Nursing Assessment and Patient Care: Identifying Signs of Abuse and Health Issues, Exams of Nursing

Download Nursing Assessment and Patient Care: Identifying Signs of Abuse and Health Issues and more Exams Nursing in PDF only on Docsity! Health Assessment Final Exam: 45 Review Questions And Best Verified Solutions>. An elderly patient is admitted to the hospital. While performing a skin assessment, the nurse discovers bruises in various stages of healing all over the patient's body. Why is it important for the nurse to promptly document and report these findings? a.The patient may have been abused. b.The patient is elderly. c.The patient may have peripheral vascular disease. d.The patient may have a cognitive deficit. - Correct answera. The patient may have been abused When the nurse observes the patient for general characteristics including age, gender, and level of alertness, what aspect of assessment are you performing? a.Inspecting b.Interviewing c.Palpating d.Ausculating - Correct answera. Inspecting The four areas to consider during the general survey include: a. Dress, medical history, nonverbal behavior, and mobility. b.Ethnicity, gender, age, and socioeconomic status. c.Physical appearance, gender, ethnicity, and medical history. d.Physical appearance, body structure, mobility, and behavior. - Correct answerd. Physical appearance, body structure, mobility, and behavior. When reading the patient's medical record, the nurse sees the following notation: Patient states, "I have had a cold for about a week, and I am having difficulty breathing." This is an example of: a.A past health history. b.A review of systems. c.A functioning assessment. d.A chief compliant. - Correct answerd.A chief compliant. Normal cervical lymph nodes are: a.Smaller than 1 cm b.Warm and red c.Fixed d.Firm - Correct answera.Smaller than 1 cm The first step to cultural competency by a nurse is to: a.Identify the meaning of health to the patient. b.Understand their own heritage and its basis in cultural values. c.Develop a frame of reference to traditional health care practices. d.Understand how a health care delivery system works. - Correct answerb.Understand their own heritage and its basis in cultural values. The nurse is conducting a physical assessment of a new patient. What data does the nurse collect that are measurable? a.Objective b.Effective c.Subjective d.Affective - Correct answera.Objective While assessing a patient, the nurse is asking questions that help the nurse perceive and communicate an understanding of what the patient is feeling. What is this called? a.Caring b.Therapeutic communication c.Sympathy d.Empathy - Correct answerd.Empathy Checking for skin temperature is best accomplished by using: a.The palms of the hands. b.The back of the hands c.The fingertips. d.The ventral surfaces of the hands. - Correct answerb.The back of the hands The nurse is conducting a patient interview and responds to the patient in a way that encourages the patient to more completely describe his or her problems. What is this called? a.Guided questioning b.Focusing c.Clarification d.Restatement - Correct answera.Guided questioning A risk factor for melanoma is: a.Brown eyes While completing a neurological assessment, a nurse is assessing a patient for abnormalities of gait. The nurse is concerned that the patient is at increased risk for a fall. Which instruction should the nurse give the patient first? a."Walk heel to toe." b."Hop on one foot." c."Walk across the room and back." d."Walk on your toes then on your heels." - Correct answerc."Walk across the room and back." The nurse is preparing to complete an assessment of a patient's posterior thorax. Which of the following should be included in this examination? a.Auscultation of lung sounds b.Auscultation of the apical impulse c.Palpation of the subclavicular lymph nodes. d.Perform the Romberg test - Correct answera.Auscultation of lung sounds A patient with a recent head injury is admitted to the emergency department. The patient appears to be dazed. The nurse asks the patient, "Do you know where you are?" Which of the following parameters is the nurse assessing? a.Attention b.Memory c.Orientation d.Mood and affect - Correct answerc.Orientation To elicit the plantar response (Babinski response), the nurse should: a.Present a noxious odor to the person and ask to identify the scent. b.Observe the person walking heel to toe. c.Stroke the lateral aspect of the sole of the foot, starting with heel and then across the ball. d.Gently tap the Achilles tendon with the thicker part of the reflex hammer. - Correct answerc.Stroke the lateral aspect of the sole of the foot, starting with heel and then across the ball. The nurse is examining the movements of a patient's eyes through each of the 6 cardinal gazes. Which crainal nerves are being assessed by the nurse? a.Abducens nerve b.Facial nerve c. Hypoglossal nerve d.Oculomotor nerve e.Trochlear nerve - Correct answera.Abducens nerve d.Oculomotor nerve e.Trochlear nerve Your patient has a productive cough and is expectorating yellow mucous at times. Which breath sound would the nurse expect to auscultate due to the presence of mucous in this patient's respiratory tract? a.Absent b.Crackles c.Stridor d.Rhonchi - Correct answerd.Rhonchi When the nurse is assessing the motor function of cranial nerve VII as part of the neurological examination, what should the nurse instruct the patient to do? a.Clench the teeth b.Smell coffee beans c.Smile d.Cover one eye - Correct answerc.Smile A patient's patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding? a.Right knee+4; Left knee +3 b.Right knee +1; Left knee 0 c.Right knee +2; Left knee +1 d.Right knee +3; Left knee +2 - Correct answerc.Right knee +2; Left knee +1 The nurse is completing a neurological assessment on a patient. To test for stereognosis the nurse would: a.Have the person close his or her eyes and then raise the patient's arm and ask them to describe its location. b.Touch the patient with a cold object. c.Place a coin in the patient's hand and ask him or her to identify it. d.Touch the patient with a tuning fork. - Correct answerc.Place a coin in the patient's hand and ask him or her to identify it. A patient has a barrel-shaped chest. A barrel - shaped chest is characterized by: a.Anteroposterior to transverse (lateral) diameter of 2:1 and the elevation of the ribs. b.Anteroposterior to transverse (lateral) diameter of 1:2 and an elliptic shape. c.Equal anteroposterior to transverse (lateral) diameter and the ribs being horizational. d.Anteroposterior to transverse (lateral) diameter of 3:7 and sloping backwards of the ribs - Correct answerc.Equal anteroposterior to transverse (lateral) diameter and the ribs being horizational. When performing a complete assessment on a patient, why must the nurse analyze assessment data? a.Determine the patient's medical diagnosis b.Change medication doses c.Initiate a plan of care d.Take ownership of patient care - Correct answerc.Initiate a plan of care Which of the following assessment findings should be reported to the patient's provider? Select all that apply. a.AP to lateral ratio of 1:2 b.Presence of crackles in bilateral lung fields c.Pulse oximetry of 88% on room air d.Symmetrical chest expansion anteriorly and posteriorly e.Respiratory rate of 20 breaths per minute - Correct answerb.Presence of crackles in bilateral lung fields c.Pulse oximetry of 88% on room air Which of the following is considered an 'adventitious' type of breath sounds? a.Bronchial b.Bronchovesicular c.Vesicular d.Wheeze - Correct answerd.Wheeze While conducting a mental status history, the nurse notes that the patient is articulate, makes spontaneous comments, and speaks at a normal rate. For which section of the mental health assessment is this information most important? a.Thoughts and perception b.Mood c.Appearance and behavior d.Speech and language - Correct answerd.Speech and language Which of the following assessments best confirms the approach to check for symmetric chest expansion? a.Placing hands on the posterior chest wall with thumbs at the level of T10 and then sliding the hands up to pinch a small fold of skin between the thumbs. b.Inspection of the shape and configuration of the chest wall. c.Placing the palmer surface of the fingers of one hand against the chest and having the person repeat the words "ninety- nine". d.Tapping with your fingers on multiple areas of the chest anteriorly and posteriorly. - Correct answera.Placing hands on the posterior chest wall with thumbs at the level of T10 and then sliding the hands up to pinch a small fold of skin between the thumbs.