Health Assessment Final Nursing, Exams of Nursing

Download Health Assessment Final Nursing and more Exams Nursing in PDF only on Docsity! Health Assessment Final Nursing The nurse is preparing to conduct a health history. Explain this to the patient. - Answer- The purpose of a health history is to provide a database of subjective information about the patient's past and current health history. You might say to the patient, "I will be asking you questions about your past and present health." This information will help the provider along with the physical exam (objective data) to develop a diagnosis or health status. The nurse is evaluating the reliability of a patient's responses, which of these statements would be correct? The patient: - Provided consistent information and therefore is reliable A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse's best response? - "Can you point to where it hurts?" A 29-year-old woman tells the nurse that she has "excruciating pain" in her back. Which would be the nurse's appropriate response to the woman's statement? - "How would you say the pain affects your ability to do your daily activities?" A patient tells the nurse that he is allergic to penicillin. What would be the nurse's best response to this information? - "Describe what happens (or the reaction) to you when you take Penicillin." The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include: - Mental illness. The review of systems provides the nurse with... - Information regarding health promotion practices, the information helps to evaluate the past and present health state of each body system, to obtain any data that may have been omitted in the section about present illness, and to evaluate health promotion and teaching opportunities. Which of these statements represents subjective data the nurse obtained from the patient regarding the patient's skin? - Patient denies any color change. The nurse is obtaining a history from a 30-year old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient? - "Do you perform testicular self-examinations?" Functional Assessment-- What information would you ask if the patient's leg was in a cast? - A functional assessment includes the activities of daily living and the person's ability to take care of their needs. This area will help to formulate a nursing diagnosis. This could be present to the patient in a standardized form and will include data on the lifestyle and type of living environment. (Page 57) self- esteem, activity/exercise, sleep/rest, nutrition/elimination, interpersonal relationships/resources, spiritual resources, coping and stress management, personal habits, environmental hazards, violence questions, and occupational health questions. If a patient had a cast on their leg, appropriate questions would include how they transfer to bed, another chair, bathing technique, coping with the situation, support during the situation. Regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason why? - Alcohol can interact with all medications and make some diseases worse. Describe a genogram. - Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family. Usually 3 generations- parents, grandparents, siblings. Also highlight the health of close family members and more details such as communicable disease, environmental hazards (smoke), tobacco use, and alcohol use. Any additional information includes the family history. The nurse is obtaining health history on an 87-year-old woman. Which of the following areas of questioning would be most useful at this time? - The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have the woman: - Slowly lift her arms above her head, and note any retraction or lag in movement. The nurse is palpating a female patient's breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation? - Supine with the arms raised over the head The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique? - The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period. The nurse is preparing to teach a woman about BSE. Which statement by the nurse is correct - "BSE on a monthly basis will help you become familiar with your own breasts and feel their normal variations." A 55-year-old postmenopausal woman is being seen in the clinic for her annual examination. She is concerned about changes in her breasts that she has noticed over the past 5 years. She states that her breasts have decreased in size and that the elasticity has changed so that her breasts seem "flat and flabby." The nurse's best reply would be: - The decrease in hormones after menopause causes atrophy of the glandular tissue in the breast and is a normal process of aging. A 43-year-old woman is at the clinic for a routine examination. She reports that she has had a breast lump in her right breast for years. Recently, it has begun to change in consistency and is becoming harder. She reports that 5 years ago her physician evaluated the lump and determined that it "was nothing to worry about." The examination validates the presence of a mass in the right upper outer quadrant at 1 o'clock, approximately 5 cm from the nipple. It is firm, mobile, and non-tender, with borders that are not well defined. The nurse replies: - Because of the change in consistency of the lump, it should be further evaluated by the physician. During a discussion about BSEs with a 30-year-old woman, what statement by the nurse is most appropriate? - Examine your breast shortly after your menstrual period each month. The nurse is discussing BSEs with a postmenopausal woman. The best time for postmenopausal women to perform BSEs is? - On the same day every month. Peau d'orange- - Lymphatic obstruction causes edema, which thickens the skin and exaggerates the hair follicles; this creates a pigskin or orange peel look. Could be an indication of cancer. Dullness- - A high-pitched muffled thud sound obtained by percussing over relatively dense organs such as liver or spleen, distended bladder, mass of adipose tissue Tympany- - A high-pitchedmusical and drum like note obtained by percussing the surface of a large air- containing space, such as the abdomen Resonance- - A low-pitched, clear, hollow note obtained by percussing over normal lung tissue Hyperresonnance- - A low-booming note obtained by percussing over the adult lungs that have increased air such as with a patient who has emphysema, present with distended abdomen Which structure is located in the left lower quadrant of the abdomen? - Sigmoid colon Aneurysm- - defect or sec formed by dilation in artery wall due to atherosclerosis, trauma, or congenital defect (aortic aneurysm) Dysphasia- - Difficulty swallowing Anorexia- - Loss of appetite Ascites - abnormal accumulation of serous fluid within the peritoneal cavity, associated with heart failure, cirrhosis, cancer or portal hypertension Bruit- - blowing, swoishing sound her through a stethoscope when an artery is partially occluded Hepatomegaly- - abnormally enlarged liver Paralytic ileus- - complete absence of peristaltic movement that may follow abdominal surgery or complete bowel obstruction Peritonitis- - inflammation of the peritoneum Nurse suspects a patient has a distended bladder. How should the nurse assess? - Percuss and palpate the midline area above the suprapubic bone. The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is: - Decreased gastric acid secretion. Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called: - Ligaments To jump rope, the should has to be capable of: - Circumduction Articulation of the mandible and temporal bone is: - Temporomandibular joint Palpation of the temporomandibular joint: - Anterior to the tragus An 85-year-old patient comments during his annual physical examination that he seems to be getting shorter as he ages. How would you explain this to the patient? - With aging, the vertebral column shortens The nurse is teaching a class on preventing osteoporosis to a group of perimenopausal women. An action to prevent or delay bone loss in this group would be? - Perform physical activity, such as fast walking. A patient states, "I can hear a crunching or grating sound when I kneel." She also states that "it is very difficult to get out of bed in the morning because of stiffness and pain in my joints." The nurse should assess for signs of what problem? - Crepitation A patient is able to flex his right arm forward without difficulty or pain but is unable to abduct his arm because of pain and muscle spasms. The nurse should suspect: - Rotator cuff lesions During an examination, the nurse asks a patient to bend forward from the waist and notices that the patient has lateral tilting. When his leg is raised straight up, the patient complains of a pain going down his buttock into his leg. The nurse suspects: - Herniated nucleus pulposus Changes with an aging adult - After 40, loss of bone matrix occurs more rapidly than new bone formation; postural changes occur with decreased height the most noticeable; decreased height is due to shortening of the vertebral column; may see kyphosis; a distribution of subcutaneous fat changes through life; there is a tendency to gain weight; loss of muscle mass; may see a shuffling pattern when walking, arms out to help balance; broader base of support; may hold hand rails and haul their body up with it; may lead with favored leg; may find the aging holding two hands on the rail Osteoporosis- - your bones are living tissue that are continually growing and changing. Each day old bone tissue dissolves and is replaced with new bone tissue. As we age, the opposite begins to occur. When this happens bone can become weak and more likely to break even with the slightest bump. The bones of the wrist, hip, and spine are most often affected. There is no cure but there is treatment Steps to bone health and osteoporosis prevention- - • Diet- milk products (low fat) with vitamin D, which is needed for absorption of calcium; Fish canned ones which are packed in their bones; Leafy green vegetables; Limit caffeine; • Exercise- weight bearing a regular program of at least 3 times a week. • Lifestyle- avoid smoking and excessive alcohol; seek help for depression • Supplements as directed by your provider Rheumatoid Arthritis- - Rheumatoid Arthritis is a chronic, systemic inflammatory disease of the joints and surrounding connective tissue. Inflammation of the synovial membrane leads to thickening; then to fibrosis, which limits movement; and finally leads to bony ankylosis. Symmetric and bilateral characterized by heat, redness, swelling, and painful motion of the affected joints; the patient may experience fatigue, weakness, anoxeria, weight loss, low grade fever, and swollen glands Osteoarthritis- - (Degenerative Joint Disease) is a non-inflammatory localized, progressive disorder involving deterioration of articular cartilage and subchondral bone and formation of new bone (osteophytes) at joint surfaces. It occurs with aging nearly all adult age 60 or older have some signs of osteoarthritis. Asymmetrical involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. Affected joints have stiffness, swelling, bony protuberance, pain with motion, limitation with movement. Adduction, Abduction, Flexion, Extension - • Adduction - movement of a body part toward the body's midline • Abduction - movement of a body part away from the body's midline • Flexion- describes the movement that decreases the angle between a segment and its proximal segment • Extension- is the opposite of flexion, describing a straightening movement that increases the angle between body parts The 2 parts of the nervous system are: - Central and Peripheral Personality and ability to understand, crying easily, and becoming angry are associated to which lobe of the brain? - Frontal A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse? - Cerebellum A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting, she gets "really dizzy" and feels like she is going to fall over. The nurse's best response would be: - You need to get up slowly when you have been lying down or sitting. Cranial Nerve 11- Accessory; asking the patient to shrug her shoulders against resistance A patient says that she has recently noticed a lump in the front of her neck below her "Adam's apple" that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule): - Mobile and not hard 4 areas of the body where lymph nodes are accessible: - Head and neck, arms, inguinal area, and axillae A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give her? - More noticeable facial bones are probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin. A patient has come in for an examination and states, "I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is?" The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his: - Parotid gland A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a __________ sound that is heard best with the __________ of the stethoscope. - Soft, whooshing, pulsatile; bell A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he has: - CVA or stroke During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be: - Firm but freely movable The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally: - Nonpalpable During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement? - Using gentle pressure, palpate with both hands to compare the two sides Visual accommodation- - Pupillary constriction when looking at a near object A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that: - Constriction of both pupils occurs in response to bright light A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that: - The patient can read at 20 feet what a person with normal vision can read at 30 feet. A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this? - Observe the distance between the palpebral fissures A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that she may have: - Macular degeneration If your patient presented with an eye injury resulting in an emergency situation what symptoms would you expect to see that would prompt an emergency? - Loss of vision Sclera is china white, although Blacks occasionally have a gray-blue or muddy color to the sclera. Also in dark-skinned people you normally may see _______________on the sclera. - Small brown merciless (freckles) Extraocular muscles- - Cranial nerves 3, 4, and 6 Chronic Open-Angle Glaucome, Macular Degeneration, Cataracts, Presbyopia- - • Chronic Open-Angle Glaucoma--Increased intraocular pressure that leads to peripheral vision loss. • Macular Degeneration--Breakdown of cells in the Macula or the Retina that leads to loss of central vision-the area of clearest vision. • Cataracts--Lens opacity, resulting from a clumping of protein in the lens. • Presbyopia--Loss of lens elasticity decreasing the len's ability to change shape to accommodate for near vision. During an assessment of a patient has had a head injury from a car accident, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated and nonreactive, left pupil is 4 mm and reacts to light. What does finding this suggest? - Increase in the intracranial pressure The nurse notes that the patient's teeth are stained yellow and asks the patient about tobacco use. The patient states that he chews one bag of tobacco every other day. What health promotion concepts should the nurse include in the teaching plan? - Smokeless tobacco (SLT) contains cancer-producing chemicals, such as nitrosamines, that increase the risk of oral cancers (pharynx, larynx, and esophagus). Early signs of oral cancer should be discussed, as well as other effects of SLT use, such as gum recession, tooth discoloration, bad breath, nicotine dependence, and unhealthy eating habits. SLT is not a healthy alternative to smoking. Using smokeless tobacco can be detrimental to a person's health. The two types of SLT most commonly used in the United States are chewing tobacco and snuff. The largest group of SLT users is American Indian/Alaskan Native children, but SLT use is also high among young white males. Pain is an early sign of oral cancer Pathway of hearing: - The normal pathway of hearing is known as air conduction (AC) and is the most efficient. An alternate route of hearing is known as bone conduction (BC); here the bones of the skull vibrate and these vibrations are transmitted directly to the inner ear and to cranial nerve VIII Hearing loss: - • A conductive hearing loss involves a mechanical dysfunction of the external or middle ear and is considered a partial loss because the person is able to hear if the sound amplitude is increased enough to reach the nerve elements in the inner ear. Common causes are impacted cerumen, foreign bodies in the ear canal, perforated tympanic membrane, and otosclerosis. • A sensorineural (or perceptive) hearing loss indicates pathology of the inner ear, cranial nerve VIII, or the auditory areas of the brain. A simple increase in amplitude may not enable the person to hear. Common causes are ototoxic drugs and presbycusis, a gradual nerve degeneration that occurs with aging. • A mixed loss is a combination of both types of hearing loss in the same ear. Cerumen: - Purpose of cerumen is to protect and lubricate the ear. Eustachian tube: - Helps equalize are pressure on both sides of the tympanic membrane. Air conduction: - Normal pathway for hearing. Ear examination of an 80-year-old patient; which findings would be normal? - High-tone frequency loss A 17-year-old student is a swimmer on her high school's swim team. She has had three bouts of otitis externa this season and wants to know what to do to prevent it. The nurse instructs her to: - Use rubbing alcohol or 2% acetic acid teardrops after every swim "Buzzing sound" in the ear - Tinnitus Changes in hearing that occur with aging: - Progression of hearing loss is slow, the aging person may find it harder to hear consonants than vowels, sounds may be garbled and difficult to localize. The anal canal: - Is the outlet for the gastrointestinal tract. Colonoscopy- - a test that allows the physician to look at the inner lining of the large intestines, with a thin flexible tube A 60-year-old man has just been told that he has benign prostatic hypertrophy (BPH). He is concerned about cancer. How should the nurse respond? What would you say? - The enlargement of your prostate is caused by hormonal changes, and not cancer Symptoms may include urinary frequency, urgency, hesitancy, straining to urinate, wear stream, intermittent stream, or sensation of not emptying A 30-year-old woman is visiting the clinic because of "pain in my bottom when I have a bowel movement." The nurse should assess for which problem? - Hemorrhoids After completing an assessment of a 60-year-old man with a family history of colon cancer, the nurse discusses with him early detection measures for colon cancer. The nurse should mention the need for a(n): - Colonoscopy every 10 years What position should a woman be in for a rectal exam - Left lateral decubitus Pigmentation of anus is darker than the surrounding skin, the anal opening is closed, and a skin sac that is shiny and blue is noted. Pain with bowel movements and occasionally noted some spots of blood- - Thrombosed hemorrhoid Anal fistula, rectal prolapse, rectal polyp, rectal fissure- - Anal fistula—An abnormal passage from inner anus or rectum out to the skin surrounding the anus. May occur from chronic GI inflammation, local abscess. The tract may drain serosanguineous or purulent drainage. Rectal prolapse—protrusion of the rectal mucous membrane through the anus Rectal polyp—protruding growth from the rectal mucous membrane Rectal fissure—longitudinal tear in the superficial mucosa at the anal margin Rectal Prolapse- - Moist, red, doughnut shaped protrusion from the anus A 62-year-old man is experiencing fever, chills, malaise, urinary frequency, and urgency. He also reports urethral discharge and a dull aching pain in the perineal and rectal area. These symptoms are most consistent with which condition? - Prostatitis During a health history of a patient who complains of chronic constipation, the patient asks the nurse about high-fiber foods. The nurse relates that an example of a high-fiber food would be: - Broccoli During a digital examination of the rectum, the nurse notices that the patient has hard feces in the rectum. The patient complains of feeling "full," has a distended abdomen, and states that she has not had a bowel movement "for several days." The nurse suspects which condition? - Fecal impaction Human Papilloma Virus- - The nurse is preparing to interview a postmenopausal woman. Which of these statements is true as it applies to obtaining the health history of a postmenopausal woman? - The nurse should ask a postmenopausal woman if she has ever had vaginal bleeding. During the examination portion of a patient's visit, she will be in lithotomy position. Which statement reflects some things that the nurse can do to make this position more comfortable for her? - Elevate her head and shoulders to maintain eye contact. A patient calls the clinic for instructions before having a Papanicolaou (Pap) smear. The most appropriate instructions from the nurse are: - Avoid intervenes, inserting anything into the vagina or douching within 24 hours of your appointment. During a vaginal examination of a 38-year-old woman, the nurse notices that the vulva and vagina are erythematous and edematous with thick, white, curdlike discharge adhering to the vaginal walls. The woman reports intense pruritus and thick white discharge from her vagina. The nurse knows that these history and physical examination findings are most consistent with which condition? - Candidiasis A 22-year-old woman is being seen at the clinic for problems with vulvar pain, dysuria, and fever. On physical examination, the nurse notices clusters of small, shallow vesicles with surrounding erythema on the labia. Inguinal lymphadenopathy present is also present. The most likely cause of these lesions is: - Herpes simplex virus type 2 A 25-year-old woman comes to the emergency department with a sudden fever of 38.3° C and abdominal pain. Upon examination, the nurse notices that she has rigid, boardlike lower abdominal musculature. When the nurse tries to perform a vaginal examination, the patient has severe pain when the uterus and cervix are moved. The nurse knows that these signs and symptoms are suggestive of: - Pelvic inflammatory disease. A 35-year-old woman is at the clinic for a gynecologic examination. During the examination, she asks the nurse, "How often do I need to have this Pap test done?" Which reply by the nurse is correct? - "After age 30 years, if you have three consecutive normal Pap tests, then you may be screened every 2 to 3 years." What problems occur as a result of atrophic vaginitis? - Itching, dryness, burning sensation, dyspareunia, mucoid discharge with noticeable blood. What specific questions would you asks an elderly female patient whose period stopped 5 years ago and has recently restarted? - When did it start, amount, color, taking any medications, history of any cancer in the family, past surgeries, any abdominal pain. Changes normally associated with menopause occur because the cells in the reproductive tract are aging? T or F - True When performing a genital examination on a 25-year-old man, the nurse notices deeply pigmented, wrinkled scrotal skin with large sebaceous follicles. On the basis of this information, the nurse would consider this as normal findings. - True Inguinal Hernia- - An inguinal hernia is herniation of bowel (usually small intestine) through a weak area in the lower abdominal wall. The area of the lower abdominal wall is also called the inguinal or groin region. 2 types of inguinal hernias - • indirect inguinal hernias, which are caused by a defect in the abdominal wall that is congenital, or present at birth • direct inguinal hernias, which usually occur only in male adults and are caused by a weakness in the muscles of the abdominal wall that develops over time A 59-year-old patient has been diagnosed with prostatitis and is being seen at the clinic for complaints of burning and pain during urination. What is the appropriate term for burning and pain during urination? - Dysuria Stress Incontinence- - Involuntary urine loss with physical strain, sneezing, or coughing due to weakness of pelvis floor. What specific questions would be most appropriate when obtaining a genitourinary history from an older man? - Frequency, urgency, nocturia, dysuria, hesitancy, straining, color, difficulty controlling your urine, accidentally urinating when you sneeze, laugh, cough or bear down, any history of kidney disease, prostate problems. When the nurse is performing a genital examination on a male patient, the patient has an erection. The nurse's most appropriate action or response is to: - Reassure the patient that this is a normal response and continue with the examination. When performing a genitourinary assessment, the nurse notices that the urethral meatus is ventrally positioned. This finding is: - hypospadias The nurse is aware of which statement to be true regarding the incidence of testicular cancer? - Men with a history of cryptorchidism are at the greatest risk for the development of testicular cancer. The nurse is describing how to perform a testicular self-examination to a patient. Which statement is most appropriate? - "If you notice an enlarged testicle or a painless lump, call your health care provider." During an examination of an aging man, the nurse recognizes that normal changes to expect would be: - Decrease in the size of the penis. When performing a genital assessment on a middle-aged man, the nurse notices multiple soft, moist, painless papules in the shape of cauliflower-like patches scattered across the shaft of the penis. These lesions are characteristic of: -