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NUR2092 Health Assessment
/ Health Assessment Exam 1- PPT and
quiz questions
Which of the following is an open-ended question? a. What brought you in today? b. Where does it hurt? c. Have you been checking your blood pressure? d. When was the last time you were seen by a doctor? - ANSWER Answer:A. It is the only choice that would invite a paragraph for an answer rather than a short statement. Which of the following is the most basic function and therefore should be tested first in an assessment of mental status? a.Behavior b. Consciousness c. Judgment d. Language - ANSWER Answer: B. According to your textbook, consciousness is the most fundamental of these particular characteristics; therefore, it would be tested first.
Which of the following is not a significant contributor to the assessment of mental status? a.Known illness or health problem b. Current medications known to affect mood or cognition c. Racial background d. Personal history; current stress, social habits, sleep habits, drug and alcohol use
- ANSWER Answer: C. The other choices are all elements of the interview that contribute to interpretation of the findings of the examination. Correct order of physical examination skills: - ANSWER Inspection, Palpation, Percussion, Auscultation NCLEX question The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the underlying tissue: A) turgor. B)texture. C)density. D)consistency. - ANSWER ANSWER: C Percussion yields a sound that depicts the location, size, and density of the underlying organ. Turgor and texture are assessed with palpation.
NCLEX question The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: A)auscultate over the area with a fetoscope. B)use a goniometer to measure the pulsations. C)use a Doppler device to check for pulsations over the area. D)check for the presence of pulsations with a stethoscope. - ANSWER ANSWER: C Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal heart tones. Stethoscopes are used to auscultate breath, bowel, and heart sounds. NCLEX question When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination? A)There is no need to wash one's hands after removing gloves, as long as the gloves are still intact. B)Wash hands before and after every physical patient encounter. C)Wash hands between the examination of each body system to prevent the spread of bacteria from one part of the body to another. D)Wear gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases. - ANSWER ANSWER: B
The nurse should wash his or her hands before and after every physical patient encounter; after contact with blood, body fluids, secretions, and excretions; after contact with any equipment contaminated with body fluids; and after removing gloves. Hands should be washed after gloves have been removed, even if the gloves appear to be intact. Gloves should be worn when there is potential contact with any body fluids. NCLEX question Which of these statements is true regarding the use of standard precautions in the health care setting? A) Standard precautions apply to all body fluids, including sweat. B)Use alcohol-based hand rub if hands are visibly dirty. C)Standard precautions are intended for use with all patients regardless of their risk or presumed infection status. D)Standard precautions are to be used only when there is nonintact skin, excretions containing visible blood, or expected contact with mucous membranes.
- ANSWER ANSWER: C Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources. They are intended for use for all patients, regardless of their risk or presumed infection status. They apply to blood and all other body fluids, secretions and excretions except sweat—regardless of whether they contain visible blood, nonintact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood or body fluids; alcohol-based hand rubs can be used if hands are not visibly soiled NCLEX question
Which patient would be most likely to present with a pulse rate that is lower than normal? a. A 70-year-old telephone salesman presenting with dehydration. b. A 20-year-old runner who had surgery 4 days ago for a fractured leg. c. A 67-year-old who presented with an exacerbation of his COPD - ANSWER Answer: B. Athletes who train for endurance are likely to have a low resting heart rate because of a high cardiac output. NCLEX question A patient's weekly blood pressure readings for 2 months have ranged between 124/84 and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this blood pressure falls within which blood pressure category? A)Normal blood pressure B)Prehypertension C)Stage I hypertension D)Stage 2 hypertension - ANSWER ANSWER: B According to the JNC-VII guidelines, prehypertension blood pressure readings are systolic 120 to 139 mm Hg or diastolic 50 to 89 mm Hg. NCLEX question The nurse should measure rectal temperatures in which of these patients? A)School-age child B)Elderly adult C)Comatose adult
D)Patient receiving oxygen by nasal cannula - ANSWER ANSWER: C Rectal temperatures should be taken when the other routes are not practical, such as for comatose or confused persons, for persons in shock, or for those who cannot close the mouth because of breathing or oxygen tubes, wired mandible, or other facial dysfunctions. NCLEX question A student is late for his appointment and has rushed across campus to the health clinic. Before assessing his vital signs, the nurse should: A)allow him 5 minutes to relax and rest before checking his vital signs. B)check the blood pressure in both arms, expecting a difference in the readings because of his recent exercise. C)monitor his vital signs immediately on his arrival at the clinic, then 5 minutes later, and notice any differences. D)check his blood pressure in the supine position because this will give a more accurate reading and will allow him to relax at the same time. - ANSWER ANSWER: A A comfortable, relaxed person yields a valid blood pressure. Many people are anxious at the beginning of an examination; the nurse should allow at least a 5- minute rest before measuring his blood pressure. The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to: A)hear the Korotkoff sounds more clearly. B)detect the presence of an auscultatory gap. C)avoid missing a falsely elevated blood pressure.
A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, "I quit smoking after my wife died 7 years ago." However, the nurse notices an open package of cigarettes in his shirt pocket. Using confrontation, the nurse could say: a. "Mr. K, I know that you are lying b. "Mr. K, come on, tell me how much you smoke." c. "Mr. K, I didn't realize that your wife had died. It must be difficult for you at this time. Please tell me more about that." d. "Mr. K, you have said that you don't smoke, but I see that you have an open package of cigarettes in your pocket." - ANSWER Answer: D A pregnant woman states, "I just know labor will be so painful that I won't be able to stand it. I know it sounds awful, but I really dread going into labor. The nurse responds by stating, "Oh, don't worry about labor so much. I have been through it, and although it is painful there are many good medications to decrease the pain." Which statement is true regarding this response? It was a: a. therapeutic response. By sharing something personal, the nurse gives hope to this woman. b. nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the woman's fears. c. therapeutic response. By providing information about the medications available, the nurse is giving information to the woman.
d. nontherapeutic response. The nurse is essentially giving the message to the woman that labor cannot be tolerated without medication. - ANSWER Answer: B During the interview portion of data collection, the nurse collects _________ data. a. Physical b. Historical c. Objective d. Subjective - ANSWER Answer: D When evaluating a patient's pain, the nurse knows that an example of acute pain would be: a. Arthritic pain b. Fibromyalgia c. Kidney Stones d. low back pain - ANSWER Answer: C A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice? a. A trained interpreter b. A male family member c. A female family member
a. palpation b. inspection c. percussion d. auscultation - ANSWER Answer: B A woman who has lived in the United States for a year after moving from Europe has learned to speak English and is almost finished with her college degree. She now dresses like her peers and says that her family in Europe would hardly recognize her. This nurse recognizes that this situation illustrates which concept? a. Assimilation b. Heritage consistency c. Biculturalism d. Acculturation - ANSWER Answer: A When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as a(n): a. ataxia b. lack of coordination c. negative Homans' sign d. positive Romberg sign - ANSWER Answer: D
During an examination, the nurse can assess mental status by which activity? a. examining the patient's electroencephalogram b. Observing the patient as he or she performs an IQ test c. Observing the patient and inferring health or dysfunction through an assessment of behaviors d. Only examining the patient's response to a specific set of questions - ANSWER Answer: C A woman brings her 70 year old husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse's best course of action? The nurse should: a. plan to perform a complete mental status examination including the cranial nerves and cerebellar function b. refer him to a neurologist c. plan to integrate the mental status examination into the history and physical examination d. reassure his wife that memory loss after a physical shock is normal and will subside soon - ANSWER Answer: A The nurse is preparing to do a mental status assessment. Which statement is true regarding the mental status assessment? a. a patient's family is the best resource for information about the patient's coping skills
A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination on him. During the tests of cognitive function the nurse would expect that he: a. may display some disruption in thought content b. will state " I am so relieved to be out of intensive care" c. will be oriented to place and person but may not be certain of the date d. may show evidence of come clouding of his level of consciousness - ANSWER Answer: C The nurse places a key in the hand of a patient and he identifies it correctly. What term would the nurse use to describe this finding? a. extinction b. stereognosis c. graphesthesia d. tactile discrimination - ANSWER Answer: B During an assessment of the cranial nerves, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these cranial nerves?
a. motor component of IV b. motor component of VII c. motor and sensory components of XI d. motor component of X and sensory component of VII - ANSWER Answer: B The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding? a. positive Babinski sign b. plantar reflex abnormal c. plantar reflex present d. plantar reflex "2+" on a scale from "0-4+" - ANSWER Answer: C
