Page: 250 Feedback: For an abdominal assessment, inspection is done first, followed by auscultation, percussion, and palpation.

40. The patient has a history of alcoholism with liver disease. The diagnostic test you would expect the health-care provider to order in relation to a liver that is compromised is level. ANS: ammonia Page: 242 Feedback: Ammonia comes from two sources: removal of amino acids during protein metabolism and degradation of proteins by colon bacteria. The liver converts ammonia in the portal blood to urea, which is excreted by the kidneys. If the liver is severely compromised, especially in situations in which decreased hepatocellular function is combined with impaired portal blood flow, ammonia levels rise.

41. The patient is complaining of shaGrpRlAoD wE erSrM igO htRqEu. adCraOnM t pain with nausea and vomiting that started 20 hours ago. She states that she is extremely uncomfortable and rates the pain a 10/10. You will perform an assessment for rebound tenderness at _ point. ANS: McBurney’s; Mcburney’s; McBurneys; Mcburneys; McBurney; Mcburney Page: 244 Feedback: The appendix is a long, narrow, wormlike tube averaging between 1 and 9 inches in length. It is located in the right lower quadrant about 2 cm below the ileocecal valve at McBurney’s point. It sometimes fills with digestive materials from the cecum and becomes infected, causing appendicitis.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 15: Assessing the Peripheral Vascular System and Regional Lymphatic System

1. Which of the following statements is true concerning the peripheral vascular system? Select all that apply. 1. Arteries are cylindrical, tubular, thick blood vessels that transport oxygenated blood away from both the ventricles of the heart to tissues in every part of the body. 2. Veins in the upper extremities, head, neck, and truck carry deoxygenated blood to the inferior vena cava. 3. Arterioles consist of a thin endometrial wall that is only one cell thick and bring oxygenated blood to the tissue cells. 4. Blood is forced upward in the deep veins by contraction of the leg and thigh muscles propelling the blood upward within the veins against gravity.

2. The functions of the lymphatic system include which of the following? Select all that apply. 1. Immunity and spread of infection 2. Production of potassium 3. Maintaining sodium balance 4. Production of white blood cells 5. Fluid and protein balance

GRADESMORE.COM 3. The student nurse explains the diagnostic tests that assist in diagnosing peripheral vascular insufficiencies and blockages in the lymphatic system to the instructor. Which diagnostic tests are correctly identified by the student? Select all that apply. 1. Angiogram 2. Computed tomography (CT) scan 3. Duplex ultrasound 4. Abdominal ultrasound 5. Magnetic resonance angiography

4. The patient is diagnosed with a bacterial infection. What organs of the body contain lymphatic tissue that assist in fighting infections? Select all that apply. 1. Spleen 2. Thymus 3. Bone marrow 4. Ovaries 5. Tonsils and adenoids 6. Parts of liver and lung 7. Peyer’s patches

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

5. The patient has a family history of peripheral artery disease. The nurse is teaching the patient the risk factors of peripheral artery disease. What are the risk factors? Select all that apply. 1. Advancing age 2. Diabetes 3. Smoking 4. Numbness or tingling 5. High blood pressure 6. Enlarged lymph nodes 7. Obesity 8. High cholesterol

6. When palpating the carotid artery, the nurse focuses on which of the following characteristics of the carotid pulse? Select all that apply. 1. Rate 2. Rhythm 3. Amplitude 4. Temperature 5. Flexibility

GRADESMORE.COM 7. The patient is diagnosed with peripheral artery disease (PAD). Based on this diagnosis, what questions would the nurse ask about the patient’s past medical history? Select all that apply. 1. Do you have high blood pressure? 2. Do you have high cholesterol? 3. Do you have frequent urinary tract infections? 4. Do you smoke? 5. Have you been overweight? 6. Do you have a history of diabetes?

8. The nurse is preparing for a physical examination of the peripheral vascular and lymphatic systems. What equipment does the nurse collect for this assessment? Select all that apply. 1. Syringe 2. Thermometer 3. Blood pressure cuff 4. Doppler gel 5. Doppler stethoscope 6. Stethoscope 7. Gloves

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

9. The patient is an uncontrolled diabetic with peripheral vascular disease. The nurse needs to notify the physician immediately if the patient develops which signs of arterial or venous blockage? Select all that apply. 1. Unable to feel a pulse in an extremity 2. Edema of the extremity 3. Extremity cool to touch 4. Extremity pale and mottled 5. Severe varicose veins in an extremity 6. Capillary refill time less than 3 seconds

10. Which of the following are normal findings when assessing the upper extremities? Select all that apply. 1. Pale in color 2. No edema or ulcerations 3. Fingernail beds pale and white 4. Venous pattern unilateral 5. Fingernails even thickness 6. Nail base 160-degree angle of attachment GRADESMORE.COM 7. Temperature warm to touch

11. The patient comes to the outpatient clinic stating that he has a sore throat and an earache. The nurse assesses the lymph nodes of the head and neck. What technique does the nurse perform to assess the lymph nodes? 1. Using the finger pads of the index and middle fingers, gently massage the lymph nodes using circular motions. 2. Using the finger pads of the index and middle fingers, use firm pressure to be able to feel the deeper lymph nodes. 3. Using the finger pads of the index and middle fingers, gently palpate the lymph nodes of the head and neck. 4. Using the finger pads of the index and middle fingers, rotate the lymph nodes in a right to left motion.

12. The lymph nodes of the head and neck have been assessed by the nurse. What is the correct documentation by the nurse indicating normal findings? 1. Left submandibular lymph node tender 2. Left preauricular lymph node hard 3. Tonsillar node nontender, movable, and 0.5 cm in size

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Right postauricular node 2.5 cm in size and matted

13. The patient is admitted with a heart condition. The appropriate technique for palpating the carotid arteries is to: 1. Deeply palpate both arteries simultaneously. 2. Massage the right carotid artery and then the left carotid artery. 3. Palpate both arteries at the same time to compare amplitudes. 4. Palpate the right carotid artery and then the left carotid artery.

14. The student nurse explains to the instructor the region of the body where the carotid artery can be found and palpated. The student nurse correctly identifies which of the following landmarks for palpating the carotid artery? 1. Between the trachea and sternocleidomastoid muscle 2. Between the clavicle and trachea 3. Between the sternocleidomastoid muscle and lateral neck 4. Between the trachea and suprasternal notch

Mm OoRnEi. 15. Peripheral artery disease (PAD) iG sR mA osDt EcoSm nC wO hiMch racial or ethnic group? 1. Caucasians 2. African Americans 3. Asians 4. Italians

16. What statement best describes lymph fluids? 1. Lymph fluid is a clear body fluid containing white blood cells (WBCs), proteins, and fats. 2. Lymph fluid seeps into the blood vessels from the spaces of body tissues. 3. Lymph fluid is stored in the bloodstream and then flows back into the lymphatic system. 4. Lymph fluid moves in all directions with the assistance of valves.

17. Which of the following statements is true concerning the circulatory system? 1. Aneurysms are narrowing or occlusion of arteries due to atherosclerotic plaques. 2. Intermittent claudication is pain felt in the lower extremities due to decreased blood flow. 3. Peripheral artery disease is a weakening of an arterial wall that can develop within the arterial system. 4. Lymphedema is an accumulation of blood in the tissues caused by trauma to the tissues.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

18. A patient has presented to the urgent care center with symptoms of shortness of breath and bilateral leg edema. He has a past medical history of congestive heart failure. What is the purpose of inspecting for jugular vein distention (JVD)? 1. To assess for accumulation of fluid seeping into tissues 2. To assess the peripheral circulation for signs of obstruction 3. To assess for signs of increased central venous pressure 4. To assess protruding veins resulting from incompetent valves

19. The patient had congestive heart failure that is now resolved. The nurse documents a normal finding for jugular vein distention. What would the nurse document? 1. Visible jugular vein distention 2. Protruding jugular veins 3. Pulsating jugular veins 4. No visible jugular vein distention

20. You are assessing circulation in the upper extremities. The brachial pulse is palpated at what landmark? GRADESMORE.COM 1. The lateral side of the wrist 2. The antecubital fossa, medial side of the arm 3. The antecubital fossa, lateral side of the arm 4. The medial side of the wrist

21. The nurse is assessing the amplitude of the radial pulse. The nurse documents that the radial pulse is a +2. What does this mean? 1. The pulse is normal. 2. The pulse is weak, barely palpable. 3. The pulse is full, increased. 4. The pulse is bounding.

22. Which of the following is a normal capillary refill time? 1. More than 3 seconds 2. More than 4 seconds 3. Less than 4 seconds 4. Less than 3 seconds

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

23. During the history of present illness, the patient states that sometimes her fingers and toes turn somewhat bluish, white, or red especially during cold weather. The patient is describing which condition? 1. Intermittent claudication 2. Raynaud phenomenon 3. Peripheral artery disease 4. Thrombosis

24. Mrs. Swanson is having her annual physical examination. She reports that she is having leg pain when walking long distances. You suspect that she may have peripheral arterial disease. Why is it important to ask patients with peripheral artery disease if they smoke? 1. Smoking causes the vessels in the upper and lower extremities to dilate. 2. Smoking causes atherosclerotic plaques to form in the arteries outside of the heart and brain. 3. Smoking causes vasoconstriction in the upper and lower extremity vessels. 4. Smoking causes excessive amounts of tissue fluid in the interstitial spaces to develop.

25. You are performing a peripheral vascular assessment. What is the purpose of auscultating the carotid arteries? 1. To assess for signs of obstruction GRADESMORE.COM 2. To assess carotid artery circulation 3. To assess for signs of increased central venous pressure 4. To assess for peripheral circulation

26. The patient has been diagnosed with arterial insufficiency of the lower extremities. During inspection of the lower extremities, you note that the patient has a 2 cm x 3 cm ulcer on the right ankle area. Which of the following is a characteristic of an arterial ulcer? 1. It appears irregularly shaped with uneven edges. 2. The skin is warm when palpated. 3. The skin is edematous with fluid drainage. 4. It appears “punched out” with round, smooth, well-defined borders.

27. A patient has a past medical history of peripheral vascular disease. What signs or symptoms indicate that she has tissue ischemia of the lower extremities? 1. Pain and pallor 2. Warmth and redness 3. Tingling and increased hair growth 4. Tender lymph nodes and edema

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

28. A patient has moderately severe varicose veins of both lower extremities. The patient has been taught a series of exercises for varicose veins. What statement by the patient indicates a need for further teaching? 1. “Exercise slows or prevents the development of varicose veins.” 2. “It is important to elevate and rest the legs after performing exercises.” 3. “All exercises should be performed gently.” 4. “I can continue to exercise even if I am experiencing pain or discomfort.”

29. When assessing the lower extremities, which is the best position to assess the patient? 1. Lateral 2. Standing 3. Supine 4. Prone

30. The patient has chronic peripheral vascular disease and is at risk for open areas and ulcerations of the lower extremities. What should the nurse tell the patient to reduce the risk for ulcerations? GRADESMORE.COM 1. “Inspect your feet daily.” 2. “You may walk barefoot.” 3. “You may wear open-toed shoes.” 4. “Wear support hose during the day and night.”

31. An elderly patient arrives in the emergency department with severe dehydration. What is the nurse assessing in the picture? 1. Lymph nodes of the hand 2. Capillary refill 3. Lymphedema 4. Pitting edema

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

32. The patient was admitted for complications of peripheral vascular disease. The nurse assesses the lower extremities. What assessment is the nurse performing in the figure? 1. Palpating lymph nodes 2. Palpating for edema 3. Palpating for an aneurysm 4. Palpating temperature

33. Put the steps in order for auscultating the carotid arteries for a bruit (1–6). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Auscultate for a bruit when the patient is holding his or her breath. 2. Document your findings. 3. Tell the patient to exhale. 4. Explain the technique to the patient. 5. Ask the patient to breathe in aGnR dAhD olE dS itM . ORE.COM 6. Repeat on the opposite side.

34. The nurse is assessing capillary refill. Put the sequence of steps in order (1–7). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Document your findings. 2. Remove colored nail polish. 3. Release the nail bed. 4. Note the amount of time for the pink color to return to the nail bed. 5. Press down on the nail bed until the nail bed blanches. 6. Hold the patient’s hand higher than heart level. 7. Explain the technique.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. After the patient sits up, wait 1 minute and inspect the leg veins in the dependent position. 5. Remove and discard gloves. 6. Palpate the right and left inguinal groin areas to assess lymph nodes. 7. Assess the femoral pulses in the right and left lower legs. 8. Inspect each leg from the groin to the toes.

36. You are assessing the popliteal pulses. Put the sequence of steps to do this assessment in order (1–6). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Hold the back of the knee with both hands. 2. Document your findings. 3. Extend the index and middle fingers of your hands on the popliteal fossa. 4. Palpate the popliteal artery. 5. Repeat with the other knee. 6. Ask the patient to flex the right or left knee at approximately 120 degrees.

37. is a bacterial infection of the skin and subcutaneous tissues where the skin appears red and swollen. It feels warm, hot, and tender.

GRADESMORE.COM 38. You are assessing a patient who has +3 pitting edema of both lower extremities. You know that this indentation is about a mm indentation.

39. The pulse that is located in the groin area below the inguinal ligament, halfway between the symphysis pubis and the anterior-superior iliac spine, is called the pulse.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers 1. Which of the following statements is true concerning the peripheral vascular system? Select all that apply. 1. Arteries are cylindrical, tubular, thick blood vessels that transport oxygenated blood away from both the ventricles of the heart to tissues in every part of the body. 2. Veins in the upper extremities, head, neck, and truck carry deoxygenated blood to the inferior vena cava. 3. Arterioles consist of a thin endometrial wall that is only one cell thick and bring oxygenated blood to the tissue cells. 4. Blood is forced upward in the deep veins by contraction of the leg and thigh muscles propelling the blood upward within the veins against gravity. ANS: 1, 4 Page: 262-263

2. 3. 4.

Feedback This is correct. Arteries are cylindrical, tubular, thick blood vessels that transport oxygenated blood away from both the ventricles of the heart to tissues in every part of the body. This is incorrect. Veins in the upper extremities, head, neck, and truck carry deoxygenated blood to the right atrium of the heart. This is incorrect. Capillaries consist of a thin endometrial wall that is only one cell thick and bring oxygenateG dR blA ooDdEtS oM thOe RtiE ss. ueCcOeM lls. This is correct. Blood is forced upward in the deep veins by contraction of the leg and thigh muscles propelling the blood upward within the veins against gravity.

1. 2. 3. 4.

Feedback This is correct. The lymphatic system is the first line of defense against disease. This is incorrect. The lymphatic system is not involved in the production of potassium. This is incorrect. The lymphatic system is not actively involved with maintaining the sodium balance in the body. This is correct. White blood cells function as part of the lymphatic system by fighting off invading bacteria.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is correct. As blood moves through the arteries and veins, 10% of the fluid filtered by the capillaries, along with vital proteins, becomes trapped in the tissues of the body. The lymphatic system collects this fluid and returns it to the circulatory system.

3. The student nurse explains the diagnostic tests that assist in diagnosing peripheral vascular insufficiencies and blockages in the lymphatic system to the instructor. Which diagnostic tests are correctly identified by the student? Select all that apply. 1. Angiogram 2. Computed tomography (CT) scan 3. Duplex ultrasound 4. Abdominal ultrasound 5. Magnetic resonance angiography ANS: 1, 2, 3, 5 Page: 265

1. 2. 3. 4. 5.

Feedback This is correct. Angiogram is an imaging x-ray that uses a special dye to visualize blood flow through arteries or veins. This is correct. CT scan is a noninvasive test that can help the medical specialist map the blood flow in the affecG teRdAaD reE asSoMf O thReEp. erC ipO heMral system. This is correct. Duplex ultrasound is a noninvasive test that can help the medical specialist map the blood flow in the affected areas of the peripheral system. This is incorrect. Abdominal ultrasound does not assess the peripheral vascular system. This is correct. Magnetic resonance angiography is a noninvasive test that can help the medical specialist map the blood flow in the affected areas of the peripheral system.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4. 5. 6. 7.

Feedback This is correct. The spleen is the largest lymphatic organ in the body and filters blood. This is correct. The thymus produces lymphocytes. This is correct. Bone marrow produces lymphocytes. This is incorrect. The ovaries do not contain lymphoid tissue. This is correct. Tonsils and adenoids are the body’s initial line of defense of the immune system. This is correct. Parts of the liver and lung contain lymphoid tissue. This is correct. Peyer’s patches are a cluster of lymphoid tissue in the intestines.

GRADESMORE.COM

ANS: 1, 2, 3, 5, 7, 8 Page: 267

1. 2. 3. 4. 5. 6. 7. 8.

Feedback This is correct. Advancing age is a risk factor of peripheral artery disease. This is correct. Diabetes is a risk factor of peripheral artery disease. This is correct. Smoking is a risk factor of peripheral artery disease. This is incorrect. Numbness or tingling is not a risk factor of peripheral artery disease. This is correct. High blood pressure is a risk factor of peripheral artery disease. This is incorrect. Enlarged lymph nodes are not a risk factor of peripheral artery disease. This is correct. Obesity is a risk factor of peripheral artery disease. This is correct. High cholesterol is a risk factor of peripheral artery disease.

6. When palpating the carotid artery, the nurse focuses on which of the following characteristics of the carotid pulse? Select all that apply. 1. Rate 2. Rhythm 3. Amplitude 4. Temperature

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

5. Flexibility ANS: 1, 2, 3 Page: 270-271

1. 2. 3. 4. 5.

Feedback This is correct. Characteristics of the carotid pulse include rate, rhythm, and amplitude. This is correct. Characteristics of the carotid pulse include rate, rhythm and amplitude. This is correct. Characteristics of the carotid pulse include rate, rhythm, and amplitude. This is incorrect. Temperature is a characteristic of the skin. This is incorrect. Flexibility of the carotid artery is not normally assessed.

7. The patient is diagnosed with peripheral artery disease (PAD). Based on this diagnosis, what questions would the nurse ask about the patient’s past medical history? Select all that apply. 1. Do you have high blood pressure? 2. Do you have high cholesterol? 3. Do you have frequent urinary tract infections? 4. Do you smoke? 5. Have you been overweight? GRADESMORE.COM 6. Do you have a history of diabetes? ANS: 1, 2, 4, 5, 6 Page: 265

1. 2.

3. 4. 5. 6.

Feedback This is correct. High blood pressure is a major risk factor for peripheral vascular disease. This is correct. PAD is a term used to describe narrowing or occlusion by atherosclerotic plaques of arteries outside of the heart and brain. PAD occurs with a buildup of fatty deposits (cholesterol) and atherosclerotic vascular changes to the endothelial lining of blood vessels. This is incorrect. Urinary tract infections are not related to PAD. This is correct. Patients who smoke or have a medical history of diabetes and heart disease have a higher risk of having PAD. This is correct. Being overweight increases body fat, increasing the risk of fat accumulating in the arteries. This is correct. Patients who have a medical history of diabetes and heart disease have a higher risk of having PAD.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4. 5. 6. 7.

Feedback This is incorrect. A syringe is not needed for this assessment. This is incorrect. A thermometer is not needed for this assessment. This is incorrect. A blood pressure cuff is not needed for this assessment. This is correct. Doppler gel is used prior to using the Doppler stethoscope. This is correct. A Doppler stethoscope is used to amplify arterial pulses when unable to palpate the pulses. This is correct. A stethoscope is used to assess the carotid artery. This is correct. Gloves are used to maintain infection control.

GRADESMORE.COM 9. The patient is an uncontrolled diabetic with peripheral vascular disease. The nurse needs to notify the physician immediately if the patient develops which signs of arterial or venous blockage? Select all that apply. 1. Unable to feel a pulse in an extremity 2. Edema of the extremity 3. Extremity cool to touch 4. Extremity pale and mottled 5. Severe varicose veins in an extremity 6. Capillary refill time less than 3 seconds ANS: 1, 3, 4 Page: 274

1. 2. 3. 4.

Feedback This is correct. Inability to feel a pulse in an extremity is a sign of arterial or venous blockage. This is incorrect. Edema is an accumulation of fluid seeping into the tissues; therefore, this is not an indication of arterial or venous blockage. This is correct. Extremity cool to touch may indicate decreased or no circulation; this is a sign of arterial or venous blockage. This is correct. Extremity pale and mottled is a sign of arterial or venous blockage.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is incorrect. Varicose veins are protruding veins that are a risk factor for arterial or venous blockage, however these are not signs that the physician needs to be called immediately. This is incorrect. Capillary refill time of less than 3 seconds is a normal finding.

1. 2. 3. 4. 5. 6. 7.

Feedback This is incorrect. Color uniform and pink is a normal finding. This is correct. No edema or ulcerations are normal findings. This is incorrect. FingernaG il R bA edDs E piSnM kO isRaEn. orCmOaM l finding. This is incorrect. Venous pattern normal and symmetrical is a normal finding. This is correct. Fingernails even thickness is a normal finding. This is correct. Nail base 160-degree angle of attachment is a normal finding. This is correct. Temperature warm to touch is a normal finding.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. Lymph nodes should not be massaged, only gently palpated. This is incorrect. Firm pressure is not used to palpate lymph nodes because it causes unnecessary pain for patients with tender lymph nodes. This is correct. Using the finger pads of the index and middle fingers, gently palpate lymph nodes using circular motions. This is incorrect. Lymph nodes are not palpated in a right to left motion. Gently palpate nodes using circular motions.

1. 2. 3. 4.

Feedback This is incorrect. Submandibular lymph node needs to be nontender to be normal. GRAlymph DESMnode OREshould .COMbe soft to be considered normal. This is incorrect. Preauricular This is correct. Tonsillar node can be movable, discrete, nontender, and less than 1 cm in size to be considered normal. This is incorrect. Postauricular node needs to be less than 1 cm in size and movable to be considered normal.

Feedback This is incorrect. Carotid arteries should not be deeply palpated simultaneously because blood supply will be decreased to the brain, resulting in the patient losing consciousness. This is incorrect. Carotid arteries should not be massaged because this causes an

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

adverse reflex effect on the baroreceptors of the heart and may decrease the patient’s heart rate and blood pressure or cause a cardiac arrhythmia. This is incorrect. Carotid arteries should never be palpated at the same time. This will prevent any blood from reaching the patient’s head, resulting in the patient losing consciousness. This is correct. Gently palpate one carotid artery and then gently palpate the carotid artery on the other side of the neck. This prevents a decreased blood supply to the brain and arrhythmias.

GRADESMORE.COM

This is correct. The carotid arteries are found between the trachea and sternocleidomastoid muscle on each side of the neck. This is incorrect. The carotid arteries are found between the trachea and sternocleidomastoid muscle on each side of the neck. This is incorrect. The carotid arteries are found between the trachea and sternocleidomastoid muscle on each side of the neck. This is incorrect. The carotid arteries are found between the trachea and sternocleidomastoid muscle on each side of the neck.

15. Peripheral artery disease (PAD) is most common in which racial or ethnic group? 1. Caucasians 2. African Americans 3. Asians 4. Italians ANS: 2 Page: 268

Feedback This is incorrect. Caucasians are not the racial/ethnic group at the highest risk for PAD.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3. 4.

This is correct. Diabetes and high blood pressure are more common among African Americans, which places this racial/ethnic group at the higher risk for PAD. This is incorrect. Asians are not the racial/ethnic group at the highest risk for PAD. This is incorrect. Italians are not the racial/ethnic group at the highest risk for PAD.

1. 2. 3. 4.

Feedback This is correct. Lymph fluid is a clear body fluid that contains a type of WBCs, along with proteins and fats. This is incorrect. Lymph fluid seeps outside the blood vessels into the spaces of body tissues. This is incorrect. Lymph fluid is stored in the lymphatic system to flow back into the bloodstream.

GRADESMORE.COM

This is incorrect. Lymph fluid moves unidirectional within the lymphatic system with the assistance of valves and movement.

1. 2.

Feedback This is incorrect. An aneurysm is a weakening of an arterial wall that can develop within the arterial system. This is correct. Intermittent claudication is a symptom of peripheral arterial disease. Cramp-like pain is felt in the buttock, thighs, or calves during exercise or walking, which is due to decreased blood flow and oxygen (tissue ischemia) to the legs. This is incorrect. Peripheral arterial disease is a term used to describe narrowing or occlusion by atherosclerotic plaques of arteries outside of the heart and brain.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is incorrect. Lymphedema is an accumulation of lymph fluid in the tissues caused by invasive surgery, obesity, removal of lymph nodes, radiation, and chemotherapy.

1. 2. 3.

Feedback This is incorrect. Assessing for the accumulation of fluid seeping into tissues is assessing for edema. This is incorrect. Peripheral circulation involves the upper and lower extremities. This is correct. The purpose for inspecting for JVD is to assess for signs of increased central venous pressure. Patients with congestive heart failure will present with JVD due to increased central venous pressure. This is incorrect. VaricoseGvReiAnD s aErS eM prO otRruEd. inCgOvM eins resulting from incompetent valves.

1. 2. 3. 4.

Feedback This is incorrect. Visible jugular vein distention is not a normal finding. This is incorrect. Protruding jugular veins are not a normal finding. This is incorrect. Pulsating jugular veins are not a normal finding. This is correct. No visible pulsation or jugular vein distention is a normal finding.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

20. You are assessing circulation in the upper extremities. The brachial pulse is palpated at what landmark? 1. The lateral side of the wrist 2. The antecubital fossa, medial side of the arm 3. The antecubital fossa, lateral side of the arm 4. The medial side of the wrist ANS: 2 Page: 273

1. 2. 3. 4.

Feedback This is incorrect. The brachial pulse is palpated at the antecubital fossa, medial side of the arm. The radial pulse is at the lateral side of the wrist. This is correct. The brachial pulse is palpated at the antecubital fossa, medial side of the arm. This is incorrect. The brachial pulse is palpated at the antecubital fossa, medial side of the arm. This is incorrect. The brachial pulse is palpated at the antecubital fossa, medial side of the arm. The ulna artery is located at the medial side of the wrist.

21. The nurse is assessing the amplitude of the radial pulse. The nurse documents that the radial pulse is a +2. What does this mean? GRADESMORE.COM 1. The pulse is normal. 2. The pulse is weak, barely palpable. 3. The pulse is full, increased. 4. The pulse is bounding. ANS: 1 Page: 274

1. 2. 3. 4.

Feedback This is correct. A normal pulse amplitude is documented as a +2 (on a scale of 0 to +4). This is incorrect. A weak, barely palpable pulse amplitude is documented as a +1. This is incorrect. A full, increased pulse amplitude is documented as a +3. This is incorrect. A bounding pulse amplitude is documented as a +4.

22. Which of the following is a normal capillary refill time? 1. More than 3 seconds 2. More than 4 seconds 3. Less than 4 seconds 4. Less than 3 seconds

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 4 Page: 275

1. 2. 3. 4.

Feedback This is incorrect. Normal capillary refill time is less than 3 seconds. This is incorrect. Normal capillary refill time is less than 3 seconds. This is incorrect. Normal capillary refill time is less than 3 seconds. This is correct. Normal capillary refill time is less than 3 seconds.

3. 4.

GRADESMORE.COM Feedback This is incorrect. Intermittent claudication is a symptom of peripheral artery disease. Cramp-like pain is felt in the buttock, thighs, or calves during exercise or walking, which is due to decreased blood flow and oxygen (tissue ischemia) to the legs. This is correct. Raynaud phenomenon is a result of cold-induced vasospasm of the small blood vessels in the fingers and toes, causing blanching, cyanosis, or redness of the hands and feet. This is incorrect. Peripheral artery disease is a narrowing or occlusion by atherosclerotic plaques of arteries outside of the heart and brain. This is incorrect. A thrombosis is a blood clot and does not have a relationship to cold weather.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Page: 266

1. 2. 3. 4.

Feedback This is incorrect. Smoking causes the vessels in the upper and lower extremities to constrict not dilate. This is incorrect. Peripheral arterial disease is a term used to describe narrowing or occlusion by atherosclerotic plaques of arteries outside of the heart and brain. This is correct. Smoking causes vasoconstriction in the upper and lower extremity vessels, resulting in decreased blood flow to the extremities. This is incorrect. Edema is a localized or generalized condition in which body tissues contain an excessive amount of tissue fluid in the interstitial spaces.

25. You are performing a peripheral vascular assessment. What is the purpose of auscultating the carotid arteries? 1. To assess for signs of obstruction 2. To assess carotid artery circulation 3. To assess for signs of increased central venous pressure 4. To assess for peripheral circulation ANS: 1 Page: 271

1. 2. 3. 4.

GRADESMORE.COM Feedback This is correct. The purpose of assessing the carotid arteries is to assess carotid artery flow for signs of obstruction. This is incorrect. Carotid artery circulation is assessed when inspecting and palpating the carotid arteries. This is incorrect. The purpose of inspecting jugular vein distention is to assess for signs of increased central venous pressure. This is incorrect. The purpose of assessing upper and lower extremities is to assess for peripheral circulation.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. Venous ulcers appear irregularly shaped with uneven edges. This is incorrect. Skin with arterial insufficiency is cool when palpating. This is incorrect. Skin with venous insufficiency is edematous with fluid drainage. This is correct. Arterial ulcer areas appear “punched out” with round, smooth, welldefined borders.

1. 2. 3. 4.

Feedback This is correct. Pain and pallor are signs and symptoms of tissue ischemia. This is incorrect. Warmth and redness are signs and symptoms of inflammation or GRADESMORE.COM infection. This is incorrect. Numbness, tingling, and hair loss are symptoms of tissue ischemia. This is incorrect. Lymph nodes are not found in the lower leg area.

1. 2. 3. 4.

Feedback Exercise slows or prevents the development of new varicose veins. The patient needs to elevate and rest the legs after performing exercises. All exercises should be performed gently. This is the correct answer. The patient needs to stop exercising immediately if there is any pain or discomfort.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

29. When assessing the lower extremities, which is the best position to assess the patient? 1. Lateral 2. Standing 3. Supine 4. Prone ANS: 3 Page: 276

1. 2. 3. 4.

Feedback This is incorrect. A lateral position is where the patient lies on his or her side. This prevents a good assessment of the lower extremities. This is incorrect. A standing position prevents a good assessment of the lower extremities. This is correct. A supine position (flat on the back) is best when assessing the lower extremities. This is incorrect. A prone position is where the patient lies flat on the abdomen. This prevents a good assessment of the lower extremities.

GRADESMORE.COM 30. The patient has chronic peripheral vascular disease and is at risk for open areas and ulcerations of the lower extremities. What should the nurse tell the patient to reduce the risk for ulcerations? 1. “Inspect your feet daily.” 2. “You may walk barefoot.” 3. “You may wear open-toed shoes.” 4. “Wear support hose during the day and night.” ANS: 1 Page: 280

1. 2. 3. 4.

Feedback This is correct. Patients should inspect their feet daily for signs and symptoms of open areas and ulcers. Use a mirror to check the soles of the feet. This is incorrect. Patients with peripheral vascular disease should not walk barefoot to prevent risk of injury. This is incorrect. Patients should be encouraged to wear supportive, closed-toed shoes. This is incorrect. Patients with venous insufficiency should be encouraged to wear support hose during the day and take the hose off at night.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2.

3. 4.

Feedback This is incorrect. Lymph nodes are not found in the hands. This is correct. Capillary refill is being assessed. Hold the patient’s hand higher than heart level. Press down on the nail bed until the nail bed blanches (turns white). Release the nail. Note the amount of time for the pink color to return to the nail bed. This is incorrect. Lymphedema is an accumulation of lymphatic fluid in the interstitial tissue that causes swellingGRADESMORE.COM and may occur in one or both of the arms or legs. This is incorrect. Edema d seeping into the tissues and is an accumulation of flui accumulation of fluid in the legs and feet. The technique for assessing edema is to gently apply pressure with your second and third finger pads on the edematous area and release the finger pressure. Note the depth of indentation.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Page: 277

1. 2.

3. 4.

Feedback This is incorrect. There are no lymph nodes in the lower legs. This is incorrect. Edema is an accumulation of fluid seeping into the tissues and accumulation of fluid in the legs and feet. The technique for assessing edema is to gently apply pressure with your second and third finger pads on the edematous area and release the finger pressure. Note depth of indentation. This is incorrect. An aneurysm is a weakening of an arterial wall that can develop within the arterial system and cannot be palpated. This is correct. Using the dorsal surface of your hand, palpate the temperature of each leg. Compare the temperatures of both legs.

GRADESMORE.COM

ANS: 451362 Page: 271-272 Feedback: Explain to the patient what you will be doing. Ask the patient to breathe in and hold his or her breath. Listen when the patient is holding the breath (it is important that you listen while the patient is holding her or his breath so that you do not get confused by the patient’s tracheal breath sounds). Tell the patient to exhale. Repeat on the opposite side. Document your findings.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Page: 275 Feedback: Explain the procedure. Remove colored nail polish. Hold the patient’s hand higher than heart level. Press down on the nail bed until the nail bed blanches. Release the nail bed. Note the amount of time for the pink color to return to the nail bed. Document findings.

35. You are performing a peripheral vascular assessment on the lower extremities. Put the steps in order to assess the lower extremities (1–8). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Position the patient and expose the lower legs while providing privacy. 2. Put on gloves. 3. Palpate the temperature of each leg and compare. 4. After the patient sits up, wait 1 minute and inspect the leg veins in the dependent position. 5. Remove and discard gloves. 6. Palpate the right and left inguinal groin areas to assess lymph nodes. 7. Assess the femoral pulses in the right and left lower legs. 8. Inspect each leg from the groin to the toes. ANS: 18326745 Page: 276

GRADESMORE.COM

Feedback: Position the patient and expose the lower legs while providing privacy. Inspect each leg from the groin to the toes. Palpate the temperature of each leg and compare. Put on gloves. Palpate the right and left inguinal groin areas to assess lymph nodes. Assess the femoral pulses in the right and left lower legs. After the patient sits up, wait 1 minute and inspect the leg veins in the dependent position. Remove and discard gloves.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Feedback: The sequence for assessing popliteal pulses is as follows: Ask the patient to flex the right or left knee at approximately 120 degrees. Hold the back of the knee with both hands. Extend the index and middle fingers of your hands on the popliteal fossa. Palpate the popliteal artery. Repeat with the other knee. Document your findings.

37. is a bacterial infection of the skin and subcutaneous tissues where the skin appears red and swollen. It feels warm, hot, and tender. ANS: Cellulitis; cellulitis Page: 274 Feedback: Cellulitis is a bacterial infection of the skin and subcutaneous tissues where the skin appears red and swollen. It feels warm, hot, and tender.

38. You are assessing a patient who has +3 pitting edema of both lower extremities. You know that this indentation is about a mm indentation. ANS: 6 Page: 274

GRADESMORE.COM

Feedback: Pitting edema is graded on a score of +1 to +4 depending on the depth of the indentation. A +3 pitting edema is about a 6 mm indentation.

39. The pulse that is located in the groin area below the inguinal ligament, halfway between the symphysis pubis and the anterior-superior iliac spine, is called the pulse. ANS: femoral Page: 277 Feedback: The femoral pulse is located in the groin area below the inguinal ligament, halfway between the symphysis pubis and the anterior-superior iliac spine.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 16: Assessing the Musculoskeletal System

1. Identify the range of motion movement in the accompanying figure that assesses the range of motion of the elbow. 1. Supination 2. Pronation 3. Flexion 4. Extension

2. The patient is complaining of acute pain in his shoulder after playing tennis. Assessment of the shoulder includes which of the following four motions? 1. Abduction, adduction, supination, and pronation 2. Lateral bending, extension, dorsiflG exRioAnD, E anSdMpO laR nE ta. r fCleOxM ion 3. Flexion, extension, internal rotation, and external rotation 4. Inversion, eversion, protraction, and retraction

3. You are performing an assessment of the vertebrae and assess the posture shown in the accompanying figure. What type of posture do you see in the picture? 1. Lordosis 2. Scoliosis 3. Kyphosis 4. Normal posture

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. What diagnostic test would you expect the health-care provider to order to assess injuries to a tendon, a ligament, or soft tissue? 1. X-ray 2. Ultrasound 3. Magnetic resonance imaging (MRI) 4. Computed tomography (CT) scan

5. The patient reports that he exercises at the local gym 7 days a week for a minimum of 60 minutes each day. He reports that he is able to lift weights up to 100 lb. An elevation of which enzyme may indicate muscle injury secondary to strenuous exercise? 1. Creatinine phosphokinase (CPK) 2. Lactate dehydrogenase (LDH) 3. Serum glutamic oxaloacetic transaminase (SGOT) 4. Serum glutamic-pyruvic transaminase (SGPT)

6. Mr. Brown’s knee assessment shows 4/5 muscle strength bilaterally with full flexion and extension. The nurse assesses the skiG nR teA mDpE erS atM urOeRaE nd.nCoO teMs increased warmth of the left knee joint. Which of the following is most concerning? 1. The muscle strength is 4/5. 2. Knee joint movement should include flexion deviation. 3. The warmth that is present in the left knee joint. 4. Muscle strength is symmetrical.

7. You are performing an assessment of the lower extremities. The accompanying figure indicates which range of motion movement of the hip? 1. Flexion against resistance

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. Extension against resistance 3. Abduction against resistance 4. Adduction against resistance

8. The movement of the sole of the foot away from the floor toward the knee demonstrates: 1. Plantar flexion. 2. Dorsiflexion. 3. Eversion 4. Inversion.

9. The patient had a total hip replacement several years ago. You are going to assess the range of motion of both hips. The range of motion movements for the hip joint include: 1. Supination, dorsiflexion, adduction, and extension. 2. Flexion, internal rotation, supination, and pronation. 3. Adduction, abduction, flexion, and internal rotation. 4. Extension, abduction, inversion, and eversion.

10. External shoulder rotation is demGoR nsAtrD atE edSiMnOwRhE ic. hC ofOtM he following figures?

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

11. A patient reports that she has had bilateral knee pain for the last 10 years. You review her past medical history and note osteoarthritis as a diagnosis. This type of arthritis is caused by: 1. A progressive, inflammatory, autoimmune disorder. 2. A progressive disease whereby the bone matrix is not being replaced. GRADESMORE.COM 3. A progressive disease whereby the protective cartilage wears down. 4. A progressive disease that causes enlargement of the ends of the joints.

12. A 28-year-old client fell off his bicycle while mountain biking. He states that his back hurts but is nonspecific about the location. The patient denies hitting his head. What question or statement should the nurse ask next? 1. “Where does your upper back hurt?” 2. “Point to the location where your back hurts.” 3. “Does the pain hurt in the lumbar area?” 4. “Does the pain radiate to your legs?”

13. Who is at greater risk for osteoporosis? 1. An African American man who is thin 2. A Hispanic woman who is obese 3. A Caucasian man who is underweight 4. A Caucasian woman who is of normal weight

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

14. You are assessing the vertebral column. Which assessment techniques will you perform? 1. Inspection only 2. Inspection and palpation 3. Inspection, palpation, and percussion 4. Inspection, palpation, and muscle strength

15. You are assessing the upper arm muscle strength. What is considered to be a minimal normal muscle strength? 1. 1/5 2. 2/5 3. 3/5 4. 4/5 5. 5/5

16. You are assessing the range of motion of the knee. Which of the following movements are appropriate to assess? Select all that apply. 1. Internal rotation 2. External rotation 3. Abduction GRADESMORE.COM 4. Adduction 5. Flexion 6. Extension

17. You are assessing the range of motion of the ankle. Which of the following movements are appropriate to assess? Select all that apply. 1. Inversion 2. Eversion 3. Flexion 4. Extension 5. Dorsiflexion 6. Plantar flexion

18. You are inspecting and palpating the upper extremities. What will you assess for? Select all that apply. 1. Tenderness 2. Position 3. Depressions 4. Bulges

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

5. Changes in temperature

19. A patient needs an assistive device to ambulate. Which of the following are assistive devices? Select all that apply. 1. Walker 2. Rolling walker 3. Wheelchair 4. Cane 5. Crutches ANS; 1, 2, 4, 5 Page:

1. 2. 3. 4. 5.

Feedback This is correct. A walker is considered an assistive device. This is correct. A rolling walker is considered an assistive device. This is incorrect. A wheelchair is not an assistive device because the patient does not walk with a wheelchair. This is correct. A cane is considered an assistive device. This is correct. Crutches are considered an assistive device.

GRADESMORE.COM 20. The musculoskeletal system is a complex system that provides structure, support, protection, and movement. Which is a true statement about the musculoskeletal system? Select all that apply. 1. The skeletal system provides attachment points for ligaments and tendons. 2. Movement occurs when muscles contract. 3. Muscle movement is generally involuntary. 4. Muscles relax in response to neurological stimulus.

21. Joints are areas where two or more bones come together. Which of the following statements are true about joints? Select all that apply. 1. Joints that move allow for functional movement of body parts. 2. Ligaments help to stabilize joints. 3. Fused joints are irregularly shaped and flat and are found in the foot. 4. Synovial fluid serves to lubricate and provide nutrients to the joint. 5. Ball and socket joints allow for greater movement. 6. Hinge joints are found in the elbow and the shoulder.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

22. When assessing specific musculoskeletal injuries, use of the five “P”s will increase your knowledge about the injury during your focused assessment. Select the correct five “P”s below. Select all that apply. 1. Pain 2. Position 3. Paralysis 4. Paresthesia 5. Pronation 6. Pallor 7. Pulselessness

23. You are a nursing student and need to recognize the normal findings of a musculoskeletal assessment. Identify below all of the normal findings about the musculoskeletal system. Select all that apply. 1. The range of motion of each joint should be symmetric to the opposite limb. 2. Muscle strength should be at least 8/10 in the lower extremities. 3. Limitations against resistance may indicate a problem in the joint. 4. Stretching exercises such as yoga build muscle strength. 5. Bending, lifting, and performing repetitive motions increase the risk of injury.

GRADESMORE.COM 24. When inspecting the upper extremities with the patient in a relaxed standing position, the nurse expects to observe which of the following? Select all that apply. 1. Straight upper arms 2. Symmetry between left and right upper extremities 3. Forward rounding of the shoulders 4. Wrists in line with the lower arm, palms facing thighs 5. Hyperextension of the elbows

25. When standing, the patient exhibits forward flexion at the hip joint. What may this indicate? Select all that apply. 1. Normal position for the hip joint 2. Tightness of the muscular structure 3. A problem with the lower back 4. A knee injury

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Eating foods rich in calcium, vitamin D, magnesium, and phosphorus 2. Maintaining an ideal body weight 3. Exercising on a regular basis 4. Performing stretching and flexibility exercises 5. Maintaining good body mechanics

27. Assessment of the geriatric patient’s posture and gait can be assessed as he or she enters the room. This will help the nurse to identify a patient’s risk.

28. is an unsteady gait, which can be used to compensate for an injury or pain in an extremity. It may also indicate a problem with cerebellar function.

29. Asking a patient to rub the back of his head with his right hand and then the left hand allows functional assessment of rotation of the shoulder joint.

GRADESMORE.COM 30. An exaggerated curvature in the thoracic spine is a common finding in an elderly person due to osteoporosis. This condition of the vertebrae is known as .

31. Identify the test. Ask the patient to flex both wrists and press them together for 1 minute. Ask the patient if there is any numbness and tingling sensations. This test is known as test.

32. The patient reports that he injured his ankle while playing soccer. The health-care provider requested an x-ray of the ankle, which was negative for a fracture. The health-care provider tells the patient his ligament was injured. This injury is called a .

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

34. The patient reports that she is having pain with erythema on the right side of her left great toe. You assess the patient’s left foot and note a lateral deviation and enlarged joint of the left great toe. This deviation and enlargement is called .

35. The patient has degenerative disc disease with a complication of foot drop. This is where the foot is at degrees to the lower leg.

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers

1. Identify the range of motion movement in the accompanying figure that assesses the range of motion of the elbow. 1. Supination 2. Pronation 3. Flexion 4. Extension ANS: 2 Page: 299-300

1. 2. 3. 4.

Feedback This is incorrect. Supination is the movement of the hand from palm facing down to palm facing up. This is correct. Pronation is the movement of the hand from the palm facing up to the GRADESMORE.COM palm facing down. This is incorrect. Flexion is the movement of the hand toward the shoulder from a neutral position. This is incorrect. Extension is the movement of the hand from the shoulder to a neutral position.

2. The patient is complaining of acute pain in his shoulder after playing tennis. Assessment of the shoulder includes which of the following four motions? 1. Abduction, adduction, supination, and pronation 2. Lateral bending, extension, dorsiflexion, and plantar flexion 3. Flexion, extension, internal rotation, and external rotation 4. Inversion, eversion, protraction, and retraction ANS: 3 Page: 297-298

1. 2. 3.

Feedback This is incorrect. The shoulder is able to abduct and adduct, it is not able to supinate and pronate. This is incorrect. The shoulder is not able to laterally bend, dorsiflex, or plantar flex. This is correct. The shoulder is able to flex/extend and internally/externally rotate.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is incorrect. The shoulder is not able to invert and evert, nor protract or retract.

1. 2. 3. 4.

GRADESMORE.COM

Feedback This is incorrect. Lordosis is curvature of the spine that looks like an arched lower back. There is an increased inward curvature of the lumbar spine. This is incorrect. Scoliosis is an abnormal curvature of the spine in a lateral manner. It may look like a “C” or an “S” on visualization. This is incorrect. Kyphosis is a curvature of the spine that resembles a slouching or hunchback posture. It occurs in the thoracic spine. This is correct. This is normal standing posture.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. X-rays are commonly done to assess bones and bony structures, but not tendons and ligaments. This is incorrect. Ultrasound uses sound waves to examine organs, soft tissues, and blood vessels. This is correct. MRI assesses soft tissue to determine the nature and severity of injury to tendons, ligaments, bones, and soft tissue. This is incorrect. CT scan may be done if the patient is unable to undergo an MRI due to a metal implant. It does not give as clear a picture of tendon and ligament injury.

1. 2. 3. 4.

GRADESMORE.COM Feedback This is correct. Elevation of CPK can indicate muscular injury secondary to strenuous exercise, a disease process, or an injury. This is incorrect. LDH is a nonspecific test that can be used to evaluate a number of diseases and conditions including stroke, certain cancers, heart attack, and liver disease. This is incorrect. SGOT is an enzyme present in heart and liver cells that is released into the bloodstream when those organs are injured or damaged. This is incorrect. SGPT is an enzyme present in heart and liver cells that is released into the bloodstream when those organs are injured or damaged.

6. Mr. Brown’s knee assessment shows 4/5 muscle strength bilaterally with full flexion and extension. The nurse assesses the skin temperature and notes increased warmth of the left knee joint. Which of the following is most concerning? 1. The muscle strength is 4/5. 2. Knee joint movement should include flexion deviation. 3. The warmth that is present in the left knee joint. 4. Muscle strength is symmetrical. ANS: 3 Page: 297

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. This is not an area of concern because normal muscle strength is 4/5. This is incorrect. This is a normal finding because knee joint movement includes flexion. This is correct. Warmth of skin may indicate signs of inflammation or infection. This is incorrect. Muscle strength should be equal on both sides.

7. You are performing an assessment of the lower extremities. The accompanying figure indicates which range of motion movement of the hip? 1. Flexion against resistance GRADESMORE.COM 2. Extension against resistance 3. Abduction against resistance 4. Adduction against resistance ANS: 4 Page: 307

1. 2. 3. 4.

Feedback This is incorrect. Flexion is the forward movement of the hip toward the anterior aspect of the body. This is incorrect. Extension is the movement of the hip backward, away from the anterior aspect of the body. This is incorrect. Abduction is the movement of the lower extremity away from the midline of the body. This is correct. Adduction is the movement of the lower extremity toward the midline of the body.

8. The movement of the sole of the foot away from the floor toward the knee demonstrates: 1. Plantar flexion. 2. Dorsiflexion. 3. Eversion

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Inversion. ANS: 2 Page: 308

1. 2. 3. 4.

Feedback This is incorrect. Plantar flexion is the movement of the sole of the foot toward the floor. This is correct. Dorsiflexion is the movement of the sole of the foot away from the floor. This is incorrect. Eversion is the movement of the great toe/foot away from the midline of the body. This is incorrect. Inversion is the movement of the great toe/foot toward the midline of the body.

GRADESMORE.COM

ANS: 3 Page: 306-307

1. 2. 3. 4.

Feedback This is incorrect. The hip joint is not able to dorsiflex or perform supination. This is incorrect. The hip joint is not able to supinate or pronate. This is correct. The hip joint is able to accomplish all of these range of motion activities. This is incorrect. The hip joint is not able to invert or evert.

10. External shoulder rotation is demonstrated in which of the following figures?

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

GRADESMORE.COM

4. ANS: 4 Page: 299

1. 2.

Feedback This is incorrect. This figure demonstrates abduction of the shoulder joint. This is incorrect. This figure demonstrates adduction of the shoulder joint.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

This is incorrect. This figure demonstrates internal rotation of the shoulder joint. This is correct. This figure demonstrates external rotation of the shoulder joint.

11. A patient reports that she has had bilateral knee pain for the last 10 years. You review her past medical history and note osteoarthritis as a diagnosis. This type of arthritis is caused by: 1. A progressive, inflammatory, autoimmune disorder. 2. A progressive disease whereby the bone matrix is not being replaced. 3. A progressive disease whereby the protective cartilage wears down. 4. A progressive disease that causes enlargement of the ends of the joints. ANS: 3 Page: 287

1. 2. 3. 4.

Feedback This is incorrect. Rheumatoid arthritis is a progressive, inflammatory, autoimmune disorder. This is incorrect. Osteoporosis is a progressive disease. The bone matrix is not being replaced by new bone. This is correct. Osteoarthritis is a progressive disease. The protective cartilage at the ends of the bones wears down. This is correct. Rheumatoid arthritis causes enlargement of the metacarpophalangeal and GRADESMORE.COM interphalangeal joints.

1. 2. 3. 4.

Feedback This is incorrect. This question is too generalized. This is correct. Having the patient specifically locate the pain by pointing to the location will help you narrow your assessment to that area. This is incorrect. The specific location of the pain is a priority, then you can ask about radiation. This is incorrect. The best answer is pointing to the location, then you can ask about radiation to the lower legs.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

13. Who is at greater risk for osteoporosis? 1. An African American man who is thin 2. A Hispanic woman who is obese 3. A Caucasian man who is underweight 4. A Caucasian woman who is of normal weight ANS: 4 Page 288

1. 2. 3. 4.

Feedback This is incorrect. African Americans are not at the highest risk for osteoporosis. This is incorrect. Hispanics are not at the highest risk for osteoporosis. This is incorrect. Caucasian men are not at the highest risk for osteoporosis. This is correct. Caucasian women are more likely to have bone loss.

14. You are assessing the vertebral column. Which assessment techniques will you perform? 1. Inspection only 2. Inspection and palpation GRADESMORE.COM 3. Inspection, palpation, and percussion 4. Inspection, palpation, and muscle strength ANS: 2 Page: 294

1. 2. 3. 4.

Feedback This is incorrect. Inspection is not the only assessment technique; palpation of vertebral column is needed. This is correct. Inspection and palpation assess for abnormalities in the structure of the vertebral column. This is incorrect. Percussion does not assess the vertebral column. This is correct. Muscle strength is not a technique to assess the vertebral column.

15. You are assessing the upper arm muscle strength. What is considered to be a minimal normal muscle strength? 1. 1/5 2. 2/5 3. 3/5 4. 4/5 5. 5/5

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 4 Page: 310

1. 2. 3. 4. 5.

Feedback This is incorrect. This is not normal. This indicates that the muscle is only able to contract slightly. This is incorrect. This is not normal. This indicates that the joint is only able to move in a gravity eliminated position. This is incorrect. This is not normal. This indicates that the joint is only able to move against gravity. This is correct. The patient should demonstrate strength of at least 4/5 in all of the motions in the lower extremities. This is incorrect. The minimal muscle strength is a 4/5, not a 5/5.

16. You are assessing the range of motion of the knee. Which of the following movements are appropriate to assess? Select all that apply. 1. Internal rotation 2. External rotation 3. Abduction 4. Adduction GRADESMORE.COM 5. Flexion 6. Extension ANS: 5, 6 Page: 308

1. 2. 3. 4. 5. 6.

Feedback This is incorrect. This is a range of motion movement for the hip. This is incorrect. This is a range of motion movement for the hip. This is incorrect. This is a range of motion movement for the hip. This is incorrect. This is a range of motion movement for the hip. This is correct. Flexion is a range of motion movement for the knee. This is correct. Extension is a range of motion movement for the knee.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

6. Plantar flexion ANS: 1, 2, 5, 6 Page: 309

1. 2. 3. 4. 5. 6.

Feedback This is correct. Inversion is a range of motion movement for the ankle. This is correct. Eversion is a range of motion movement for the ankle. This is incorrect. This is a range of motion movement for the hip and knee. This is incorrect. This is a range of motion movement for the hip and knee. This is correct. Flexion is a range of motion movement for the ankle. This is correct. Extension is a range of motion movement for the ankle.

18. You are inspecting and palpating the upper extremities. What will you assess for? Select all that apply. 1. Tenderness 2. Position 3. Depressions 4. Bulges 5. Changes in temperature

GRADESMORE.COM

ANS: 1, 3, 4, 5 Page: 295-296

1. 2. 3. 4. 5.

Feedback This is correct. You inspect and palpate for tenderness. This is incorrect. You do not inspect and palpate for position but for alignment. This is correct. You inspect and palpate for depressions. This is correct. You inspect and palpate for bulges. This is correct. You inspect and palpate for changes in temperature.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4. 5.

20. The musculoskeletal system is a complex system that provides structure, support, protection, and movement. Which is a true statement about the musculoskeletal system? Select all that apply. 1. The skeletal system provides attachment points for ligaments and tendons. 2. Movement occurs when muscles contract. 3. Muscle movement is generally involuntary. 4. Muscles relax in response to neurological stimulus. ANS: 1, 2 Page: 281

1. 2. 3. 4.

Feedback This is correct. The skeletal system provides attachment points for ligaments and GRADESMORE.COM tendons. This is correct. Movement occurs when muscles contract. This is incorrect. Muscle movement is generally voluntary, not involuntary. This is incorrect. Muscles contract, not relax, in response to neurological stimulus.

1. 2. 3.

Feedback This is correct. Joints allow for functional movement of body parts. This is correct. Ligaments help to stabilize joints. This is incorrect. Fused joints are found primarily in the skull. They are irregular and

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. 5. 6.

flat. There are irregular bones in the foot but they are not fused. This is correct. Synovial fluid serves to lubricate and provide nutrients to the joint. This is correct. Ball and socket joints allow for greater movement. This is incorrect. Hinge joints are found in the elbows, knees, fingers, and toes. The shoulder is a ball and socket joint.

GRADESMORE.COM

This is correct. Pain is one of the five “P”s. This is incorrect. Position is not one of the five “P”s This is correct. Paralysis is one of the five “P”s. This is correct. Paresthesia is one of the five “P”s This is incorrect. Pronation is not one of the five “P”s This is correct. Pallor is one of the five “P”s This is correct. Pulselessness is one of the five “P”s

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4. 5.

This is correct. Range of motion should be symmetric bilaterally. This is incorrect. Muscle strength should be at least 4/5 in lower extremities. This is correct. Limitation against resistance indicates there may be a problem in the joint. This is correct. Stretching exercises like yoga build muscle strength. This is correct. Bending, lifting, and repetitive motions increase the risk of injury to the joints.

24. When inspecting the upper extremities with the patient in a relaxed standing position, the nurse expects to observe which of the following? Select all that apply. 1. Straight upper arms 2. Symmetry between left and right upper extremities 3. Forward rounding of the shoulders 4. Wrists in line with the lower arm, palms facing thighs 5. Hyperextension of the elbows ANS: 1, 2, 4 Page: 296

1. 2. 3. 4. 5.

Feedback This is correct. Upper arms should be straight when standing. GRbeAD ESMOREbetween .COM right and left extremities. This is correct. There should symmetry This is incorrect. There should be no forward rounding of the shoulders. This is correct. Wrists should be in line with the lower arm with palms facing the thighs. This is incorrect. There should be slight bending at the elbow.

1. 2. 3.

Feedback This is incorrect. Forward flexion of the hip indicates a problem with the hip joint. This is correct. Forward flexion of the hip when standing may indicate tightness of the muscular structure. This is correct. Forward flexion of the hip when standing may indicate a problem with

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

the lower back. This is incorrect. An increase in flexion of the knee may indicate a knee injury.

26. Prevention of disease and disability of the musculoskeletal system can be accomplished by working to maintain a level of wellness. This can be accomplished through which of the following? Select all that apply. 1. Eating foods rich in calcium, vitamin D, magnesium, and phosphorus 2. Maintaining an ideal body weight 3. Exercising on a regular basis 4. Performing stretching and flexibility exercises 5. Maintaining good body mechanics ANS: 1, 2, 3, 4, 5 Page: 311

2. 3. 4. 5.

Feedback This is correct. Eating a diet that includes foods rich in calcium, vitamin D, magnesium, and phosphorus improves the level of wellness of the musculoskeletal system. This is correct. Maintaining an ideal body weight improves the wellness of the musculoskeletal system by decreasing its workload. This is correct. Regular phyGsR icA alDeE xeSrcMisOeRhE el. psCtOoMkeep muscles and bones strong and active. This is correct. Flexing and flexibility exercises help to keep the musculoskeletal system strong and active. This is correct. Good body mechanics help to prevent injuries to the musculoskeletal system.

27. Assessment of the geriatric patient’s posture and gait can be assessed as he or she enters the room. This will help the nurse to identify a patient’s risk. ANS: fall Page: 290 Feedback: When assessing gait and posture in some patients, you may need to provide them with something to hold on to while they walk. Geriatric patients and some patients with neurological conditions may not have the best balance, placing them at risk for falls.

28. is an unsteady gait, which can be used to compensate for an injury or pain in an extremity. It may also indicate a problem with cerebellar function.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: Ataxia Page: 291 Feedback: Ataxia is a shuffling gait that allows for some mobility when an extremity is compromised by injury or pain. It may also be indicative of a problem in cerebellar function.

29. Asking a patient to rub the back of his head with his right hand and then the left hand allows functional assessment of rotation of the shoulder joint. ANS: external Page: 299 Feedback: Placing the palmar surface of the hands up and behind the neck moves the shoulders to a position of external rotation.

30. An exaggerated curvature in the thoracic spine is a common finding in an elderly person due to osteoporosis. This condition of the vertebrae is known as .

GRADESMORE.COM

ANS: kyphosis Page: 295

Feedback: Kyphosis is an exaggerated curvature of the spine due to osteoporosis that occurs in the elderly.

31. Identify the test. Ask the patient to flex both wrists and press them together for 1 minute. Ask the patient if there is any numbness and tingling sensations. This test is known as test. ANS: Phalen’s; Phalens Page: 302 Feedback: Phalen’s test reproduces numbness and burning along the median nerve pathway in a person with carpal tunnel syndrome.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

33. Mrs. Green complains of pain in both hands related to osteoarthritis. During the musculoskeletal assessment of her hands, you discover nodes on the distal joints of her fingers. These nodes are commonly identified as nodes. ANS: Heberden’s; Herberdens Page: 297 Feedback: Heberden’s nodes are bony enlargements on the distal joints and are commonly seen in osteoarthritis.

GRADESMORE.COM 34. The patient reports that she is having pain with erythema on the right side of her left great toe. You assess the patient’s left foot and note a lateral deviation and enlarged joint of the left great toe. This deviation and enlargement is called . ANS: hallux valgus Page: 306 Feedback: Hallux valgus (bunion) is a lateral deviation and an enlarged joint of the great toe.

35. The patient has degenerative disc disease with a complication of foot drop. This is where the foot is at degrees to the lower leg. ANS: 90; ninety Page: 291 Feedback: Foot drop is a weakness or paralysis of the muscles of the lower leg or the inability to control plantar flexion of the ankle. It may indicate nerve injury or muscle or neurological disorders. This is where the foot is at 90 degrees to the lower leg, much like the letter L.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

36. You are performing a musculoskeletal assessment. Put the steps of the assessment in order (1–4). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Assessing strength 2. Palpating 3. Inspecting 4. Assessing range of motion ANS: 3241 Page: 289 Feedback: The musculoskeletal assessment is done in the following order: inspecting, palpating, assessing range of motion, and assessing strength.

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 17: Assessing the Neurological System

1. The nursing student is reviewing sleep habits with the patient. The patient states he always “feels sleepy” during the day and he sleeps 4 to 5 hours per night. The student nurse should educate the patient by making which of the following statements? 1. “Sleep deprivation can affect your cerebral function.” 2. “Sleep deprivation can result in increased intracranial pressure.” 3. “Sleep deprivation puts you at risk for a stroke.” 4. “Four to five hours of sleep per night is adequate for an adult.”

2. The nurse is educating the patient on foods to avoid that may trigger headaches. The nurse knows the client needs further education by which of the following statements? 1. “I will need to avoid chocolate.” 2. “I will be limiting my trips to the local coffee shop.” 3. “It will be okay. I can still have my weekly Chinese food.” 4. “I will eliminate fruit and brown rice from my diet.”

GRADESMORE.COM 3. The nurse is performing a neurological assessment and needs to assess the patient’s position sense and coordination of movement. Which assessment technique should the nurse perform? 1. Gait and position sense test 2. Finger to nose test 3. Heel to shin test 4. Tandem walking

4. Your patient presents to the doctor’s office with a complaint of experiencing problems with balance and coordination. You immediately recall this may indicate damage to the: 1. Cerebellum. 2. Brainstem. 3. Cranial nerves. 4. Pons.

5. The nurse just performed as assessment of the patient’s gait as part of the complete neurological assessment. The nurse documents “unable to perform tandem walking.” What did she assess for? 1. Muscular weakness 2. Dorsiflexion foot weakness

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. Balance and gait 4. Cerebellar function

6. The nurse needs to perform the Romberg test as part of her neurological assessment. The Romberg test assesses: 1. Position sense, cerebellar function, balance, and coordination. 2. Coordination of movement and position sense. 3. Cerebellar function, coordination, and point-to-point movements. 4. Motor function and proprioception.

7. The nurse at the college health clinic is assessing a 19-year-old male. The patient presents with a headache, neck stiffness, deep red rash on his abdomen, and flulike symptoms. The nurse applies pressure and the rash does not fade. The nurse recalls this is indicative of: 1. Transient ischemic attack. 2. Concussion. 3. Meningitis. 4. Encephalopathy.

GRADESMORE.COM 8. The nurse is assessing cranial nerve VII, the facial nerve, on a 43-year-old female patient. The patient exhibits new onset asymmetrical muscles while smiling and puffing her cheeks. This is referred to as: 1. Bell’s palsy. 2. Trigeminal neuralgia. 3. Lyme disease. 4. Congenital defect.

9. Concussion is a traumatic brain injury. Which of the following has been proven to be a temporary result of a concussion? 1. Short-term blindness 2. Short-term paralysis 3. Short-term memory loss 4. Long-term memory loss

10. The nurse is performing a neurological assessment on her patient. She is assessing sensation of the skin. The patient reports he is experiencing numbness and tingling in both of his feet. The nurse recalls this is called:

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Paralysis. 2. Aphasia. 3. Neuropathy. 4. Transient ischemic attack.

11. During the end of shift report, the nurse stated the client experienced damage to Broca’s area of the brain. What finding would the nurse expect to find during the neurological assessment? 1. Dysphasia 2. Aphasia 3. Receptive aphasia 4. Expressive aphasia

12. As part of the neurological assessment the nurse asked the patient to shrug both shoulders against resistance. The nurse is assessing which cranial nerve? 1. Cranial nerve XII 2. Cranial nerve XI 3. Cranial nerve X 4. Cranial nerve VIII

GRADESMORE.COM 13. The nurse needs to assess abduction of the patient’s upper extremity. Which is the correct method for this assessment? 1. Ask the patient to move the upper extremity away from the body up to 180 degrees. 2. Ask the patient to move the upper extremity away from the body up to 90 degrees. 3. Ask the patient to move the upper extremity toward the waist up to 90 degrees. 4. Ask the patient to move the upper extremity backward with the thumb facing forward.

14. After performing a neurological assessment the nurse documents “Client is lethargic.” The student recalls this level of consciousness to mean that the patient is: 1. Disoriented. 2. Drowsy. 3. Difficult to arouse. 4. Unconscious.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Cranial nerve IV 2. Cranial nerve III 3. Cranial nerve X 4. Cranial nerve I

16. After assessing cranial nerve V, the nurse documents her findings as: “Patient was unable to clench jaw and move jaw side to side.” This assessment indicates: 1. A normal assessment. 2. Bell’s palsy. 3. Trigeminal neuralgia. 4. Absence of gag reflex.

17. What test assesses cranial nerve VIII? 1. Whisper test 2. Romberg test 3. Pharyngeal sensation test 4. Wisping cotton on both cheeks

GRADESMORE.COM 18. The nurse assesses cranial nerve IX (glossopharyngeal nerve) and cranial nerve X (vagus nerve). The results exhibit difficulty with swallowing and a coarse, raspy voice after taking a sip of water. Based on these findings, which action should the nurse perform next? 1. Order a full liquid diet. 2. Order a regular diet with observation during all meals. 3. Notify the health-care provider. 4. Repeat the examination to validate results.

19. The nurse is performing a neurological assessment and asks the patient to stick out his tongue and move it side to side. Which cranial nerve is being assessed? 1. Cranial nerve VII 2. Cranial nerve V 3. Cranial nerve XII 4. Cranial nerve VIX

20. The nurse is performing the finger to nose test. Which of the following is the nurse assessing? 1. Cerebellar function, coordination, and point-to-point movements

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. Coordination of movement and position sense 3. Coordination only 4. Proprioception only

21. The nurse is assessing graphesthesia. This technique assesses: 1. The sensation of touch or tactile stimulation. 2. The sensation of position and balance. 3. The indication of loss in sensory nerves. 4. The sensation of proprioception.

22. The American Stroke Association developed the mnemonic FAST as an easy way to remember the sudden signs of stroke. What does the S indicate? 1. Sleepy 2. Speech difficulty 3. Sudden loss of consciousness 4. Snoring respirations

GRADESMORE.COM 23. The nurse documented: “The patient has anosmia when CNI is assessed.” What is anosmia? 1. Inability to smell or identify the correct scent 2. Poor visual acuity; distant objects appear blurred 3. Hypersensitive smell when identifying different scents 4. Ability to identify scents in one nare but not the other

24. A mother brings her teenage son to his health-care provider’s office for follow-up of a concussion injury. The mother states, “I am concerned because he just does not remember to follow through with simple tasks.” Which statement by the nurse is appropriate? 1. “This is a temporary loss of memory from the concussion injury.” 2. “This is typical behavior for an adolescent boy.” 3. “This is unusual and should have been resolved by now.” 4. “I will let the doctor know right away.”

25. What deep tendon reflex involves the examiner stretching the biceps tendon to assess cervical 5 and 6? 1. Triceps reflex 2. Biceps reflex 3. Brachioradialis reflex

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Quadriceps reflex

26. The nurse has put an object in the patient’s hand to assess the perception of the object’s shape. What is the name of this assessment technique? 1. Deep tendon reflexes 2. Pronator drift 3. Graphesthesia 4. Stereognosis

27. The nurse is assessing the brachioradialis reflex. What would be a normal finding? 1. Clonus of the arm 2. Flexion and extension of the forearm 3. Flexion and supination of the knee 4. Flexion and supination of the forearm

28. When assessing the assessment technique of pronator drift, the patient should close his or her eyes and the nurse would observe the patient’s arms for change in position for seconds. GRADESMORE.COM 1. 30 to 40 2. 20 to 30 3. 10 to 20 4. 15 to 20

29. Which of the following advanced assessment techniques would assess for the neuron disease of the corticospinal tract? 1. Plantar reflex 2. Achilles reflex 3. Triceps reflex 4. Biceps reflex

30. Which of the following advanced deep tendon reflex assessments would indicate abnormal findings of lumbar 2, 3, and 4? 1. Plantar reflex 2. Achilles reflex 3. Quadriceps reflex

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Triceps reflex

31. The nurse is assessing the patient’s sensation and movement of the extremities. Which finding would indicate the patient is exhibiting paraplegia? 1. Absence of movement on the right side upper and lower extremities 2. Absence of movement and sensation in bilateral lower extremities 3. Absence of movement and sensation in upper and lower extremities 4. Absence of movement and sensation in upper extremities

32. The patient was in a motor vehicle accident and suffered traumatic brain injury. What posture is this patient exhibiting? 1. Decerebrate posturing 2. Decorticate posturing 3. Rigidity GRADESMORE.COM 4. Hypertonia

33. You are assessing gait. What is the purpose of the assessment technique shown in the image? 1. To assess position sense 2. To assess balance and gait 3. To assess coordination 4. To assess posture

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

34. After completing an assessment on gait and position, the nurse identifies the patient exhibits ataxia, defective muscle coordination. The nurse recalls this may be related to which of the following? Select all that apply. 1. Drugs 2. Alcohol 3. Cerebellar disease 4. Smoking 5. Vertigo

35. The nurse received a report that the patient has Parkinson’s disease. What assessment findings would the patient exhibit during the neurological assessment? Select all that apply. 1. Bradykinesia 2. Rigidity of extremities 3. Tremors of hands 4. Postural stability 5. Dysdiadochokinesia

36. There are numerous diagnostic tests to assist in neurological diagnosis. Select from the list which diagnostic tests would aid in a neurological diagnosis. Select all that apply. 1. Computed tomography (CT) scan GRADESMORE.COM 2. Lumbar puncture 3. Positron emission tomography (PET) scan 4. Chest x-ray 5. Complete metabolic blood panel

37. Inspection is a key assessment technique. While obtaining a review of systems, which of the following are observations the nurse would make? Select all that apply 1. Is the patient dressed appropriately for weather and culture? 2. Is the patient able to communicate? 3. What is the patient’s affect? 4. Does the patient recall the month and year? 5. Is the patient’s heart rate regular?

38. The nurse is assessing the patient with a diagnosis of myasthenia gravis. Which assessment findings should the nurse expect? Select all that apply. 1. Muscle fatigue 2. Slurred speech 3. Drooping eyelid

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Spastic movements 5. Short-term memory loss

39. When the nurse is assessing mental status, he or she should assess which of the following? Select all that apply. 1. Orientation 2. Level of consciousness 3. Ability to move all four extremities 4. Short- and long-term memory 5. Gait

40. Identify the normal findings of the finger to nose test. Select all that apply. 1. Patient is able to put the cap on the pen accurately and smoothly. 2. Patient is able to touch the nurse’s finger and nose accurately. 3. Patient is unable to touch the stationary finger with eyes closed. 4. Patient exhibits dysmetria. 5. Patient has spasticity when performing the examination.

GRADESMORE.COM 41. You are performing a neurological assessment on a 78-year-old female patient. You are assessing her level of consciousness. What questions should you ask? Select all that apply. 1. What is your name? 2. What is the name of your health-care provider? 3. What is the name of the town where you grew up? 4. What is your favorite color? 5. What is today’s date? 6. Who is the president of the United States?

42. You are about to begin a neurological assessment. Put the steps in order (1–6). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Assess cranial nerve function. 2. Assess motor system. 3. Perform inspection/observation. 4. Assess level of consciousness and mental status. 5. Assess sensory system. 6. Assess reflexes.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

44. You are going to assess graphesthesia. Place the steps of the assessment technique in the correct sequence (1–6). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Ask the patient to close the eyes. 2. Write a letter on the palm of the hand. 3. Ask the patient to state which letter was written on the palm of the hand. GRADESMORE.COM 4. Have the patient extend arm and turn palm toward ceiling. 5. Explain the technique. 6. Repeat on the opposite palm.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

47. The Mini-Mental State Examination (MMSE) is a valuable tool to assess impairment.

48. You are performing a neurological assessment. The normal diameter range of pupils is to mm.

49. Using the handle of a reflex hammer, stroke the lateral side of the sole of the patient’s right foot upward toward the great toe. The reflex is being assessed.

GRADESMORE.COM 50. You are a nurse working in the emergency room. The patient is a 21-year-old male who was in a serious motor vehicle accident. You are assessing the patient’s mental status using the Glasgow coma scale. The Glasgow coma scale evaluates the following three responses: , , and .

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers 1. The nursing student is reviewing sleep habits with the patient. The patient states he always “feels sleepy” during the day and he sleeps 4 to 5 hours per night. The student nurse should educate the patient by making which of the following statements? 1. “Sleep deprivation can affect your cerebral function.” 2. “Sleep deprivation can result in increased intracranial pressure.” 3. “Sleep deprivation puts you at risk for a stroke.” 4. “Four to five hours of sleep per night is adequate for an adult.” ANS: 1 Page: 317

1. 2. 3. 4.

Feedback This is correct. Sleep deprivation can affect cerebral function. This is incorrect. Increased intracranial pressure is cause by an injury or infarct, not sleep deprivation. This is incorrect. Sleep deprivation is not a risk factor for stroke. This is incorrect. Adults should sleep a minimum of 6 to 8 hours per night.

2. The nurse is educating the patient on foods to avoid that may trigger headaches. The nurse GRADESMORE.COM knows the client needs further education by which of the following statements? 1. “I will need to avoid chocolate.” 2. “I will be limiting my trips to the local coffee shop.” 3. “It will be okay. I can still have my weekly Chinese food.” 4. “I will eliminate fruit and brown rice from my diet.” ANS: 4 Page: 317

1. 2. 3. 4.

Feedback Chocolate is a trigger food for headaches because it contains the amino acid tyramine. Coffee should be limited because increased caffeine is a trigger for headaches. Chinese food contains monosodium glutamate (MSG), which is a trigger additive for headaches. This is the correct answer. Fruits and whole grains have not been identified as triggers for headaches and do not contain preservatives.

3. The nurse is performing a neurological assessment and needs to assess the patient’s position sense and coordination of movement. Which assessment technique should the nurse perform? 1. Gait and position sense test

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. Finger to nose test 3. Heel to shin test 4. Tandem walking ANS: 3 Page: 332

1. 2. 3. 4.

Feedback This is incorrect. Gait and position sense tests for balance, coordination, muscle strength, and tone. This is incorrect. Finger to nose tests for coordination and point to point movements. This is correct. Heel to shin tests for coordination of movement and position sense. This is incorrect. Tandem walking assesses balance and gait.

GRADESMORE.COM

ANS: 1 Page: 313

1. 2. 3. 4.

Feedback This is correct. Damage to the cerebellum exhibits symptoms of problems with balance and coordination. This is incorrect. Damage to the brainstem indicates brain death. This is incorrect. This is a vague answer and not specific to one cranial nerve. This is incorrect. Damage to the pons exhibits loss of control of respiratory function.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. Tandem walking does not assess for muscle weakness. This is incorrect. Tandem walking does not assess for dorsiflexion foot weakness. This is correct. Tandem walking assesses for balance and gait. This is incorrect. Tandem walking does not assess for cerebellar function.

1. 2. 3. 4.

Feedback This is correct. The Romberg test assesses cerebellar function, position sense, balance, and coordination. This is incorrect. The heel to shin test assesses coordination of movement and position sense. This is incorrect. The fingerGRADESMORE.COM to nose test assesses cerebellar function, coordination, and point to point movements. This is incorrect. Pronator drift assesses motor function and proprioception.

1. 2. 3.

Feedback This is incorrect. Transient ischemic attack is temporary loss of muscular function on one side of the body as a result of a clot in the brain. This is incorrect. A concussion is a bruise on the brain and does not have rash as a symptom. This is correct. Meningitis presents with a deep, red rash on the abdomen that does not

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

fade when pressure is applied. This is incorrect. Encephalopathy is swelling of the meninges and does not have rash as a symptom.

8. The nurse is assessing cranial nerve VII, the facial nerve, on a 43-year-old female patient. The patient exhibits new onset asymmetrical muscles while smiling and puffing her cheeks. This is referred to as: 1. Bell’s palsy. 2. Trigeminal neuralgia. 3. Lyme disease. 4. Congenital defect. ANS: 1 Page: 327

1. 2. 3. 4.

Feedback This is correct. Bell’s palsy can exhibit unilateral muscle weakness of the facial muscles. This is incorrect. Trigeminal neuralgia is indicated when the patient cannot clench the jaw. This is incorrect. Lyme disease is a tick-borne disease, which affects the large GRADESMORE.COM muscles. This is incorrect. This symptom is of new onset so would not be a congenital defect.

1. 2. 3. 4.

Feedback This is incorrect. Blindness has not been proven to be a temporary result of a concussion. This is incorrect. Paralysis has not been proven to be a temporary result of a concussion. This is correct. Short-term memory loss is proven to be a temporary result of a concussion. This is incorrect. Long-term memory loss is not a temporary result of a concussion but

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

would be a permanent loss.

1. 2. 3. 4.

Feedback This is incorrect. Paralysis is loss of function of muscles. This is incorrect. Aphasia is difficulty with speech, understanding language, or reading and writing. This is correct. Neuropathy is numbness and/or tingling in extremities caused by nerve damage or injury. This is incorrect. Transient ischemic attack is stroke or neuropathy indicated by loss of sensation.

GRADESMORE.COM

1. 2. 3. 4.

Feedback This is incorrect. Dysphasia is a general term for difficulty speaking. If there is damage to Broca’s area, the deficit is specifically expressive aphasia. This is incorrect. Aphasia is a result of damage to the right side of the brain not specific to Broca’s area. This is incorrect. Receptive aphasia is a result of damage to Wernicke’s area of the brain. This is correct. Expressive aphasia is caused by damage to Broca’s area of the brain.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. The hypoglossal nerve is a motor nerve of tongue movement. This is correct. The spinal accessory nerve is a motor nerve of head and shoulder movement. This is incorrect. The vagus nerve does not control head and shoulder movement. This is incorrect. The vestibulocochlear nerve is a sensory nerve of hearing.

13. The nurse needs to assess abduction of the patient’s upper extremity. Which is the correct method for this assessment? 1. Ask the patient to move the upper extremity away from the body up to 180 degrees. 2. Ask the patient to move the upper GRADESMORE.COM extremity away from the body up to 90 degrees. 3. Ask the patient to move the upper extremity toward the waist up to 90 degrees. 4. Ask the patient to move the upper extremity backward with the thumb facing forward. ANS: 1 Page: 330

1. 2. 3. 4.

Feedback This is correct. Abduction is moving the extremity away from the body up to 180 degrees. This is incorrect. Abduction is moving the extremity away from the body up to 180 degrees, not 90 degrees. This is incorrect. This is adduction, not abduction. This is incorrect. This is extension, not abduction.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 2 Page: 323

1. 2. 3. 4.

Feedback This is incorrect. A patient can be disoriented to time, person, and place. This does not define lethargy. This is correct. This is the definition of lethargy. A patient is drowsy. This is incorrect. Somnolent is the term used to describe a patient who is difficult to arouse. This is incorrect. Coma is the term used to describe a patient who is unconscious.

15. While performing a neurological assessment the nurse has the patient hold one nostril closed and identify two to three distinct scents with the open nostril. Which cranial nerve has just been assessed? 1. Cranial nerve IV 2. Cranial nerve III 3. Cranial nerve X 4. Cranial nerve I ANS: 4 Page: 314

1. 2. 3. 4.

GRADESMORE.COM

Feedback This is incorrect. Cranial nerve IV is the trochlear nerve. This is incorrect. Cranial nerve III is the oculomotor nerve. This is incorrect. Cranial nerve X is the vagus nerve This is correct. Cranial nerve I is the olfactory nerve.

Feedback This is incorrect. This is not a normal assessment if the patient cannot clench the jaw and move it from side to side.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3. 4.

This is incorrect. Bell’s palsy is paralysis of the facial muscles. This is correct. Trigeminal neuralgia is when the patient is unable to clench the jaw or move it side to side. This is incorrect. Cranial nerve V is the trigeminal nerve and does not assess gag reflex.

17. What test assesses cranial nerve VIII? 1. Whisper test 2. Romberg test 3. Pharyngeal sensation test 4. Wisping cotton on both cheeks ANS: 1 Page: 327

1. 2. 3. 4.

Feedback This is correct. The Whisper test assesses the vestibulocochlear nerve, cranial nerve VIII. This is incorrect. The Romberg test assesses balance and proprioception. This incorrect. The pharyngeal sensation tests the glossopharyngeal nerve, cranial nerveisVIX.

GRADESMORE.COM

This is incorrect. Wisping cotton on both cheeks assesses the facial nerve, cranial nerve VIII.

18. The nurse assesses cranial nerve IX (glossopharyngeal nerve) and cranial nerve X (vagus nerve). The results exhibit difficulty with swallowing and a coarse, raspy voice after taking a sip of water. Based on these findings, which action should the nurse perform next? 1. Order a full liquid diet. 2. Order a regular diet with observation during all meals. 3. Notify the health-care provider. 4. Repeat the examination to validate results. ANS: 3 Page: 319

1. 2. 3.

Feedback This is incorrect. The patient is at risk for aspiration and should not eat. The healthcare provider needs to be notified. This is incorrect. The patient is at risk for aspiration and should not eat. The healthcare provider needs to be notified. This is correct. The health-care provider needs to be notified. The patient is at risk for aspiration and will need a speech therapy evaluation.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is incorrect. Repeating the examination places the patient at risk for aspiration.

1. 2. 3. 4.

Feedback This is incorrect. Facial nerve (cranial nerve VII) is a sensation nerve of the face. This is incorrect. Trigeminal nerve (cranial nerve V) is a motor nerve of the jaw. This is correct. Hypoglossal nerve (cranial nerve XII) is a motor nerve of the tongue. This is incorrect. Glossopharyngeal nerve (cranial nerve VIX) is a motor nerve of the pharynx.

GRADESMORE.COM 20. The nurse is to performing f of inger nose test. the Which

the following is

the nurse assessing? 1. Cerebellar function, coordination, and point-to-point movements 2. Coordination of movement and position sense 3. Coordination only 4. Proprioception only ANS: 1 Page: 330

1. 2. 3. 4.

Feedback This is correct. The finger to nose test assesses cerebellar function, coordination, and point-to-point movements. This is incorrect. Coordination of movement and sense is not tested by the finger to nose test. This is incorrect. This finger to nose test does not assess coordination only. This is incorrect. This finger to nose test does not assess proprioception.

21. The nurse is assessing graphesthesia. This technique assesses: 1. The sensation of touch or tactile stimulation. 2. The sensation of position and balance.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. The indication of loss in sensory nerves. 4. The sensation of proprioception. ANS: 1 Page: 336

1. 2. 3. 4.

Feedback This is correct. Graphesthesia assesses the sensation of touch or tactile stimulation. This is incorrect. The Romberg test assesses position and balance. This is incorrect. Neuropathy is the loss in sensation of sensory nerves. This is incorrect. Pronator drift assesses for proprioception.

1. 2. 3. 4.

GRADESMORE.COM

Feedback This is incorrect. Being sleepy is not the first sign of a stroke. This is correct. Speech difficulty is a sign of a stroke. This is incorrect. Sudden loss of consciousness is not part of the mnemonic for a stroke. This is incorrect. Snoring respirations is not part of the mnemonic for a stroke.

23. The nurse documented: “The patient has anosmia when CNI is assessed.” What is anosmia? 1. Inability to smell or identify the correct scent 2. Poor visual acuity; distant objects appear blurred 3. Hypersensitive smell when identifying different scents 4. Ability to identify scents in one nare but not the other ANS: 1 Page: 324

1. 2.

Feedback This is correct. Anosmia is the inability to smell or identify the correct scent. This is incorrect. Myopia, or nearsightedness, is poor visual acuity; distant objects appear blurred.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

This is incorrect. Anosmia is not hypersensitive smell. This is incorrect. This is not a true assessment finding.

1. 2. 3. 4.

Feedback This is correct. Long-term memory and temporary short-term memory loss are proven with concussion and traumatic injury from contact sports. This is incorrect. This is not typical behavior for an adolescent boy. This is incorrect. This is not an appropriate response, as it will increase the stress the mother is exhibiting. This is incorrect. The physician does not need to be immediately notified, as there is GRADESMORE.COM no life-threatening symptom being exhibited.

25. What deep tendon reflex involves the examiner stretching the biceps tendon to assess cervical 5 and 6? 1. Triceps reflex 2. Biceps reflex 3. Brachioradialis reflex 4. Quadriceps reflex ANS: 2 Page: 339

1. 2. 3. 4.

Feedback This is incorrect. Triceps reflex assesses cervical 6 and 7, and the triceps tendon. This is correct. Biceps reflex assesses cervical 5 and 6, and stretches the biceps tendon This is incorrect. Brachioradialis reflex assesses cervical 5 and 6, and the brachioradialis muscle. This is incorrect. Quadriceps reflex assesses lumbar 2, 3, and 4.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. Deep tendon reflexes do not assess perception. This is incorrect. Pronator drift assesses proprioception This is incorrect. Graphesthesia assesses the sensation of touch or tactile stimuli. This is correct. Stereognosis assesses the perception of the shape of an object.

GRADESMORE.COM

ANS: 4 Page: 340

1. 2. 3. 4.

Feedback This is incorrect. This is not an abnormal reflex response. This is incorrect. This is not the expected normal response. This is the response for the triceps reflex. This is incorrect. This is not a deep tendon reflex finding of the lower extremity. This is correct. Flexion and supination of the forearm is a normal response when assessing the brachioradialis reflex.

28. When assessing the assessment technique of pronator drift, the patient should close his or her eyes and the nurse would observe the patient’s arms for change in position for seconds. 1. 30 to 40 2. 20 to 30 3. 10 to 20 4. 15 to 20 ANS: 2

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Page: 335

1. 2. 3. 4.

Feedback This is incorrect. This is too long of a time frame. The correct time is 20 to 30 seconds. This is correct. This is the recommended time. This is incorrect. This is too short of a time frame. The correct time is 20 to 30 seconds. This is incorrect. This is too short of a time frame. The correct time is 20 to 30 seconds.

29. Which of the following advanced assessment techniques would assess for the neuron disease of the corticospinal tract? 1. Plantar reflex 2. Achilles reflex 3. Triceps reflex 4. Biceps reflex ANS: 1 Page: 343

2. 3. 4.

GRADESMORE.COM Feedback This is correct. The plantar reflex abnormal response is the Babinski reflex. The big toe extends upward and the other toes fan out, indicating neuron disease of the corticospinal tract. This is incorrect. The Achilles reflex simply assesses the plantar flexion. This is incorrect. The triceps reflex assesses sensory and motor pathways at the level of cervical discs 6 and 7. This is incorrect. The biceps reflex assesses sensory and motor pathways at the level of cervical discs 5 and 6.

30. Which of the following advanced deep tendon reflex assessments would indicate abnormal findings of lumbar 2, 3, and 4? 1. Plantar reflex 2. Achilles reflex 3. Quadriceps reflex 4. Triceps reflex ANS: 3 Page: 341 Feedback

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

This is incorrect. Plantar reflex does not assess lumbar discs. This is incorrect. Achilles reflex assesses sensory and motor pathways at the level of S1 and S2. This is correct. Quadriceps reflexes directly assesses sensory and motor pathways at the level of lumbar discs 2, 3, and 4. This is incorrect. Triceps reflex assesses sensory and motor pathways at the level of cervical 6 and 7.

1. 2. 3. 4.

Feedback This is incorrect. This indicates right-sided hemiparesis. This is correct. This is paraplegia. GR DESMORE.COM This is incorrect. This is quadriplegia. A This is incorrect. This is not paraplegia or quadriplegia.

Feedback This is correct. Decerebrate posturing is arms stiffly extended, adducted, and

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3. 4.

hyperpronated with hyperextension of the legs and plantar flexion of the feet. This is incorrect. Decorticate posturing is internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers. This is incorrect. Rigidity is not a form of posturing, it is increased motor tone. This is incorrect. Hypertonia is not a form of posturing, it is increased muscle tone.

1. 2. 3. 4.

GRADESMORE.COM

Feedback This is incorrect. Tandem walking does not assess for position sense. This is correct. Tandem walking assesses balance and gait. This is incorrect. Tandem walking does not assess for coordination, but balance and gait. This is incorrect. Tandem walking does not assess for posture, but balance and gait.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4. 5.

Feedback This is correct. Drugs can cause ataxia. This is correct. Alcohol can cause ataxia. This is correct. Cerebellar disease may be related to ataxia. This is incorrect. Smoking does not cause or contribute to ataxia. This is incorrect. Vertigo does not cause ataxia but perceptions that the area around the patient is spinning.

GRADESMORE.COM

This is correct. Bradykinesia is slowness of movement and is a symptom of Parkinson’s disease. This is correct. Rigidity of extremities is a symptom of Parkinson’s disease This is correct. Tremors of hands are a symptom of Parkinson’s disease. This is incorrect. Postural instability, not stability, is a symptom of Parkinson’s disease. This is correct. Dysdiadochokinesia is uncoordinated, slow, and clumsy movements and may be a sign of Parkinson’s disease.

36. There are numerous diagnostic tests to assist in neurological diagnosis. Select from the list which diagnostic tests would aid in a neurological diagnosis. Select all that apply. 1. Computed tomography (CT) scan 2. Lumbar puncture 3. Positron emission tomography (PET) scan 4. Chest x-ray 5. Complete metabolic blood panel ANS: 1, 2, 3 Page: 316 Feedback

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4. 5.

This is correct. CT scan will help aid in diagnosing disorders of the brain and spinal tract. This is correct. Lumbar puncture will help in diagnosing diseases of the spinal tract and fluid. This is correct. PET scan is similar to a CT scan and can assist in neurological disease diagnosis. This is incorrect. Chest x-ray is not helpful in diagnosing neurological conditions. This is incorrect. Completed metabolic blood panel is general bloodwork related to electrolytes and kidney functioning and is not a typical test used in diagnosing neurological disease.

1. 2. 3. 4. 5.

GRADESMORE.COM

Feedback This is correct. The nurse can observe whether the patient is dressed appropriately. This is correct. This is an objective assessment of communication and the ability to speak. This is correct. The nurse can observe the patient’s affect. Affect can be observed through facial expression or body movement. This is incorrect. This is an objective mental status assessment assessing orientation. This is incorrect. The nurse palpates the pulse or auscultates heart rate for regularity.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4. 5.

Feedback This is correct. Muscle fatigue is a symptom of myasthenia gravis. This is correct. Slurred speech is a symptom of myasthenia gravis. This is correct. Drooping eyelid is a symptom of myasthenia gravis. This is incorrect. Spastic movements are a sign of Parkinson’s disease, not myasthenia gravis. This is incorrect. Short-term memory loss is not a normal sign of myasthenia gravis.

1. 2. 3. 4. 5.

Feedback This is correct. Orientation is the second part of the mental status assessment. GRADESMORE.COM This is correct. Level of consciousness is the first part of the mental status assessment. This is incorrect. Ability to move all four extremities is not part of the mental status assessment. This is correct. Short- and long-term memory are assessed in the mental health assessment. This is incorrect. Gait is not part of the mental status assessment.

Feedback This is correct. This is assessed in the finger to nose test. Patient is able to put the cap on the pen accurately and smoothly.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3.

4. 5.

This is correct. This is assessed in the finger to nose test. Patient touches the nurse’s finger and nose accurately and smoothly in all locations. This is incorrect. This is not a normal finding of the finger to nose assessment. Patient touches the nurse’s finger accurately and smoothly in one location with eyes closed. This is incorrect. Dysmetria is the inability to perform point-to-point movements. This is incorrect. Assessing spasticity is not assessed in the finger to nose test.

41. You are performing a neurological assessment on a 78-year-old female patient. You are assessing her level of consciousness. What questions should you ask? Select all that apply. 1. What is your name? 2. What is the name of your health-care provider? 3. What is the name of the town where you grew up? 4. What is your favorite color? 5. What is today’s date? 6. Who is the president of the United States? ANS: 1, 2, 3, 5, 6 Page: 322

1. 2. 3. 4. 5. 6.

Feedback GRADESMORE.COM This is correct. You are assessing orientation to person. This can be validated using secondary resources. This is correct. You are assessing short-term memory. This can be validated using secondary resources. This is correct. You are assessing long-term memory. This can be validated using secondary resources. This is incorrect. You cannot validate a person’s favorite color with a secondary source. This is correct. You are assessing orientation to time. This can be validated using secondary resources. This is correct. You are assessing current events and short-term memory. This can be validated using secondary resources.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 341256 Page: 322 Feedback: The neurological assessment starts with inspection and observation of the patient. Second, the level of consciousness and mental status are assessed. Third, assess cranial nerve function followed by assessing the motor system then the sensory system. Last, the five deep tendon reflexes are assessed.

43. You are working in the emergency room. A patient reports that he fell off a ladder washing windows. You are assessing his shoulder and head movement. Place the steps of the assessment technique in the correct order (1–6) to assess cranial nerve XI, the spinal accessory muscle. (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Ask the patient to shrug his shoulders against resistance of examiner pushing down on shoulders. 2. Ask the patient to turn head to his right side against resistance of your hand and repeat on other side. 3. Wash your hands. 4. Have the patient sit on the end of the bed or examining table. 5. Stand in front of the patient. GRADESMORE.COM 6. Document your findings. ANS: 345126 Page: 329 Feedback: Always start the assessment by washing your hands, preferably in front of the patient. Position the patient so you can sit and stand in front of the patient to start the assessment. You will have the patient shrug shoulders against resistance and then have the patient turn his head from side to side against resistance. Lastly, you will document your findings.

44. You are going to assess graphesthesia. Place the steps of the assessment technique in the correct sequence (1–6). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Ask the patient to close the eyes. 2. Write a letter on the palm of the hand. 3. Ask the patient to state which letter was written on the palm of the hand. 4. Have the patient extend arm and turn palm toward ceiling. 5. Explain the technique. 6. Repeat on the opposite palm. ANS: 541236

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Page: 336-337 Feedback: You start the assessment by explaining the technique. Instruct the patient to extend the arm with the palm toward the ceiling and then close the eyes. Write a letter on the palm of the hand and ask the patient what letter was written. The technique is repeated on the opposite hand.

45. Place the assessment techniques in the correct order to assess cranial nerve V sensation (1– 6). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Ask the patient to close the eyes. 2. Ask the patient to open the eyes. 3. Tell the patient to inform you every time a light wisp of cotton is felt by stating “now.” 4. Stand in front of the patient and touch the patient’s upper and then lower extremities lightly with the wisp of cotton. 5. Document your findings. ANS: 31425 Page: 325 Feedback: To assess skin sensation, you will first explain the technique to the patient. Ask the patient to close the eyes. Stand in front of the patient and touch the upper and lower extremities GRADESMORE.COM with a wisp of cotton. Lastly, document your findings if the patient felt the wisp of cotton on all extremities.

46. The nurse is assessing a 19-year-old male who has intermittent mild to moderate twitching of his face and upper extremities. You suspect the patient is having a , which is a symptom of a neurological disorder produced by abnormal electrical activity in the brain. ANS: seizure Page: 318 Feedback: A seizure is a symptom of a medical or neurological disorder. Abnormal electrical activity in the brain produces abnormal body movements such as mild to severe twitching, jerking of the muscles, changes in level of consciousness, and rigidity of the body.

47. The Mini-Mental State Examination (MMSE) is a valuable tool to assess impairment. ANS: cognitive

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Page: 323 Feedback: Mental status should be assessed for orientation, memory, and level of consciousness. This is an important indicator of level of neurological status. The Mini-Mental State Examination (MMSE) is a valuable tool to assess cognitive impairment.

48. You are performing a neurological assessment. The normal diameter range of pupils is to mm. ANS: 2; 8 Page: 325 Feedback: Normal pupil diameter range is 2 to 8 mm.

GRADESMORE.COM 49.49. Using the handle of a reflex hammer, stroke the lateral side of the sole of the patient’s right foot upward toward the great toe. The reflex is being assessed. ANS: plantar Page: 342 Feedback: To assess the plantar reflex, use the handle of the reflex hammer and stroke the lateral side of the sole of the patient’s right foot upward toward the great toe. Assess the response of the toes.

50. You are a nurse working in the emergency room. The patient is a 21-year-old male who was in a serious motor vehicle accident. You are assessing the patient’s mental status using the Glasgow coma scale. The Glasgow coma scale evaluates the following three responses: , , and . ANS: eye; motor; verbal (in any order) Page: 323

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Feedback: The Glasgow coma scale (GCS) is an evidence-based assessment of mental status. This scale is widely used and recognized among all interdisciplinary professionals. The scale is based on a score of 3 to 15. This is a more objective way to assess the patient’s level of consciousness. The scale evaluates eye response, motor response, and verbal response, and assesses by checking, observing, and stimulating.

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 18: Assessing the Female Breasts, Axillae, and Reproductive System

1. A woman comes to the clinic because of spotting or bleeding in between her menstrual cycles. Which question is most important for the nurse to ask? 1. “Does the spotting occur during ovulation?” 2. “Does the spotting occur after your period?” 3. “Does the spotting occur during or after sexual intercourse?” 4. “Does the spotting occur during heavy stress?”

2. A woman with a history of dysmenorrhea comes to the clinic for a follow-up appointment. Which question indicates that the nurse understands the major symptoms associated with this condition? 1. “Have you missed any more work during your periods?” 2. “How many pads or tampons did you use last month?” 3. “Has your partner been supportive of your mood swings?” 4. “Did it help to use a nonpetroleum-based lubricant?”

ReEn.stCruOaM 3. A woman comes to the clinic becaG usReAoD fE heSaM vyOm l bleeding each month. Which question is most important for the nurse to ask? 1. “Have you noticed if anything you do makes the bleeding worse?” 2. “How long ago did you start having heavy periods?” 3. “Do you get cramps when you have your period?” 4. “How many pads/tampons do you generally use in 24 hours?”

4. A woman comes to the clinic because she has noticed nipple discharge from her left breast. Which information should the nurse communicate immediately to the health-care provider? 1. Clear discharge 2. Yellow discharge 3. Green discharge 4. Bloody discharge

5. When conducting a health history and physical examination of the breasts, which information is most significant? 1. Patient reports that one breast has always been larger than the other breast. 2. Inspection reveals an area of dimpling or retraction around the nipple. 3. Palpation elicits breast tenderness in both breasts.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Inspection reveals inverted nipples.

6. A 36-year-old female patient visits an outpatient clinic for a routine gynecological examination. When conducting a review of systems, which information would the nurse find as most significant? 1. White or yellow vaginal discharge 2. Frequent abdominal bloating 3. Spotting during ovulation 4. Breast tenderness before menses

7. When observing how a new graduate nurse does an inspection of the female breast, which position illustrates a need for further teaching? 1. Patient seated with the arms hanging by her side 2. Patient seated with the arms placed over her head 3. Patient seated with her hands behind her back 4. Patient seated leaning forward

8. A college student is in an outpatieG ntRcA linDiE cS foM rO aR roE ut.inCeOgM ynecologic examination. When taking the patient’s history, which information is most significant? 1. “I have had such lumpy breasts lately, especially before my periods.” 2. “Lately I have noticed that the area around my right nipple has a rash that is sore and itchy all the time.” 3. “It seems like a week and a half before my period I get a whitish yellow vaginal discharge.” 4. “How come I get a really bad side ache for about a day in the middle of every cycle?”

9. Which approach is best for the nurse to use when palpating the female breast? 1. A circular pattern 2. A radial spoke method 3. A vertical strip pattern 4. A horizontal pattern

10. A nurse is reviewing the chart of a clinic patient and notes the following: “Denies pain, lump, nipple discharge, rash, swelling or trauma.” The nurse recognizes this data relates most directly to which part of a health assessment and physical examination? 1. Biographic data 2. Past history

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. Review of systems 4. Physical examination

11. A female patient presents with a possible diagnosis of polycystic ovary syndrome (PSOS). Which question indicates that the nurse understands the major symptoms associated with PSOS? 1. “Have you noticed a lack of facial hair?” 2. “Have you lost a lot of weight?” 3. “Have your periods been irregular?” 4. “Do you have dysmenorrhea?”

12. A nurse is inspecting the external genitalia of a 34-year-old woman and notices sparse pubic hair. This symptom may be a result of: 1. Candidiasis. 2. Endocrine disease. 3. Fungal infections. 4. Pediculosis pubis.

13. In order to determine a woman’sGseRlfA-cDaE reSaM biOliR tyEr. elC atO edMto breast self-examination, the nurse finds which statement by the patient indicates the need for further teaching? 1. “I make a check mark on the calendar every month after I do a breast examination.” 2. “As soon as I notice symptoms of premenstrual syndrome I make sure I conduct a breast selfexamination.” 3. “I always stand in front of the mirror before my shower to inspect my breasts.” 4. “When I examine my breast, I lie flat on the bed, placing a pillow under the side being examined.”

14. The nurse is correct to question which of the following comments made by a 27-year-old sexually active patient with a history of multiple partners? 1. “I had a Pap test last year, so I need another Pap test in 2 years.” 2. “I was screened for sexually transmitted infections 2 to 3 years ago.” 3. “I was told I should be checked for human papillomavirus (HPV) with my Pap test.” 4. “I do not need to have a mammogram until I am 40 years old.”

15. The nurse is correct to question which of the following comments regarding a woman’s understanding of contraceptive choice(s)? 1. “My birth control pills are a form of contraception to prevent pregnancy.”

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. “I recommend a male or female condom to all my single friends because it may protect them from sexually transmitted infections.” 3. “I hate taking birth control pills because they make me nauseous.” 4. “I have a friend with regular periods and she successfully used the rhythm method and never got pregnant until she was ready.”

16. A 51-year-old patient comes in for a gynecological examination and complains of dry skin, mood changes, irritability, and weight gain. She reports no menstruation in the past 12 months. To obtain further information, which question best encourages the patient to express herself? 1. “Have you had trouble sleeping?” 2. “Have you noticed your hair getting thinner?” 3. “Have you tried a nonpetroleum-based lubricant to help with vaginal dryness?” 4. “How has menopause affected your quality of life?”

17. Which assessment finding relates most directly to a diagnosis of fibrocystic breast disease? 1. Painless lumps in the breast tissue noted to be associated with a woman’s menstrual cycle 2. Painful, fluid-filled lumps located in the breast 3. A solid, round breast lump in a 23-year-old female that moves easily when pushed 4. A hard, fixed, isolated lump in theGrR igA htDuEpS peMr O quRaE dr.aC ntOoM f the right breast

18. A 36-year-old female patient complains she is missing work because of heavy menstrual bleeding. The patient is having heavy menstrual bleeding if she is: 1. Passing small clots. 2. Passing clots the size of a penny. 3. Changing tampons or pads every 1 to 2 hours. 4. Changing tampons or pads every 3 to 4 hours.

19. A female patient is on the schedule for a routine Pap smear today. The patient calls to report she has been using an over-the-counter cream for several days for a possible vaginal infection. The nurse knows that the patient: 1. Will need to reschedule the Pap smear. 2. Needs to be reassured that vaginal creams will not interfere with the examination. 3. Will need to douche before coming in for the examination. 4. Will need a prescription of antibiotics after the Pap smear to treat the infection.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

20. Which of the following patients is most at risk for the development of breast cancer? 1. A 49-year-old woman with history of menarche at age 14 and menopause at age 48 2. A 64-year-old woman with history of menarche at age 10 and menopause at age 53 3. A 45-year-old woman who drinks alcohol on special occasions 4. A 45-year-old woman who had four children and each child was breastfed 9 to 12 months

21. Which symptoms most clearly relates to trichomoniasis? 1. Fishy odor 2. Frothy discharge 3. Thick, white, curd-like discharge 4. Bleeding after sexual intercourse

22. Which question by the nurse best illustrates an understanding of the importance of a patientcentered approach that includes cultural considerations when performing a breast examination? 1. “May I have permission to uncover and expose your breasts?” 2. “Would you ask your partner to please wait outside while I do the examination?” 3. “I am training new students today and they need to observe a breast examination, is that okay?” 4. “Did you know your left breast is a lot bigger than your right breast?”

GRADESMORE.COM 23. With a patient standing and leaning forward, the nurse uses the assessment technique of inspection to observe for: 1. Lumps and tenderness. 2. Tissue density and lumps. 3. Tenderness and nipple deviations. 4. Nipple deviations and skin changes.

24. A female patient is scheduled for a gynecologic examination and Pap smear. The most common position to prepare the patient for a pelvic examination would be to place the patient in: 1. The Trendelenburg position. 2. The supine position. 3. The prone position. 4. The lithotomy position.

25. When conducting a patient history, which symptom indicates that the patient is experiencing normal changes associated with menopause?

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Vaginal bleeding 2. Urinary and bowel incontinence 3. Decreased vaginal secretions 4. Increased breast tenderness

26. A patient states her menstrual cycle is very regular and, according to her calendar, she had a period that started on March 2 that included bleeding for 4 days. Her last menstrual period started on March 31 and she bled 3 to 4 days. Based on this information the patient has a menstrual cycle that lasts how many days? 1. 28 days 2. 29 days 3. 30 days 4. 31 days

27. During a breast examination, the nurse palpates the lymph nodes under the axilla. The nurse knows that which of the following statements is true? 1. Finding a soft, tender, movable lump in the axilla is always a significant finding. 2. The axillary lymph nodes are the last place that cancer may spread. 3. Breast infection or disease may cause enlargement of the lymph node(s). 4. The lymphatic circulation moves fG roRmAtDhE eS axMilO laRtoEw.aCrdOtM he breast.

28. A 23-year-old woman comes to the clinic because of heavy bleeding during her periods that lasts for 7 days. The nurse would document this as: 1. Amenorrhea. 2. Menorrhagia. 3. Metrorrhagia. 4. Oligomenorrhea.

29. A 16-year-old student tells the school nurse she cannot participate in the school field trip today because of severe menstrual cramps, nausea, and diarrhea. These symptoms most clearly relate to: 1. Amenorrhea. 2. Menorrhagia. 3. Primary dysmenorrhea. 4. Secondary dysmenorrhea.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

30. In the accompanying figure, what is the breast palpation technique pattern for assessing the breasts? 1. Vertical strip pattern 2. Radial spoke pattern 3. Circular pattern 4. Bimanual pattern

GRADESMORE.COM

31. You are performing a breast assessment and start by inspecting the breast. In the accompanying figure, what do you see? 1. Breast dimpling 2. Breast nodule 3. Nipple inversion 4. Nipple eversion

32. You are inspecting the nipples of both breasts. What should you assess? Select all that apply. 1. Size 2. Position 3. Firmness 4. Discharge 5. Crusting

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

6. Tenderness 7. Presence of accessory nipple

33. To determine a woman’s risk for ovarian cancer, which of the following risk factor(s) should the nurse consider? Select all that apply. 1. Increasing age 2. Underweight in early adulthood 3. Family history 4. Multiparity 5. Use of oral contraceptives 6. Use of estrogen hormone replacement therapy (HRT) 7. BRCA1 or BRCA2 gene mutation

34. A thorough breast assessment requires the patient to be in several positions. The recommended positions for inspecting the breasts include which of the following? Select all that apply. 1. Seated with the arms hanging by each side 2. Seated with the arms placed over the head 3. Seated with the hands on the hips GRADESMORE.COM 4. Standing and leaning forward 5. Supine and turning to the right and left side

35. You are performing a breast assessment and start palpating the breasts using the vertical strip method. You feel a lump in the right upper quadrant of the left breast and further assess for which of the following? Select all that apply. 1. Shape 2. Color 3. Consistency 4. Location 5. Size 6. Movable or fixed 7. Tenderness

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers 1. A woman comes to the clinic because of spotting or bleeding in between her menstrual cycles. Which question is most important for the nurse to ask? 1. “Does the spotting occur during ovulation?” 2. “Does the spotting occur after your period?” 3. “Does the spotting occur during or after sexual intercourse?” 4. “Does the spotting occur during heavy stress?” ANS: 3 Page: 350-351

1. 2. 3. 4.

Feedback This is incorrect. Spotting during ovulation can be normal. This is incorrect. Spotting after a period is not as serious as postcoital bleeding. This is correct. Postcoital bleeding may be a sign of a serious disease or infection. This is incorrect. Stress does not cause spotting.

2. A woman with a history of dysmenorrhea comes to the clinic for a follow-up appointment. Which question indicates that the nurse understands the major symptoms associated with this condition? GRADESMORE.COM 1. “Have you missed any more work during your periods?” 2. “How many pads or tampons did you use last month?” 3. “Has your partner been supportive of your mood swings?” 4. “Did it help to use a nonpetroleum-based lubricant?” ANS: 1 Page: 350

1. 2. 3. 4.

Feedback This is correct. Dysmenorrhea may cause pain so severe that it often disrupts normal activities such as going to work. This is incorrect: The primary consequence of dysmenorrhea is severe pain but may include heavy bleeding. This is incorrect. Mood swings are mostly associated with premenstrual syndrome. This is incorrect. Vaginal dryness is commonly associated with menopause.

3. A woman comes to the clinic because of heavy menstrual bleeding each month. Which question is most important for the nurse to ask? 1. “Have you noticed if anything you do makes the bleeding worse?” 2. “How long ago did you start having heavy periods?” 3. “Do you get cramps when you have your period?”

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. “How many pads/tampons do you generally use in 24 hours?” ANS: 4 Page: 350

1. 2. 3. 4.

Feedback This is incorrect. The patient does not cause the amount of menstrual flow. This is incorrect. It does provide a history of the present illness but does not provide the most important information to obtain a measurement of the amount of bleeding. This is incorrect. This is a basic question, however, the nurse should ask focused questions related to the history of the present illness, heavy bleeding. This is correct. Heavy bleeding is a subjective report and women vary in their perceptions of what is acceptable blood loss. Asking for the specific number of pads or tampons provides important objective data.

GRADESMORE.COM

ANS: 4 Page: 362

1. 2. 3. 4.

Feedback This is incorrect. Clear discharge may or may not be normal. This is incorrect. Yellow, white, or green discharge may or may not be normal. This is incorrect. Green discharge may or may not be normal. This is correct. Bloody nipple discharge is never normal.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

This is incorrect. It is significant only if it is a new finding. This is correct. Signs of breast tissue dimpling or retracting may indicate abnormal growth or be a sign of breast cancer. This is incorrect. Breast tenderness, especially in relationship with the menstrual cycle, is normal. This is incorrect. Inverted nipples may be normal. If nipples cannot be everted, it warrants further evaluation.

1. 2. 3. 4.

Feedback This is incorrect. A white GRADESMORE.COM or yellow vaginal discharge may be normal. This is correct. The most d for ovarian cancer is abdominal common symptom reporte bloating and warrants follow up. This is incorrect. Spotting during the time of ovulation is normal. This is incorrect. Breast tenderness during menses is common.

1. 2. 3.

Feedback Inspection of the breast includes having the patient seated with arms hanging by each side. Inspection of the breasts includes having the patient place her arms over her head. This is the correct answer. Inspection of the breast includes having the patient seated with hands on the hips, not behind the back.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Inspection of the breast includes having the patient lean forward.

8. A college student is in an outpatient clinic for a routine gynecologic examination. When taking the patient’s history, which information is most significant? 1. “I have had such lumpy breasts lately, especially before my periods.” 2. “Lately I have noticed that the area around my right nipple has a rash that is sore and itchy all the time.” 3. “It seems like a week and a half before my period I get a whitish yellow vaginal discharge.” 4. “How come I get a really bad side ache for about a day in the middle of every cycle?” ANS: 2 Page: 362

1. 2. 3. 4.

Feedback This is incorrect. Lumpy breasts prior to the start of menses is a normal finding. This is correct. Paget’s disease is a type of breast cancer that may occur in the areola area and presents as bumpy, persistently itchy, red, scaly, or tingly. This is incorrect. An increase in a whitish-yellow vaginal discharge is normal during ovulation. This is incorrect. Many women experience pelvic or lower abdominal pain during ovulation. This is known as Mittelschmerz.

GRADESMORE.COM

9. Which approach is best for the nurse to use when palpating the female breast? 1. A circular pattern 2. A radial spoke method 3. A vertical strip pattern 4. A horizontal pattern ANS: 3 Page: 360

1. 2. 3.

Feedback This is incorrect. A circular pattern does not ensure that all breast tissue is examined. This is incorrect. A radial spoke method does not ensure that all breast tissue is examined. This is correct. Evidence supports the use of a vertical strip technique to ensure that all breast tissue is examined and ensure the entire nipple area complex is included in the examination. This is incorrect. A horizontal pattern does not ensure that all breast tissue is examined.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2.

Feedback This is incorrect. Biographic data includes the patient’s name, age, address, birthplace, ethnic origin, etc. This is incorrect. Past history, while important because it may have an effect on the patient’s current health status, includes information that records childhood illnesses, chronic illnesses, previous surgeries, obstetrical history, injuries, etc. This is correct. The review of systems includes subjective data the patient says about herself. For example, the patient is reporting that she has not experienced pain, a lump, nipple discharge, or a rash. These are pertinent negatives being documented. This is incorrect. The last step of the complete health assessment includes objective data recorded from the physical examination that describes findings based on inspection and palpation. FGoRr A exDaE mS plMeO , “RBEre.aC stO s aMre symmetrical” or “No lesions noted.”

1. 2. 3. 4.

Feedback This is incorrect. One of the clinical manifestations of PSOS is hirsutism. This is incorrect. One of the clinical manifestations of PSOS is obesity. This is correct. One of the clinical manifestations of PSOS is irregular periods. This is incorrect. Dysmenorrhea is not a major clinical manifestation of PSOS.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. Candidiasis is a yeast infection commonly occurring in the groin area and external genitalia but does not cause loss of pubic hair. This is correct. No pubic hair or sparse pubic hair is associated with aging, endocrine disease, nutritional deficiencies, or genetics. This is incorrect. Fungal infections are commonly found in the groin areas and the external genitalia but do not cause loss of pubic hair. This is incorrect. Pediculosis pubis, commonly referred to as lice, may be found in the pubic hair but do not generally cause a loss of pubic hair.

13. In order to determine a woman’s self-care ability related to breast self-examination, the nurse finds which statement by the patient G inRdA icD atE esStM heOnReE ed.fC orOfM urther teaching? 1. “I make a check mark on the calendar every month after I do a breast examination.” 2. “As soon as I notice symptoms of premenstrual syndrome I make sure I conduct a breast selfexamination.” 3. “I always stand in front of the mirror before my shower to inspect my breasts.” 4. “When I examine my breast, I lie flat on the bed, placing a pillow under the side being examined.” ANS: 2 Page: 368

1. 2.

3. 4.

Feedback Keeping track on a calendar is the best method to ensure adherence to perform breast self-examination. This is the correct answer. This patient needs further teaching because the best time to examine the breasts is 7 to 9 days after the last menstrual period, when breasts are less lumpy or tender. Standing in front of the mirror to inspect the breast is a correct technique in performing a breast self-examination. Lying flat on the bed with a pillow under the side being examined is a correct technique in performing a breast self-examination.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback Women between the ages of 21 and 29 should have a Pap test every 3 years. This is the correct answer. Women older than 26 years of age with multiple sexual partners should be screened for chlamydia and gonorrhea annually. Current recommendations include that HPV testing be done with the Pap test between the ages of 21 and 29 every 3 years and over the age of 30 every 5 years. Mammograms are recommended starting at the age of 40 if the woman wishes to have this test.

15. The nurse is correct to question which of the following comments regarding a woman’s understanding of contraceptive choicG e(Rs)A?DESMORE.COM 1. “My birth control pills are a form of contraception to prevent pregnancy.” 2. “I recommend a male or female condom to all my single friends because it may protect them from sexually transmitted infections.” 3. “I hate taking birth control pills because they make me nauseous.” 4. “I have a friend with regular periods and she successfully used the rhythm method and never got pregnant until she was ready.”

ANS: 3 Page: 352

1. 2. 3.

Feedback Birth control pills are a form of hormonal contraception to prevent pregnancy. Both male and female condoms protect against sexually transmitted infections. This is the correct answer. This comment raises concerns because when assessing the type of contraceptive method used, it is important that the woman is satisfied with her choice. If taking birth control pills has a side effect such as nausea, a patient may choose to be inconsistent or skip taking the pills. The rhythm method is based on using abstinence from sexual intercourse during the time of ovulation and is most appropriate among women with a regular menstrual cycle.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. This is a closed-ended or direct question about insomnia that does not encourage a patient to fully express herself and does not build rapport. This is incorrect. This is a closed-ended question about the thickness of her hair that does not encourage a patient to fully express herself and does not build rapport. This is incorrect. This is a closed-ended question about vaginal lubrication that does not encourage the patient to fully express herself and does not build rapport. This is correct. This is an open-ended question of how hormonal changes of menopause may affect a patient’s quality of life. This question will assist the patient in expressing her concerns.

GRADESMORE.COM

17. Which assessment finding relates most directly to a diagnosis of fibrocystic breast disease? 1. Painless lumps in the breast tissue noted to be associated with a woman’s menstrual cycle 2. Painful, fluid-filled lumps located in the breast 3. A solid, round breast lump in a 23-year-old female that moves easily when pushed 4. A hard, fixed, isolated lump in the right upper quadrant of the right breast ANS: 1 Page: 352

2. 3. 4.

Feedback This is correct. Fibrocystic breast disease is benign, painless lumps or thickening of the tissue that are felt in a woman’s breast and are usually associated with hormonal changes during a woman’s menstrual cycle. This is incorrect. Fluid-filled lumps in the breast that may or may not be painful are breast cysts and are not related to fibrocystic breast disease. This is incorrect. Fibroadenomas are common in younger women and are characterized as solid, round, rubbery lumps that move easily when pushed. This is incorrect. A hard, fixed, isolated lump in the right upper quadrant would be a warning sign for breast cancer.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. It is normal to pass small blood clots during menstruation. This is incorrect. Blood clots are not significant unless they are the size of a quarter or larger. This is correct. Changing a tampon or pad every 1 to 2 hours is considered to be heavy menstrual bleeding. This is incorrect. It is normal to change a tampon or pad every 3 to 4 hours.

19. A female patient is on the schedule for a routine Pap smear today. The patient calls to report she has been using an over-the-countGerRcAreDaE mSfM orOsR evEe. raC lO daMys for a possible vaginal infection. The nurse knows that the patient: 1. Will need to reschedule the Pap smear. 2. Needs to be reassured that vaginal creams will not interfere with the examination. 3. Will need to douche before coming in for the examination. 4. Will need a prescription of antibiotics after the Pap smear to treat the infection. ANS: 1 Page: 364

1. 2. 3.

Feedback This is correct. A woman should not have sexual intercourse, douche, or use vaginal creams or sprays 24 hours before a Pap smear because it can alter the results. This is incorrect. This is false because vaginal creams may alter the results of the Pap smear. This is incorrect. Using a douche 24 hours prior to a Pap smear may alter the results and douching is not recommended because it depletes the vagina of normal healthy bacteria. This is incorrect. Without a vaginal culture the nurse cannot know whether the infection is fungal, bacterial, or viral.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2.

3. 4.

Feedback This is incorrect. The risk of developing breast cancer is less with a decreased exposure to estrogens such as with a late start of menses and early end to menses. This is correct. The risk of developing breast cancer increases with age and with the increased exposure to estrogens with a history of periods that start early and/or end later in life. This is incorrect. Moderate levels of alcohol intake is a risk factor for breast cancer. This is incorrect. Pregnancy minimizes exposure to estrogen as does breastfeeding. Never having children and waiting to have a child after the age of 30 is associated with an increased risk of breast cancer.

21. Which symptoms most clearly relates to trichomoniasis?

GRADESMORE.COM 1. Fishy odor 2. Frothy discharge 3. Thick, white, curd-like discharge 4. Bleeding after sexual intercourse ANS: 2 Page: 355

1. 2. 3. 4.

Feedback This is incorrect. A strong fishy odor is most characteristic of bacterial vaginosis. This is correct. A frothy discharge is most characteristic of trichomoniasis. This is incorrect. A thick, white, curd-like discharge is most characteristic of candidiasis. This is incorrect. Bleeding after sexual intercourse is characteristic of chlamydia.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. “Did you know your left breast is a lot bigger than your right breast?” ANS: 1 Page: 355-356

1. 2. 3.

Feedback This is correct. Cultural considerations may include asking permission to examine or expose the breasts. This is incorrect. In some cultures, a woman may prefer to have her husband or significant other present during the assessment. This is incorrect. Exposing the breasts for an examination may be embarrassing and the nurse should provide privacy while allowing the patient to maintain modesty and dignity. This is incorrect. A more patient-centered approach would include being sensitive to a woman’s self-image and self-esteem.

23. With a patient standing and leaning forward, the nurse uses the assessment technique of inspection to observe for: 1. Lumps and tenderness. 2. Tissue density and lumps. 3. Tenderness and nipple deviations. 4. Nipple deviations and skin changeG s.RADESMORE.COM ANS: 4 Page: 359

1. 2. 3.

Feedback This is incorrect. To assess for lumps and tenderness, the nurse will use the assessment technique of palpation. This is incorrect. To assess tissue density and lumps, the nurse will use the assessment technique of palpation. This is incorrect. To assess for tenderness, the nurse will use the assessment technique of palpation. To assess for nipple deviations, the nurse will use the assessment technique of inspection. This is correct. The nurse will use the assessment technique of inspection with the patient standing and leaning forward to check for skin changes and nipple deviations.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. The lithotomy position. ANS: 4 Page: 364

2. 3. 4.

Feedback This is incorrect. The Trendelenburg position has the patient lying flat on her back with the feet higher than the head. This is not the most common position for a gynecologic examination. This is incorrect. The supine position has the patient lying flat on her back. This is not the most common position for a gynecologic examination. This is incorrect. The prone position has the patient lying on her stomach. This is not the most common position for a gynecologic examination. This is correct. The lithotomy position has the patient lying in a supine position with feet in stirrups to allow for visual and physical access to the perineal region. This is the most common position for a gynecologic examination.

25. When conducting a patient history, which symptom indicates that the patient is experiencing normal changes associated with menopause? 1. Vaginal bleeding 2. Urinary and bowel incontinence GRADESMORE.COM 3. Decreased vaginal secretions 4. Increased breast tenderness ANS: 3 Page: 348

1. 2. 3. 4.

Feedback This is incorrect. Bleeding during menopause could be a sign of a serious problem and needs to be reported. This is incorrect. A decrease in estrogen during menopause may cause pelvic muscles to weaken and as a result may lead to urinary incontinence but not bowel incontinence. This is correct. A decrease in estrogen during menopause often results in vaginal dryness. This is incorrect. Breast tenderness is characteristic of normal hormonal changes during the menstrual cycle, not menopause.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 29 days 3. 30 days 4. 31 days ANS: 2 Page: 349

1. 2. 3. 4.

Feedback This is incorrect. Most lumps that are soft and movable are not breast cancer, but all lumps warrant further evaluation and hormonal changes may cause breast tenderness. This is incorrect. If a woman has breast cancer, the axillary lymph nodes are one of the first places the cancer may spread. This is correct. Breast infection or disease may cause enlargement of the lymph node(s). This is incorrect. The lymphatic circulation moves from the breast toward the axillary nodes.

27. During a breast examination, the nurse palpates the lymph nodes under the axilla. The nurse knows that which of the following statements is true? 1. Finding a soft, tender, movable lump in the axilla is always a significant finding. 2. The axillary lymph nodes are the last place that cancer may spread. 3. Breast infection or disease may caG usReAeD nlE arS geMmOeRnE t o.fCthOeMlymph node(s). 4. The lymphatic circulation moves from the axilla toward the breast. ANS: 3 Page: 346

1. 2. 3. 4.

28. A 23-year-old woman comes to the clinic because of heavy bleeding during her periods that lasts for 7 days. The nurse would document this as: 1. Amenorrhea. 2. Menorrhagia. 3. Metrorrhagia.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Oligomenorrhea. ANS: 2 Page: 350

1. 2. 3. 4.

Feedback This is incorrect. Amenorrhea is the absence of menses. This is correct. Menorrhagia is defined as excessive or prolonged duration of menses. This is incorrect. Metrorrhagia is uterine bleeding at irregular intervals. This is incorrect. Oligomenorrhea is decreased or light menses.

1. 2. 3.

GRADESMORE.COM Feedback This is incorrect. Amenorrhea is the absence of menses This is incorrect. Menorrhagia is defined as excessive or prolonged duration of menses This is correct. Primary dysmenorrhea is defined as menstrual pain that includes a range of symptoms such as lower abdominal pain, headache, nausea, vomiting, diarrhea, irritability, fatigue, and depression This is incorrect. Secondary dysmenorrhea is menstrual pain associated with starting menses later in life and is generally associated with disorders of the reproductive system such as endometriosis or fibroids.

30.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

In the accompanying figure, what is the breast palpation technique pattern for assessing the breasts? 1. Vertical strip pattern 2. Radial spoke pattern 3. Circular pattern 4. Bimanual pattern ANS: 2 Page: 360-361

3. 4.

Feedback This is incorrect. Vertical strip pattern palpation starts at the sternum palpating up and down in straight lines toward the outer perimeter of the breast, ending up in the axillary area This is correct. Radial spoke method, also known as the wedge pattern palpation, divides the breast into wedges. Start at the periphery of the breast and palpate toward the nipple. This is incorrect. Circular pattern palpation starts by palpating the areola first and moving in a circular motion from the areola to the outer perimeter of the breast. This is incorrect. The bimanual technique is a two hand palpation technique used for breast palpation is better toGuR seAfD orEaSwMoOmRaE n. wC ithOM large pendulous breasts

31. You are performing a breast assessment and start by inspecting the breast. In the accompanying figure, what do you see? 1. Breast dimpling 2. Breast nodule 3. Nipple inversion 4. Nipple eversion

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 3 Page: 358

1. 2. 3. 4.

Feedback This is incorrect. Breast dimpling is puckering of the skin inward; this may be a sign of breast pathology. This is incorrect. Breast nodule is a lump in the breast; this may be felt on palpation. This is correct. Nipple inversion occurs when the nipple is pointing inwards and cannot be fully seen at the areola; appear to be indented inward towards the breast. This is incorrect. Nipple eversion is a nipple that is everted and pointing outwards at the areola.

32. You are inspecting the nipples of both breasts. What should you assess? Select all that apply. 1. Size 2. Position 3. Firmness 4. Discharge 5. Crusting 6. Tenderness GRADESMORE.COM 7. Presence of accessory nipple

ANS: 1, 2, 4, 5, 7 Page: 358 1. 2. 3. 4. 5. 6. 7.

This is correct. Size of the nipple is inspected during a nipple assessment. This is correct. Position of the nipple is inspected during a nipple assessment. This is incorrect. Firmness of the nipple is not part of the nipple assessment. This is correct. Nipple discharge is inspected during a nipple assessment. This is correct. Crusting of the nipple is inspected during a nipple assessment. This is incorrect. Tenderness is palpated, not inspected, during a nipple assessment. This is correct. Presence of an accessory nipple is inspected during a nipple assessment.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

6. Use of estrogen hormone replacement therapy (HRT) 7. BRCA1 or BRCA2 gene mutation ANS: 1, 3, 6, 7 Page: 354

1. 2. 3. 4. 5. 6. 7.

Feedback This is correct. A woman’s risk of developing ovarian cancer increases with age. This is incorrect. Recent studies indicate that women who were obese in early adulthood are more likely to develop ovarian cancer. This is correct. About 10% to 15% of ovarian cancers occur because of a genetic mutation. This is incorrect. Women who never had children have an increased risk of ovarian cancer. This is incorrect. Oral contraceptive use has been associated with a lower risk of ovarian cancer. This is correct. Women who have taken estrogen-only HRT after menopause have an increased risk of ovarian cancer. This is correct. The BRCA1 and BRCA2 gene mutations are risk factors for ovarian cancer.

GRADESMORE.COM quires theassessment patient to be 34. A thorough breast re in

several positions. The recommended positions for inspecting the breasts include which of the following? Select all that apply. 1. Seated with the arms hanging by each side 2. Seated with the arms placed over the head 3. Seated with the hands on the hips 4. Standing and leaning forward 5. Supine and turning to the right and left side ANS: 1, 2, 3, 4 Page: 357

1. 2. 3. 4. 5.

Feedback This is correct. The first position is seated with the arms hanging by each side. This is correct. The second position is seated with the arms placed over the head. This is correct. The third position is seated with the hands on the hips. This is correct. The fourth position is standing and leaning forward. This is incorrect. The patient does not lie supine and turn from side to side.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4. 5. 6. 7.

Feedback This is correct. You assess the shape of the lump and document whether it is round, oval, or irregular. This is incorrect. You will not be able to assess the color of the lump because it is under the skin. This is correct. You assess the consistency of the lump and determine if it is hard, soft, or gel-like. This is correct. You assess the location using the clock face to identify the location. This is correct. You assess the size and measure in centimeters. GRADESMORE.COM This is correct. You assess whether it is movable or fixed. This is correct. You assess for tenderness.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 19: Assessing the Male Breasts and Reproductive System

1. The nursing instructor is reviewing the anatomy of reproductive systems with a group of nursing students. Which areas should the student expect will be assessed during a focused assessment of the reproductive system of a male patient? Select all that apply. 1. Areolae 2. Glans penis 3. Urethra 4. Prostate gland

2. A group of nursing students is reviewing information about the male reproductive structures. The students demonstrate understanding of the information when they identify which of the following as accessory organs? Select all that apply. 1. Testis 2. Vas deferens 3. Penis 4. Prostate gland 5. Bulbourethral glands

GRADESMORE.COM 3. The nurse is assessing the breasts of a male patient. What are the normal expected findings? Select all that apply. 1. Both breasts are symmetric in appearance. 2. No lesions are present. 3. There is a small lump in axillae on the left side. 4. The color is even and matches ethnicity. 5. The left areola is slightly puckered.

4. You are inspecting the skin of the male genitalia. What are you assessing? Select all that apply. 1. Shape 2. Color 3. Lesions 4. Drainage 5. Hair distribution

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

5. A male patient come to the urgent care center with a chief complaint of yellow-green urethral drainage. The health-care provider orders a culture to be sent to the laboratory. Which of the following supplies will the nurse need? Select all that apply. 1. Mask 2. Gloves 3. Penlight 4. Culturette tube 5. Swab

6. A male patient reports that he has some type of drainage coming out of his penis. A nurse should assess which of the following? Select all that apply. 1. Color of discharge 2. Amount of discharge 3. Consistency of discharge 4. Odor of discharge 5. Texture of discharge

7. You are about to obtain a sexual history on a 56-year-old male patient. What are the specific areas that need to be discussed during this assessment? Select all that apply. 1. Spouse satisfaction GRADESMORE.COM 2. Partners 3. Practices 4. Past sexually transmitted infections 5. Protection 6. Erectile dysfunction

8. A 31-year-old male reports scrotal pain and tenderness. The OLDCARTS mnemonic is a useful reminder for the nurse to use when collecting information about this patient’s reported clinical manifestations. The nurse recognizes that each of the letters in OLDCARTS stands for which of the following terms? 1. Onset, level of pain, duration, characteristics, aggravating/alleviating factors, relieving factors, treatment, and severity 2. Onset, location, duration, characteristics, aggravating/alleviating factors, relieving factors, treatment, and severity 3. Onset, location, duration, changes, aggravating/alleviating factors, relieving factors, treatment, and symptoms 4. Onset, location, duration, characteristics, aggravating/alleviating factors, repeating patterns, treatment, and symptoms

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

9. A 56-year-old male patient is being seen in the clinic and reports painful hematuria with frequent urination for the past several weeks. The nurse recognizes the clinical manifestations may indicate which significant health issue? 1. Prostate cancer 2. Bladder cancer 3. Kidney cancer 4. Testicular cancer

10. A patient is being seen in the clinic. He reports painful urination with a white discharge for the past several weeks. The nurse recognizes the clinical manifestations may indicate which significant health issue? 1. Chlamydia 2. Bladder cancer 3. Kidney cancer 4. Gonorrhea

11. A 24-year-old male patient is being seen in the clinic requesting screening for several sexually transmitted infections. The nurse prepares to provide information on the importance of health screenings. Which screening sGhR ouAldDtEhS eM nuOrsReEb. eC suOreMto discuss? 1. Biannual clinic screenings for human immunodeficiency virus (HIV) 2. Annual testicular self-examinations 3. Monthly prostate specific antigen testing 4. Monthly digital rectal examinations

12. A 19-year-old male patient is being seen in the clinic for a routine sports physical. The nurse prepares to provide health education on testicular self-examinations. What information is best to share with the patient? 1. The examination should be completed in a cool shower. 2. A warm shower can assist in relaxation during the examination. 3. Use firm pressure when checking each testicle. 4. Examine the penis skin surfaces for any ulcers or lesions.

13. You are inquiring about sexual practices with a male patient. You know that latex condoms protect against: 1. Human immunodeficiency virus (HIV). 2. Human papilloma virus (HPV). 3. Hepatitis virus.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. All of the above.

14. The instructor is reviewing the hormones associated with breast development in males. The student nurse recognizes that which hormone is responsible? 1. Progesterone 2. Testosterone 3. Estrogen 4. Adrenaline

15. When teaching how to perform a testicular self-examination the nurse should recommend which procedure for palpating the testicle? 1. Use the first two fingers of each hand to palpate firmly. 2. Firmly palpate using all the fingers of both hands. 3. Palpate firmly using the palmar surface of one hand. 4. Gently palpate using the thumb and first two fingers of one hand.

16. The nurse is completing the reproductive health history questions. Which reported clinical DaEl?SMORE.COM manifestation would be considered aG bnRoA rm 1. A white, cheesy substance 2. Recent increased size of scrotum 3. Yellow urine first thing in morning 4. Only one sex partner

17. The most common presentation of male breast cancer is: 1. Painless upper outer quadrant lump. 2. Painful areolar mass. 3. Painless, palpable, subareolar lump or mass. 4. Painful upper outer quadrant lump.

18. While teaching a young male about the risk factors of penile cancer the nurse makes sure to include education on which of the following topics? 1. Prevention of HIV and AIDS 2. Benefits of circumcision 3. Body size 4. Alcohol consumption

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

19. You are preparing to perform a male health assessment on a 42-year-old man. A preliminary step includes: 1. Obtaining a signed consent. 2. Assuring confidentiality and privacy. 3. Putting on tangential lighting. 4. Discussing all the change of positions required for the assessment.

20. The nurse is going to palpate the areola of a male breast. What is a priority nursing intervention? 1. Put on gloves. 2. Explain the technique. 3. Press on the areola. 4. Massage the areola.

21. The nurse is preparing to examine a Hispanic male. The nurse wants to provide culturally sensitive care. Which approach is the best when working with this patient? 1. Ask if the patient would prefer a female examiner. 2. Introduce yourself before the examGiR naAtiD onE.SMORE.COM 3. Ask if the patient would like his partner present. 4. Quickly look over the genital area.

22. A 42-year-old male has come to the clinic for an annual physical. The nurse notes in the patient’s history that there is a strong history of male breast cancer in the patient’s family. What should the nurse provide to the patient before he leaves the clinic? 1. A referral for a mammogram 2. Education on how to perform a breast self-examination 3. A referral to a breast surgeon 4. Instructions on when to call an oncologist

23. During a class on sexually transmitted diseases the instructor asks a student which sexually transmitted disease produces a soft, small, cauliflower-shaped growth. What is the correct response? 1. Condyloma acuminatum 2. Chancroid lesion 3. Tinea cruris 4. Skin tag

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

24. A male patient calls to schedule a screening test for chlamydia and gonorrhea. Which instructions should the nurse provide at this time? 1. “Make sure to drink lots of water before coming in.” 2. “Do not urinate for 1 hour prior to the appointment.” 3. “Collect any early morning drainage and bring it with you.” 4. “Take some over-the-counter pain reliever before coming in.”

25. During the health history the nurse attempts to provide the older male patient with information about misconceptions of aging. Which statement is correct? 1. “Erectile dysfunction (ED) is not a natural part of aging.” 2. “Prostate enlargement is a natural part of aging.” 3. “You should expect difficulties with achieving an erection by age 65.” 4. “Erectile dysfunction is purely a psychological disorder with no cure.”

26. The two assessment techniques used to assess the male breasts are: 1. Palpation and percussion. GRADESMORE.COM 2. Inspection and percussion. 3. Inspection and palpation. 4. Percussion and palpation.

27. The nurse is performing a male health assessment. When is the appropriate time to discuss the patient’s sexual health? 1. At the beginning of the assessment 2. During the genital examination 3. Toward the end of the assessment 4. Before the assessment

28. When assessing the sexual history of a patient, the nurse should use which general guide? 1. The 4 Ps 2. The 4 Cs 3. Confidentiality 4. HIPAA

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

29. You are assessing the groin area for inguinal bulging. If you suspect a hernia, you will ask the patient to: 1. Turn partially on his left side. 2. Hold his breath. 3. Cough. 4. Breathe in deeply.

30. You are inspecting the skin of a middle-aged man and see these yellow-white papules on the skin of the penis. They are called .

31. A male patient has been diagnosis with syphilis. You know that the initial symptom is a skin lesion presenting as a sore called a .

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers 1. The nursing instructor is reviewing the anatomy of reproductive systems with a group of nursing students. Which areas should the student expect will be assessed during a focused assessment of the reproductive system of a male patient? Select all that apply. 1. Areolae 2. Glans penis 3. Urethra 4. Prostate gland ANS: 2, 3, 4 Page: 381-384

1. 2. 3. 4.

Feedback This is incorrect. The breasts are not part of the male reproductive system. The areas of the male reproductive system include the glans penis, urethra, and prostate gland. This is correct. The areas of the male reproductive system include the glans penis, urethra, and prostate gland. This is correct. The areas of the male reproductive system include the glans penis, urethra, and prostate gland. This is correct. The areas of the male reproductive system include the glans penis, urethra, and prostate gland.

GRADESMORE.COM 2. A group of nursing students is reviewing information about the male reproductive structures. The students demonstrate understanding of the information when they identify which of the following as accessory organs? Select all that apply. 1. Testis 2. Vas deferens 3. Penis 4. Prostate gland 5. Bulbourethral glands ANS: 2, 4, 5 Page: 371-372

Feedback This is incorrect. The organs of the male reproductive system include the two testes (where sperm cells and testosterone are made), the penis, the scrotum, and the accessory organs (epididymis, vas deferens, seminal vesicles, ejaculatory duct, urethra, bulbourethral glands, and prostate gland). This is correct. The organs of the male reproductive system include the two testes (where sperm cells and testosterone are made), the penis, the scrotum, and the accessory organs (epididymis, vas deferens, seminal vesicles, ejaculatory duct, urethra, bulbourethral glands, and prostate gland).

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is incorrect. The organs of the male reproductive system include the two testes (where sperm cells and testosterone are made), the penis, the scrotum, and the accessory organs (epididymis, vas deferens, seminal vesicles, ejaculatory duct, urethra, bulbourethral glands, and prostate gland). This is correct. The organs of the male reproductive system include the two testes (where sperm cells and testosterone are made), the penis, the scrotum, and the accessory organs (epididymis, vas deferens, seminal vesicles, ejaculatory duct, urethra, bulbourethral glands, and prostate gland). This is correct. The organs of the male reproductive system include the two testes (where sperm cells and testosterone are made), the penis, the scrotum, and the accessory organs (epididymis, vas deferens, seminal vesicles, ejaculatory duct, urethra, bulbourethral glands, and prostate gland).

3. The nurse is assessing the breasts of a male patient. What are the normal expected findings? Select all that apply. 1. Both breasts are symmetric in appearance. 2. No lesions are present. 3. There is a small lump in axillae on the left side. 4. The color is even and matches ethnicity. 5. The left areola is slightly puckered.

GRADESMORE.COM

ANS: 1, 2, 4 Page: 380-381

Feedback This is correct. Normal assessment findings of the breast include: breasts are symmetric; skin has even color; there are no lesions, dimpling, or puckering; there are no lumps or masses; the axillary area has no lumps or masses; the areola is smooth, has uniform color, and is without skin changes; and the nipple is everted, skin intact, and without drainage. This is correct. Normal assessment findings of the breast include: breasts are symmetric; skin has even color; there are no lesions, dimpling, or puckering; there are no lumps or masses; the axillary area has no lumps or masses; the areola is smooth, has uniform color, and is without skin changes; and the nipple is everted, skin intact, and without drainage. This is incorrect. A small lump in the axillae on the left side may not be normal and requires further evaluation. Normal assessment findings of the breast include: breasts are symmetric; skin has even color; there are no lesions, dimpling, or puckering; there are no lumps or masses; the axillary area has no lumps or masses; the areola is smooth, has uniform color, and is without skin changes; and the nipple is everted, skin intact, and without drainage. This is correct. Normal assessment findings of the breast include: breasts are symmetric; skin has even color; there are no lesions, dimpling, or puckering; there are no lumps or masses; the axillary area has no lumps or masses; the areola is smooth, has uniform

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

color, and is without skin changes; and the nipple is everted, skin intact, and without drainage. This is incorrect. Puckering of the areola could be a sign of an underlying mass under the skin. Normal assessment findings of the breast include: breasts are symmetric; skin has even color; there are no lesions, dimpling, or puckering; there are no lumps or masses; the axillary area has no lumps or masses; the areola is smooth, has uniform color, and is without skin changes; and the nipple is everted, skin intact, and without drainage.

4. You are inspecting the skin of the male genitalia. What are you assessing? Select all that apply. 1. Shape 2. Color 3. Lesions 4. Drainage 5. Hair distribution ANS: 2, 3, 4, 5 Page: 382 Feedback 1. 2. 3. 4. 5.

GRADESMORE.COM

This is incorrect. During inspection the shape of the skin is not assessed. This is correct. During inspection the color of the skin is assessed. This is correct. During inspection lesions of the skin are assessed. This is correct. During inspection drainage of the skin is assessed. This is correct. During inspection hair distribution of the skin is assessed.

1. 2.

Feedback This is incorrect. A mask is not needed to collect urethral drainage. This is correct. Gloves should be worn when collecting urethral drainage.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4. 5.

This is incorrect. A penlight is not needed to collect urethral drainage. This is correct. A culturette tube contains a swab and is needed to collect the specimen. This is incorrect. A swab is not needed because it is already contained in the culturette tube.

1. 2. 3. 4. 5.

Feedback This is correct. When assessing drainage the color of the drainage is assessed. This is correct. When assessing drainage the amount of the drainage is assessed. This is correct. When assessing drainage the consistency of the drainage is assessed. This is correct. When assessing drainage the odor of the drainage is assessed. GRAdrainage DESMOthe REtexture .COM of the drainage is not assessed. This is incorrect. When assessing

7. You are about to obtain a sexual history on a 56-year-old male patient. What are the specific areas that need to be discussed during this assessment? Select all that apply. 1. Spouse satisfaction 2. Partners 3. Practices 4. Past sexually transmitted infections 5. Protection 6. Erectile dysfunction ANS: 2, 3, 4, 5, 6 Page: 377

1. 2. 3.

Feedback This is incorrect. A sexual history would not include an assessment about spouse satisfaction. This is correct. A sexual history would include an assessment about whether the patient is in a relationship. This is correct. A sexual history would include an assessment about the types of sexual practices the patient engages in.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. 5. 6.

This is correct. A sexual history would include a history of past sexually transmitted infections. This is correct. A sexual history would include the type of protection that is being used during sexual activity. This is correct. The patient is 56 years old and a sexual history would include an assessment of whether erectile dysfunction may be occurring.

GRADESMORE.COM

Feedback This is incorrect. The “L” does not stand for level of pain. The mnemonic OLDCARTS (onset, location, duration, characteristics, aggravating/alleviating factors, relieving factors, treatment, and severity) is a useful reminder for identifying attributes of a symptom. This is correct. The mnemonic OLDCARTS (onset, location, duration, characteristics, aggravating/alleviating factors, relieving factors, treatment, and severity) is a useful reminder for identifying attributes of a symptom. This is incorrect. The “C” does not stand for changes. The mnemonic OLDCARTS (onset, location, duration, characteristics, aggravating/alleviating factors, relieving factors, treatment, and severity) is a useful reminder for identifying attributes of a symptom. This is incorrect. The “R” does not stand for repeating patterns. The mnemonic OLDCARTS (onset, location, duration, characteristics, aggravating/alleviating factors, relieving factors, treatment, and severity) is a useful reminder for identifying attributes of a symptom.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3.

Feedback This is incorrect: Prostate cancer may have no symptoms or difficulty starting the stream. Bladder cancer is the fourth most common cancer in men. The most common signs or symptoms are hematuria, dysuria, and frequency of urination. This is correct. Bladder cancer is the fourth most common cancer in men. The most common signs or symptoms are hematuria, dysuria, and frequency of urination. This is incorrect. Testicular cancer presents with a painless lump, swelling, and pain in the testes. Bladder cancer is the fourth most common cancer in men. The most common signs or symptoms are hematuria, dysuria, and frequency of urination. This is incorrect. Bladder cancer is the fourth most common cancer in men. The most common signs or symptoms are hematuria, dysuria, and frequency of urination.

GRADESMORE.COM 10. A patient is being seen in the clinic. He reports painful urination with a white discharge for the past several weeks. The nurse recognizes the clinical manifestations may indicate which significant health issue? 1. Chlamydia 2. Bladder cancer 3. Kidney cancer 4. Gonorrhea ANS: 1 Page: 374

Feedback This is correct. Chlamydia is a sexually transmitted infection (STI) with the most common symptoms in men being penile white discharge, dysuria, and pain with urination. This is incorrect. Bladder cancer does not have white penile discharge as a symptom. Chlamydia is an STI with the most common symptoms in men being penile discharge, dysuria, and pain with urination. This is incorrect. Kidney cancer does not have a symptom of penile discharge. Chlamydia is an STI with the most common symptoms in men being penile discharge, dysuria, and pain with urination.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is incorrect. The most common symptom of gonorrhea is a yellow mucopurulent discharge. Chlamydia is an STI with the most common symptoms in men being penile discharge, dysuria, and pain with urination.

11. A 24-year-old male patient is being seen in the clinic requesting screening for several sexually transmitted infections. The nurse prepares to provide information on the importance of health screenings. Which screening should the nurse be sure to discuss? 1. Biannual clinic screenings for human immunodeficiency virus (HIV) 2. Annual testicular self-examinations 3. Monthly prostate specific antigen testing 4. Monthly digital rectal examinations ANS: 2 Page: 375

Feedback This is incorrect. Annual clinical screenings for human immunodeficiency virus (HIV) are not recommended. The CDC (2015) recommends for individuals to be tested for HIV between the ages of 13 and 64 at least once as part of their routine health care examination. The nurse should take any opportunity to provide health promotion education. The American Cancer Society recommends a testicular examination by a GRADESMORE.COM doctor as part of a routine cancer-related check-up. This is correct. The nurse should take any opportunity to provide health promotion education. The American Cancer Society recommends a testicular examination by a doctor as part of a routine cancer-related check-up. This is incorrect. The patient is only 24 years old and would not have monthly prostate specific antigen testing. The nurse should take any opportunity to provide health promotion education. The American Cancer Society recommends a testicular examination by a doctor as part of a routine cancer-related check-up. This is incorrect. Monthly digital rectal examinations are not recommended for any patient. The nurse should take any opportunity to provide health promotion education. The American Cancer Society recommends a testicular examination by a doctor as part of a routine cancer-related check-up.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 2 Page: 386

3. 4.

Feedback This is incorrect. The examination should be done in a warm shower. Testicular assessment is easier to perform while in the shower or taking a warm bath. The warmth will relax the scrotal area and the water will make it easier to smoothly move over the skin surface. This is correct. All males should be taught how to perform a testicular self-examination. Testicular assessment is easier to perform while in the shower or taking a warm bath. The warmth will relax the scrotal area and the water will make it easier to smoothly move over the skin surface. This is incorrect. When performing a testicular examination, gentle pressure should be used, not firm pressure. This is incorrect. The surface of each testis is examined, not the penis.

1. 2. 3. 4.

Feedback Latex condoms, when used consistently and correctly, are highly effective in preventing the sexual transmission of HIV along with other viruses. Latex condoms, when used consistently and correctly, are highly effective in preventing the sexual transmission of HPV along with other viruses. Latex condoms, when used consistently and correctly, are highly effective in preventing the sexual transmission of hepatitis along with other viruses. This is correct. Latex condoms, when used consistently and correctly, are highly effective in preventing the sexual transmission of HIV, HPV, and hepatitis viruses.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 2 Page: 370

2. 3.

Feedback This is incorrect. Progesterone is more abundant in women and is not associated with breast development in males. The male hormone, testosterone, inhibits the development and growth of breast tissue in males. This is correct. The male hormone, testosterone, inhibits the development and growth of breast tissue in males. This is incorrect. Estrogen is a female hormone and is not associated with breast development in males. The male hormone, testosterone, inhibits the development and growth of breast tissue in males. This is incorrect. Adrenalin is not a hormone that influences breast development in males. The male hormone, testosterone, inhibits the development and growth of breast tissue in males.

15. When teaching how to perform a testicular self-examination the nurse should recommend which procedure for palpating the testicle? 1. Use the first two fingers of each hand to palpate firmly. 2. Firmly palpate using all the fingers of both hands. 3. Palpate firmly using the palmar suG rfR acAeDoE f oSnMeOhR anEd. . COM 4. Gently palpate using the thumb and first two fingers of one hand. ANS: 4 Page: 386

Feedback This is incorrect. The first two fingers of each hand should not be used to palpate firmly. Males should be taught to perform testicle self-examinations by instructing to feel each testicle with both hands by placing the index and middle fingers under the testicle with the thumbs placed on top. This is incorrect. All the fingers of both hands should not be used to palpate firmly. Males should be taught to perform testicle self-examinations by instructing to feel each testicle with both hands by placing the index and middle fingers under the testicle with the thumbs placed on top. This is incorrect. Using the palmar surface of one hand is not used to palpate testes. Males should be taught to perform testicle self-examinations by instructing to feel each testicle with both hands by placing the index and middle fingers under the testicle with the thumbs placed on top. This is correct. Males should be taught to perform testicle self-examinations by instructing to feel each testicle with both hands by placing the index and middle fingers under the testicle with the thumbs placed on top.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

16. The nurse is completing the reproductive health history questions. Which reported clinical manifestation would be considered abnormal? 1. A white, cheesy substance 2. Recent increased size of scrotum 3. Yellow urine first thing in morning 4. Only one sex partner ANS: 2 Page: 376

1. 2. 3. 4.

Feedback This is incorrect. Smegma, a white, cheesy substance, is a normal finding. This is correct. Hydrocele is an accumulation of fluid around the testes resulting in scrotal swelling and is an abnormal finding. This is incorrect. Yellow urine first thing in the morning is a normal finding. This is incorrect. Having only one sex partner is not abnormal.

17. The most common presentation of male breast cancer is: 1. Painless upper outer quadrant lump.

GRADESMORE.COM 2. Painful areolar mass. 3. Painless, palpable, subareolar lump or mass. 4. Painful upper outer quadrant lump. ANS: 3 Page: 380

3. 4.

Feedback This is incorrect. The most common presentation of male breast cancer is not a painless upper outer quadrant lump. The most common presentation of male breast cancer is a painless, palpable, subareolar lump or mass. This is incorrect. The most common presentation of male breast cancer is not a painful areolar mass. The most common presentation of male breast cancer is a painless, palpable, subareolar lump or mass. This is correct. The most common presentation of male breast cancer is a painless, palpable, subareolar lump or mass. This is incorrect. The most common presentation of male breast cancer is not a painful upper outer quadrant lump. The most common presentation of male breast cancer is a painless, palpable, subareolar lump or mass.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. Prevention of HIV and AIDS is a risk factor for testicular cancer. This is correct. The benefits of circumcision would be appropriate to discuss. A risk factor for penile cancer is being uncircumcised. This is incorrect. Body size, specifically tall height, is a risk factor for testicular cancer. This is incorrect. Alcohol consumption is a risk factor for male breast cancer.

19. You are preparing to perform a male health assessment on a 42-year-old man. A preliminary step includes: 1. Obtaining a signed consent. 2. Assuring confidentiality and privacy.

GRADESMORE.COM 3. Putting on tangential lighting. 4. Discussing all the change of positions required for the assessment. ANS: 2 Page: 377

1. 2.

3. 4.

Feedback This is incorrect. You do not need to obtain a signed consent to perform a male health assessment. This is correct. Reassuring the patient that confidentiality will be maintained during the examination of the male genitalia is very important because this can be sensitive or embarrassing for the male patient. This is incorrect. Putting on tangential lighting is not needed as a preliminary step. This is incorrect. Discussing all the change of positions required for this assessment is not required. The patient will only be in the supine or standing position.

20. The nurse is going to palpate the areola of a male breast. What is a priority nursing intervention? 1. Put on gloves. 2. Explain the technique. 3. Press on the areola.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Massage the areola. ANS: 1 Page: 379

1. 2. 3. 4.

Feedback This is correct. You should put on gloves prior to palpating the areola in case there may be discharge. This is incorrect. The technique should be explained prior to inspecting. This is incorrect. The priority is to put on gloves prior to palpating and pressing on the areola. This is incorrect. The priority is to put on gloves prior to palpating and pressing on the areola. The areola is not massaged.

21. The nurse is preparing to examine a Hispanic male. The nurse wants to provide culturally sensitive care. Which approach is the best when working with this patient? 1. Ask if the patient would prefer a female examiner. 2. Introduce yourself before the examination. 3. Ask if the patient would like his partner present. 4. Quickly look over the genital area.

GRADESMORE.COM

ANS: 3 Page: 378

1. 2. 3.

Feedback This is incorrect. Certain cultures may only allow same-gender health-care providers to perform their assessment. This is incorrect. You should introduce yourself prior to any examination for any culture. This is correct. Cultural and racial considerations may place restrictions on discussing sexual issues. Certain cultures may only allow same-gender health-care providers to perform their assessment. Hispanics value modesty, so the nurse should recognize that the area between the waist and knees is considered particularly private. This is incorrect. It is inappropriate for you to quickly look over the genital area for any culture to prepare for a physical assessment of the male genitalia.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Instructions on when to call an oncologist ANS: 2 Page: 385-386

1. 2. 3. 4.

Feedback This is incorrect. The health-care provider writes the referral for the mammogram, if needed. This is correct. It is the nurse’s role to provide education on breast self-examination. This is incorrect. It is not within the nurse’s role to refer a patient to a breast surgeon. This is incorrect. It is not within the nurse’s role to give instructions on when to call an oncologist.

GRADESMORE.COM

ANS: 1 Page: 383

1. 2.

3. 4.

Feedback This is correct. Condyloma acuminatum (genital warts) are soft, small, cauliflowershaped growths on the skin that are caused by HPV. This is incorrect. Chancroid lesion is a bacterial sexually transmitted infection that involves a painful, open sore covered with gray or yellow-gray material with irregular borders. This is incorrect. Tinea cruris is a fungal infection of the groin, which is also known as “jock itch.” This is incorrect. A skin tag is not a sexually transmitted lesion.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Page: 385

1. 2. 3. 4.

Feedback This is incorrect. Patients do not have to drink lots of water before coming in for a screening test for chlamydia and gonorrhea. This is correct. For accurate cultures the patient should be instructed to not urinate for at least 1 hour prior to obtaining the culture. This is incorrect. Patients should not collect early morning drainage and bring it with them. It is the nurse’s responsibility to correctly obtain the culture. This is incorrect. Taking a pain reliever is not necessary prior to obtaining a culture.

1. 2. 3. 4.

GRADESMORE.COM Feedback This is correct. ED becomes more common as men get older; however, it is not a natural part of aging. This is incorrect. Prostate enlargement is a not a natural part of aging. This is incorrect. ED becomes more common as men get older; however, there is no age limit. This is incorrect. ED is not a psychological disorder. ED is strongly linked to a number of other common diseases in men, such as diabetes, heart disease, high blood pressure, high cholesterol, vascular disease, neurologic conditions, and chronic liver or kidney disease.

26. The two assessment techniques used to assess the male breasts are: 1. Palpation and percussion. 2. Inspection and percussion. 3. Inspection and palpation. 4. Percussion and palpation. ANS: 3 Page: 379 Feedback

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

This is incorrect. Percussion is not used to assess the male breast. Inspection and palpation are the two techniques used to assess the male breasts. This is incorrect. Percussion is not used to assess the male breast. Inspection and palpation are the two techniques used to assess the male breasts. This is correct. Inspection and palpation are the two techniques used to assess the male breasts. This is incorrect. Percussion is not used to assess the male breasts. Inspection and palpation are the two techniques used to assess the male breasts.

3. 4.

Feedback This is incorrect. The best time is not at the beginning of the assessment because you Eh.eCbOesMt time to discuss sexual health is have not established rapport wGitR hA thDeEpS atM ieO ntR .T toward the end of the assessment. This gives time to build a relationship and rapport with the patient. This is incorrect. The best time is not during the genital examination. The best time to discuss sexual health is toward the end of the assessment. This gives time to build a relationship and rapport with the patient. This is correct. The best time to discuss sexual health is toward the end of the assessment. This gives time to build a relationship and rapport with the patient. This is incorrect. The best time is not before the assessment. The best time to discuss sexual health is toward the end of the assessment. This gives time to build a relationship and rapport with the patient.

28. When assessing the sexual history of a patient, the nurse should use which general guide? 1. The 4 Ps 2. The 4 Cs 3. Confidentiality 4. HIPAA ANS: 1 Page: 377

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Feedback This is correct. When conducting the sexual history, use of the four Ps (partners, practices, protection, and past sexually transmitted infections - STIs) as a general guide is helpful to avoid missing important information. This is incorrect. There is no 4 Cs guide in sexual health assessment. When conducting the sexual history, use of the four Ps (partners, practices, protection, and past STIs) as a general guide is helpful to avoid missing important information. This is incorrect. Confidentiality is not a guide; it is a core duty. When conducting the sexual history, use of the four Ps (partners, practices, protection, and past STIs) as a general guide is helpful to avoid missing important information. This is incorrect. HIPAA stands for Health Insurance Portability and Accountability; this is a federal law. When conducting the sexual history, use of the four Ps (partners, practices, protection, and past STIs) as a general guide is helpful to avoid missing important information.

GRADESMORE.COM

ANS: 3 Page: 376

1. 2. 3. 4.

Feedback This is incorrect. Asking the patient to partially turn on his left side will not give you better visualization of the suspected hernia. This is incorrect. Asking the patient to hold his breath will not give you better visualization of the suspected hernia. This is correct. Asking the patient to cough will give you better visualization of any suspected bulging. This is incorrect. Asking the patient to breathe in deeply will not give you better visualization of the suspected hernia.

30.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

You are inspecting the skin of a middle-aged man and see these yellow-white papules on the skin of the penis. They are called . ANS: epidermoid cysts Page: 383 Feedback: Epidermoid cysts are sebaceous cysts that are yellow or white papules, nontender, cutaneous lesions. This is a normal finding.

31. A male patient has been diagnosis with syphilis. You know that the initial symptom is a skin lesion presenting as a sore called a . ANS: chancre Page: 375 Feedback: Syphilis is a sexually transmitted infection caused by the spirochete Treponema pallidum. The initial symptom is a sore called a chancre.

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 20: Assessing the Anus and Rectum

1. The rectum is the lower part of the sigmoid colon that contains which of the following vasculature? Select all that apply. 1. Arteries 2. Lymph nodes 3. Veins 4. Visceral nerves 5. Hemorrhoids 6. Sweat glands

2. You are performing a focused health history on a patient’s pattern of bowel elimination. Which of the following questions would you ask? Select all that apply. 1. What is your normal bowel movement pattern? 2. Do you feel bloated? 3. Have you noticed any change in the size and diameter of your stools? 4. Are you constipated? 5. Do you have any diarrhea? 6. Do you have irritable bowel syndrome?

GRADESMORE.COM 3. The ROME III Diagnostic Criteria for Functional Constipation must include which two or more of the following? Select all that apply. 1. Straining while having a bowel movement 2. Bouts of diarrhea 3. Hard or lumpy stools 4. Sensation of incomplete evacuation 5. Manual removal of stool from the rectum 6. Fewer than five bowel movements per week

4. You are about to inspect the anus. How would the male patient be positioned? Select all that apply. 1. Fowler’s 2. Supine 3. Prone 4. Side-lying 5. Lithotomy

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

5. You are about to inspect the anus of a patient complaining of soreness in the rectal area. Which supplies are needed to perform an inspection? Select all that apply. 1. Gown 2. Gloves 3. Mask 4. Shoe covers 5. Water-soluble lubricant

6. You are inspecting the anus and perianal area. Which of the following are normal findings? Select all that apply. 1. Anus is tightly closed. 2. Skin is moist and darkly pigmented. 3. Erythema and tenderness are present. 4. No lesions or ulcerations are present. 5. Small, dilated protrusions are present.

7. You are going to be performing a digital rectal examination. Identify the positions that the patient can choose to be in for this assessment. Select all that apply. 1. Lateral decubitus GRADESMORE.COM 2. Prone 3. Lithotomy 4. Standing, bending over, and holding onto the examining table 5. Standing, putting the hands on the knees, and bending over

8. You are performing a digital rectal examination and assessing the prostate gland. What will you assess for? Select all that apply. 1. Shape 2. Size 3. Smoothness 4. Lumps 5. Tenderness

9. What helps to propel waste materials from the rectum into the anal canal? 1. Intraabdominal pressure 2. Transverse folds 3. Sympathetic nerves 4. Pressure of fecal waste products

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

10. The main function of the glands in the anal canal is to: 1. Lubricate the anal canal. 2. Provide blood supply to the rectum. 3. Allow the anal tissue to contract. 4. Allow nerve impulses to travel to the rectum.

11. Which culture has the highest rates of colorectal cancer? 1. Caucasian 2. Asian 3. Chinese 4. African American

12. During a health history, a 48-year-old woman reports that she has been noticing that her stools look like “pencils.” What should be your next question? 1. “Do you think that you are constipated and need a laxative?” 2. “Have you ever had a bowel disease or a bowel obstruction?” 3. “I do not understand what you meG anRbAyD‘E loS okMlOikReEp. enCcO ilsM.’ Can you explain?” 4. “Tell me the amount of fluids you drink and types of foods that you eat.”

13. You are caring for a patient who has been on intravenous antibiotic therapy for 7 days. He has now developed watery, nonbloody, foul-smelling diarrhea. You suspect the organism causing this diarrhea is: 1. Staphylococcus. 2. Streptococcus. 3. Clostridium difficile. 4. A virus.

14. A patient comes to the urgent care center stating that today he noticed bright red blood in his stool. He denies abdominal pain, nausea, or vomiting. He states that he had a similar episode that occurred last week. Bright red blood usually indicates: 1. Upper gastrointestinal bleeding. 2. Bleeding low in the colon or rectum. 3. Bleeding higher in the colon. 4. Bleeding caused by digestion of blood.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

15. You are performing a focused history on a patient who is complaining of rectal pain and itching. He reports small amounts of blood on the toilet paper after having a bowel movement. You inspect the anal area and note a large, red, soft protrusion next to the anus. This is called a(n): 1. Internal hemorrhoid. 2. External hemorrhoid. 3. Rectal polyp. 4. Anal fistula.

16. The patient reports that he has not had a bowel movement in 7 days. He has had several doses of a laxative without any results. The nurse is going to assess for fecal impaction by performing a digital rectal examination. What instruction should the nurse give to the patient prior to the assessment? 1. “Drink 8 ounces of water in the next hour to help soften the stool.” 2. “Tell me if you are feeling any discomfort or pain.” 3. “You cannot move at all during this assessment or serious injury will occur.” 4. “Hold your breath and push as I insert my finger in your rectum.”

GRADESMORE.COM 17. You are performing a digital rectal assessment and want to assess the anal sphincter muscle tone. As you are gently inserting your finger into the rectum, what instructions will you give to the patient? 1. “Push against my finger.” 2. “Take a deep breath in.” 3. “Hold your breath and push.” 4. “Relax and breathe in and out.”

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

19. The rectum partially or fully intussuscepts and comes out through the anus. This condition is called .

20.20. The nurse has performed a digital rectal examination and found the following findings that are seen in this picture. What is the name of the condition?

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers 1. The rectum is the lower part of the sigmoid colon that contains which of the following vasculature? Select all that apply. 1. Arteries 2. Lymph nodes 3. Veins 4. Visceral nerves 5. Hemorrhoids 6. Sweat glands ANS: 1, 3, 5 Page: 388

1. 2. 3. 4. 5. 6.

Feedback This is correct. Blood vessels make up the vasculature of the rectum. Arteries are part of the vasculature in the rectum. This is incorrect. Blood vessels make up the vasculature of the rectum. Lymph nodes are not part of the vasculature system but part of the lymphatic system. This is correct. Blood vessels make up the vasculature of the rectum. Veins are part of the vasculature of the rectum. This is incorrect. Blood vessels make up the vasculature of the rectum. Visceral nerves are not part of the vasculature in the rectum. AaDkE This is correct. Blood vesseGlsRm eS upMtO heRvEa.scCuO laM ture of the rectum. A hemorrhoid is a dilated vein. This is incorrect. Blood vessels make up the vasculature of the rectum. Sweat glands are apocrine glands in the anal canal and are not part of the vasculature.

1. 2.

Feedback This is correct. This is an open-ended question asking the patient to tell you about his or her normal bowel patterns. This is incorrect. This is not specifically related to patterns of elimination.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4. 5. 6.

Individuals may feel bloated related to gastrointestinal diseases. This is correct. A change in the size and diameter of stools is a bowel pattern. This is correct. The symptom of constipation is a bowel pattern. This is correct. The symptom of diarrhea is a bowel pattern. This is incorrect. This is part of the past medical history and would not be asked during the focused history related to bowel patterns.

3. The ROME III Diagnostic Criteria for Functional Constipation must include which two or more of the following? Select all that apply. 1. Straining while having a bowel movement 2. Bouts of diarrhea 3. Hard or lumpy stools 4. Sensation of incomplete evacuation 5. Manual removal of stool from the rectum 6. Fewer than five bowel movements per week ANS: 1, 3, 4, 5 Page: 390

1. 2. 3. 4. 5. 6.

Feedback This is correct. Straining during at least 25% of defecations is one of the Rome III GRADESMORE.COM diagnostic criteria. This is incorrect. Bouts of diarrhea is not one of the Rome III diagnostic criteria. This is correct. Lumpy or hard stools in at least 25% of defecations is one of the Rome III diagnostic criteria. This is correct. Sensation of incomplete evacuation for at least 25% of defecations is part of the Rome III diagnostic criteria. This is correct. Manual maneuvers to facilitate at least 25% of defecations is part of the Rome III diagnostic criteria. This is incorrect. Fewer than three bowel movements, not five bowel movements per week, is part of the Rome III diagnostic criteria.

4. You are about to inspect the anus. How would the male patient be positioned? Select all that apply. 1. Fowler’s 2. Supine 3. Prone 4. Side-lying 5. Lithotomy ANS: 4 Page: 391

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4. 5.

Feedback This is incorrect. A nurse cannot inspect the anus when a patient is sitting up in the Fowler’s position. This is incorrect. A nurse cannot inspect the anus when the patient is lying on his back. This is incorrect. The prone position is not a recommended position to inspect the anus. This is correct. The side-lying position is the best position to inspect the anus of a male patient. This is incorrect. The lithotomy position is an option for female patients.

1. 2. 3. 4. 5.

GRADESMORE.COM

Feedback This is incorrect. You do not need to put on a gown to inspect the rectal area. This is correct. You do need to wear gloves when inspecting the rectal area and spreading the buttocks. This is incorrect. You do not need to wear a mask to inspect the rectal area. This is incorrect. You do not need to wear shoe covers to inspect the rectal area. This is incorrect. You do not need to use water-soluble lubricant to inspect the rectal area. Water-soluble lubricant would be used for a digital rectal assessment.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4. 5.

Feedback This is correct. Anus is tightly closed is a normal finding. This is correct. Skin is moist and darkly pigmented is a normal finding. This is incorrect. Erythema and tenderness are signs of inflammation. This is an abnormal finding. This is correct. No lesions or ulcerations is a normal finding. This is incorrect. Small, dilated protrusions are indicative of hemorrhoids. This is an abnormal finding.

7. You are going to be performing a digital rectal examination. Identify the positions that the patient can choose to be in for this assessment. Select all that apply. 1. Lateral decubitus 2. Prone 3. Lithotomy 4. Standing, bending over, and holding onto the examining table 5. Standing, putting the hands on the knees, and bending over ANS: 1, 3, 4 Page: 393

1. 2. 3. 4. 5.

GRADESMORE.COM Feedback This is correct. Lateral decubitus or side-lying position with the upper extremity slightly flexed is a correct position. This is incorrect. The patient cannot be in the prone position for a digital rectal examination. This is correct. The lithotomy position is lying down on the examining table with feet in stirrups. This is a correct position and is most often chosen by women. This is correct. Standing, bending over, and holding onto the examining table is a correct and safe position. This is incorrect. Standing, putting the hands on the knees, and bending over is unsafe. A patient could fall due to lack of support.

8. You are performing a digital rectal examination and assessing the prostate gland. What will you assess for? Select all that apply. 1. Shape 2. Size 3. Smoothness 4. Lumps 5. Tenderness ANS: 1, 2, 3, 4, 5

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Page: 394 1. 2. 3. 4. 5.

This is correct. When performing a digital rectal examination and assessing the prostate gland, you should assess the shape of the prostate gland. This is correct. When performing a digital rectal examination and assessing the prostate gland, you should assess smoothness of the prostate gland. This is correct. When performing a digital rectal examination and assessing the prostate gland, you should assess for lumps on the prostate gland. This is correct. When performing a digital rectal examination and assessing the prostate gland, you should assess for lumps on the prostate gland. This is correct. When performing a digital rectal examination and assessing the prostate gland, you should assess for tenderness of the prostate gland.

9. What helps to propel waste materials from the rectum into the anal canal? 1. Intraabdominal pressure 2. Transverse folds 3. Sympathetic nerves 4. Pressure of fecal waste products ANS: 2 Page: 388

GRADESMORE.COM

Feedback 1. This is incorrect. Intraabdominal pressure does not help to specifically propel waste materials from the rectum into the anal canal. The transverse folds within the rectum propel waste materials. 2. This is correct. The rectum is made up of transverse folds that propel waste materials into the anal canal. 3. This is incorrect. The anal smooth muscle in the anus has parasympathetic nerves, not sympathetic nerves. These do not propel waste materials. 4. This is incorrect. The pressure of the fecal waste products does not propel the waste materials from the rectum into the anal canal. The transverse folds specifically help to propel waste materials.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is correct. The mucus secreting anal glands help to lubricate the anal canal to make it easier for feces to move through the canal and out of the body. This is incorrect. The arteries provide blood supply to the rectum. This is incorrect. The sphincters allow the anal canal to contract. This is incorrect. The parasympathetic nerve fibers provide impulses for anal contraction.

11. Which culture has the highest rates of colorectal cancer? 1. Caucasian 2. Asian 3. Chinese 4. African American ANS: 4 Page: 389

1. 2. 3. 4.

Feedback This is incorrect. Colorectal cancer rates are highest in African-American men and women.

GRADESMORE.COM

This is incorrect. Colorectal cancer rates are lowest in Asian/Pacific Islander men and women. This is incorrect. Colorectal cancer rates are lowest in Asian/Pacific Islander men and women. This is correct. Colorectal cancer rates are highest in African-American men and women.

12. During a health history, a 48-year-old woman reports that she has been noticing that her stools look like “pencils.” What should be your next question? 1. “Do you think that you are constipated and need a laxative?” 2. “Have you ever had a bowel disease or a bowel obstruction?” 3. “I do not understand what you mean by ‘look like pencils.’ Can you explain?” 4. “Tell me the amount of fluids you drink and types of foods that you eat.” ANS: 3 Page: 389

1. 2.

Feedback This is incorrect. You are leading the patient and offering advice. The patient should first clarify what she means by saying her stools “look like pencils.” This is incorrect. This would be a question after further clarification of what the

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

patient means specifically by saying her stools “look like pencils.” This is correct. The patient has described her stools as looking like “pencils.” The nurse would want the patient to clarify what she means and further describe the size or diameter of the stools. Change in size and diameter of stools may indicate a partial obstruction or mass in the intestines. This is incorrect. Discussing the patient’s diet is not a priority. The nurse should clarify specifically what the patient means by saying that her stools “look like pencils.”

GRADESMORE.COM

This is incorrect. The most common organism causing watery, nonbloody, foulsmelling diarrhea when a patient has been on antibiotics for an extended time is Clostridium difficile (C. difficile). This is incorrect. The most common organism causing watery, nonbloody, foulsmelling diarrhea when a patient has been on antibiotics for an extended time is Clostridium difficile (C. difficile). This is correct. Clostridium difficile (C. difficile) is an anaerobic toxin-producing gram-positive spore-forming bacterium that is widely recognized as the leading cause of nosocomial diarrhea worldwide. Patients who have recently been on antibiotics may be at risk. The symptoms of C. difficile are watery, foul-smelling, nonbloody diarrhea. This is incorrect. This is not related to a virus. The most common organism causing watery, nonbloody, foul-smelling diarrhea when a patient has been on antibiotics for an extended time is Clostridium difficile (C. difficile).

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Bleeding caused by digestion of blood. ANS: 2 Page: 390

1. 2. 3. 4.

Feedback This is incorrect. Dark red or maroon blood usually indicates bleeding higher in the colon or the small bowel. This is correct. Bright red blood usually indicates bleeding low in the colon or rectum. This patient may have hemorrhoids. This is incorrect. Dark red or maroon blood usually indicates bleeding higher in the colon or the small bowel. This is incorrect. Melena is black, tarry feces caused by digestion of blood in the gastrointestinal tract. This is commonly seen with gastrointestinal bleeding.

1. 2. 3.

Feedback This is incorrect. Internal hemorrhoids are located inside the rectum. This is correct. External hemorrhoids protrude outside the anus. This is incorrect. Polyps are abnormal overgrowths of tissue in the lining of the colon. They would not protrude outside the anus. They are most commonly diagnosed during a colonoscopy. This is incorrect. An anal fistula will drain pus and abnormal fluid from the anus.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. “Hold your breath and push as I insert my finger in your rectum.” ANS: 2 Page: 393

1. 2.

Feedback This is incorrect. Telling the patient to drink water in the next hour will not soften the stool. Increasing daily water intake helps to prevent dry, hard stool. This is correct. A digital rectal examination for fecal impaction may be an uncomfortable assessment for the patient. Encourage the patient to let you know if he is experiencing any discomfort or pain. This is incorrect. If a patient squirms during insertion of the finger, this will not cause serious injury; however, it is a sign that the patient is uncomfortable. Encourage the patient to take deep, relaxing breaths. This is incorrect. The patient should not hold his breath and push out during a digital rectal examination. Patients are asked to bear down on the finger when the nurse is assessing the anal sphincter during a digital rectal assessment. Encourage patients to take some deep, relaxing breaths.

17. You are performing a digital rectal assessment and want to assess the anal sphincter muscle tone. As you are gently inserting youGr R fiA ngDeE r iS nM toOthReEr. ecCtuOmM, what instructions will you give to the patient? 1. “Push against my finger.” 2. “Take a deep breath in.” 3. “Hold your breath and push.” 4. “Relax and breathe in and out.” ANS: 1 Page: 394

2. 3.

Feedback This is correct. Gently touch the anus with your index finger and ask the patient to bear down on your finger as you gently insert your index finger into the lower rectum. Assess the rectal sphincter muscle tone. This is incorrect. Taking a deep breath without bearing down on the nurse’s inserted finger will not enable the nurse to assess the rectal sphincter muscle tone. This is incorrect. The patient should not hold his or her breath and push. The patient should breathe normally and push down on the nurse’s inserted finger to allow assessment of the rectal sphincter muscle tone. This is incorrect. The patient should try to relax but must bear down on the nurse’s finger to allow for assessment of the rectal sphincter muscle tone.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

18. The health-care provider reviewed a patient’s recent blood work and noted the patient to be anemic. A fecal occult blood test (FOBT) was ordered. You have obtained a stool sample. Put the steps in order to test the stool for occult blood (1–8). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Close the specimen-side FOBT slide. 2. Set up the FOBT by opening up the side for the sample application. 3. Apply a sample specimen to both of the FOBT windows. 4. Observe the specimen site’s color. 5. Put on gloves. 6. Remove and discard gloves. 7. Open the opposite side of the FOBT slide. 8. Drop one or two drops on each window as directed. ANS: 25317846 Page: 395 Feedback: Set up the FOBT by opening up the side for the sample application. Put on gloves. Apply a sample specimen to both of the FOBT windows. Close the specimen-side FOBT slide. Open the opposite side of the FOBT slide and follow the directions for dropping one or two drops on each window. Observe the specimen site’s color. Remove and discard gloves.

GRADESMORE.COM 19. The rectum partially or fully intussuscepts and comes out through the anus. This condition is called . ANS: rectal prolapse Page: 392 Feedback: Rectal prolapse occurs when the rectum partially or fully intussuscepts and comes out through the anus. This is an abnormal finding.

20.20. The nurse has performed a digital rectal examination and found the following findings that are seen in this picture. What is the name of the condition?

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: benign prostatic hyperplasia Page: 395

Feedback: Enlargement of the prostate gland occurs with advancing age. The exact cause is unknown, but declining testosterone and increasing estrogen levels are thought to cause enlargement of the prostate gland.

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 21: Assessing the Newborn

1. The nurse knows that a full-term newborn infant needs to be in a warm environment for which of the following reasons? 1. The newborn has vernix caseosa covering the skin. 2. The newborn has lanugo covering the skin. 3. The newborn is unable to shiver. 4. The newborn’s skin is thin and transparent.

2. You are caring for a new mother who just had her first child. You teach this mother how to support the newborn’s head when she is holding her child. Why is this important? 1. The newborn neck is short. 2. The newborn neck is proportionally long. 3. The newborn neck can support the head at a 45-degree angle. 4. The newborn neck is weak and unable to support the head.

3. You are a nurse working in an obstetrical outpatient clinic. A new mother complains of fatigue and then starts to cry loudly. The moG thRerAsDtaEteSs MthOaR t sEh. eC doOeM s not want to be alone with her newborn. Which of the following actions should the nurse take? 1. Suggest she send her guests home so she can rest and have the house to herself. 2. Reassure the mother that this is normal and it will get better. 3. Report the findings to her health-care provider immediately. 4. Use distraction by reminding her how lucky she is to have a healthy baby.

4. A new mother is sharing how excited she is that her newborn has blue eyes. The nurse knows that the permanent color of the iris is not set until the child is: 1. 2 to 3 months. 2. 5 to 6 months. 3. 12 months. 4. 18 months.

5. The nurse knows that the newborn is at higher risk for developing ear infections because: 1. The Eustachian tubes are short, wide, and horizontal. 2. The Eustachian tubes are long, narrow, and horizontal. 3. The outer ear canal is longer than in an adult. 4. The space between the ears and the nasopharynx is longer than in an adult.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

6. In conducting a newborn health assessment, the nurse notices enlarged breasts and a milky drainage from one of the breasts. This finding is a result of: 1. Newborn breast cancer. 2. Release of the maternal hormone prolactin. 3. Retention of the maternal hormone estrogen. 4. A side effect related to the use of Pitocin.

7. The correct procedure to use when measuring head circumference of an infant is for the nurse to: 1. Place the infant in a supine position and measure the greatest diameter of head-occipital frontal area. 2. Place the infant in a prone position and measure the greatest diameter of head-occipital frontal area. 3. Place the infant in a sitting position and measure the greatest diameter of head-occipital frontal area. 4. Place the infant in the mother’s lap and measure the greatest diameter of head-occipital frontal area.

GRADESMORE.COM 8. A nurse measures the circumference of a newborn head and chest and finds the circumference of the head is 12.4 inches and the chest is 13.8 inches. Based on these measurements, the nurse knows which of the following? 1. These are normal findings. 2. The head circumference is normal but the chest circumference is too big. 3. Both the chest and the head circumference are too big. 4. Chest circumference should not be larger than head circumference.

9. The nurse is assessing a newborn with a suspected cephalohematoma. Which of the following findings would be consistent with a cephalohematoma? 1. Some bruising and swelling noted on one side of the head 2. Edema noted on the entire top of the head 3. Molding of the entire shape of the head 4. Blue hands and feet

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

10. A nurse is doing a heel stick to collect a laboratory sample for a phenylketonuria (PKU) test prior to discharge of a newborn from the hospital. Which question indicates the mother has a basic understanding of reason(s) for sticking her newborn? 1. “I understand the test will determine if the baby is missing something needed for normal growth and development.” 2. “I understand the test will prevent my baby from developing newborn jaundice.” 3. “I understand the test will measure my baby’s blood sugar to prevent hypoglycemia.” 4. “I understand the test is a drug screen done before we take a newborn home.”

11. When giving a newborn a bath, the newborn starts to cry and the nurse notices the eyelids and the nape of the infant’s neck become very red in color. The nurse knows this finding is characteristic of: 1. Lanugo. 2. Vernix caseosa. 3. Mongolian spots. 4. Nevus simplex.

12. A nurse is conducting a review of systems with a new teenage mother who is recovering from a cesarean section. Which of the following questions will encourage the mother to fully express herself and build rapport? GRADESMORE.COM 1. “Are you scared to take this baby home?” 2. “How do you plan to take care of yourself and a newborn?” 3. “Why is the baby’s father not here to help?” 4. “How do you think your newborn will affect your life?”

13. When using the Ballard Gestational Age Assessment tool on an infant born 2 hours ago, the nurse places one hand below the infant’s elbow and, while holding the infant’s hand, briefly sets the elbow in flexion and then extension and then releases the infant’s hand to observe the angle of recoil. This describes an assessment technique called the: 1. Arm recoil. 2. Square window. 3. Popliteal angle. 4. Scarf sign.

14. When assessing a newborn using the Ballard Gestational Age Assessment tool the nurse assesses skin turgor, color, and texture. The nurse knows the easiest place to assess the infant’s skin is in which location? 1. Abdomen

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. Arm 3. Chest 4. Toes

15. A 39-weeks’ gestation newborn was born by cesarean section 1 hour ago and the recorded weight is 5 lb 3 oz. This newborn is considered: 1. Post term-birth. 2. Small for gestational age (SGA). 3. Appropriate for gestational age. 4. Large for gestational age (LGA).

16. When assessing a newborn using the Ballard Gestational Age Assessment tool the nurse folds down the pinna of the ear and releases. The ear recoils instantly. This finding is characteristic of a newborn who is: 1. 24 weeks’ gestational age. 2. 30 weeks’ gestational age. 3. 39 weeks’ gestational age. 4. 42 weeks’ gestational age.

GRADESMORE.COM 17. During assessment of a quiet, alert newborn the nurse counts the apical pulse for 1 full minute and finds a heart rate of 130 beats per minute (bpm). The nurse knows that the expected heart rate for this newborn ranges from: 1. 80 to 100 bpm. 2. 90 to 110 bpm. 3. 120 to 160 bpm. 4. 162 to 180 bpm.

18. The Ballard Gestational Age Assessment tool assesses the gestational age of a newborn by assessing which of the following? 1. Neuromuscular and social maturity 2. Physical and social maturity 3. Neuromuscular and physical maturity 4. Physical maturity only

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

19. A 36-weeks’ gestation newborn weighs 9 lb 2 oz. Which of the following comments by the mother indicates a need for further instructions regarding the infant’s risk for complications? 1. “Since my baby is so big I will not have to feed so often and can plan on extra sleep.” 2. “Since my baby is early I will set my alarm clock to be sure I wake up to nurse more often.” 3. “Since my baby is early I will be sure everyone keeps a hat on the baby’s head.” 4. “I still need to be sure my baby does not lose too much weight the first 3 to 5 days.”

20. During assessment of the umbilical cord, a nurse discovers a two-vessel umbilical cord to include one vein and one artery. The nurse needs to know that a two-vessel cord may be associated with which of the following anomalies? 1. Increased risk of cardiac, renal, and neurologic disorders 2. Increased risk of cardiac, renal, and gastrointestinal anomalies 3. Increased risk of gastrointestinal anomalies and neurologic disorders 4. Increased risk of Down syndrome or Turner syndrome

21. During a routine assessment of a newborn prior to discharge, the nurse finds an axillary temperature of 99.2°F. Which of the following actions by the charge nurse is most appropriate? 1. Retake the temperature in 30 minutes. 2. Take a rectal temperature. GRADESMORE.COM 3. No action necessary. 4. Call the health-care provider prior to discharge.

22. A nursing student reports to the charge nurse that she noticed a newborn with a respiratory rate of 48 breaths per minute that included several short pauses to the rhythm that last for 20 to 24 seconds. Which of the following actions by the charge nurse is most appropriate? 1. The charge nurse reassures the nursing student that many newborns have short pauses during respiration. 2. The charge nurse explains that any irregularity in the respiratory rate should be reported immediately. 3. The charge nurse reminds the nursing student to be sure to document her findings on the electronic medical record. 4. The charge nurse notifies the health-care provider.

23. When measuring the blood pressure of a newborn the nurse notes a decrease of 10 mm Hg in the thigh when compared to the measurement in the arm. This drop in blood pressure is characteristic of: 1. Acrocyanosis. 2. Anomalies of the aorta.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. Renal failure. 4. Postural hypotension.

24. The nurse observes a newborn for signs of being in the active alert phase. Which of the following is the best description of this phase? 1. Newborn may smile, vocalize, and respond to people talking to her or him. 2. Newborn’s respiratory rate will be regular. 3. Newborn will lay still and focus on objects in front of her or him. 4. Respirations may be irregular and the newborn may not be interested in stimulation.

25. When measuring the initial length and weight of the newborn it is most important for the nurse to: 1. Wait until the infant is in the quiet alert phase. 2. Wait until the infant has had an initial bath to avoid infection. 3. Put on gloves if the infant has not had an initial bath. 4. Record the measurements in inches and centimeters.

26. When assessing a newborn’s tranGsiR tiA onDtE oSexMtO raR utEer.inCeOliMfe the Apgar score is used to evaluate the following categories: 1. Heart rate, respiratory rate, reflexes, skin color, and weight. 2. Square window, arm recoil, popliteal angle, scarf sign, heel to ear, and lanugo. 3. Heart rate, respiratory rate, muscle tone, reflex irritability, and skin color. 4. Lanugo, plantar surface, posture, square window, and scarf sign.

27. When obtaining a newborn’s blood pressure, which of the following is most important for the nurse to consider? 1. Size of the blood pressure cuff 2. Infant sleep-wake cycle 3. Availability of a blanket to swaddle the infant 4. Availability of outside assistance to restrain the infant’s hand or foot

28. When conducting a newborn assessment of the infant’s anterior fontanels it is best for the infant to be: 1. Crying. 2. Active and alert. 3. Active and crying.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Sleeping and quiet.

29. When assessing a sleeping newborn, the nurse auscultates a heart rate of 102. The nurse knows that this recording is a(n): 1. Episode of tachycardia. 2. Episode of bradycardia. 3. Normal finding. 4. Episode of apnea.

30. On day 4 postpartum, a mother returns to the clinic for a routine follow-up. Her newborn was 7 lb 8 oz at birth and now weighs 6 lb 3 oz. The nurse realizes that: 1. Weight loss of this amount is normal. 2. Weight loss of greater than 2% is a concern. 3. Weight loss of greater than 5% is a concern. 4. Weight loss of greater than 10% is a concern.

31. After delivery, the midwife placeG sR aA neDwEbSoM rnOsR kiE n .toCsOkM in on its mother’s chest for 1 hour. Prior to obtaining an initial weight on the newborn, the nurse knows that standard precautions indicate which of the following is true? 1. Once a nurse washes his or her hands, he or she may handle the newborn. 2. Once a nurse uses hand sanitizer, he or she may handle the newborn. 3. If the newborn has not had an initial bath, the nurse needs to wear gloves. 4. If the maternal history does not include TORCH infections, the nurse does not need to wear gloves.

32. A new graduate takes an initial weight on a newborn. The newborn weighs 5 lb 3 oz, The new graduate comments to the charge nurse, “This is a small baby, it must be premature.” Which of the following is the most appropriate response? 1. “You are correct, this newborn is premature and will need extra precautions.” 2. “You must determine the infant’s gestational age before you can determine if the newborn is premature.” 3. “You are correct, just by looking at this newborn you can determine it is probably just small for gestational age.” 4. “This weight is within a normal weight range for a full-term infant.”

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

33. A nurse is conducting a general assessment of a newborn born 18 hours ago. What action by the nurse best assesses the newborn for jaundice? 1. Assessing the newborn’s tongue 2. Blanching the skin on the infant’s nose 3. Assessing the newborn’s gum line 4. Assessing capillary refill of the newborn’s fingernails

34. A nurse is inspecting and palpating the newborn head. Which of the following findings is of concern? 1. A diamond-shaped, soft, flat area at the anterior part of the head 2. A triangular-shaped, soft area at the posterior of the head 3. A half-inch laceration on the top of the head 4. A bulging, diamond-shaped area at the anterior part of the head

35. The nurse is assessing a 5-day-old newborn and notices the sclera is yellow. Which of the following does the nurse know is true regarding a jaundiced newborn? 1. Jaundice begins at the toes and moves up. 2. Jaundice begins at the head and moves toward the toes. 3. Jaundice noticed in the eyes is a laG teRsA igDnEoS f nMeOwRbE or. n CjaOuM ndice. 4. Jaundice is most common before 24 hours of age.

36. When conducting a newborn assessment, the nurse is inspecting the nose for patency. While occluding the left nostril with a finger, the nurse observes flaring of the right nostril. The nurse knows which of the following to be true regarding the newborn’s nose? 1. Infants frequently have continual nasal drainage. 2. Infants will open their mouths to breathe if they have a nasal obstruction. 3. Infants are obligate nose breathers. 4. Flaring of the nostrils is a normal finding.

37. When conducting a newborn assessment of the infant’s ears, the nurse claps her hand next to the infant’s ear and observes for which of the following expected finding? 1. The infant will turn his or her head away from the sound. 2. The infant will turn his or her head toward the sound. 3. The infant will initiate a rooting reflex. 4. The infant will startle and start to cry.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

38. When conducting a newborn assessment of the mouth the nurse knows to assess which of the following? 1. Rooting reflex, sucking reflex, and gag reflex 2. Rooting reflex, Babinski reflex, and red reflex 3. Sucking reflex, gag reflex, and red reflex 4. Sucking reflex, Babinski reflex, and gag reflex

39. The nurse is conducting a health screening of a pregnant woman at a local health fair. What data from the psychosocial history should the nurse recognize as being an increased risk for the development of heart defects, developmental delays, and neurological abnormalities? 1. Smoking during pregnancy 2. Using street drugs during pregnancy 3. Consuming alcohol during pregnancy 4. Having a family history of congenital anomalies

40. The nurse is teaching a nursing student how to assess the heart and lungs of a newborn. Which of the following statements by the nursing student would indicate a correct understanding of the teaching? 1. “As long as the baby is crying I mG igR htAaDs E wS elM lO asR seEss.tChO eM newborn’s heart sounds and lungs.” 2. “I will place the newborn on the mother’s bed so she can observe my assessment.” 3. “I am going to skip gloves because they are too big and I am scared to drop the newborn.” 4. “While the newborn is asleep and is skin to skin on its mother’s chest, I will assess the heart and lungs.”

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. “Your infant should have at least six to eight wet diapers a day and two to three stools a day.” 4. “Your infant should have at least eight to ten wet diapers a day and three to four stools a day.”

43. A nurse is teaching newborn care during prenatal classes. Which of the following should be included regarding when to notify the pediatrician? 1. If the infant has vomiting or diarrhea 2. If the infant has a temperature of 99.8°F 3. If the infant has eight wet diapers per day 4. If the umbilical cord does not fall of by day 9

44. The nurse is conducting a neurologic health assessment. Which of the following is an abnormal finding? 1. The nurse offers a finger on the ulnar side of the hand and observes a tight grasp of the newborn’s fingers as the nurse gently lifts the infant. 2. The nurse makes a loud noise and the infant extends the arms and legs, fans out the fingers, and brings in both arms and legs. 3. The nurse strokes a finger on the upper edge of the sole of the infant’s foot across the ball of the infant’s foot and observes fanning of the toes. 4. The nurse brushes the infant’s cheek on the left side near the mouth and notices the infant turns the head away and closes the mGoR utA hD tiE ghStlMyO . RE.COM

45. The nurse is caring for a newborn who had a circumcision procedure 3 hours ago. Which of the following provides a clue that the newborn might be experiencing pain? 1. Infant has a smooth or nonfurrowed brow. 2. Infant is quiet and calm. 3. Infant’s eyes are wide open with little blinking. 4. Infant’s heart rate is 140 bpm.

46. When conducting a newborn assessment the nurse detects a small tuft of hair at the base of the spine with a sacral dimple. This finding is characteristic of which of the following? 1. Pilonidal dimple 2. Spina bifida 3. Neurologic deficits 4. Hydrocele

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

47. The nurse is reviewing a newborn’s intake and output for the last 36 hours. There is no documentation that the newborn has passed meconium. The nurse inspects the abdomen and finds that the newborn’s abdomen appears distended. The nurse is concerned this finding may indicate which of the following? 1. Ambiguous genitalia 2. Intestinal obstruction 3. Dehydration 4. Spina bifida

48. When observing a new graduate nurse doing a newborn abdominal assessment, which technique illustrates a need for further teaching? 1. The nurse places the infant in the supine position. 2. The nurse inspects the umbilical cord to determine the number of vessels. 3. The nurse waits to palpate the abdomen until after a feeding. 4. The nurse uses the bell of the stethoscope to auscultate bowel sounds in all four quadrants.

49. The newborn skin is critical to the transition from intrauterine life. The skin performs which of the following functions? Select all that apply. 1. Acts as a barrier to water loss, light, and irritants 2. Increases the risk of bacteria, virusGeR s,AaD ndEiS nfMeO ctR ioE n .COM 3. Provides resilience to mechanical trauma 4. Provides sensation and tactile discrimination 5. Maintains thermal regulation

50.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

You are inspecting the face of a newborn infant and note pearly white spots on the newborn’s nose as seen in the above picture. These spots are called .

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers

1. 2. 3. 4.

Feedback This is incorrect. Vernix caseosa is a thick, cheesy substance that protects the skin in utero but does not affect thermoregulation. This is incorrect. Lanugo is fine, soft hair that may cover the newborn’s body but does not affect thermoregulation. This is correct. The thermoregulatory system is most affected by the infant’s inability to contract and shiver. This fat. is incorrect. Premature infants have thin, transparent skin with less subcutaneous

GRADESMORE.COM

1. 2. 3. 4.

Feedback This is incorrect. The newborn neck is short, but the reason the newborn cannot support the head is because of weak neck muscles. This is incorrect. The newborn neck is short, not long. This is incorrect. It is not until around the age of 4 months that an infant can hold his or her head up at a 45-degree angle. This is correct. The newborn neck muscles are weak and cannot support the head.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. You are a nurse working in an obstetrical outpatient clinic. A new mother complains of fatigue and then starts to cry loudly. The mother states that she does not want to be alone with her newborn. Which of the following actions should the nurse take? 1. Suggest she send her guests home so she can rest and have the house to herself. 2. Reassure the mother that this is normal and it will get better. 3. Report the findings to her health-care provider immediately. 4. Use distraction by reminding her how lucky she is to have a healthy baby. ANS: 3 Page: 440

1. 2. 3.

Feedback This is incorrect. It is okay to make sure the mother gets rest, but she may need the social support. This is incorrect. Fatigue and moodiness are normal, but a fear to be left alone with a newborn may be of concern. This is correct. The nurse should be alert to potential signs of postpartum depression and a mother who reports she is afraid to be alone with her baby may be a clue for potential abuse, so close follow-up is warranted. This is incorrect. This response by the nurse is not a therapeutic communication technique and does not address the mother’s fear.

GRADESMORE.COM 4. A new mother is sharing how excited she is that her newborn has blue eyes. The nurse knows that the permanent color of the iris is not set until the child is: 1. 2 to 3 months. 2. 5 to 6 months. 3. 12 months. 4. 18 months. ANS: 3 Page: 398

1. 2. 3.

Feedback This is incorrect. Eye color depends on the protein melanin and the melanocytes are not mature at 2 to 3 months. Eye color is mature at 12 months. This is incorrect. Eye color depends on the protein melanin and the melanocytes are not mature at 5 to 6 months. Eye color is mature at 12 months. This is correct. Eye color depends on the protein melanin and it will take up to 1 year before the melanocytes mature and present a permanent eye color. Eye color is mature at 12 months. This is incorrect. Eye color is mature at 12 months.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is correct. A child’s Eustachian tubes are shorter, wider, and more horizontal, and this provides an increased risk factor for newborns to develop ear infections. This is incorrect. The Eustachian tubes in a child are short, wide, and horizontal. This is incorrect. The outer ear canal is shorter in a child than in an adult. This is incorrect. The location of the Eustachian tubes is in close proximity to the nasopharynx places.

6. In conducting a newborn health assessment, the nurse notices enlarged breasts and a milky drainage from one of the breasts. This finding is a result of: 1. Newborn breast cancer. 2. Release of the maternal hormone prolactin. 3. Retention of the maternal hormoneGeRsA troDgEeS n.MORE.COM 4. A side effect related to the use of Pitocin. ANS: 3 Page: 399

1. 2. 3.

Feedback This is incorrect. It is a normal finding for a newborn to temporarily have enlarged breasts and neonatal milk. This is incorrect. Prolactin has no effect on the newborn’s breast. This is correct. Maternal hormones such as estrogen may cross the placenta during pregnancy and result in enlarged breasts and neonatal milk, especially in full-term infants. This is incorrect. Enlarged breasts of the neonate is not a side effect of Pitocin.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. Place the infant in a sitting position and measure the greatest diameter of head-occipital frontal area. 4. Place the infant in the mother’s lap and measure the greatest diameter of head-occipital frontal area. ANS: 1 Page: 409

1. 2. 3. 4.

Feedback This is correct. To prevent the measuring tape from slipping, lay the infant supine and place the center of the tape at the back of the infant’s head. This is incorrect. If the infant is in the prone position it is hard to keep the measuring tape in place. This is incorrect. If the infant is in a sitting position it is hard to keep the measuring tape in place. This is incorrect. If the infant is in the mother’s lap it is hard to keep the measuring tape in place.

8. A nurse measures the circumference of a newborn head and chest and finds the circumference of the head is 12.4 inches and the chest is 13.8 inches. Based on these measurements, the nurse knows which of the following? GRADESMORE.COM 1. These are normal findings. 2. The head circumference is normal but the chest circumference is too big. 3. Both the chest and the head circumference are too big. 4. Chest circumference should not be larger than head circumference. ANS: 4 Page: 409

1. 2. 3. 4.

Feedback This is incorrect. Normal range for head circumference is 12.5 to 14.5 in. and normal range for chest circumference is 11.8 to 13.8 in. This is incorrect. The head circumference is small and the chest circumference is large. This is incorrect. The head circumference is small and the chest circumference is large. This is correct. Chest circumference should not be greater than head circumference. Ideally, head circumference should be about 2 cm greater than the chest circumference.

9. The nurse is assessing a newborn with a suspected cephalohematoma. Which of the following findings would be consistent with a cephalohematoma?

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Some bruising and swelling noted on one side of the head 2. Edema noted on the entire top of the head 3. Molding of the entire shape of the head 4. Blue hands and feet ANS: 1 Page: 417

1. 2. 3. 4.

Feedback This is correct. A cephalohematoma is a unilateral collection of blood that does not cross the suture line and may or may not include bruising. This is incorrect. Diffuse edema of the fetal scalp that crosses the suture lines is referred to as caput succedaneum. This is incorrect. Molding that distorts the shape of the head is a common deviation. This is incorrect. Blue hands and feet is called acrocyanosis.

10. A nurse is doing a heel stick to collect a laboratory sample for a phenylketonuria (PKU) test prior to discharge of a newborn from the hospital. Which question indicates the mother has a basic understanding of reason(s) for sticking her newborn? 1. “I understand the test will determine if the baby is missing something needed for normal growth and development.” GRADESMORE.COM 2. “I understand the test will prevent my baby from developing newborn jaundice.” 3. “I understand the test will measure my baby’s blood sugar to prevent hypoglycemia.” 4. “I understand the test is a drug screen done before we take a newborn home.” ANS: 1 Page: 309

2. 3. 4.

Feedback This is correct. A metabolic profile includes the PKU blood test to screen for a missing enzyme that causes an inability to break down phenylalanine. When deficient, this may lead to serious neurological disabilities and prevent normal growth and development. This is incorrect. A blood test is recommended to assess serum bilirubin levels but the test will not prevent jaundice. This is incorrect. A blood test will measure the baby’s blood sugar but will not prevent hypoglycemia. This is incorrect. A metabolic profile is mandatory in many states and is done by a heel stick when a newborn is 24 hours old.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3.

Feedback This is incorrect. Lanugo is a normal finding described as fine hair covering the body, oftentimes found on the upper head, back, and shoulders. This is incorrect. Vernix caseosa is a thick, white, cheese-like coating made up of oil on the skin and dead skin cells. It is often visible in the folds of the skin. This is incorrect. Mongolian spots are bluish-black pigmented areas more common in infants of African, Asian, and Mediterranean descent. They are often found on the sacral area. This is correct. Nevus simplex, also called stork bites, are small capillaries close to the surface of the skin. They are flat and red in color and become more noticeable when the infant cries. They are most commonly seen on the nape of the neck and eyelids.

GRADESMORE.COM 12. A nurse is conducting a review of systems with a new teenage mother who is recovering from a cesarean section. Which of the following questions will encourage the mother to fully express herself and build rapport? 1. “Are you scared to take this baby home?” 2. “How do you plan to take care of yourself and a newborn?” 3. “Why is the baby’s father not here to help?” 4. “How do you think your newborn will affect your life?” ANS: 4 Page: 400

1. 2. 3. 4.

Feedback This is incorrect. The nurse should demonstrate caring and genuineness. This is incorrect. When gathering information, the nurse should be nonjudgmental and attempt to build rapport. This is incorrect. When gathering information, the nurse should be nonjudgmental. This is correct. Asking open-ended questions of how a newborn may affect a mother’s quality of life will likely assist the client to express any concerns.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is correct. The arm recoil is part of the gestational age assessment in which the angle of recoil of the forearm is scored and recorded. This is incorrect. The square window is part of the gestational age assessment in which the angle between the hand and the wrist is scored and recorded. This is incorrect. The popliteal angle is part of the gestational age assessment in which the angle formed by the upper and lower leg is scored and recorded. This is incorrect. The scarf sign is part of the gestational age assessment in which the position of the infant’s elbow on the chest is scored and recorded.

GRADESMORE.COM 14. When assessing a newborn using the Ballard Gestational Age Assessment tool the nurse assesses skin turgor, color, and texture. The nurse knows the easiest place to assess the infant’s skin is in which location? 1. Abdomen 2. Arm 3. Chest 4. Toes ANS: 1 Page: 405

1. 2. 3. 4.

Feedback This is correct. The abdomen is the easiest place to assess skin turgor, color, and texture. This is incorrect. The arm is not the easiest place to assess skin turgor, color, and texture. This is incorrect. The chest is not the easiest place to assess skin turgor, color, and texture. This is incorrect. The toes are not the easiest place to assess skin turgor, color, and texture.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3.

Feedback This is incorrect. A post-term birth occurs after the completion of 42 weeks’ gestation and this recorded weight is below the expected weight range for a full- or post-term birth. This is correct. SGA refers to a term newborn whose weight falls below the 10th percentile. A normal weight range for a full-term infant is 5 lb 8 oz to 8 lb 13 oz. This is incorrect. Term birth occurs between 38 and 41 and 4/7 weeks’ gestation and this recorded weight falls below the normal findings of weight range for a full-term infant, which is 5 lb 8 oz to 8 lb 13 oz. This is incorrect. Large for gestational age refers to a newborn who weighs above the 90th percentile when full tG erRmA. D TE hiS sM neOwRbE or.nCisOfM ull term but the weight falls below the normal weight range.

Feedback This is incorrect. To determine gestational age it is important to evaluate neuromuscular maturity and physical maturity and combine those scores to determine an accurate gestational age. At 24 weeks’ gestation the ear will not instantly recoil. This is incorrect. To determine gestational age it is important to evaluate neuromuscular maturity and physical maturity and combine those scores to determine an accurate gestational age. At 30 weeks’ gestation the ear will not recoil when bent. This is correct. To determine gestational age it is important to evaluate neuromuscular

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

maturity and physical maturity and combine those scores to determine an accurate gestational age. A newborn ear that recoils instantly is descriptive of a term newborn. This is incorrect. To determine gestational age it is important to evaluate neuromuscular maturity and physical maturity and combine those scores to determine an accurate gestational age. At 42 weeks’ gestation the ear is generally very stiff.

17. During assessment of a quiet, alert newborn the nurse counts the apical pulse for 1 full minute and finds a heart rate of 130 beats per minute (bpm). The nurse knows that the expected heart rate for this newborn ranges from: 1. 80 to 100 bpm. 2. 90 to 110 bpm. 3. 120 to 160 bpm. 4. 162 to 180 bpm. ANS: 3 Page: 411

1. 2. 3. 4.

Feedback This is incorrect. A heart rate less than 100 is abnormal and called bradycardia. This is incorrect. A heart rate less than 100 is abnormal and called bradycardia. This is correct. A heart rate of 132 is a normal finding and expected findings are GRADESMORE.COM between 120 to 160. This is incorrect. A heart rate greater than 160 is abnormal and called tachycardia.

1. 2. 3. 4.

Feedback This is incorrect. Infants born with a two-vessel umbilical cord have an increased risk of cardiac, renal, and gastrointestinal anomalies but not neurologic disorders. This is correct. Infants born with a two-vessel umbilical cord have an increased risk of cardiac, renal, and gastrointestinal anomalies. This is incorrect. Infants born with a two-vessel umbilical cord have an increased risk of gastrointestinal, cardiac, and renal anomalies but not neurologic disorders. This is incorrect. Infants born with a two-vessel umbilical cord do not have an

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

increased risk of Down Syndrome or Turner syndrome but are at increased risk for cardiac, renal, and gastrointestinal anomalies.

3. 4.

Feedback This is the correct answer. The mother will need additional teaching regarding the needs of a preterm newborn because this baby was born prior to the completion of 37 weeks’ gestation and is large for gestational age. The mother is correct, a preterm newborn will need to nurse more frequently and because this newborn is also considered large for gestational age the newborn will be at increased risk for hypoglycemia. The mother is correct because the infant is large for gestational age the infant is at increased risk for hypotheG rmRiA a.DESMORE.COM The mother is correct. Weight loss of greater than 10% in the first 3 to 5 days is an abnormal finding regardless of initial birth weight.

1. 2. 3.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

of gastrointestinal, cardiac, and renal anomalies but not neurologic disorders. This is incorrect. Infants born with a two-vessel umbilical cord do not have an increased risk of Down Syndrome or Turner syndrome but are at increased risk for cardiac, renal, and gastrointestinal anomalies.

21. During a routine assessment of a newborn prior to discharge, the nurse finds an axillary temperature of 99.2°F. Which of the following actions by the charge nurse is most appropriate? 1. Retake the temperature in 30 minutes. 2. Take a rectal temperature. 3. No action necessary. 4. Call the health-care provider prior to discharge. ANS: 3 Page: 410

1. 2. 3. 4.

Feedback This is incorrect. There is no need to retake the temperature because an axillary temperature of 97.7°F to 99.3°F is normal. This is incorrect. Rectal temperatures are not recommended as a routine method because they may cause health risks. This is correct. There is no action needed because an axillary temperature of 97.7°F to GRADESMORE.COM 99.3°F is normal. This is incorrect. There is no action needed Abnormal findings include a temperature above 100.4°F.

Feedback This is incorrect. It is normal to have some short respiratory pauses that last 5 to 10 seconds but apnea periods of 20 seconds or longer are an abnormal finding.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3. 4.

This is incorrect. It is normal for the respiratory rate to be irregular in depth, rate, and rhythm. This is incorrect. To ensure the safety of the newborn, the nurse needs to report the abnormal finding. This is correct. Notify the health-care provider if an infant has a prolonged apnea with a noted color change or more than one apneic period.

1. 2. 3.

Feedback This is incorrect. Acrocyanosis is normal finding in the first 24 to 48 hours and appears as blue hands and feet. This is correct. A differencGeRbA etDwEeeSnMtO heRsEy. stC olO icMupper and lower extremities of greater than 10 mm Hg should raise suspicion of anomalies of the aorta. This is incorrect. A difference between the systolic upper and lower extremities of greater than 10 mm Hg should raise suspicion of anomalies of the aorta, not of renal failures. This is incorrect. A difference between the systolic upper and lower extremities of greater than 10 mm Hg should raise suspicion of anomalies of the aorta, not of postural hypotension.

Feedback This is incorrect. An infant in the quiet alert phase may smile, vocalize, and respond to

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3. 4.

people talking to her or him. This is incorrect. An infant in the quiet alert phase may have a regular respiratory rate. This is incorrect. An infant in the quiet alert phase may lay still and focus on objects in front of her or him. This is correct. Phases include deep sleep, light sleep, drowsy, quiet alert, active alert, and crying. An infant in the active alert phase may appear restless, respirations may be irregular, and the infant may not be interested in stimulation.

1. 2. 3. 4.

Feedback This is incorrect. It is not necessary to wait until the infant is in a quiet alert phase to obtain measurements. GRADESMORE.COM This is incorrect. It is not necessary to wait until the infant has had an initial bath to obtain measurements. This is correct. If the infant has not had an initial bath, then standard precautions are a priority and the nurse should use gloves to prevent the acquisition of infection. This is incorrect. The nurse should record measurements in inches and centimeters, but standard precautions would be a priority.

26. When assessing a newborn’s transition to extrauterine life the Apgar score is used to evaluate the following categories: 1. Heart rate, respiratory rate, reflexes, skin color, and weight. 2. Square window, arm recoil, popliteal angle, scarf sign, heel to ear, and lanugo. 3. Heart rate, respiratory rate, muscle tone, reflex irritability, and skin color. 4. Lanugo, plantar surface, posture, square window, and scarf sign. ANS: 3 Page: 402

1. 2.

Feedback This is incorrect. The Apgar score includes heart rate, respiratory rate, muscle tone, reflex irritability, and skin color at 1 and 5 minutes after birth. This is incorrect. Square window, arm recoil, popliteal angle, scarf sign, heel to ear,

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

and lanugo refer to items in the Ballard Gestational Age Assessment tool. This is correct. The Apgar score includes heart rate, respiratory rate, muscle tone, reflex irritability, and skin color at 1 and 5 minutes after birth. This is incorrect. Lanugo, plantar surface, posture, square window, and scarf sign refer to items in the Ballard Gestational Age Assessment tool.

2. 3. 4.

Feedback This is correct. To obtain an accurate blood pressure reading the nurse must use a cuff that is the appropriate size, which can affect the accuracy of the blood pressure reading. This is incorrect. The preferred time to obtain the blood pressure reading is while the infant is calm or asleep. GRADESMORE.COM This is incorrect. Swaddling the infant is a useful technique to calm and soothe an infant but use of an accurate size cuff is most important. This is incorrect. The nurse should gently restrain the newborn limb being used for a blood pressure reading.

28. When conducting a newborn assessment of the infant’s anterior fontanels it is best for the infant to be: 1. Crying. 2. Active and alert. 3. Active and crying. 4. Sleeping and quiet. ANS: 4 Page: 417

1. 2.

Feedback This is incorrect. It is more difficult to assess the fontanels with a newborn who is crying as it may be difficult to determine if the fontanels are bulging. This is incorrect. It is not the best time to inspect the fontanels when the infant is active and alert. The best time is to inspect the fontanels is with a newborn sleeping or

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

quiet. This is incorrect. It is more difficult to assess the fontanels with a newborn that is active and crying. This is correct. The nurse should take advantage of when the newborn is sleeping or quiet to assess the anterior fontanels, heart, lungs, abdomen, and eyes.

1. 2. 3.

Feedback This is incorrect. Tachycardia is defined as a heart rate greater than 160. This is incorrect. Bradycardia is defined as a heart rate less than 100 and may be an expected finding in a sleeping newborn. This is correct. The heart rate must be interpreted in the context of the infant’s activity ADE SMOmay RE.have COMa heart rate as low as 100, while an level. An infant who is in G aR deep sleep infant who is crying may have a heart rate above 160. This is incorrect. Apnea is defined as a pause in the respiratory rate for periods of 20 seconds or longer.

1. 2. 3.

Feedback This is incorrect. This is not a normal amount of weight loss. No more than 10% weight loss is normal. This is incorrect. A 2% weight loss would fall within normal limits. This is incorrect. A 5% weight loss would fall within normal limits.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is correct. A normal weight loss after 3 to 4 days is no more than 10% of birth weight and this newborn has lost more than 10%.

31. After delivery, the midwife places a newborn skin to skin on its mother’s chest for 1 hour. Prior to obtaining an initial weight on the newborn, the nurse knows that standard precautions indicate which of the following is true? 1. Once a nurse washes his or her hands, he or she may handle the newborn. 2. Once a nurse uses hand sanitizer, he or she may handle the newborn. 3. If the newborn has not had an initial bath, the nurse needs to wear gloves. 4. If the maternal history does not include TORCH infections, the nurse does not need to wear gloves. ANS: 3 Page: 407

1. 2. 3. 4.

Feedback This is incorrect. Washing one’s hands is not sufficient if the infant has not had a bath. The nurse needs to wear gloves. This is incorrect. If the infant has not had a bath, the nurse needs to wear gloves before handling the newborn. GRADESMORE.COM This is correct. If the infant has not had an initial bath, standard precautions should be followed and gloves should be used to prevent the acquisition of infection. This is incorrect. Regardless of maternal history, the nurse needs to use standard precautions.

Feedback This is incorrect. To determine the infant’s gestational age, you must consider both the physical and neuromuscular examination to determine if the newborn is premature.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3. 4.

This is correct. A newborn assessment of weight must be related to gestational age. This is incorrect. A nurse cannot just look at the newborn to determine the infant’s gestational age. This is incorrect. The average weight for a full-term infant is 3,400 g or 7 lb 8 oz.

1. 2. 3. 4.

Feedback This is incorrect. Central cyanosis is best assessed on a newborn’s tongue. This is correct. Skin color is easier to assess by blanching the skin and color is best assessed on the infant’s forehead, nose, or sternum. This is incorrect. Color is best assessed on the infant’s sternum, not the gum line. This is incorrect. Color is best assessed along with capillary refill on the infant’s RAnurse DESMisOassessing RE.COMcolor, not capillary refill time. sternum, but with jaundiceGthe

1. 2. 3. 4.

Feedback This is incorrect. The anterior fontanel should be soft and flat and is an expected finding. This is incorrect. The posterior fontanel may or may not be palpable but is an expected finding. This is incorrect. Sometimes lacerations result from a fetal scalp electrode. This is correct. A bulging fontanel is abnormal. The fontanel should be soft and flat.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

35. The nurse is assessing a 5-day-old newborn and notices the sclera is yellow. Which of the following does the nurse know is true regarding a jaundiced newborn? 1. Jaundice begins at the toes and moves up. 2. Jaundice begins at the head and moves toward the toes. 3. Jaundice noticed in the eyes is a late sign of newborn jaundice. 4. Jaundice is most common before 24 hours of age. ANS: 2 Page: 418

1. 2. 3. 4.

Feedback This is incorrect. Jaundice recedes from the toes and moves up but starts at the head. This is correct. Jaundice begins at the head and moves to the toes. This is incorrect. A yellow sclera is often the first sign of jaundice. This is incorrect. Jaundice that appears before 24 hours of age is a concerning and abnormal finding.

36. When conducting a newborn assessment, the nurse is inspecting the nose for patency. While occluding the left nostril with a finger, the nurse observes flaring of the right nostril. The nurse knows which of the following to be true regarding the newborn’s nose? 1. Infants frequently have continual nGaR saAl D drEaiSnM agOeR . E.COM 2. Infants will open their mouths to breathe if they have a nasal obstruction. 3. Infants are obligate nose breathers. 4. Flaring of the nostrils is a normal finding. ANS: 3 Page: 398

1. 2. 3. 4.

Feedback This is incorrect. Infants may have some mucus discharge but there should be no drainage. This is incorrect. Infants do not develop the response of opening the mouth due to an obstruction until several weeks after birth. This is correct. Infants are obligate nose breathers. This is incorrect. Flaring of the nostrils is a sign of respiratory distress.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. The infant will startle and start to cry. ANS: 2 Page: 418

1. 2. 3.

Feedback This is incorrect. It is expected that the infant will turn his or her head toward the sound. This is correct. It is expected that the infant will turn his or her head toward the sound. This is incorrect. The rooting reflex is assessed by gently stroking the infant’s cheek, moving from the mouth outwards. The infant should turn his or her head toward the direction of your finger. This is incorrect. The nurse is observing to determine if the infant turns his or her head toward the sound.

GRADESMORE.COM

ANS: 1 Page: 419-420 Heading: Techniques of Physical Assessment: Newborn Integrated Processes: Nursing Process Client Need: Health Promotion and Maintenance Cognitive Level: Knowledge [Remembering] Concept: Assessment; Newborn Difficulty: Easy

1. 2. 3. 4.

Feedback This is correct. The newborn should be assessed for the rooting, sucking, and gag reflexes. This is incorrect. The Babinski reflex is part of the neurologic examination and the red reflex is part of the eye examination. This is incorrect. The red reflex is part of the eye examination, not assessment of the mouth, and this assessment includes the rooting reflex. This is incorrect. The Babinski reflex is part of the neurologic examination and the examiner needs to include the rooting reflex.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3.

Feedback This is incorrect. Smoking during pregnancy can lead to prematurity, low birth weight, and increased risk of sudden infant death syndrome. This is incorrect. Drug substance abuse during pregnancy may lead to prematurity, low birth weight, and drug withdrawal in the newborn. This is correct. Drinking alcohol during pregnancy can cause fetal alcohol syndrome, which may cause facial anomalies, deafness, heart defects, developmental delays, and neurological abnormalities. This is incorrect. It is important to assess a client for a family history of congenital anomalies but this is not part of the psychosocial history.

GRADESMORE.COM 40. The nurse is teaching a nursing student how to assess the heart and lungs of a newborn. Which of the following statements by the nursing student would indicate a correct understanding of the teaching? 1. “As long as the baby is crying I might as well assess the newborn’s heart sounds and lungs.” 2. “I will place the newborn on the mother’s bed so she can observe my assessment.” 3. “I am going to skip gloves because they are too big and I am scared to drop the newborn.” 4. “While the newborn is asleep and is skin to skin on its mother’s chest, I will assess the heart and lungs.” ANS: 4 Page: 398, 410

1. 2. 3. 4.

Feedback This is incorrect. It is better to take advantage of when the newborn is sleeping or quiet to assess the anterior fontanels, heart, lungs, abdomen, and eyes. This is incorrect. The best place to assess a newborn is on a radiant warmer bed to avoid heat loss. The bed is not a preheated surface. This is incorrect. Appropriate infection control measures include wearing gloves until the newborn has had an initial bath. This is correct. It is best to take advantage of the newborn that is sleeping or quiet. Because the newborn may be undressed, he or she needs to be kept warm to avoid heat loss. The mother’s chest provides an alternative prewarmed surface.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

41. A nurse is teaching a prenatal class on breastfeeding. Which of the following statements by the expectant mothers would indicate a correct understanding of breastfeeding? 1. “I plan to make my husband give the baby a bottle of formula at night and I will nurse during the day so I can get some sleep.” 2. “I plan to breastfeed this baby because my last child was sick all the time.” 3. “The minute I deliver my baby I am going to sleep for 8 hours with no one kicking me.” 4. “I heard that if my baby starts cereal at 2 months that he or she will sleep through the night.” ANS: 2 Page: 439-440 Heading: American Academy of Pediatrics; Healthy People 2020; WHO Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Pregnancy; Newborn Care Difficulty: Moderate

1. 2.

3. 4.

Feedback This is incorrect. The American Academy of Pediatrics recommends exclusive breastfeeding for about theGfRirA stD6EmSoMnO thR sE of.aCbOaM by’s life. This is correct. Breastfeeding has a protective effect for the infant, giving increased immunity for the baby against getting respiratory infections, ear infections, gastric intestinal disease, and allergies. This is incorrect. The World Health Organization encourages mothers to breastfeed within the first few hours after birth. This is incorrect. The American Academy of Pediatrics recommends exclusive breastfeeding for about the first 6 months of a baby’s life.

42. The nurse is doing a home visit on a breastfeeding mother and a 1-week-old newborn. The mother is concerned that the infant is not getting enough milk. Which of the following is the best response to the mother? 1. “Your infant should have at least two to four wet diapers a day and one to two stools a day.” 2. “Your infant should have at least four to six wet diapers a day and one to two stools a day.” 3. “Your infant should have at least six to eight wet diapers a day and two to three stools a day.” 4. “Your infant should have at least eight to ten wet diapers a day and three to four stools a day.” ANS: 3 Page: 438 Feedback

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

This is incorrect. By day 6 an infant should have about six to eight wet diapers a day and two to three stools a day, so two to four wet diapers a day and one to two stools a day is not enough. This is incorrect. By day 6 an infant should have at least six to eight wet diapers a day and two to three stools a day, so four to six wet diapers a day and one to two stools a day is not enough. This is correct. By day 6 an infant should have at least six to eight wet diapers a day and two to three stools a day. This is incorrect. It would be okay for an infant to have eight to ten diapers a day and three to four stools a day, but it is not necessary as the infant only needs to have at least six to eight wet diapers a day and two to three stools a day.

1. 2. 3. 4.

GRADESMORE.COM Feedback This is correct. To determine the cause and to avoid dehydration, it is important to call the pediatrician if an infant has vomiting or diarrhea. This is incorrect. This is considered a normal temperature. A parent should notify the pediatrician if the temperature is 100.4°F or above. This is incorrect. This is normal. Infants should have at least six to eight wet diapers a day. This is incorrect. This is normal. The infant’s umbilical cord usually falls off between 7 to 10 days after birth.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 4 Page: 436

1. 2. 3. 4.

Feedback This is incorrect. An infant in pain will usually not have a relaxed face. A nonfurrowed brow is a normal behavioral cue. This is incorrect. An infant in pain is likely to be whiny and difficult to soothe. This is correct. A behavioral cue of pain in a newborn is a hyper-alert state of arousal evidenced by the infant’s eyes being continually open wide with little blinking noted. This is incorrect. A heart rate of 120 to 140 bpm is a normal finding. Physiologic manifestations of pain may include bradycardia or tachycardia, tachypnea or apnea, cyanosis, modeling, duskiness, or pallor.

GRADESMORE.COM

ANS: 3 Page: 437

1. 2. 3. 4.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Page: 434

1. 2. 3. 4.

Feedback This is incorrect. A pilonidal dimple is a normal finding that appears as a small depression at the base of the sacrum without any clinical significance. This is correct. A tuft of hair present at the base of the spine with a sacral dimple may indicate spina bifida. This is incorrect. The examination to assess for neurological deficits consists of observation and eliciting various reflexes. This is incorrect. A hydrocele is an abnormal finding to describe fluid surrounding the testicles of a newborn.

GRADESMORE.COM

ANS: 2 Page: 434

2. 3. 4.

Feedback This is incorrect. Ambiguous genitalia is an abnormal finding that is characterized by a clitoris that is excessively prominent and an anti-vaginal orifice that is not clearly patent, but this finding does not interfere with the newborn passing meconium. This is correct. Failure to pass meconium within 24 hours may indicate an intestinal obstruction. This is incorrect. Dehydration is suspected if a newborn has no urine present within 24 hours. This is incorrect. Spina bifida is an opening in the spinal cord that may or may not be palpated or visualized but will not interfere with a newborn passing meconium.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 3 Page: 427

1. 2.

Feedback Placing the infant in the supine position to assess the abdomen is the correct technique. The nurse should inspect the umbilical cord. An umbilical cord should have three vessels to include two arteries and one vein. A two-vessel cord indicates an increased risk of cardiac, renal, and gastrointestinal anomalies. This is the correct answer. The nurse should not palpate the infant’s abdomen after a feeding because it may cause the infant to spit up some of the feeding. The best time to palpate the infant’s abdomen is prior to a feeding or 2 to 3 hours after a feeding. Using the bell to auscultate bowel sounds in all four quadrants for 1 full minute is a correct technique.

49. The newborn skin is critical to the transition from intrauterine life. The skin performs which of the following functions? Select all that apply. 1. Acts as a barrier to water loss, light, and irritants 2. Increases the risk of bacteria, viruses, and infection 3. Provides resilience to mechanical trauma 4. Provides sensation and tactile discrimination 5. Maintains thermal regulation

GRADESMORE.COM

ANS: 1, 3, 4, 5 Page: 398 1. 2. 3. 4. 5.

This is correct. Acting as a barrier to water loss, light, and irritants is a function of the skin. This is incorrect. The newborn skin does not increase risk, but rather protects the skin and decreases the risk of bacteria, viruses, infection. This is correct. Providing resilience to mechanical trauma is a function of the skin. This is correct. Providing sensation and tactile discrimination is a function of the skin. This is correct. Maintaining thermal regulation is a function of the skin.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

50. You are inspecting the face of a newborn infant and note pearly white spots on the newborn’s nose as seen in the above picture. These spots are called . ANS: milia Page: 415 Feedback: Milia are pearly white cysts on the skin formed from the sebaceous glands. They are often found on the nose. GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 22: Assessing the Child and Adolescent

1. You are assessing a 4-year-old child who has ear pain. According to the American Academy of Pediatrics, this stage of pediatric development is called: 1. Baby. 2. Toddler. 3. Preschool. 4. Grade school.

2. According to Tanner’s staging of sexual maturity, female staging is based on: 1. Hair growth and breast bud development. 2. Height, weight, and body mass index. 3. Age of girl and pubic hair development. 4. Breast size/shape and the distribution of pubic hair.

3. When should infants at risk for lead poisoning be tested? 1. 1 to 3 months GRADESMORE.COM 2. 3 to 6 months 3. 6 to 9 months 4. 9 to 12 months

4. A comprehensive health history will require many questions. At what age can children actively participate in the review of systems? 1. Age 3 2. Age 4 3. Age 5 4. Age 6

5. Children may not always be able to express their chief complaint. Which of the following is a priority assessment during the health history? 1. Standing posture 2. Nonverbal body language 3. Vital signs 4. Parent’s report

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

6. During the health history, the nurse reviews information about factors that may affect the physical and cognitive development of the child. Which question or statement by the nurse would be most appropriate? 1. “Describe your pregnancy and delivery.” 2. “Has your child had any major illnesses or injuries?” 3. “What brought you in today?” 4. “Tell me about your child’s immunizations.”

7. During an initial comprehensive health history, the mother reveals that her child has not had any immunizations. She states, “My religion is against giving my child immunizations.” What is your best response? 1. “Shame on you! You are hurting your child.” 2. “This is against the law. You could go to jail.” 3. “What is your religion? I will let your health-care provider know.” 4. “I am going to have to report this immediately to the Department of Public Health.”

8. You are performing a psychosocial history on a teenager. He states that he is very active in sports and rides his bicycle 5 miles daily. What should the nurse ask next? 1. “What type of sports do you play?G ” RADESMORE.COM 2. “Are you able to maintain good grades in school?” 3. “What type of protective equipment do you wear?” 4. “Do you wear a cup when you play football?”

9. You are doing a psychosocial history on a 12-year-old girl. She reports that she has many friends that she “hangs out” with daily after school. You assess whether she smokes because you know that children usually try their first cigarette around age: 1. 9. 2. 10. 3. 11. 4. 12.

10. When assessing a toddler’s abdomen, excessive high-pitched tympanic sounds could indicate: 1. An underlying mass. 2. A paralytic ileus. 3. An early bowel obstruction. 4. Peritoneal inflammation.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

11. A mother reports that she is concerned that her 9-year-old daughter is overweight and has poor eating habits. What is the recommended and easiest method to assess daily intake? 1. Teach the 9-year-old girl how to write down everything she eats over a period of 3 days. 2. Ask the mother for a verbal report of the foods her daughter ate yesterday. 3. Document a food diary that includes a 24-hour period including all snacks. 4. Document a food diary that includes 2 weekdays and 1 weekend day.

12. A mother is upset because her 6-year-old son continues to wet the bed every night. You know that this condition is called: 1. Urinary incontinence. 2. Stress incontinence. 3. Nocturnal enuresis. 4. Diurnal enuresis.

13. The FLACC Scale is used to assess pain in children ages 2 months to 7 years. What criteria are evaluated on this scale? 1. Face, lips, activity, color, cooperatGioRnADESMORE.COM 2. Flail, listen, action, cry, color 3. Face, legs, activity, cry, consolability 4. Flail, legs, adjustment, color, cooperation

14. The Review of Systems (ROS) is an essential component of the health history in the evaluation of a child. The ROS uses information from: 1. The physical examination. 2. A conversation with the parent and child about the body systems. 3. A review of all medical records and past examinations. 4. A review of the chief complaint.

15. A 13-year-old female is undergoing a pre-school health assessment. Questions regarding smoking, drinking alcohol, and current sexual activity are best approached by the nurse: 1. In a private conversation with the patient. 2. In a private area with one parent present. 3. During the initial interview with both parents present. 4. With the parent, as these topics should not be addressed with this age patient.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

16. When auscultating an apical pulse of a child, the diaphragm of the stethoscope should be placed over the apex of the heart. The apex is located at: 1. The 2nd intercostal space at the midclavicular line. 2. The 4th or 5th intercostal space at the left midclavicular line. 3. The 3rd intercostal space at the left sternal border. 4. The 2nd intercostal space at the right sternal border.

17. When using an otoscope to assess the ear of a child under 3 years, the examiner should: 1. Tip the head slightly toward the examiner. 2. Pull the pinna down and forward slightly. 3. Pull the pinna down and back. 4. With the pinna in its usual position, hold it back against the head.

18. Learning disability is a term used for a wide variety of specific learning differences. Children with learning disabilities: 1. Often have problems with motivation. 2. Should be tested in middle school to implement an educational plan. GeRrAinDteEllSigMeO 3. Frequently have problems with low ncReEle.vC elO s.M 4. Are at risk for adjustment difficulties.

19. When you are assessing a child’s capillary refill, a normal finding would be: 1. Greater than 4 seconds. 2. Greater than 5 seconds. 3. Less than 4 second. 4. 2 to 3 seconds.

20. The congenital displacement of the urethral opening of the penis to below the glans penis is called: 1. Hypospadias. 2. Cryptorchidism. 3. Epispadias. 4. Phimosis.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

21. You are assessing a 15-year-old boy and are discussing testicular self-examination. He states, “I do not know anything about that examination and I would never do that!” Which of the following remarks by the nurse is most appropriate? 1. “Adolescent boys over the age of 14 should start performing testicular self-examinations.” 2. “You should know what your normal testicles feel like to check for abnormal lumps.” 3. “You should have been told about doing a testicular examination in your health education class.” 4. “Do you know where your testicles are?”

22. A 5-year-old boy is being assessed for right leg pain. What pain scale will you use? 1. Face, Legs, Activity, Cry, Consolability (FLACC) Scale 2. Comfort B Scale 3. OUCHER! Scale 4. Visual Analog Scale

23. At what age is head circumference measurement stopped? 1. Age 1 2. Age 2 3. Age 3 GRADESMORE.COM 4. Age 4

24. You are assessing the mouth of a 5-year-old child. You know that baby teeth are expected to fall out by: 1. Age 3. 2. Age 4. 3. Age 5. 4. Age 6.

25. You are performing a pediatric assessment on a 13-year-old boy. Select your equipment. Select all that apply. 1. Sterile gloves 2. Stand-up scale 3. Length board 4. Paper measuring tape 5. Adult stethoscope 6. Rectal thermometer

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

26. During a review of systems of the skin, which of the following questions are appropriate to ask a teenager? Select all that apply. 1. Do you have any piercings or tattoos? 2. Do you pick or try to pop your acne pimples? 3. Do you color your hair? 4. Do you have any problems with oily skin or skin blemishes? 5. Do you go to the tanning salon? 6. Do you bite your nails?

27. You are assessing the posture and gait of a 14-month-old toddler. What are the normal assessment findings? Select all that apply. 1. Wide base of support 2. May be knock-kneed 3. Often pigeon-toed 4. May be bowlegged

28. A 16-year-old girl reports that she has a severe allergy to peanuts. You educate the patient that children who are allergic to peanuts may also be allergic to which of the following? Select all that apply. GRADESMORE.COM 1. Milk products 2. Chocolate chip cookies 3. Pistachios 4. Cashews 5. Walnuts

29. When examining an inner ear in a child, the structures that should be identified include which of the following? Select all that apply. 1. The tympanic membrane 2. Portions of the mandible (dense, whitish streak) 3. The umbo 4. The cone of light

30. You are assessing a 6-year-old child who is showing signs of respiratory distress. What would be the abnormal findings that you may assess? Select all that apply. 1. Intercostal retractions 2. Nasal flaring 3. Grunting

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Skin pallor 5. Change in level of consciousness

31. When testing for human immunodeficiency virus (HIV) in the adolescent, it is important to maintain the three C’s. What are the three C’s? Select all that apply. 1. Crisis management 2. Informed consent 3. Connectivity 4. Counseling 5. Confidentiality

32. Identify the true statements about pediatric cardiac assessment. Select all that apply. 1. Normal heart sounds are best heard with the bell of the stethoscope at all landmarks. 2. For children age 7 and older, the mitral area is located at or near the 3rd left intercostal space 3. Normally, pulsations are felt at the five landmarks on the chest wall next to the sternal border. 4. Erb’s point is at the left sternal border in the 5th intercostal space at the apex of the heart. 5. For children up to age 7, the mitral area is located at or near the 4th intercostal space.

GRADESMORE.COM 33. Special considerations that are helpful to know when examining a child include which of the following? Select all that apply. 1. During gait assessment a child should wear shoes to help with stability. 2. Have the child place his or her hand over the examiner’s hand when palpating the abdomen. 3. Playing a game of “Simon Says” can help to evaluate range of motion. 4. Newborns present with a rounded or C-shaped curve to the spine.

34. A child’s normal development includes which of the following? Select all that apply. 1. Occurs in a caudal to cephalic fashion 2. Proceeds in an orderly, sequential pathway 3. Begins with acquisition of fine motor skills followed by gross motor skills 4. Becomes increasingly integrated and organized

35. A 14-year-old boy was playing football and suffered a concussion. Symptoms of a concussion include which of the following? Select all that apply. 1. Agitation 2. Headache 3. Nausea

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Photophobia 5. Memory loss 6. Anosmia

36. You are performing a physical assessment on a 3-year-old toddler. Correctly order the techniques of the physical examination (1–5). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Assess the mouth and tongue using a tongue blade. 2. Take a tympanic temperature. 3. Assess the respiratory rate. 4. Auscultate lung sounds. 5. Perform a general survey.

37. A stiff neck or limited range of motion with muscle spasm that causes contracture of the musculature of the neck is called .

38. Swelling of the lips and tongue in response to an allergic reaction in a child is called GRADESMORE.COM .

39. Pediatric breath sounds that are heard over the periphery of the lung fields with inspiration longer and louder than expiration are called breath sounds.

40. wheezing, and asthma.

smoking puts children at high risk for respiratory infections,

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

41.41. You are assessing a toddler who has just learned how to walk. Look at the picture and identify the type of legs that are normally seen in this age group. It is called .

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers 1. You are assessing a 4-year-old child who has ear pain. According to the American Academy of Pediatrics, this stage of pediatric development is called: 1. Baby. 2. Toddler. 3. Preschool. 4. Grade school. ANS: 3 Page: 441

1. 2. 3. 4.

Feedback This is incorrect. Baby: 0 to 12 months This is incorrect. Toddler: 1 to 3 years This is correct. Preschool child: 3 to 5 years This is incorrect. Grade school child: 5 to 12 years

2. According to Tanner’s staging of sexual maturity, female staging is based on: 1. Hair growth and breast bud development. 2. Height, weight, and body mass index. 3. Age of girl and pubic hair developG mRenAtD . ESMORE.COM 4. Breast size/shape and the distribution of pubic hair. ANS: 4 Page: 442

1. 2. 3. 4.

Feedback This is incorrect. Tanner’s female staging is not based on hair growth and breast bud development. This is incorrect. Tanner’s female staging is not based on height, weight, and body mass index. These are not part of sexual development. This is incorrect. Tanner’s female staging is not based on the female’s age and pubic hair development. This is correct. In females, Tanner’s staging is based on breast size/shape and the distribution of pubic hair.

3. When should infants at risk for lead poisoning be tested? 1. 1 to 3 months 2. 3 to 6 months 3. 6 to 9 months

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. 9 to 12 months ANS: 4 Page: 443

1. 2. 3. 4.

Feedback This is incorrect. This is too early. Infants are not tested at 1 to 3 months. This is incorrect. This is too early. Babies are not tested at 3 to 6 months. This is incorrect. This is too early. Babies are not tested at 6 to 9 months. This is correct. Infants at risk should be tested beginning at 9 to 12 months and retested at 24 months.

4. A comprehensive health history will require many questions. At what age can children actively participate in the review of systems? 1. Age 3 2. Age 4 3. Age 5 4. Age 6 ANS: 1 Page: 444

1. 2. 3. 4.

GRADESMORE.COM

Feedback This is correct. Children as young as 3 years of age can effectively participate in the health interview. This is incorrect. Children are able to participate as early as age 3 in the health history. This is incorrect. Children are able to participate as early as age 3 in the health history. This is incorrect. Children are able to participate as early as age 3 in the health history.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. Standing posture of the child is not a priority assessment. This is correct. Observe the child’s nonverbal body language and level of comfort. Some signs of pain may be facial grimacing, restlessness, rigid posture, or irritability. This is incorrect. Vital signs of the child are not taken during the health history. This is incorrect. The parent’s report is important but is not assessed during the health history.

1. 2. 3. 4.

Feedback This is correct. Prenatal and birth history will provide information about factors that RADESMdevelopment ORE.COM of the child. may affect the physical andGcognitive This is incorrect. Past medical history asks specifically about past medical illnesses. This is incorrect. This question would be the first question to identify the reason for the visit. This is incorrect. This question would be asked to assess whether the child is up to date on his or her immunizations.

Feedback This is incorrect. Nurses should not be judgmental. This is a nontherapeutic statement.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3. 4.

This is incorrect. Even if it is against the law, nurses should not make a threatening statement to the mother. This is correct. You should document the religion and alert the health-care provider who will know the state’s law related to vaccination exemptions. This is incorrect. This is a threatening statement and the health-care provider should be the reporter.

8. You are performing a psychosocial history on a teenager. He states that he is very active in sports and rides his bicycle 5 miles daily. What should the nurse ask next? 1. “What type of sports do you play?” 2. “Are you able to maintain good grades in school?” 3. “What type of protective equipment do you wear?” 4. “Do you wear a cup when you play football?” ANS: 3 Page: 446

1. 2. 3. 4.

Feedback This is incorrect. The patient acknowledged that he plays sports; however, nurses need to assess whether he uses protective equipment for all sports. This is incorrect. The nurse does not need to know if the teenager has good academic GRADESMORE.COM standing. This is correct. This is an open-ended question allowing the nurse to assess whether protective equipment is used for all the different types of sports. This is incorrect. This is a closed-ended question that has a limited answer.

1. 2. 3.

Feedback This is incorrect. This is too young. Children usually try smoking around age 11. This is incorrect. This is too young. Children usually try smoking around age 11. This is correct. If children do try their first cigarette, it is around the age of 11, and many are addicted by the time they turn 14.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is incorrect. Children usually try smoking around age 11.

1. 2. 3. 4.

Feedback This is incorrect. An underlying mass would not produce high-pitched tympanic sounds. This is incorrect. Absent bowel sounds are heard with a paralytic ileus. This is correct. An early bowel obstruction may cause excessive high-pitched bowel sounds. This is incorrect. Peritoneal inflammation leads to decreased bowel sounds.

GRADESMORE.COM 11. A mother reports that she is concerned that her 9-year-old daughter is overweight and has poor eating habits. What is the recommended and easiest method to assess daily intake? 1. Teach the 9-year-old girl how to write down everything she eats over a period of 3 days. 2. Ask the mother for a verbal report of the foods her daughter ate yesterday. 3. Document a food diary that includes a 24-hour period including all snacks. 4. Document a food diary that includes 2 weekdays and 1 weekend day. ANS: 4 Page: 447

1. 2. 3. 4.

Feedback This is incorrect. A 9-year-old child may not be responsible and accurate. This is incorrect. This is not the most reliable method because foods and drinks may be forgotten. This is incorrect. A 24-hour diet recall may not give a whole picture of the child’s eating pattern and may not be accurate. This is correct. The most common and easiest method to assess daily intake is a 24hour recall. To improve reliability of the daily recall, the family should document a food diary that includes 2 weekdays and 1 weekend day in the diary.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. Urinary incontinence is specific to an adult pattern of leaking of urine. This is incorrect. Stress urinary incontinence occurs with a stress activity such as coughing and more commonly refers to an adult condition. This is correct. Nocturnal enuresis is bedwetting at night. This is incorrect. Diurnal enuresis is daytime wetting.

13. The FLACC Scale is used to assess pain in children ages 2 months to 7 years. What criteria are evaluated on this scale? 1. Face, lips, activity, color, cooperation

GRADESMORE.COM 2. Flail, listen, action, cry, color 3. Face, legs, activity, cry, consolability 4. Flail, legs, adjustment, color, cooperation ANS: 3 Page: 471

1. 2. 3. 4.

Feedback This is incorrect. Lips, color, and cooperation are not part of the FLACC Scale. This is incorrect. Flail, listen, action, and color are not part of the FLACC Scale. This is correct. Face, legs, activity, cry, and consolability are the five areas that are assessed when using the FLACC Scale. This is incorrect. Flail, adjustment, color, and cooperation are not part of the FLACC Scale.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 2 Page: 444

1. 2. 3. 4.

Feedback This is incorrect. The physical examination is objective information and not a part of the ROS. This is correct. The ROS is the subjective information received from the parent and child about the body systems. This is incorrect. The ROS is subjective information. The medical record review is part of the patient history. This is incorrect. The ROS covers all of the body systems, not just the chief complaint.

GRADESMORE.COM

ANS: 1 Page: 446

2. 3. 4.

Feedback This is correct. Adolescents are less likely to truthfully share information about smoking, drugs, and drinking while the parent is present. The nurse should wait until she is alone with the adolescent and ask these questions when other sensitive topics are discussed. This is incorrect. These topics should not be addressed by the nurse initially with just one parent. This is incorrect. These topics should not be addressed by the nurse initially with both parents. This is incorrect. These topics should be addressed by the nurse initially with a 13year-old patient.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 2 Page: 466

1. 2. 3. 4.

Feedback This is incorrect. The 2nd intercostal space on the left is at the base of the heart, not the apex. This is correct. The 4th or 5th intercostal space at the midclavicular line is the correct position for listening over the heart’s apex. This is incorrect. The 3rd intercostal space at the left sternal border is not the best position to listen to the apex of the heart; this is the tricuspid valve. This is incorrect. The 2nd intercostal space on the right is at the base of the heart, not the apex.

1. 2. 3. 4.

GRADESMORE.COM

Feedback This is incorrect. The head should be tipped slightly away from the examiner. This is incorrect. The pinna should be pulled gently down and back to straighten the ear canal, not down and forward. This is correct. The pinna of a young child’s ear is pulled gently down and back to straighten the ear canal. This is incorrect. The pinna should not be held back against the head.

18. Learning disability is a term used for a wide variety of specific learning differences. Children with learning disabilities: 1. Often have problems with motivation. 2. Should be tested in middle school to implement an educational plan. 3. Frequently have problems with lower intelligence levels. 4. Are at risk for adjustment difficulties. ANS: 4 Page: 445 Feedback

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2.

3. 4.

This is incorrect. Children with learning disabilities have the same motivation as typical children. This is incorrect. Children with a question of learning disabilities should be tested at the earliest age they are identified to put an educational plan in place as soon as possible to maximize their potential and maintain their self-esteem. This is incorrect. Children with learning disabilities have intelligence that extends across the same gamut as typical children. This is correct. Children with learning differences are often misunderstood as having a problem with motivation or intelligence, placing them at risk for difficulties with adjustment in the home or at school.

19. When you are assessing a child’s capillary refill, a normal finding would be: 1. Greater than 4 seconds. 2. Greater than 5 seconds. 3. Less than 4 second. 4. 2 to 3 seconds. ANS: 4 Page: 476 Feedback 1. 2. 3. 4.

GRADESMORE.COM

This is incorrect. Capillary refill of over 4 seconds indicates poor perfusion and requires further investigation. This is incorrect. Capillary refill of over 5 seconds indicates poor perfusion and requires further investigation. This is incorrect. This is too short a time span for capillaries to refill. This is correct. Capillary refill should be 2 to 3 seconds and indicates good perfusion to the tissue.

20. The congenital displacement of the urethral opening of the penis to below the glans penis is called: 1. Hypospadias. 2. Cryptorchidism. 3. Epispadias. 4. Phimosis. ANS: 1 Page: 527

Feedback This is correct. Hypospadias is a congenital defect in which the urethra opens on the ventral side of the penis rather than at the tip.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3. 4.

This is incorrect. Cryptorchidism is a condition where the testes are undescended. This is incorrect. Epispadias is a congenital condition in which the urethra opens on the dorsal side of the penis rather than at the tip. This is incorrect. Phimosis occurs when the foreskin is advanced and tightly fixed over the glans penis.

2. 3. 4.

Feedback This is incorrect. This answer does not address the adolescent’s comment. This statement has incorrect information: Adolescent boys over the age of 14 should start performing testicular self-eG xaRmAinDaE tiS onM. ORE.COM This is correct. This statement explains why it is important to do a self-testicular examination. This is incorrect. This is ineffective communication and does not address the adolescent’s comment. This is incorrect. You should not ask a question to address the adolescent’s comment.

Feedback This is incorrect. The Face, Legs, Activity, Cry, Consolability (FLACC) Scale is a measurement used to assess pain for children between the ages of 2 months and 7 years or individuals who are unable to communicate their pain. This is incorrect. The Comfort B Scale observes the child’s face for a full 2 minutes.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

This is correct. The OUCHER! is a poster displaying two scales: a number scale for older children and a picture scale for younger children. This 5-year-old child should select the picture that best describes his pain. This is incorrect. The Visual Analog Scale is used mostly with adults.

23. At what age is head circumference measurement stopped? 1. Age 1 2. Age 2 3. Age 3 4. Age 4 ANS: 3 Page: 477

1. 2. 3. 4.

Feedback This is incorrect. Head circumference is measured at 1 year. This is incorrect. Head circumference is measured at 2 years. This is correct. Head circumference is measured up to 3 years of age. This is incorrect. Head circumference is no longer measured at 4 years of age.

GRADESMORE.COM 24. You are assessing the mouth of a 5-year-old child. You know that baby teeth are expected to fall out by: 1. Age 3. 2. Age 4. 3. Age 5. 4. Age 6. ANS: 4 Page: 482

1. 2. 3. 4.

Feedback This is incorrect. Baby teeth do no fall out by age 3. There are 20 baby teeth by age 3. This is incorrect. Baby teeth do not fall out by age 4. This is incorrect. Baby teeth do not fall out by age 5. This is correct. Baby teeth begin to fall out by age 6.

25. You are performing a pediatric assessment on a 13-year-old boy. Select your equipment. Select all that apply. 1. Sterile gloves

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. Stand-up scale 3. Length board 4. Paper measuring tape 5. Adult stethoscope 6. Rectal thermometer ANS: 2, 5 Page: 456

1. 2. 3. 4. 5. 6.

Feedback This is incorrect. You need clean gloves, not sterile gloves. This is correct. A stand-up scale is appropriate for a 13-year-old boy. This is incorrect. A length board is not used on a 13-year-old boy; a stadiometer would be appropriate. This is incorrect. A paper measure is not used on a 13-year-old boy; this is used for head and chest circumference for babies. This is correct. An adult stethoscope can be used on a 13-year-old boy. This is incorrect. Rectal temperatures are not routinely done.

26. During a review of systems of the skin, which of the following questions are appropriate to ask a teenager? Select all that apply. GRADESMORE.COM 1. Do you have any piercings or tattoos? 2. Do you pick or try to pop your acne pimples? 3. Do you color your hair? 4. Do you have any problems with oily skin or skin blemishes? 5. Do you go to the tanning salon? 6. Do you bite your nails? ANS: 1, 2, 4, 5 Page: 448-449

1. 2. 3. 4. 5. 6.

Feedback This is correct. Tattooing is a common practice that affects the skin. This is correct. Popping acne skin lesions allows bacteria to penetrate deeper into the skin, causing more inflammation and the possibility of permanent scarring. This is incorrect. This question assesses the hair, not the skin. This is correct. Problems with oily skin or skin blemishes is common among teenagers. This is correct. Sun lamp products such as tanning beds have a black-box warning against their use by children under 18. This is incorrect. Assessing nails is part of the nail assessment.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is correct. A toddler’s balance is often unsteady and a wide base of support for walking is used. This is incorrect. Children ages 2 to 7 may be normally knock-kneed. This is incorrect. A pigeon-toed gait is not normal and usually results from an abnormal rotation of the tibia. This is correct. Toddlers are often bowlegged after beginning to walk until their back and leg muscles are more fully developed.

28. A 16-year-old girl reports that she has a severe allergy to peanuts. You educate the patient that children who are allergic to peanuts may also be allergic to which of the following? Select GRADESMORE.COM all that apply. 1. Milk products 2. Chocolate chip cookies 3. Pistachios 4. Cashews 5. Walnuts ANS: 3, 4, 5 Page: 450

1. 2. 3. 4. 5.

Feedback This is incorrect. Milk is not related to a peanut allergy but is the most commonly diagnosed allergy. This is incorrect. Chocolate chip cookies are not related to a peanut allergy. If they contained nuts, this would place the child at risk. This is correct. Pistachio is a tree nut. The proteins in peanuts are similar in structure to those in tree nuts. This is correct. Cashew is a tree nut. The proteins in peanuts are similar in structure to those in tree nuts. This is correct. Walnut is a tree nut. The proteins in peanuts are similar in structure to those in tree nuts.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is correct. The tympanic membrane should be pearly gray and translucent. This is incorrect. Portions of the malleolus, not the mandible, may be identified in the inner ear examination. This is correct. The umbo should be identified in the inner ear examination. This is correct. The cone of light should be identified in the inner ear examination.

1. 2. 3. 4. 5.

Feedback This is correct. Intercostal retractions are an indicator of increased work of breathing. This is correct. Nasal flaring is an indicator of increased work of breathing. This is correct. Grunting is a sign that the child is having difficulty breathing. This is correct. Skin pallor is often a sign of decreased oxygenation due to increased work of breathing. This is correct. A change in level of consciousness can be a reflection of a decrease in oxygenation due to the increase in work of breathing.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. Connectivity 4. Counseling 5. Confidentiality ANS: 2, 4, 5 Page: 443

1. 2. 3. 4. 5.

Feedback This is incorrect. Crisis management is not a component of HIV testing. This is correct. Informed consent is an important component in HIV testing. This is incorrect. Connectivity is not a component of HIV testing. This is correct. Counseling is a very important component of HIV testing. This is correct. Confidentiality is a very important component of HIV testing.

GRADESMORE.COM

ANS: 5 Page: 499

1. 2. 3. 4. 5.

Feedback This is incorrect. Normal heart sounds are best heard with the diaphragm of the stethoscope. This is incorrect. For children age 7 and older, the mitral area is located at or near the 5th left intercostal space. This is incorrect. Normally pulsations are not felt at the five landmarks on the chest wall. This is incorrect. Erb’s point is at the 3rd intercostal space, not the 5th intercostal space on the left sternal border. This is correct. For children up to age 7, the mitral area is located at or near the 5th intercostal space.

33. Special considerations that are helpful to know when examining a child include which of the following? Select all that apply. 1. During gait assessment a child should wear shoes to help with stability. 2. Have the child place his or her hand over the examiner’s hand when palpating the abdomen. 3. Playing a game of “Simon Says” can help to evaluate range of motion. 4. Newborns present with a rounded or C-shaped curve to the spine.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 2, 3, 4 Page: 503

1. 2. 3. 4.

Feedback This is incorrect. A child should not wear shoes during this assessment so the examiner can assess foot position and symmetry. This is correct. Having the child place his or her hand over the examiner’s hand can minimize the tickling sensation and provide comfort for a wary child. This is correct. Playing games with children helps them to be at ease, as a child’s work is play. This is correct. Newborns have a rounded or C-shaped curve to their spines.

1. 2. 3. 4.

GRADESMORE.COM

Feedback This is incorrect. A child’s normal development begins in a cephalic to caudal fashion. This is correct. A child’s development proceeds in an orderly, sequential pathway. This is incorrect. A child’s development begins with the acquisition of gross motor skills followed by fine motor skills. This is correct. A child’s development becomes increasingly integrated and organized.

35. A 14-year-old boy was playing football and suffered a concussion. Symptoms of a concussion include which of the following? Select all that apply. 1. Agitation 2. Headache 3. Nausea 4. Photophobia 5. Memory loss 6. Anosmia ANS: 1, 2, 3, 5 Page: 455

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4. 5. 6.

Feedback This is correct. Agitation is a symptom of a concussion. This is correct. A headache is a symptom of a concussion. This is correct. Nausea is a symptom of a concussion. This is incorrect. Photophobia is not a symptom of a concussion. This is correct. Memory loss is a symptom of a concussion. This is incorrect. Anosmia is not a symptom of a concussion.

GRADESMORE.COM Feedback: Assessment of the child should proceed from the least invasive technique to the most invasive. You should first perform a general survey, then assess the respiratory rate while the child is quiet. Then, use a stethoscope to auscultate lungs sounds, take a tympanic temperature, and lastly, assess the mouth using a tongue blade.

37. A stiff neck or limited range of motion with muscle spasm that causes contracture of the musculature of the neck is called . ANS: torticollis Page: 485 Feedback: Torticollis is a stiff neck or limited range of motion with muscle spasm of the sternocleidomastoid muscle on one side of the body causing a lateral flexion contracture of the cervical spine musculature.

38. Swelling of the lips and tongue in response to an allergic reaction in a child is called . ANS: angioedema

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Page: 482 Feedback: Angioedema of the lips is usually related to an allergic reaction.

39. Pediatric breath sounds that are heard over the periphery of the lung fields with inspiration longer and louder than expiration are called breath sounds. ANS: vesicular Page: 498 Feedback: Vesicular breath sounds are heard over the periphery of the lung fields and have an inspiratory phase that is longer and louder than the expiratory phase.

40. wheezing, and asthma.

smoking puts children at high risk for respiratory infections,

ANS: Passive Page: 446

.oCrO Feedback: Passive smoke contributesGsRigAnD ifE icS anMtlO y RtoEm biM dity and mortality. It puts children at a higher risk for respiratory infections, wheezing, and asthma.

41.41. You are assessing a toddler who has just learned how to walk. Look at the picture and identify the type of legs that are normally seen in this age group. It is called . ANS: genu varum Page: 505

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Feedback: Genu varum is the medical term for bowlegged. Toddlers are usually bowlegged after beginning to walk until their back and leg muscles are well developed.

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 23 Assessing the Pregnant Woman

1. The nurse is performing an assessment of a patient who is 38 weeks pregnant with her first child. The nurse notes a thin, brown, pigmented area on the abdomen starting at the top of the uterus and extending downward to the top of the pubis. The most appropriate response is: 1. Call the advanced practice provider. 2. Reassure the patient that this is a normal finding called linea nigra. 3. Advise the patient that this line will disappear immediately after delivery. 4. Caution the patient to monitor for itching, rashes, or pain.

4. A woman presents to the clinic because she missed her last menstrual period and thinks she may be pregnant. She reports fatigue, breast tenderness, urinary frequency, nausea, and vomiting in the morning. The health-care provider will interpret these findings as which of the following changes of pregnancy? 1. Positive 2. Presumptive 3. Probable 4. Possible

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

5. Which of the following changes in respiratory functioning during pregnancy are considered normal? 1. Increased tidal volume 2. Decreased tidal volume 3. Decreased inspiratory capacity 4. Decreased oxygen consumption

6. The nurse visits a pregnant woman at 34 weeks gestation. The woman is very concerned because she notices pain in her groin, especially when walking. This complaint may be explained as: 1. Normal, because the uterus is very heavy at 34 weeks. 2. Normal, because pain in the round ligaments of the uterus is very common. 3. Abnormal, it could be a sign of preterm labor. 4. Abnormal, it shows that the fetus is in a breech position.

7. When performing a physical assessment of a pregnant patient at 28 weeks gestation, the student nurse notes a yellow dGiR scA haDrE geScMoO mR inEg.frCoO mMone of the nipples. The student nurse correctly identifies this as: 1. Montgomery’s glands 2. Breast cancer 3. Mastitis 4. Colostrum

8. During a focused health history, the pregnant patient expresses concern about her breast size. She worries that her breasts are “too large” and will not fit in her current bras. The best response to this concern is: 1. “Don’t worry about it, big breasts are good.” 2. “I hear your concerns. It is not uncommon for breasts to enlarge during pregnancy and some women find that uncomfortable.” 3. “I have a friend who had breasts that were two cup sizes larger during pregnancy.” 4. “Let’s see if we can find some resources so that you can find some bras that are more comfortable.” 5. Both 2 and 4.

9. A normal adaptation of pregnancy is increased blood supply to the pelvic region

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

resulting in a blue discoloration of the cervix. This change is known as: 1. Ladin’s sign. 2. Hegar’s sign. 3. Goodell’s sign. 4. Chadwick’s sign.

10. The nurse is assessing a pregnant patient who is at 38 weeks gestation and thinks she is in labor. The patient states that she has had irregular contractions every few hours. The contractions are not painful. The nurse tells the patient: 1. “Labor has not yet begun and it will be awhile.” 2. “Braxton-Hicks contractions are normal at this stage of pregnancy.” 3. “Observing contractions can be helpful in determining when labor starts.” 4. All of the above.

11. A pregnant woman is concerned about sleeping positions. She is only comfortable lying flat on her back. The nurse advises the woman: 1. In the third trimester, side-lying positions are the safest. 2. In the first trimester, pregnant women should not lie prone. 3. In the second trimester, pillows are necessary to prop up the legs. 4. In the third trimester, supine pG osRitA ioD nsEhSeM lpOtR oE pr.oC mO otM e fetal blood flow.

12. You are assessing a 23-year-old patient who is 6 weeks pregnant and diagnosed with hyperemesis gravidarum. Untreated hyperemesis gravidarum can often result in which of the following conditions? 1. Miscarriage of pregnancy 2. Dehydration 3. Bowel obstruction 4. Hypertension

13. You are providing patient education to a pregnant woman. Prenatal vitamins are important during pregnancy because: 1. Pregnant women get frequent colds and need to take extra vitamin C. 2. Pregnant women need less calcium from dietary sources. 3. Pregnant women need extra electrolytes to avoid dehydration. 4. Pregnant women are at risk for iron deficiency anemia and need extra iron.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

14. The patient is 30 weeks pregnant and you are going to assess the fundal height of the uterus. How should you position the patient? 1. High Fowler’s with knees straight 2. Supine with knees bent 3. Semi-sitting with knees slightly bent 4. Semi-Fowler’s with knees at a 90-degree angle

16. A patient who is pregnant calls the office with concerns that she has not felt fetal movement. She is at 17 weeks gestation and is a G1P0. She says, “My friend is as pregnant as I am and she feels movement.” The nurse explains to the patient: 1. “Pregnant women should feel fetal movement by 12 weeks gestation. You should go to the hospital.” 2. “You should wait to feel moveGmReA ntD sE anSdMwOhR enEy.oCuOdM o you should time the movements.” 3. “The fetus is still very small and sometimes movement is not felt until 20 weeks gestation.” 4. “Sometimes when there are problems with fetal development you don’t feel movements so early.”

17. The nurse is assessing a woman on the second day after a normal, spontaneous vaginal birth without complications. The woman tells the nurse that she feels very sad and she begins to cry. She states that she is happy about the baby but she does not know why she is so sad. The best response the nurse can give is: 1. “Your baby is perfect. You have nothing to be sad about.” 2. “You have postpartum depression. It is very common. You should try medications that can make it better.” 3. “It is very common to feel sad after the delivery. Usually these feelings resolve over a few days. If they don’t, please follow up with your health-care provider.” 4. “Postpartum depression is normal and I would like you to fill out this questionnaire so that I can help you more.”

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

18. A pregnant woman is 20 weeks pregnant and is having a routine assessment. You are assessing the fetal heart rate and place the Doppler below the umbilicus in the left lower quadrant. The patient asks you why you are listening to the heart rate at that particular place. How should the nurse respond? 1. “This is the only location that the heartbeat is heard at this time.” 2. “You are 20 weeks pregnant and this is where the heartbeat always is.” 3. “Your baby’s position affects where I will be able to hear the heartbeat.” 4. “It does not matter where I place the Doppler because I will hear your baby’s heartbeat.”

19. You are going to assess the fetal heart rate. What should be done first just prior to auscultating the heart rate? 1. Perform Leopold maneuvers before fetal auscultation. 2. Encourage the mother to take some deep breaths. 3. Take the mother’s blood pressure and pulse for comparison. 4. Assess the fundal height to determine the number of weeks of gestation.

20. A pregnant woman is 14 weeks pregnant and asks how fast her uterus will enlarge throughout her pregnancy. Which of the following is the nurse’s best response? 1. “Your uterus will grow faster aGfR teA r 2D0EwSeMekOsR , aEb.oC utO4Mcm each week.” 2. “Your uterus will grow about 1 cm per week of pregnancy until you are 36 weeks.” 3. “The growth of your uterus will depend on how much amniotic fluid is retained.” 4. “I am sorry but there are no specific guidelines that tell us how much your uterus will grow.”

21. A new mother in her first trimester comes to the outpatient clinic for her monthly assessment. She reports that she is nauseous and vomits every morning. She asks, “What causes morning sickness?” The nurse should respond: 1. “Morning sickness occurs because the fetus presses on your stomach when lying down.” 2. “Don’t worry about the reason. Morning sickness will go away when you are 12 weeks pregnant.” 3. “Morning sickness occurs due to increasing hormone levels during pregnancy.” 4. “Increasing levels of the human chorionic gonadotropin causes morning sickness.”

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Increased estrogen levels. 2. Increased progesterone levels. 3. Increased human chorionic gonadotropin levels. 4. All of the above.

23. A woman has just found out that her pregnancy test was positive. She reported that her last menstrual date was August 15. Using Naegele’s Rule, when is her due date? 1. November 8 2. April 23 3. May 8 4. May 23

24. The health-care provider recently confirmed that a woman is pregnant. The new mother to be is so happy because she has been trying to get pregnant for the past year. She told the nurse that her menstrual cycles have been very irregular and unpredictable, making it very hard to conceive. She “thinks her last menstrual cycle started in early September.” What would be a reliable predictor of gestational age for this woman? 1. Fundal height measurements 2. Ultrasound in the first trimester C)OM 3. Levels of the human chorionicGgR onAaDdE otS roMpO inR(E hC.G 4. Using Naegele’s Rule for expected date of delivery

25. You are assessing the fetal heart rate of a woman who is 30 weeks pregnant. The woman asks what a normal fetal heart rate should be at this stage of pregnancy. The nurse’s best response is: 1. A fetal heart rate ranges between 120 and 160 beats per minute (bpm). 2. A normal fetal heart rate averages about 140 bpm. 3. A normal fetal heart rate should always be between 100 and 140 bpm. 4. A fetal heart rate depends on the gestational age.

26. You are a nurse working in an outpatient obstetric clinic. You should know that a key task during the health assessment of the pregnant woman is to emphasize: 1. Healthy eating patterns. 2. Normal changes during pregnancy. 3. Weight gain throughout the pregnancy. 4. Regular wellness check-ups.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

27. The pregnant women is 24 weeks pregnant and having a routine assessment. Her weight prior to getting pregnant was 149 lb. The nurse weighs the patient today at 162 lb and measures a fundal height at 23 cm. The patient states, “I am worried that I am going to put on too much weight and then I have to take it off.” Which of the following should be the nurse’s appropriate response? 1. “You can never put on too much weight when you are feeding a child too.” 2. “You should try to cut down on how much you eat because you are gaining too much weight.” 3. “Your weight is fine. You should be gaining about 2 lb per week.” 4. “You are doing good. You should gain about 25 to 35 lb throughout the pregnancy.”

28. A pregnant woman who is 18 weeks pregnant was telling the nurse during an assessment visit that she loves cats. She says, “I have five beautiful long-haired cats at home.” What would be an appropriate response by the nurse? 1. “Now that you are pregnant, you should have someone else take care of your cats until you deliver your baby.” 2. “Why do you have five cats? Isn’t that going to be too much for you to handle with a new baby?” 3. “You will have to get rid of the cats because it can be dangerous when the baby arrives.” 4. “You should avoid cat litter beGcaRuA seDtE heScMaO tsR ’E fe. ceCs O mMay contain a parasite that can cause birth defects.”

29. You are assessing a pregnant woman’s vital signs. The blood pressure (BP) in her right arm is 148/88 and in her left arm is 148/90. As a nurse, you know that: 1. Pregnant women’s blood supply increases, causing an increase in blood pressure readings. 2. Pregnant women may develop pregnancy-induced hypertension and be at risk for preeclampsia. 3. Pregnant women’s blood pressure fluctuates as the fetus grows in utero. 4. Pregnant women’s blood pressure is directly related to their fluid intake and weight gain.

30. The patient comes to the office stating that she is having “severe” contractions. The nurse palpates for contractions and assesses contractions that feel moderate. How would you describe the feeling of a moderate contraction? 1. The feeling of the cheek 2. The feeling of the tip of the nose

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. The feeling of the thigh 4. The feeling of the forehead

31. A pregnant woman who is 20 weeks pregnant reports that she has not felt her baby move in the past 24 hours. You assess the fetal heart rate at 124. You put a fetal monitor on the woman to assess fetal movement for 60 minutes. There are only five confirmations of fetal movement. What should you do? 1. Call the health-care provider immediately. 2. Tell the mother that her baby was active in the past hour. 3. Assess the fetal heart rate on the infant. 4. Put in a referral to a high-risk obstetrician.

32. Routine diagnostic blood testing during pregnancy includes which of the following? Select all that apply. 1. Complete blood count 2. Rubella and varicella titers 3. Human immunodeficiency virus 4. Blood type 5. Chlamydia GRADESMORE.COM 6. Gonorrhea 7. Syphilis 8. Hepatitis

33. A pregnant woman is 36 weeks pregnant. She comes to her health-care provider’s office stating that she is having contractions. How will you assess for contractions? Select all that apply. 1. Using the ulnar surface of both hands 2. Using the palmar surface of your hand 3. Using the fingertips of both hands 4. Using the finger pads of both hands

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. The area above the symphysis pubis is palpated to locate the fetal presenting part and thus determine how far the fetus has descended and whether the fetus is engaged. 3. The uterine fundus is palpated to determine which fetal part occupies the fundus. 4. One hand applies pressure on the fundus while the index finger and thumb of the other hand palpate the presenting part to confirm presentation and engagement.

35. Look at the picture. Identify this probable sign of pregnancy that indicates increased vascularity of the vagina and vulva. It is called . (two words)

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers 1. The nurse is performing an assessment of a patient who is 38 weeks pregnant with her first child. The nurse notes a thin, brown, pigmented area on the abdomen starting at the top of the uterus and extending downward to the top of the pubis. The most appropriate response is: 1. Call the advanced practice provider. 2. Reassure the patient that this is a normal finding called linea nigra. 3. Advise the patient that this line will disappear immediately after delivery. 4. Caution the patient to monitor for itching, rashes, or pain. ANS: 2 Page: 537

1. 2. 3. 4.

Feedback This is incorrect. This is a common finding during pregnancy. This does not require advanced assessment. This is correct. Linea nigra is the name for pigment changes that occur on the abdomen during pregnancy. This is incorrect. The linea nigra does not disappear immediately after pregnancy. This is incorrect. This is a normal skin change that will not cause itching, rashes, or pain.

GRADESMORE.COM

2. A pregnant patient calls the triage nurse complaining of generalized itching, especially on the palms of her hands and soles of her feet. She is 34 weeks pregnant and has had an uneventful pregnancy to this point. Her last appointment was 2 weeks ago. The triage nurse should: 1. Advise the patient to come into the office for further evaluation. 2. Ask the patient about possible exposures including to environmental allergens, sun, new lotions, or clothing. 3. Reassure the patient that all pregnant women have itching. Tell her to use a hydrating lotion and keep her next appointment in 2 weeks. 4. Both 1 and 2. ANS: 4 Page: 538 Feedback 1. This is incorrect. The correct answer is both answers 1 and 2. 2. This is incorrect. The correct answer is both answers 1 and 2. 3. This is incorrect. All pregnant women do not have itching. Itching can be a warning sign and should be promptly evaluated. 4. This is correct. If pruritus becomes generalized and is not associated with

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

PUPPP this must be evaluated because it can be a sign of intrahepatic cholestasis. Typically, this form of pruritus is associated with excoriations from scratching and is generalized throughout the skin, although there are no specific lesions. However, itching can also be caused by exposure to allergens, as is the case outside of pregnancy.

3. The nurse is examining a pregnant patient who is 36 weeks pregnant with twins. When the patient stands to leave the examination room, the nurse notes that she is having difficulty standing up straight. Which of the following is likely to be the cause? 1. New onset of scoliosis 2. Pregnancy-related lordosis 3. Uterine size is enlarged due to twin gestation 4. Spinal tumor ANS: 2 Page: 538 Feedback 1. This is incorrect. The patient is in her last trimester. The expanding uterus causes a shift in the center of gravity. Scoliosis is usually diagnosed as a child.

GRADESMORE.COM

2. This is correct. Lordosis occurs due to the expanding uterus, which causes a shift in the center of gravity and progressive lumbar lordosis, or concave curvature of the spine. 3. This is incorrect. The uterus is enlarged, however, the patient has a shift in the center of her gravity, causing progressive lordosis. 4. This is incorrect. The scenario did not identify that the patient had a history of any type of cancer.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. This is incorrect. These are not positive symptoms. Positive signs are signs that indicate that there is definitely a pregnancy occurring such as fetal heart sounds, quickening, or visualization of the fetus by ultrasound. 2. This is correct. Presumptive symptoms are symptoms that a woman experiences that are suggestive, but not conclusive of pregnancy including amenorrhea, breast tenderness, fatigue, nausea or vomiting, and frequent urination. 3. This is incorrect. These are not probable signs. Probable signs or symptoms are signs or symptoms that indicate that pregnancy is likely, though not definite, such as abdominal enlargement, Hegar’s sign, or Goodell’s sign. 4. This is incorrect. There are no possible signs. This is incorrect terminology.

1. 2. 3.

GRADESMORE.COM Feedback This is correct. Tidal volume increases as a result of progesterone that enables increased depth of breathing. This is incorrect. Tidal volume does not decrease but increases as a result of progesterone that enables increased depth of breathing. This is incorrect. In response to estrogenic effect on the respiratory tract, increased, not decreased, chest expansion and inspiratory capacity is possible. This is incorrect. In response to estrogenic effect on the respiratory tract there is increased, not decreased, oxygen consumption.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Page: 539

3. 4.

Feedback This is incorrect. The nurse cannot assume that the uterus feels heavy. Pain in the round ligaments of the uterus is very common. The round ligament of the uterus comes from the pelvis, passes through the internal abdominal ring, and then runs along the inguinal canal to the labia majora. This is correct. Pain in the round ligaments of the uterus is very common. The round ligament of the uterus comes from the pelvis, passes through the internal abdominal ring, and then runs along the inguinal canal to the labia majora. The round ligaments hold the uterus suspended inside the abdominal cavity. This is incorrect. Preterm labor does not present with groin pain but back pain. This is incorrect. Fetal positions can result in changes to sensation but not typically to groin pain. The pain in the groin is not related to a breech position.

7. When performing a physical assessment of a pregnant patient at 28 weeks gestation, the student nurse notes a yellow discharge coming from one of the nipples. The student nurse correctly identifies this as: 1. Montgomery’s glands 2. Breast cancer 3. Mastitis GRADESMORE.COM 4. Colostrum ANS: 4 Page: 539

1. 2. 3. 4.

Feedback This is incorrect. The Montgomery’s glands help to lubricate the areolae and do not secrete a yellow discharge. This is incorrect. Concerns about breast cancer should be addressed to the clinician; however, nipple discharge in a pregnant patient is a typical finding. This is incorrect. Mastitis is an infection of the breast, associated with pain and erythema rather than nipple discharge. This is correct. Colostrum, the yellow pre-milk, may be expressed as early as the 16th week of pregnancy.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. “I have a friend who had breasts that were two cup sizes larger during pregnancy.” 4. “Let’s see if we can find some resources so that you can find some bras that are more comfortable.” 5. Both 2 and 4. ANS: 5 Page: 539 Feedback This is incorrect. This response is judgmental and dismissive of the patient’s concerns. 2. This response validates the patient’s experience and provides reassurance and support. Both answers 2 and 4 are correct. 3. This is incorrect. Using personal information does not promote trust and it is unprofessional to share personal experiences. 4. This response is supportive and addresses the concern directly. During pregnancy, breast enlargement, increased vascularity, and hyperplasia of glandular tissue are normal and expected as a result of increased levels of estrogen and progesterone. 5. This is correct. Both 2 and 4 are correct answers. CON: Pregnancy 1.

GRADESMORE.COM 9. A normal adaptation of pregnancy is increased blood supply to the pelvic region resulting in a blue discoloration of the cervix. This change is known as: 1. Ladin’s sign. 2. Hegar’s sign. 3. Goodell’s sign. 4. Chadwick’s sign. ANS: 4 Page: 540

1. 2. 3. 4.

Feedback This is incorrect. Ladin’s sign is a softening in the midline of the uterus anteriorly at the junction of the uterus and cervix. This is incorrect. Hegar’s sign refers to a softening of the cervix and uterine isthmus. This is incorrect. Goodell’s sign is a softening of the cervix. This is correct. Chadwick’s sign is a bluish appearance of the cervix, vagina, and vulva.

10. The nurse is assessing a pregnant patient who is at 38 weeks gestation and thinks she

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

is in labor. The patient states that she has had irregular contractions every few hours. The contractions are not painful. The nurse tells the patient: 1. “Labor has not yet begun and it will be awhile.” 2. “Braxton-Hicks contractions are normal at this stage of pregnancy.” 3. “Observing contractions can be helpful in determining when labor starts.” 4. All of the above. ANS: 4 Page: 543

1. 2. 3. 4.

Feedback This is a true statement but other statements are true also. Contractions associated with labor are regular and uncomfortable so labor has not begun yet. This is a true statement but other statements are true also. Braxton-Hicks contractions are painless and irregular. This is a true statement but other statements are true also. Teaching patients to self-monitor contractions promotes understanding of the labor process. This is correct. Answers 1, 2, and 3 are all correct statements.

11. A pregnant woman is concerned about sleeping positions. She is only comfortable lying flat on her back. The nurse advises the woman: 1. In the third trimester, side-lyinG g RpA osDitE ioS nsMaOreRtEh. eC saO feMst. 2. In the first trimester, pregnant women should not lie prone. 3. In the second trimester, pillows are necessary to prop up the legs. 4. In the third trimester, supine positions help to promote fetal blood flow. ANS: 1 Page: 540-541

1. 2. 3. 4.

Feedback This is correct. Supine positions can result in compression of the inferior vena cava and lower aorta. Side-lying positions promote fetal oxygenation. This is incorrect. Any sleeping position is safe in the first trimester. This is incorrect. Pillows may be helpful to promote comfort but are not necessary. This is incorrect. This is a false statement. Obstruction of the inferior vena cava reduces venous return to the heart, leading to a fall in cardiac output, resulting in dizziness or weakness, as well as impaired blood flow to the uterus and reduced oxygenation to the fetus.

12. You are assessing a 23-year-old patient who is 6 weeks pregnant and diagnosed with hyperemesis gravidarum. Untreated hyperemesis gravidarum can often result in which of

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

the following conditions? 1. Miscarriage of pregnancy 2. Dehydration 3. Bowel obstruction 4. Hypertension ANS: 2 Page: 541

1. 2. 3. 4.

Feedback This is incorrect. Hyperemesis does not impact the development of pregnancy in the first trimester. This is correct. Vomiting many times a day can result in dehydration, causing an electrolyte imbalance. This is incorrect. Bowel obstruction does not occur as a result of vomiting. This is incorrect. Hyperemesis can often result in hypotension, not hypertension.

13. You are providing patient education to a pregnant woman. Prenatal vitamins are important during pregnancy because: 1. Pregnant women get frequent colds and need to take extra vitamin C. ADfrE SMdO 2. Pregnant women need less calcGiuRm om ieR taE ry.sC ouOrM ces. 3. Pregnant women need extra electrolytes to avoid dehydration. 4. Pregnant women are at risk for iron deficiency anemia and need extra iron. ANS: 4 Page: 541

1. 2. 3. 4.

Feedback This is incorrect. Colds are not more frequent. Further, there is no substantive evidence that supports the use of vitamin C for cold prevention. This is incorrect. Pregnant women need more calcium from dietary sources. This is incorrect. If drinking adequate amounts, the risk of dehydration is not greater than in nonpregnant patients. This is correct. The developing fetus depletes the mother’s stores of iron and a fall in maternal hemoglobin levels results in anemia.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Semi-Fowler’s with knees at a 90-degree angle ANS: 3 Page: 550

3. 4.

Feedback This is incorrect. The pregnant woman should not be positioned in high Fowler’s position with her knees straight but in a semi-sitting position with the knees slightly bent for an accurate measurement. This is incorrect. The pregnant woman should not be positioned in the supine position with her knees bent but in a semi-sitting position with the knees slightly bent for an accurate measurement. This is correct. Position the pregnant woman in a semi-sitting position with knees slightly bent for an accurate position. This is incorrect. The pregnant woman should not be positioned in a semiFowler’s position with her knees at a 90-degree angle but in a semi-sitting position with the knees slightly bent for an accurate measurement.

15. You are assessing a woman who is 30 weeks pregnant. You are palpating her abdomen for fundal height. Where should her uterus be located? 1. Between the umbilicus and the suprapubic bone 2. Just rising above the suprapubG icRbA onDeESMORE.COM 3. Between the suprapubic bone and the xiphoid process 4. Between the umbilicus and the xiphoid process ANS: 4 Page: 539-540 Feedback 1. This is incorrect. Fundal height at the level of the umbilicus roughly corresponds to 20 weeks gestation. At 26 weeks the fundal height should be above the umbilicus. 2. This is incorrect. The fundal height should not be just rising above the suprapubic bone. Fundal height at the level of the umbilicus roughly corresponds to 20 weeks gestation. At 26 weeks the fundal height should be above the umbilicus. 3. This is incorrect. This is a very broad range and should be more specific. Fundal height at the level of the umbilicus roughly corresponds to 20 weeks gestation. At 26 weeks the fundal height should be above the umbilicus. 4. This is correct. The uterus is located between the umbilicus and the xiphoid process during the third trimester. Fundal height at the level of the umbilicus roughly corresponds to 20 weeks gestation. At 26 weeks the fundal height should be above the umbilicus.

16. A patient who is pregnant calls the office with concerns that she has not felt fetal

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

movement. She is at 17 weeks gestation and is a G1P0. She says, “My friend is as pregnant as I am and she feels movement.” The nurse explains to the patient: 1. “Pregnant women should feel fetal movement by 12 weeks gestation. You should go to the hospital.” 2. “You should wait to feel movements and when you do you should time the movements.” 3. “The fetus is still very small and sometimes movement is not felt until 20 weeks gestation.” 4. “Sometimes when there are problems with fetal development you don’t feel movements so early.” ANS: 3 Page: 551

Feedback This is incorrect. It is very unusual to feel movement at 12 weeks gestation given the fetal size at that time. This is incorrect. Timing of fetal movements in the early second trimester is not predictive of fetal health This is correct. Pregnant women can usually feel internal fetal movement from around 16 to 20 weeks gestation. This is incorrect. Fetal movements in the early second trimester are not predictive of fetal health.

2. 3. 4.

GRADESMORE.COM

Feedback This is incorrect. This comment is dismissive of the patient’s feelings and does not acknowledge that “postpartum blues” are very common in the first few days following delivery. This is incorrect. Postpartum depression cannot be diagnosed in the first few

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

days after delivery. This is correct. “Postpartum blues” or feelings of sadness are common in the days following delivery. These feelings usually rapidly resolve without treatment. While postpartum blues are transient, persistent feelings of depression or anxiety may indicate a more serious problem and should be evaluated promptly. This is incorrect. Screening instruments such as the Edinburgh Postnatal Depression Scale (EPDS) or the Postpartum Depression Screening Scale are very useful in determining which women need follow-up. The postpartum visit with obstetrical providers at 6 weeks after delivery is an optimal time to evaluate depression rather than in the days immediately following delivery.

GRADESMORE.COM

ANS: 3 Page: 554

1. 2. 3. 4.

Feedback This is incorrect. There is not just one location to hear a fetal heartbeat. The location is determined by the fetal position. This is incorrect. The baby moves at 20 weeks and could be in any position. Fetal position affects where fetal heart sounds are heard. This is correct. Fetal position affects where fetal heart sounds are heard. This is incorrect. It does matter where the Doppler is placed. Fetal position affects where fetal heart sounds are heard.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Page: 554

1. 2.

Feedback This is correct. Performing Leopold maneuvers before fetal auscultation guides the nurse where to place the Doppler to listen for the fetal heart rate. This is incorrect. This is a noninvasive assessment. Telling the mother to take some deep breaths is not going to affect the fetal heart rate. The nurse should perform Leopold maneuvers before fetal auscultation to guide the nurse where to place the Doppler to listen for the fetal heart rate. This is incorrect. The mother’s blood pressure and pulse should be taken routinely but not just prior to assessing the fetal heart rate. The nurse should perform Leopold maneuvers before fetal auscultation to guide the nurse where to place the Doppler to listen for the fetal heart rate. This is incorrect. Assessing fundal height assesses fetal growth and not specifically number of weeks of gestation. The nurse should perform Leopold maneuvers before fetal auscultation to guide the nurse where to place the Doppler to listen for the fetal heart rate.

20. A pregnant woman is 14 weeks pregnant and asks how fast her uterus will enlarge throughout her pregnancy. Which of the following is the nurse’s best response? 1. “Your uterus will grow faster after 20 weeks, about 4 cm each week.” AD 2. “Your uterus will grow about 1GcRm peEr S wMeeOkRoEf . prCegOnMancy until you are 36 weeks.” 3. “The growth of your uterus will depend on how much amniotic fluid is retained.” 4. “I am sorry but there are no specific guidelines that tell us how much your uterus will grow.” ANS: 2 Difficulty: Moderate Page: 539

1. 2. 3.

Feedback This is incorrect. The uterus does not grow faster after 20 weeks, it continues to grow about 1 cm per week. This is correct. The uterus typically enlarges by 1 cm per week until 38 weeks. This is incorrect. The growth of the uterus does not depend on how much amniotic fluid is retained, it depends on fetal growth. The uterus typically enlarges by 1 cm per week until 38 weeks. This is incorrect. There are some guiding principles about how much the uterus will grow. The uterus typically enlarges by 1 cm per week until 38 weeks.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3.

Feedback This is incorrect. Morning sickness is not caused by the fetus pressing on the mother’s stomach while sleeping. Increasing levels of human chorionic gonadotropin or estrogen result in nausea and vomiting in the first trimester. This is incorrect. This statement is not answering the mother’s question or addressing her concerns. This is correct. This statement answers the mother’s questions and does not use medical terminology so that the mother can understand that her nausea and vomiting are related to increased pregnancy hormones. Increasing levels of human chorionic gonadotropin (hCG) or estrogen result in nausea and vomiting in the first trimG esRteAr.DTEhS isMnO auRsE ea.aCnO dM vomiting usually subsides by the 12th week of pregnancy. This is incorrect. This is a false statement and is also using medical terminology that the mother may not understand. Morning sickness is caused by increasing levels of human chorionic gonadotropin (hCG) or estrogen, resulting in nausea and vomiting in the first trimester.

22. During a routine prenatal assessment, a pregnant woman who is 32 weeks pregnant complains that she is having more episodes of heartburn and problems with constipation. The nurse knows that these symptoms are related to: 1. Increased estrogen levels. 2. Increased progesterone levels. 3. Increased human chorionic gonadotropin levels. 4. All of the above. ANS: 2 Page: 541

Feedback This is incorrect. Increased estrogen levels do not cause the symptoms of heartburn and problems with constipation. Increased progesterone levels result

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

in decreased motility and slower emptying times, resulting in acid reflux. Increased progesterone levels also increase water absorption from the colon, resulting in constipation. This is correct. Increased progesterone levels result in decreased motility and slower emptying times, resulting in acid reflux. Increased progesterone levels also increase water absorption from the colon, resulting in constipation. This is incorrect. Increased human chorionic gonadotropin levels do not cause heartburn and constipation. Increased progesterone levels result in decreased motility and slower emptying times, resulting in acid reflux. Increased progesterone levels also increase water absorption from the colon, resulting in constipation. This is incorrect. Increased estrogen levels and increased human chorionic gonadotropin levels do not cause acid reflux and constipation.

GRADESMORE.COM

ANS: 4 Page: 544

Feedback This is incorrect. According to Naegele’s Rule: August is Month 8 – 3 months is May. Menstrual date is day 15, add 7 days. Expected delivery date is May 23. This is incorrect. According to Naegele’s Rule: August is Month 8 – 3 months is May. Menstrual date is day 15, add 7 days. Expected delivery date is May 23. This is incorrect. According to Naegele’s Rule: August is Month 8 – 3 months is May. Menstrual date is day 15, add 7 days. Expected delivery date is May 23. This is correct. According to Naegele’s Rule: August is Month 8 – 3 months is May. Menstrual date is day 15, add 7 days. Expected delivery date is May 23.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. Fundal height measurements 2. Ultrasound in the first trimester 3. Levels of the human chorionic gonadotropin (hCG) 4. Using Naegele’s Rule for expected date of delivery ANS: 2 Page: 544

3. 4.

Feedback This is incorrect. The women just found out she is pregnant and fundal height would not be taken this early. Ultrasound would be more reliable to identify gestational age. This is correct. Ultrasound during the first trimester is a reliable indicator of gestational age for women who are unsure of last menstrual period or who have very irregular menstrual cycles. This is incorrect. Levels of the human chorionic gonadotropin (hCG) confirm pregnancy and do not identify gestational age. This is incorrect. Using Naegele’s Rule for expected date of delivery would be unreliable because the woman is not sure of her last menstrual date. Ultrasound would be more reliable to identify gestational age.

OhMo is 30 weeks pregnant. The 25. You are assessing the fetal heGaR rt A raDteEoSf M aO wRoE m. anCw woman asks what a normal fetal heart rate should be at this stage of pregnancy. The nurse’s best response is: 1. A fetal heart rate ranges between 120 and 160 beats per minute (bpm). 2. A normal fetal heart rate averages about 140 bpm. 3. A normal fetal heart rate should always be between 100 and 140 bpm. 4. A fetal heart rate depends on the gestational age. ANS: 1 Page: 554

1. 2.

3. 4.

Feedback This is correct. This is the best answer because it is a range. A normal fetal heart rate ranges between 120 and 160 bpm. This is incorrect. Even though a fetal heart rate may average about 140 bpm, the best response would be giving the mother the range between 120 and 160 bpm. This is incorrect. A normal fetal heart rate should not be below 100 bpm. This indicates fetal deceleration and fetal distress. This is incorrect. The fetal heart rate does not depend on gestational age.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3.

Feedback This is incorrect. Healthy eating patterns are important to discuss but the key task during the health assessment of the pregnant woman is to emphasize the normality of changes associated with pregnancy. This is correct. A key task during the health assessment of the pregnant woman is to emphasize the normality of changes associated with pregnancy. This is incorrect. Weight in general is important to discuss but the key task during the health assessment of the pregnant woman is to emphasize the normality of changes associated with pregnancy. This is incorrect. Patients should know that regular wellness checks are important during pregnancy but the key task during the health assessment of the pregnant woman is to emphasize the normality of changes associated with pregnancy.

GRADESMORE.COM

1. 2. 3.

Feedback This is incorrect. This statement is not addressing the patient’s comment with factual information. This is incorrect. The patient has only gained 13 lb at 24 weeks. She is not gaining too much weight. This is incorrect. The patient should be gaining about 1 lb per week after 12

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

weeks gestation. This is correct. The nurse is praising the patient and giving her factual information about how much weight she should gain throughout the pregnancy.

28. A pregnant woman who is 18 weeks pregnant was telling the nurse during an assessment visit that she loves cats. She says, “I have five beautiful long-haired cats at home.” What would be an appropriate response by the nurse? 1. “Now that you are pregnant, you should have someone else take care of your cats until you deliver your baby.” 2. “Why do you have five cats? Isn’t that going to be too much for you to handle with a new baby?” 3. “You will have to get rid of the cats because it can be dangerous when the baby arrives.” 4. “You should avoid cat litter because the cats’ feces may contain a parasite that can cause birth defects.” ANS: 4 Page: 546 Feedback 1.

3. 4.

GRADESMORE.COM

This is incorrect. This is giving advice to the patient. The nurse needs to educate the patient on the risks of exposure to cat feces containing the parasite toxoplasma that can cause birth defects. Pregnant women should avoid contact with cat litter and should wear gloves when gardening. This is incorrect. Nurses should not ask “why” questions and make the assumption that maybe the woman would not be able to care for the cats and a new baby. This is incorrect. The woman does not have to get rid of the cats but needs to know the risks of cleaning up cat litter boxes. This is correct. This nurse is telling the patient why it is important to avoid contact with cat litter boxes.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: 2 Page: 548

1. 2.

3. 4.

Feedback This is incorrect. Blood volume is increased 40% to 45% above pre-pregnancy levels but this should not cause the hypertension. This is correct. Measurement of BP is one of the most important aspects of prenatal care. Pregnant women may develop pregnancy-induced hypertension (PIH). Elevated BPs may also indicate the presence of pre-eclampsia, a potentially life-threatening illness. This is incorrect. Pregnant women’s blood pressure should not fluctuate as the fetus grows in utero. This is incorrect. Pregnant women’s blood pressure is not directly related to their fluid intake and weight gain. It may be related to salt intake.

GRADESMORE.COM

ANS: 2 Page: 551

1. 2. 3. 4.

Feedback This is incorrect. A mild contraction feels like the firmness of a check. This is correct. A moderate contraction feels like the firmness of the tip of a nose. This is incorrect. A moderate contraction does not feel like the firmness of a thigh but the tip of the nose. This is incorrect. A strong contraction feels like the firmness of the forehead while a moderate contraction feels like the firmness of the tip of the nose.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. Assess the fetal heart rate on the infant. 4. Put in a referral to a high-risk obstetrician. ANS: 2 Page: 551

2. 3. 4.

Feedback This is incorrect. The fetus has moved five times in the last 60 minutes. Pregnant women can usually feel internal fetal movement from around 16 to 20 weeks gestation. Fetal movement in a healthy fetus can vary from 12 movements in 24 hours to 10 movements in 2 hours. This is correct. Inform the mother that the baby has moved in the past hour. She is early on in her pregnancy and is not as aware of the movement. This is incorrect. You do not need to assess the fetal heart rate because it was already taken and recorded at 124 bpm. This is incorrect. The pregnancy is normal and the baby is moving.

32. Routine diagnostic blood testing during pregnancy includes which of the following? Select all that apply. 1. Complete blood count 2. Rubella and varicella titers GRADESMORE.COM 3. Human immunodeficiency virus 4. Blood type 5. Chlamydia 6. Gonorrhea 7. Syphilis 8. Hepatitis ANS: 1, 2, 3, 4, 5, 6, 7, 8 Page: 544

1. 2. 3. 4.

5. 6.

Feedback This is correct. A complete blood count is part of routine blood work for a pregnant woman. This is correct. Rubella and varicella titers are part of routine blood work for a pregnant woman to assess whether the woman had measles and chicken pox. This is correct. Human immunodeficiency virus (HIV) is part of routine blood work for a pregnant woman. This is correct. Identifying the blood type of a pregnant woman is part of the routine blood work. This is correct. Patients are tested for sexually transmitted diseases routinely; testing for chlamydia is part of routine blood work for a pregnant woman. This is correct. Patients are tested for sexually transmitted diseases routinely; testing for gonorrhea is part of routine blood work for a pregnant woman.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

7. 8.

This is correct. Patients are tested for sexually transmitted diseases routinely; testing for syphilis is part of routine blood work for a pregnant woman. This is correct. Patients are tested for sexually transmitted diseases routinely; testing for hepatitis is part of routine blood work for a pregnant woman.

1. 2. 3. 4.

Feedback This is incorrect. The ulnar surface of both hands are not used but the palmar surface of your fingers are used to assess for contractions. This is correct. You should use the palmar surface of the fingers to assess for contractions.

GRADESMORE.COM

This is incorrect. You do not use the fingertips but the finger pads of both hands to assess for contractions. This is correct. You should use the finger pads of both hands (bimanual palpation) to assess for contractions.

34. You are performing Leopold’s Maneuver. Put in order the sequence of how you would perform this technique (1–4). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234.) 1. Each side of the maternal abdomen is palpated to determine which side is the fetal spine and which is the extremities. 2. The area above the symphysis pubis is palpated to locate the fetal presenting part and thus determine how far the fetus has descended and whether the fetus is engaged. 3. The uterine fundus is palpated to determine which fetal part occupies the fundus. 4. One hand applies pressure on the fundus while the index finger and thumb of the other hand palpate the presenting part to confirm presentation and engagement. ANS: 3124 Page: 552

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Feedback: First, the uterine fundus is palpated to determine which fetal part occupies the fundus. Second, each side of the maternal abdomen is palpated to determine which side is the fetal spine and which is the extremities. Third, the area above the symphysis pubis is palpated to locate the fetal presenting part and thus determine how far the fetus has descended and whether the fetus is engaged. Finally, one hand applies pressure on the fundus while the index finger and thumb of the other hand palpate the presenting part to confirm presentation and engagement.

35. Look at the picture. Identify this probable sign of pregnancy that indicates increased vascularity of the vagina and vulvGaR. A It D isEcS alM leO dRE.COM . (two words) ANS: Chadwick’s sign; chadwick’s sign; Chadwicks sign; chadwicks sign Page: 540 Feedback: Chadwick’s sign develops in the 6th to 8th weeks of pregnancy. A violet/bluish hue can be visualized that indicates increased vascularity of the vagina and vulva.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Chapter 24: Assessing the Older Adult

1. The nurse is making a home visit to an elderly client. Which statement made by the client’s adult daughter would cause the nurse to assess the client for skin breakdown? 1. “My mother takes a walk in the neighborhood every afternoon.” 2. “My mother is able to go to the bathroom without assistance.” 3. “My mother takes medication for her high blood pressure, diabetes, and a multivitamin.” 4. “My mother eats three well-balanced meals a day.”

2. The nurse is working in a senior housing complex assessing an 85-year old-resident. Which finding would be of greatest concern to the nurse? 1. A blood pressure of 160/70 mm/Hg 2. A heart rate of 60 beats per minute 3. An echocardiogram report documenting an enlarged left ventricle 4. An irregular heartbeat of 120 beats per minute

3. The elderly patient who is alert and oriented tells the nurse that she is incontinent when coughing and sneezing. The nurse knGoR wA sD thE atSthMiO sR paEti. enCt O haMs which type of incontinence? 1. Urge incontinence 2. Stress incontinence 3. Functional incontinence 4. Overflow incontinence

4. Which statement made by the elderly patient would concern the nurse the most? 1. “I only urinate once a day.” 2. “My doctor said my body mass index (BMI) is 20.” 3. “I have lost 5 pounds since I had bronchitis last month.” 4. “My sense of taste is not as good as it used to be.”

5. What is the correct technique for assessing the carotid artery in the elderly? 1. Palpate both carotid arteries at the same time to compare carotid upstroke. 2. Auscultate for a bruit while the patient takes a deep breath. 3. Palpate each carotid artery one at a time. 4. Gently massage the carotid artery using a lateral motion.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

6. How would the nurse appropriately conduct the Whispered Voice test in the elderly patient? 1. Have the patient stand in front of the nurse. 2. Stand in front of the patient and whisper two or three words. 3. Have the patient cover the ear the nurse is not assessing. 4. Conduct the Whispered Voice test to both ears at the same time.

7. An elderly patient reports that she wakes up with “greasy eyelids” every day. What is an inflammation and infection of the eyelid called? 1. Ptosis 2. Cataract 3. Blepharitis 4. Pterygium

8. What is the cause of hair turning gray or white in the elderly? 1. Decreased melanin production 2. Decreased hormone production 3. Changes in hair follicle function 4. Decreased production of albumin

GRADESMORE.COM

9. The nurse is performing a physical assessment on an elderly patient. Which finding would be considered normal aging? 1. Increased perspiration and sweating 2. Increased accumulation of ear cerumen 3. Increased pupillary reflex 4. Auscultation of an S3 heart sound

10. The elderly patient is diagnosed with gallstones and the patient asks how they developed. What is the nurse’s best response? 1. “There is a decreased production of pancreatic enzymes in the elderly.” 2. “Gastric acidity is reduced in the elderly.” 3. “There is an increased accumulation of biliary sludge in the elderly.” 4. “There is a decreased production of the intrinsic factor in the elderly.”

11. The elderly patient reports to the nurse that he coughs a lot during and after meals. What would be most important for the nurse to ask this patient first?

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. “How much do you drink during the day?’ 2. “Does the cough keep you awake at night?” 3. “Do you have difficulty swallowing?” 4. “Does it hurt when you cough?”

12. When assessing the thyroid in the older adult, which finding would concern the nurse? 1. The lateral lobes are not palpable. 2. The lateral lobes are smooth and firm. 3. There is varying texture and firmness in the lobes. 4. The lobes are nontender.

13. The daughter of an elderly patient is talking to the nurse about her parents. Which statement by the daughter would concern the nurse the most regarding risk factors for elder abuse? 1. “My parents emigrated from Italy when they were teenagers.” 2. “My father takes care of my mother 24 hours a day because she has Alzheimer’s disease.” 3. “My parents are financially secure but are always worried about spending money.” 4. “We have a nurse’s aide who comes to give my mother a shower once a week.”

GRADESMORE.COM 14. When administering the Mini Nutritional Assessment (MNA) to the elderly patient, which of the following would concern the nurse the most? 1. The patient has a weight loss between 1 and 3 kg in the last 3 months. 2. The patient is ambulatory, but does not go out. 3. The patient has a body mass index (BMI) of less than 19. 4. The patient has mild dementia.

15. The elderly patient’s daughter is talking with the nurse. Which of the following statements made by the daughter would concern the nurse that the patient is a frail elder? 1. “My mother fell last week and I noticed some bruises on her left arm.” 2. “My mother weighed the same last year at her physical examination.” 3. “My mother goes to the Senior Center twice a week.” 4 “My mother still cooks her own meals.”

16. When performing a cardiac assessment, which of the following findings indicates the possibility of hypertrophy of the left ventricle? 1. An S4 heart sound 2. An S3 heart sound

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. An ejection click 4. Opening snap

17. Which abdominal assessment finding would be considered normal in the elderly frail patient? 1. Cullen’s sign 2. Pulsation upon inspection 3. Hyperactive bowel sounds 4. Ascites

18. A 78-year-old women lives by herself. She has no family that lives locally. Which of the following assessments would you perform to understand how she perceives her current level of functioning? 1. Tinel’s test 2. Barthel’s ADL index 3. CAGE questionnaire 4. AD8

GRADESMORE.COM 19. The nurse is assessing an 80-year-old patient in a community health outpatient clinic. The patient is reliable. She states that she is tired all the time. She states, “I am old now. I just do not like to do anything anymore and I do not care if I see my family. My kids all have their own lives and families.” What would the nurse suspect in this patient? 1. Alzheimer’s disease 2. Delirium 3. Depression 4. Dementia

20. A 78-year-old patient is complaining of chronic achy joint pain. She states, “I am so tired of living with pain.” What is important to remember about pain and the elderly? 1. The older adult will report pain accurately. 2. The older adult may not be compliant in taking pain medication. 3. The older adult is willing to report pain. 4. Older adults are not able to give reliable self-reports of pain.

21. Which of the following is considered a normal aging change in the elderly patient? 1. Presence of overgrowth of the gum tissues 2. A yellow color in the hard palate

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. Decreased saliva and a dry mouth 4. A dry, red soft palate

22. The nurse is performing a physical assessment of the elderly patient. What would the nurse expect to find if the patient has cellulitis of the left lower extremity? 1. Skin that is cool to the touch 2. Loss of hair on one or both legs 3. Thick, leathery skin 4. Skin that is red and swollen

23. The nurse is performing a physical assessment of the elderly patient. For which of the following would the nurse notify the health-care provider as being abnormal? 1. Nystagmus when assessing the eyes 2. Tympany when percussing the abdomen 3. Femoral lymph nodes that are less than 1.0 cm 4. Negative Romberg test

GRADESMORE.COM 24. An elderly patient with gout is being assessed by the nurse. What finding would the nurse expect to see in this patient? 1. Microtia 2. Macrotia 3. Tophi 4. Presbycusis

25. The nurse is assessing gait and position sense in the elderly patient. Which of the following would be correct for the nurse to ask of the patient? 1. Ask the patient to walk away and then back, walking on his or her toes. 2. Ask the patient to walk heel-to-toe away and then back. 3. Ask the patient to hop on both feet. 4. Ask the patient to do a deep knee bend and assist the patient back up to standing if necessary.

26. The nurse is performing a neurological assessment on a 78-year-old male patient. The nurse has asked the patient to close his eyes. The nurse places a paper clip in the palm of the patient’s hand and asks the patient to identify the object. He states, “It is a safety pin.” What is the nurse assessing for? 1. Graphesthesia

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. Stereognosis 3. Cerebellar function and point-to-point movements. 4. Position sense and cerebellar function.

27. Which statement made by the elderly patient would lead the nurse to assess the patient for geriatric syndrome? Select all that apply. 1. “I wear a hearing aid.” 2. “I do not have any open sores on my skin.” 3. “I take a half hour nap every afternoon.” 4. “I have a cup of coffee for breakfast and usually a bowl of soup or cereal for lunch and dinner.” 5. “I fell in my bedroom last week.”

28. When assessing the lungs of the elderly patient, which of the following procedures is correct? Select all that apply. 1. Shave the chest of a patient with excessive hair to improve the sound. 2. Instruct the patient with adventitious lung sounds to cough before reassessing. 3. Instruct the patient to breathe forcefully through the nose while auscultating lung sounds. 4. Use the bell of the stethoscope directly over the bare skin to auscultate lung sounds. 5. Auscultate for bronchial breath soG unRdA sD ovEeS r tMhO eR laE ry.nC x,OtrMachea, and posterior nape of the neck.

29. The daughter of the elderly patient is talking to the nurse. Which of the following statements made by the daughter would concern the nurse regarding an increase in the risk of falls in the elderly? Select all that apply. 1. “My mother takes an anticonvulsant for seizure control.” 2. “My mother is able to get up out of the chair in one single movement.” 3. “My mother is sometimes incontinent.” 4. “My mother takes a benzodiazepine for her anxiety.” 5. “My mother sometimes gets confused.”

30. Which of the following would be important to include in the teaching plan for the elderly patient to help reduce the risk of osteoporosis? Select all that apply. 1. Limit the amount of walking each day to reduce the stress on your joints. 2. Make sure you get enough vitamin D in your diet. 3. Medications will not affect your bones. 4. Make sure you get enough calcium in your diet. 5. Stop smoking.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

31. When assessing the elderly patient, what cultural considerations are important for the nurse to know? Select all that apply. 1. Older Americans are predominantly white. 2. African Americans usually develop the onset of chronic illness earlier than whites. 3. Some cultures believe in withholding information about the older adult’s diagnosis. 4. The nurse should share medical information with only the patient. 5. Demographics of the older American is expected to change dramatically in a few decades.

32. When assessing the elderly female patient, which findings would the nurse document as expected as normal aging changes? Select all that apply. 1. Increased vaginal secretions 2. Increased interest in sex 3. Thin, gray pubic hair 4. Decreased breast tissue 5. Softer, smaller breast nipples

GRADESMORE.COM 33. When performing a medication assessment on the elderly patient, which of the following would concern the nurse? Select all that apply. 1. The patient takes a daily vitamin and an antihypertensive medication daily. 2. The patient has a primary care provider, an endocrinologist, a surgeon, and a rheumatologist. 3. The patient takes medications at 0800, 1000, 1200, 1600, and 1800. 4. The patient uses three different pharmacies. 5. The patient has cough syrup in the medicine cabinet that is 16 months old.

34. Which of the following statements made by the elderly patient would alert the nurse to warning signs that the patient should stop driving? Select all that apply. 1. “I got lost driving to my daughter’s new house 50 miles away.” 2. “I have had several traffic tickets this past year.” 3. “I have pain in my neck when I turn my head.” 4. “I only drive during the day.” 5. “I have trouble getting out of my chair in my living room.”

35. Which of the following statements is correct regarding alcohol use/abuse in the elderly? Select all that apply. 1. More women than men abuse alcohol.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. People who abuse alcohol generally have poor personal hygiene. 3. Those who abuse alcohol usually live alone. 4. Those who abuse alcohol tend to be married 5. Alcohol use/abuse in the elderly may be difficult to assess and/or diagnose.

36. When obtaining a health history and assessing an elderly patient in her home, which of the following would concern the nurse? Select all that apply. 1. The female patient begins talking about when her children were born. 2. The house is very cluttered with newspapers on the floor. 3. The patient’s teeth are broken and missing. 4. The patient’s legs have no edema. 5. The patient is speaking in a loud tone.

37. You are performing a comprehensive health assessment on a 68-year-old female. What normal assessment findings would the nurse expect to find in this elderly patient? Select all apply. 1. Skin tenting 2. Thin, fragile skin 3. Actinic keratosis GRADESMORE.COM 4. Solar lentigo 5. Nevi less than 0.6 cm

38. You are a nurse working in the veterans’ hospital. A 70-year-old patient reports that he has been smoking since age 20 and just has no desire to stop smoking because it is his one enjoyment in life at his age. He has a diagnosis of chronic obstructive pulmonary disease (COPD). What assessment finding(s) would the nurse expect to find in this patient? Select all that apply. 1. Clubbing of the nails 2. Inspiratory to expiratory ratio of 1:2 3. Barrel chest 4. Decreased costal angle 5. Pursed-lip breathing

39. Which of the following would be considered an abnormal finding in the elderly patient? Select all that apply. 1. An absent palpable apical pulse in an obese older adult 2. A lift or heave upon inspection 3. Dullness when percussing the abdomen

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. 2+ radial and brachial pulse 5. Positive Romberg test

40. Under the Affordable Care Act (ACA) signed into law in 2010, which preventive services are free of charge? Select all that apply. 1. Yearly mammograms for women aged 40 and older 2. Diabetes screenings 3. Zoster vaccines 4. Prostate cancer screenings 5. Annual eye examinations

41. A daughter brings her elderly motherGRADESMORE.COM to the outpatient clinic because she has several bruises on her arm. You see the above alteration in skin. You explain to the daughter that these are not bruises but areas of ruptured fragile capillaries causing bruising of the skin. This is called (two words).

42. A patient has fallen in the nursing home. You are going to use the PLATT mnemonic to document the fall assessment. The “L” in the PLATT mnemonic stands for of the fall.

43. Loss of muscle mass with aging is called

44. Identify the assessment tool: The uses a three-item recall test to assess memory and a simple scored clock-drawing test that takes about 3 minutes to administer. The tool is used to identify early mental decline and mild cognitive decline.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

45. You are assessing an older adult’s gait and balance. Put the Get Up and Go Test in proper order (1–7). (Enter the number of each step in the proper sequence. Do not use punctuation or spaces. Example: 1234) 1. Say “Go” to the patient and start timing the test. 2. Give the command, “Turn around.” 3. Give the command, “Walk back to the chair.” 4. Give the command, “Stand up from the arm chair.” 5. Explain to the patient that you will be giving him or her commands to follow. 6. Give the command, “Sit down.” 7. Give the command, “Walk in a line for 10 feet.”

GRADESMORE.COM

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

Answers 1. The nurse is making a home visit to an elderly client. Which statement made by the client’s adult daughter would cause the nurse to assess the client for skin breakdown? 1. “My mother takes a walk in the neighborhood every afternoon.” 2. “My mother is able to go to the bathroom without assistance.” 3. “My mother takes medication for her high blood pressure, diabetes, and a multivitamin.” 4. “My mother eats three well-balanced meals a day.” ANS: 3 Page: 563

1. 2. 3. 4.

Feedback This is incorrect. Reduced mobility is a risk factor, thus walking every afternoon is not a risk factor. This is incorrect. Incontinence is a risk factor, thus the ability to self-toilet is not a risk factor. This is correct. Diabetes and polypharmacy are risk factors for skin breakdown. This is incorrect. Poor nutrition is a risk factor, thus eating three well-balanced meals a day is not a risk factor.

2. The nurse is working in a senior hG ouRsA inD gE coSmMpOleRxEa. ssC esOsiMng an 85-year old-resident. Which finding would be of greatest concern to the nurse? 1. A blood pressure of 160/70 mm/Hg 2. A heart rate of 60 beats per minute 3. An echocardiogram report documenting an enlarged left ventricle 4. An irregular heartbeat of 120 beats per minute ANS: 4 Page: 557

3. 4.

Feedback This is incorrect. Blood pressure increases in the elderly because the heart’s pumping mechanism declines and arterial resistance increases, causing an increase in blood pressure. This is incorrect. The normal heart rate is 60 to 100 beats per minute. The heart rate decreases in the elderly. Also, atrial pacemaker cell and the Bundle of His fibers can decrease the electrical activity of the heart, leading to a decrease in the heart rate. This is incorrect. In the elderly, the heart muscle becomes thinner, decreases in strength, and becomes less compliant; however, a thickening in the left ventricle is common. This is correct. Atrial fibrillation is the most common arrhythmia in older adults. It is a fast, irregular heartbeat that may cause symptoms of heart palpitations, dizziness, and shortness of breath.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. The elderly patient who is alert and oriented tells the nurse that she is incontinent when coughing and sneezing. The nurse knows that this patient has which type of incontinence? 1. Urge incontinence 2. Stress incontinence 3. Functional incontinence 4. Overflow incontinence ANS: 2 Page: 559

1. 2.

Feedback This is incorrect. Urge incontinence is the sudden urge to urinate. This is correct. Stress incontinence is leaking small amounts of urine with intraabdominal pressure, such as with coughing, sneezing, and exercising, that may be related to the weakening of the pelvic floor muscles. This is incorrect. Functional incontinence occurs more often with older adults with chronic arthritis, Parkinson’s disease, or Alzheimer’s disease. There is an inability to control bladder function before reaching the bathroom due to limitations in moving, thinking, or communicating. This is incorrect. Overflow incontinence is caused by bladder muscle weakness where the individuals cannot completely empty their bladders.

GRADESMORE.COM

Feedback This is correct. The number of nephrons in the kidneys decreases in the older adult, affecting the kidneys’ ability to function properly. Urinating once a day would cause concern for the nurse related to kidney function. This is incorrect. A normal range for BMI is 18.5 to 24.9. A BMI of 20 is trending toward the low end, but BMI numbers decrease in the older patient. Older adults who are underweight (BMI of less than 19) often have loss of muscle mass, a compromised immune system, and risk of health complications. This is incorrect. Unintentional weight loss may be influenced by decreased cognition, chronic or acute disease, or psychosocial factors.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

According to the Mini Nutritional Assessment (MNA), a weight loss during the last 3 months between 2.2 and 6.6 pounds would cause concern. As this patient has lost 5 pounds, it could be attributed to the recent acute illness. This patient would need further assessment, but this is not the most concerning finding. This is incorrect. Taste buds decrease in the older adult, causing a decreased sensation of taste.

2. 3. 4.

Feedback This is incorrect. You should not palpate, massage, or palpate both carotid arteries at the same time. This causes an adverse reflex effect on the baroreceptors of the heart and may decrease the patient’s heart rate and blood pressure. This is incorrect. AuscultatinGgRfA orDaEcSaM roO tiR dE br. uiCt O shMould be done with the patient holding his or her breath so that you do not get confused by the patient’s tracheal breath sounds. This is correct. You should palpate each carotid artery one at a time to prevent bilateral occlusion of arterial blood flow to the brain. This is incorrect. Massaging the carotid artery should be avoided. This may cause an adverse reflex effect on the baroreceptors of the heart and may decrease the patient’s heart rate and blood pressure. The carotid artery should be gently palpated.

1. 2.

Feedback This is incorrect. To conduct the Whispered Voice test, the patient should be in the seated position in front of the nurse. This is incorrect. To conduct the Whispered Voice test, the nurse should stand behind

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

the patient. The nurse will stand about 2 feet away to either the right or left side of the patient and whisper three random words, letters, or numbers. This is correct. The nurse should assess one ear at a time while the patient covers the ear that is not being tested. This is incorrect. The nurse should assess one ear at a time while the patient covers the ear that is not being tested.

7. An elderly patient reports that she wakes up with “greasy eyelids” every day. What is an inflammation and infection of the eyelid called? 1. Ptosis 2. Cataract 3. Blepharitis 4. Pterygium ANS: 3 Page: 603

1. 2. 3. 4.

Feedback This is incorrect. Ptosis is drooping of the eyelid caused by muscle or nerve dysfunction, injury, or disease. This is incorrect. A cataract is an opacity of the lens caused by aging, long-term ReAtaDbE exposure to ultraviolet light,Gm olS icMdOisR orEd. erC s,OtrMauma, and medications. This is correct. Blepharitis is an inflammation and infection of the eyelid margins. This is incorrect. Pterygium is a gelatinous, abnormal growth of the conjunctiva that occurs commonly on the nasal side.

1. 2.

Feedback This is correct. Less melanin is produced in the elderly, causing hair to turn gray or white. This is incorrect. Hormonal changes are not related to hair color. Hormonal changes cause women to lose hair or develop facial hair. Decreased hormone production causes thinning of hair or hair loss of the scalp, axillary, and pubic areas. This is incorrect. Hair follicles may produce thinner, smaller hairs or none at all,

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

causing senescent alopecia. This is incorrect. Albumin and protein levels assess nutritional stores and are not related to hair color changes.

1. 2. 3. 4.

Feedback This is incorrect. The elderly patient will have decreased function of sweat glands, causing decreased perspiration and sweating. This is correct. There is an increased accumulation of ear cerumen. This is incorrect. Pupillary response is slower, not faster. This is incorrect. Auscultation of an S3 or S4 heart sound may be a sign of heart failure or cardiomyopathy, or weakening of the heart muscle.

GRADESMORE.COM

1. 2. 3.

Feedback This is incorrect. Decreased production of pancreatic enzymes causes malabsorption of essential nutrients. This is incorrect. Reduced gastric acidity may alter absorption of medications. This is correct. There is decreased function of the gallbladder in the elderly with slower emptying time, causing increased accumulation of biliary sludge and the risk for gallstones. This is incorrect. There is a decrease in production of the intrinsic factor, causing decreased absorption of vitamin B12 that may lead to pernicious anemia.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

11. The elderly patient reports to the nurse that he coughs a lot during and after meals. What would be most important for the nurse to ask this patient first? 1. “How much do you drink during the day?’ 2. “Does the cough keep you awake at night?” 3. “Do you have difficulty swallowing?” 4. “Does it hurt when you cough?” ANS: 3 Page: 564, 592

2. 3. 4.

Feedback This is incorrect. It is important to ask about fluid intake and hydration, which would assist in liquefying secretions, but it is not the most important question to ask. It is most important to first ask if the patient has difficulty breathing related to the increased coughing. This is incorrect. It is important to ask if the patient is getting sufficient sleep and rest, but it is not the most important question to ask. This is correct. A cough may be a sign that the patient is having difficulty swallowing food or fluids. This may need a referral for a swallow evaluation. This is incorrect. Although it is important to know if the coughing is causing pain, it is most important to first ask if the patient has difficulty breathing.

GRADESMORE.COM

1. 2. 3. 4.

Feedback This is incorrect. Whether using the anterior or posterior approach, the lateral lobes may or may not be palpable. This is a normal finding and would not concern the nurse. This is incorrect. The lateral lobes should be smooth and firm. This is a normal finding and would not concern the nurse. This is correct. Variations in the texture and firmness is an abnormal finding and would concern the nurse. This is incorrect. The lobes should not be tender. This is a normal finding.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2.

3. 4.

Feedback This is incorrect. There is no evidence that those who emigrated to this country earlier in their lives are at risk for elder abuse. This is correct. One out of 10 older adults experiences some form of abuse or neglect by a caregiver each year, and the incidence is expected to increase. Most elder abuse is committed by relatives, spouses, significant others, and caregivers. The responsibilities and demands of elder caregiving, which escalate as the elder’s condition deteriorates, can be very stressful to the caregiver. Alzheimer’s disease is a form of dementia that is progressive and degenerative. This is incorrect. Elder abuse can affect people of all ethnic backgrounds and social status. This is incorrect. Although caregivers may abuse the elderly patient, this aide only comes once a week and the husband is the primary caregiver, increasing the risk for him rather than the nurse’s aide.GRADESMORE.COM

14. When administering the Mini Nutritional Assessment (MNA) to the elderly patient, which of the following would concern the nurse the most? 1. The patient has a weight loss between 1 and 3 kg in the last 3 months. 2. The patient is ambulatory, but does not go out. 3. The patient has a body mass index (BMI) of less than 19. 4. The patient has mild dementia. ANS: 3 Page: 570

Feedback This is incorrect. The MNA is scored on a scale of 0 to 14. The higher the score, the less risk of malnutrition. A weight loss of between 1 and 3 kg in the last 3 months is a score of 2 on a 0 to 3 scale in this category of weight loss. This patient has a minimal risk for malnutrition. This is incorrect. This patient who gets out of bed but does not go out has a score of 1 on a 0 to 2 scale in the mobility category. This patient has a minimal risk for malnutrition. This is correct. This patient with a BMI of less than 19 has a score of 0 on a scale of 0

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

to 3 in the BMI category. This patient is at high risk for malnutrition. This is incorrect. This patient with mild dementia has a score of 1 on a 0 to 2 scale in the neuropsychological problems category. This patient has a mild risk for malnutrition.

1. 2. 3.

Feedback This is correct. Frail individuals are a high risk for falls, disability, hospitalization, and mortality. Balance and gait impairments are symptoms of frailty. This is incorrect. Elderly patients should be assessed for three of the eight components of frailty that include unintentional weight loss. This is incorrect. Elderly patients should be assessed for three of the eight components of frailty that include decreaG seRdAaD ctE ivSitM yO anRdEe. ngCaO gM ement. Going to the Senior Center twice a week would indicate activity and engagement. This is incorrect. Elderly patients should be assessed for three of the eight components of frailty that include decreased activity and engagement, and low energy expenditure.

16. When performing a cardiac assessment, which of the following findings indicates the possibility of hypertrophy of the left ventricle? 1. An S4 heart sound 2. An S3 heart sound 3. An ejection click 4. Opening snap ANS: 1 Page: 614

1. 2.

Feedback This is correct. An S4 heart sound may indicate thickening (hypertrophy) of the left ventricle, hypertension, artic stenosis, or be heard after a myocardial infarction. This is incorrect. An S3 heart sound may indicate congestive heart failure, aortic valve regurgitation, and be present after a myocardial infarction.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

This is incorrect. An ejection click may be heard at valves with defective leaflets such as in mitral valve prolapse. This is incorrect. An opening snap may indicate mitral stenosis.

17. Which abdominal assessment finding would be considered normal in the elderly frail patient? 1. Cullen’s sign 2. Pulsation upon inspection 3. Hyperactive bowel sounds 4. Ascites ANS: 2 Page: 615

1. 2.

3. 4.

Feedback This is incorrect. Cullen’s sign is caused by superficial bleeding under the skin (ecchymosis) around the umbilicus and may indicate intra-abdominal bleeding. This is correct. Peristalsis and aortic pulsations may be visible in very thin patients. Pulsations are increased with the presence of aortic aneurysm, an outpouching and weakening of an artery. This is incorrect. Hyperactive bowel sounds could indicate an early bowel obstruction. This is incorrect. Ascites is an abnormal accumulation of fluid in the peritoneal cavity.

GRADESMORE.COM

1. 2.

3. 4.

Feedback This is incorrect. Tinel’s test or Phelan’s test is used to assess for pain that may indicate carpal tunnel syndrome. This is correct. Barthel’s Index of Basic Activities of Daily Living (ADLs) assesses the functional status and the patient’s ability to care for himself or herself and meet essential tasks for daily life. This is incorrect. The CAGE questionnaire is used to assess older adults with alcoholism. This is incorrect. The AD8 is an 8-item questionnaire that distinguishes between people

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

who have dementia and those who do not.

19. The nurse is assessing an 80-year-old patient in a community health outpatient clinic. The patient is reliable. She states that she is tired all the time. She states, “I am old now. I just do not like to do anything anymore and I do not care if I see my family. My kids all have their own lives and families.” What would the nurse suspect in this patient? 1. Alzheimer’s disease 2. Delirium 3. Depression 4. Dementia ANS: 3 Page: 647-648

2. 3. 4

Feedback This is incorrect. Alzheimer’s disease is a form of dementia and is a progressive, degenerative cognitive disorder. There are problems with thinking, behaving, and remembering things. This is incorrect. Delirium is an acute, irreversible state of disorientation and confusion. This is correct. Depression is a mood disorder marked by loss of interest or pleasure in living.

GRADESMORE.COM

This is incorrect. Dementia is a progressive, irreversible decline in mental function, marked by memory impairment and, often, deficits in reasoning, judgment, abstract thought, registration, comprehension, learning, task execution, and use of language.

Feedback This is incorrect. The older adult may not be able to report pain accurately. Cognitive status of the patient must also be taken into consideration when assessing pain in the elderly. This is correct. Between 25% and 59% of older adult patients do not take their medications as prescribed. Most cases (75%) of nonadherence among older adults are intentional due to dose or side effects of the drugs.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

3. 4.

This is incorrect. Some older adults may be unwilling to report pain. This is incorrect. Older adults are able to give reliable self-reports of pain using different methods.

21. Which of the following is considered a normal aging change in the elderly patient? 1. Presence of overgrowth of the gum tissues 2. A yellow color in the hard palate 3. Decreased saliva and a dry mouth 4. A dry, red soft palate ANS: 3 Page: 588

2. 3. 4.

Feedback This is incorrect. Gingival hyperplasia (an enlargement or overgrowth of the gum tissues) produces firm, nonpainful gums. This may be related to systemic illness, side effects of medications such as phenytoin (Dilantin), and poor oral hygiene. This is incorrect. A hard palate that is yellow in color would indicate jaundice. This is correct. A normal finding is xerostomia (dry mouth). There is less saliva being produced, causing a dry mouth. This is incorrect. The soft palate should be pink and moist.

GRADESMORE.COM

1. 2. 3. 4.

Feedback This is incorrect. Skin that is cool to the touch indicates arterial insufficiency. This is incorrect. Loss of hair on one or both legs or feet indicates arterial insufficiency. This is incorrect. Thick, leathery skin indicates venous insufficiency. This is correct. Cellulitis is a bacterial skin infection where the skin appears red and swollen, and feels hot and tender.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. 3. 4.

Feedback This is correct. Nystagmus is an involuntary, cyclical movement of the eyes. It occurs when the patient gazes at or follows an object. It may also occur if the patient has a fixed gaze in the peripheral field. It may indicate a neurological disorder. This is incorrect. Tympany in all four quadrants of the abdomen is a normal finding. This is incorrect. Femoral lymph nodes that are less than 1.0 cm, movable, and nontender is a normal finding. This is incorrect. A negative Romberg test, where the patient maintains position without swaying or falling to one side, with and without opening eyes, is a normal finding.

24. An elderly patient with gout is being assessed by the nurse. What finding would the nurse GRADESMORE.COM expect to see in this patient? 1. Microtia 2. Macrotia 3. Tophi 4. Presbycusis ANS: 3 Page: 600

1. 2. 3. 4.

Feedback This is incorrect. Microtia is a congenital deformity where the ear is incompletely formed or a small ear of less than 4 cm in height in the adult. This is incorrect. Macrotia is abnormally large ears, greater than 10 cm vertical height in adults. This is correct. Tophi are hard, whitish or cream colored, nontender deposits of uric acid crystals indicative of gout. This is incorrect. Presbycusis is a normal progressive sensorineural hearing loss (cranial nerve VIII) that is more prevalent after 50 years of age. This loss is demonstrated by high-frequency hearing loss and difficulty discriminating spoken words.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4.

Feedback This is incorrect. The patient should walk away from the nurse on his or her toes and then back to the nurse on his or her heels. This is correct. The patient should walk heel-to-toe away from the nurse and then back. This is called tandem walking and assesses for muscular weakness. This is incorrect. The patient should hop on the right foot and then alternate to the left foot. This assesses position sense and cerebellar function. This is incorrect. The patient should be asked to do a shallow knee bend to assess for muscular weakness.

26. The nurse is performing a neurological assessment on a 78-year-old male patient. The nurse GRADESMORE.COM has asked the patient to close his eyes. The nurse places a paper clip in the palm of the patient’s hand and asks the patient to identify the object. He states, “It is a safety pin.” What is the nurse assessing for? 1. Graphesthesia 2. Stereognosis 3. Cerebellar function and point-to-point movements. 4. Position sense and cerebellar function. ANS: 2 Page: 643

Feedback This is incorrect. To assess for the sensation of touch or tactile stimulation (graphesthesia), the nurse would ask the patient to extend the right arm and turn the palm face up. The patient then is asked to close his eyes. The nurse would write a letter on the palm and ask the patient to identify the letter. This process is then repeated on the left hand. This is correct. Stereognosis assesses the perception of a shape of an object. The patient closes his eyes and the nurse places an object in the patient’s hand. The patient is then asked to identify the object. This is incorrect. To assess for cerebellar function, coordination, and point-to-point movements, the patient is given a pen cap. The pen is held about 12 inches away from the patient at eye level and the patient is asked to recap the pen. The patient is then

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

asked to touch the tip of the nurse’s finger, which is held at the patient’s eye level. This is repeated several times with the nurse moving his or her finger in each direction up, down, right, and left. This is incorrect. The Romberg test assesses for position sense and cerebellar function, balance, and coordination. The patient is asked to stand with feet together and arms at the sides and look straight ahead for 30 to 60 seconds without any support. The patient is then asked to close his or her eyes and continue to stand in this position for 20 seconds (with nurse behind for safety). The nurse observes for the patient swaying or falling to one side without opening the eyes.

2. 3.

GRADESMORE.COM

Feedback This is correct. The term “geriatric syndrome” is used to capture those clinical conditions in older adults that do not fit into discrete disease categories. Impaired hearing is one of the signs. This is incorrect. Pressure ulcers are one of the signs of geriatric syndrome. This patient does not have any open sores on the skin. This is incorrect. Sleep complaints are a sign of geriatric syndrome. This patient takes a nap for a half hour every afternoon. Napping more often during the daytime hours would be an abnormal finding in the sleep patterns of an older adult. A half hour does not meet these criteria. This is correct. Anorexia is a sign of geriatric syndrome. A cup of coffee for breakfast and usually a bowl of soup or cereal for lunch and dinner is a sign of poor appetite and nutrition. This is correct. Falls are a sign of geriatric syndrome.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. Use the bell of the stethoscope directly over the bare skin to auscultate lung sounds. 5. Auscultate for bronchial breath sounds over the larynx, trachea, and posterior nape of the neck. ANS: 2, 5 Page: 611

2. 3.

4. 5.

Feedback This is incorrect. If the patient has a hairy chest or back, you should dampen the area with a warm wet cloth or apply a thin coat of Surgilube on the diaphragm of the stethoscope to crease the friction. This is correct. Some adventitious sounds are cleared with cough. The patient should be asked to cough and then breath sounds should be reassessed. This is incorrect. The patient should be asked to inhale and exhale through the mouth. The patient should breathe more deeply than normally and be allowed to rest if lightheadedness or hyperventilation occurs. This is incorrect. The diaphragm of the stethoscope should be used, although auscultation should never be over clothes to ensure clarity of the sounds. This is correct. Bronchial breath sounds are heard over the larynx, trachea, and posterior nape of the neck.

GRADESMORE.COM 29. The daughter of the elderly patient is talking to the nurse. Which of the following statements made by the daughter would concern the nurse regarding an increase in the risk of falls in the elderly? Select all that apply. 1. “My mother takes an anticonvulsant for seizure control.” 2. “My mother is able to get up out of the chair in one single movement.” 3. “My mother is sometimes incontinent.” 4. “My mother takes a benzodiazepine for her anxiety.” 5. “My mother sometimes gets confused.” ANS: 1, 3, 4, 5 Page: 645

Feedback This is correct. According to the Hendrich II Fall Risk Model, a total score of 5 or higher puts the older adult at risk for falls. Administration of any antiepileptics (anticonvulsants) scores 2 points. Phenytoin is one such medication. This patient is at risk for falls. This is incorrect. Muscle weakness is one of the risk factors for fall. This patient is able to rise from a chair in a single movement with no loss of balance. The Hendrich II Fall Risk Model includes the Get-Up-and-Go Test, which scores this ability to rise from a chair with a score of 0. This patient is not at risk of falls. This is correct. The Hendrich II Fall Risk Model scores 1 point for altered elimination (incontinence). This patient is at risk for falls.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. 5.

This is correct. The Hendrich II Fall Risk Model scores the administration of any benzodiazepines (lorazepam) with a score of 1. This patient is at risk for falls. This is correct. Confusion, disorientation/impulsivity receives a score of 4 on the Hendrich II Fall Risk Model. This patient is at risk for falls.

1. 2. 3. 4. 5

Feedback This is incorrect. Bone changes may be influenced by a lack of weight-bearing exercises, such as walking. This is correct. Bone changes may be influenced by a decreased intake of vitamin D. This is incorrect. Bone changes may be influenced by medications, such as steroids. This is correct. Bone cha GRADESMORE.COMdecreased intake of calcium. nges may be influenced by This is correct. Smoking is a risk factor for osteoporosis.

1. 2. 3.

Feedback This is correct. The American Psychological Association (2013) reports that older Americans are predominantly white. This is incorrect. The American Psychological Association (2013) reports that the onset of chronic illness in minorities is usually earlier than in whites. This is correct. Some cultures believe that older adults should not be told their diagnoses and this should only be shared with family members.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. 5.

This is incorrect. Some cultures believe that older adults should not be told their diagnoses and this should only be shared with family members. This is correct. The American Psychological Association (2013) reports that the demographics of the older American will undergo a dramatic transformation in the next few decades.

1. 2. 3. 4. 5

Feedback This is incorrect. Normally, there is a decrease in the vaginal secretions, causing the vagina to become dry. This is incorrect. Women may begin to have a decreased interest in sexual activity. This is correct. Normally, thG erReAisDgEraSyM inOgRaE nd.tC hiOnM ning of the pubic hair. This is correct. Normally, there is a loss of alveolar, glandular, and lobular tissue. This is correct. Normally, the breasts are softer, smaller, and less erect.

33. When performing a medication assessment on the elderly patient, which of the following would concern the nurse? Select all that apply. 1. The patient takes a daily vitamin and an antihypertensive medication daily. 2. The patient has a primary care provider, an endocrinologist, a surgeon, and a rheumatologist. 3. The patient takes medications at 0800, 1000, 1200, 1600, and 1800. 4. The patient uses three different pharmacies. 5. The patient has cough syrup in the medicine cabinet that is 16 months old. ANS: 2, 3, 4, 5 Page: 563

1. 2. 3.

Feedback This is incorrect. Although polypharmacy would concern the nurse, two medications, one of which is a vitamin, would not concern the nurse. This is correct. This patient has four health-care providers, which increases the risk of multiple prescribers and compliancy. This would concern the nurse. This is correct. This patient takes medications five times a day. This would concern the

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

4. 5.

nurse because of multiple dosing schedules and compliancy. This is correct. This would concern the nurse as there are several filling pharmacies. This is correct. This would concern the nurse as a safety alert. Patients should be asked to review the expiration date of medication in the medication cabinet at least once a year.

2. 3.

4. 5.

Feedback This is incorrect. Getting lost, especially in familiar locations, is a warning sign for when to stop driving. Getting lost in unfamiliar locations, particularly 50 miles away from familiar locations, might be expected of anyone. This is correct. A warning siG gR nA foD rE wS heMnOtoRE sto.pCdOriMving is getting multiple traffic tickets or warnings from law enforcement. This is correct. Difficulty turning around to check the rear view while backing up or changing lanes is a warning sign for when to stop driving. Pain when turning one’s head would present difficulty. This is incorrect. Driving at night may create difficulty with headlight glare. Driving only during the day would eliminate this concern. This is correct. A warning sign for when to stop driving is impaired ambulation such as difficulty walking or getting into and out of chairs.

35. Which of the following statements is correct regarding alcohol use/abuse in the elderly? Select all that apply. 1. More women than men abuse alcohol. 2. People who abuse alcohol generally have poor personal hygiene. 3. Those who abuse alcohol usually live alone. 4. Those who abuse alcohol tend to be married 5. Alcohol use/abuse in the elderly may be difficult to assess and/or diagnose. ANS: 2, 3, 5 Page: 566

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3. 4. 5.

Feedback This is incorrect. In general, more men than women are alcohol-dependent or have alcohol problems, although women are more sensitive to the effects of alcohol than men. This is correct. The older adult alcoholic usually has poor personal hygiene. This is correct. The older adult alcoholic usually is socially isolated and lonely. This is incorrect. The older adult alcoholic usually is grieving due to loss of spouse, family, or friends. This is correct. In the older adult population, alcoholism is more challenging to assess and diagnose due to chronic illness, polypharmacy, and cognitive disorders.

1. 2. 3. 4. 5.

GRADESMORE.COM Feedback This is incorrect. During the interview of a health history, older adults will often share lifetime stories and reminisce or recall information from past experiences. This is correct. A cluttered house creates a fall risk. This is correct. Teeth wear down or fall out; gums recede, increasing risk for periodontal disease. The patient may have difficulty chewing solid foods. This is incorrect. This is a normal finding. Swollen legs could indicate heart failure. This is correct. Patients who have difficulty hearing speak loudly.

37. You are performing a comprehensive health assessment on a 68-year-old female. What normal assessment findings would the nurse expect to find in this elderly patient? Select all apply. 1. Skin tenting 2. Thin, fragile skin 3. Actinic keratosis 4. Solar lentigo 5. Nevi less than 0.6 cm ANS: 2, 4, 5 Page: 555, 577, 578

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

1. 2. 3.

4. 5.

Feedback This is incorrect. Tenting of the skin may indicate dehydration or weight loss. This is correct. As a person ages, the skin becomes thin and fragile. This is incorrect. Actinic keratosis is a rough, scaly patch that most often develops on chronically sun-exposed areas such as the face, the dorsum of the hands and forearms, upper chest, and the scalp of bald men, often described as “stuck-on cornflakes” This is commonly seen in Caucasian older adults and is considered an abnormal finding. This is correct. Solar lentigo (liver spots) are hyperpigmented macular lesions commonly seen on the exposed body surface areas of the older adult. This is correct. Nevi are uniform brown color with regular borders, less than 0.6 cm across, and are a normal finding in the older adult.

1. 2. 3.

4. 5.

Feedback This is correct. Clubbing of the nails occurs with chronic lack of oxygen or hypoxia. The tips of the fingers and nails change in shape and size. This is incorrect. An inspiratory to expiratory ratio (I:E) of 1:2 is considered a normal finding. This is correct. A barrel chest is characterized by an anterior-to-posterior ratio of 1:1; the costal angle is greater than 90 degrees. The normal nail bed is 160 degrees. This may be a seen in long-term cardiac and respiratory conditions. This is incorrect. In a patient with COPD you would find an increased costal angle. This is correct. Pursed-lip breathing is breathing through the nose and exhaling through pursed-lips. The patient looks like he is whistling. This is commonly seen in patients with COPD.

39. Which of the following would be considered an abnormal finding in the elderly patient? Select all that apply. 1. An absent palpable apical pulse in an obese older adult

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

2. A lift or heave upon inspection 3. Dullness when percussing the abdomen 4. 2+ radial and brachial pulse 5. Positive Romberg test ANS: 2, 3, 5 Page: 612, 617, 643

1. 2. 3. 4. 5.

Feedback This is incorrect. An apical pulse may not be palpable in an obese older adult due to the increased layers of fat. This is correct. A lift or heave is a sustained, forceful, outward thrusting of the ventricle secondary to increased workload. This is an abnormal finding. This is correct. When percussing the abdomen, dullness may indicate increased tissue density such as organ enlargement or an underlying mass. This is incorrect. A 2+ radial and brachial pulse is considered a normal finding. This is correct. A positive Romberg test indicates that the patient is swaying or falling to one side and may indicate cerebellar dysfunction or lesions in the cerebellum or spinal cord. This is an abnormal finding.

40. Under the Affordable Care Act (ACA) signed into law in 2010, which preventive services are free of charge? Select all that apply. GRADESMORE.COM 1. Yearly mammograms for women aged 40 and older 2. Diabetes screenings 3. Zoster vaccines 4. Prostate cancer screenings 5. Annual eye examinations ANS: 1, 2, 4 Page: 649

2. 3. 4. 5.

Feedback This is correct. The ACA provides for affordable and accessible health care for all Americans, including those enrolled in Medicare. People on Medicare no longer have to pay any out-of-pocket costs for most preventive services. Yearly mammograms for eligible beneficiaries age 40 and older are covered under the ACA. This is correct. Diabetes screenings are available free of charge to patients. This is incorrect. Although the zoster vaccine is recommended for all adults aged 60 and older to protect against shingles, this is not free of charge to patients under the ACA. This is correct. Prostate cancer screenings are available free of charge to patient sunder the ACA. This is incorrect. Annual eye examinations are not free of charge to patients under the ACA.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

41. A daughter brings her elderly mother to the outpatient clinic because she has several bruises on her arm. You see the above alteration in skin. You explain to the daughter that these are not bruises but areas of ruptured fragile capillaries causing bruising of the skin. This is called (two words). ANS: senile purpura Page: 578 Feedback: Senile purpura are areas of ruptured fragile capillaries and bruising of the skin caused by loss of subcutaneous fat.

42. A patient has fallen in the nursingGRADESMORE.COM home. You are going to use the PLATT mnemonic to document the fall assessment. The “L” in the PLATT mnemonic stands for of the fall. ANS: location Page: 645 Feedback: The “L” in the PLATT mnemonic stands for location of the fall.

43. Loss of muscle mass with aging is called

ANS: sarcopenia Page: 646 Feedback: Sarcopenia is loss of muscle mass with aging. It is a key manifestation of frailty.

GRADESMORE.COM .

WWW.GRADESMORE.COM .

Essential Health Assessment 1st Edition Thompson Test Bank

ANS: Mini-Cog; MiniCog; minicog Page: 647 Feedback: The Mini-Cog Assessment is a simple screening tool to identify early mental decline and mild cognitive decline. This tool uses a three-item recall test to assess memory and a simple scored clock-drawing test that takes about 3 minutes to administer.

GRADESMORE.COM

Feedback: First, explain to the patient that you will be giving him or her commands to follow. Second, say “Go” to the patient and start timing the test. Third, give the command, “Stand up from the arm chair.” Fourth, give the command, “Walk in a line for 10 feet.” Fifth, give the command “Turn around.” Sixth, give the command, “Walk back to the chair.” Finally, give the command, “Sit down.”

GRADESMORE.COM .