Nursing 2058 Health Assessment Exam 2 Study Guide: Best Exam Solutions, Exams of Nursing

Download Nursing 2058 Health Assessment Exam 2 Study Guide: Best Exam Solutions and more Exams Nursing in PDF only on Docsity! NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score Health Assessment Exam 2: Study Guide Chapter 1: 1. When performing a physical assessment, the first technique the nurse will always use is: a. Palpation. b. Inspection. c. Percussion. d. Auscultation. B The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, during which auscultation takes place before palpation and percussion). The assessment of each body system begins with inspection. A focused inspection takes time and yields a surprising amount of information. NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score 2. The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase: a. Usually yields little information. b. Takes time and reveals a surprising amount of information. c. May be somewhat uncomfortable for the expert practitioner. d. Requires a quick glance at the patient’s body systems before proceeding with palpation. B A focused inspection takes time and yields a surprising amount of information. Initially, the examiner may feel uncomfortable, staring at the person without also doing something. A focused assessment is NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score d. Auscultation A Palpation uses the sense of touch to assess the patient for these factors. Inspection involves vision; percussion assesses through the use of palpable vibrations and audible sounds; and auscultation uses the sense of hearing. 5. The nurse is preparing to assess a patient’s abdomen by palpation. How should the nurse proceed? a. Palpation of reportedly “tender” areas are avoided because palpation in these areas may cause pain. b. Palpating a tender area is quickly performed to avoid any discomfort that the patient may experience. c. The assessment begins with deep NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score palpation, while encouraging the patient to relax and to take deep breaths. d. The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched. D Light palpation is initially performed to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first. 6. The nurse would use bimanual palpation technique in which situation? a. Palpating the thorax of an infant NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score b. Palpating the kidneys and uterus c. Assessing pulsations and vibrations d. Assessing the presence of tenderness and pain B Bimanual palpation requires the use of both hands to envelop or capture certain body parts or organs such as the kidneys, uterus, or adnexa. The other situations are not appropriate for bimanual palpation. 7. The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the of the underlying tissue. a. Turgor b. Texture c. Density d. Consistency NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score percuss in this area again. d. Consider this finding as abnormal, and refer the patient for additional treatment. A Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound. The other responses are not correct. 10. The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next? a. Ask the patient to take deep breaths to relax the abdominal musculature. b. Consider this finding as normal, and proceed with the abdominal assessment. c. Increase the amount of strength NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score used when attempting to percuss over the abdomen. d. Decrease the amount of strength used when attempting to percuss over the abdomen. C The thickness of the person’s body wall will be a factor. The nurse needs a stronger percussion stroke for persons with obese or very muscular body walls. The force of the blow determines the loudness of the note. The other actions are not correct. 11. The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4- year-old child. The nurse should: a. Palpate over the area for increased pain and tenderness. b. Ask the child to take shallow breaths, and percuss over the NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score area again. c. Immediately refer the child because of an increased amount of air in the lungs. d. Consider this finding as normal for a child this age, and proceed with the examination. D Percussion notes that are loud in amplitude, low in pitch, of a booming quality, and long in duration are normal over a child’s lung. 12. A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient? NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score 14. The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: a. Is used to listen for high-pitched sounds. b. Is used to listen for low-pitched sounds. c. Should be lightly held against the person’s skin to block out low- pitched sounds. d. Should be lightly held against the person’s skin to listen for extra heart sounds and murmurs. A The diaphragm of the stethoscope is best for listening to high-pitched sounds such as NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score breath, bowel, and normal heart sounds. It should be firmly held against the person’s skin, firmly enough to leave a ring. The bell of the stethoscope is best for soft, low-pitched sounds such as extra heart sounds or murmurs. 15. Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should: a. Warm the endpiece of the stethoscope by placing it in warm water. b. Leave the gown on the patient to ensure that he or she does not get chilled during the examination. c. Ensure that the bell side of the stethoscope is turned to the “on” position. d. Check the temperature of the NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score room, and offer blankets to the patient if he or she feels cold. D The examination room should be warm. If the patient shivers, then the involuntary muscle contractions can make it difficult to hear the underlying sounds. The end of the stethoscope should be warmed between the examiner’s hands, not with water. The nurse should never listen through a gown. The diaphragm of the stethoscope should be used to auscultate for bowel sounds. 16. The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations? a. Palpation b. Inspection c. Percussion d. Auscultation A NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score for astigmatism c. Using the grid on the lens aperture dial to visualize the external structures of the eye d. Rotating the lens selector dial to bring the object into focus D The ophthalmoscope is used to examine the internal eye structures. It can compensate for nearsightedness or farsightedness, but it will not correct for astigmatism. The grid is used to assess size and location of lesions on the fundus. The large full spot of light is used to assess dilated pupils. Rotating the lens selector dial brings the object into focus. 19. 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. NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score 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. 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. 20. The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? The nurse: NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score a. Performs the examination from the left side of the bed. b. Examines tender or painful areas first to help relieve the patient’s anxiety. c. Follows the same examination sequence, regardless of the patient’s age or condition. d. Organizes the assessment to ensure that the patient does not change positions too often. D The steps of the assessment should be organized to ensure that the patient does not change positions too often. The sequence of the steps of the assessment may differ, depending on the age of the person and the examiner’s preference. Tender or painful areas should be assessed last. NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score physical patient encounter. c. Hands are washed before the examination of each body system to prevent the spread of bacteria from one part of the body to another. d. Gloves are worn throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases. 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 potential contact with any body fluids is present. NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score 23. The nurse is examining a patient’s lower leg and notices a draining ulceration. Which of these actions is most appropriate in this situation? a. Washing hands, and contacting the physician b. Continuing to examine the ulceration, and then washing hands c. Washing hands, putting on gloves, and continuing with the examination of the ulceration d. Washing hands, proceeding with rest of the physical examination, and then continuing with the examination of the leg ulceration C The examiner should wear gloves when the potential contact with NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score any body fluids is present. In this situation, the nurse should wash his or her hands, put on gloves, and continue examining the ulceration. 24. During the examination, offering some brief teaching about the patient’s body or the examiner’s findings is often appropriate. Which one of these statements by the nurse is most appropriate? a. “Your atrial dysrhythmias are under control.” b. “You have pitting edema and mild varicosities.” NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score d. Halfway through the examination B The Moro or startle reflex is elicited at the end of the examination because it may cause the infant to cry. 27. When preparing to perform a physical examination on an infant, the nurse should: a. Have the parent remove all clothing except the diaper on a boy. b. Instruct the parent to feed the infant NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score immediately before the examination. c. Encourage the infant to suck on a pacifier during the abdominal examination. d. Ask the parent to leave the room briefly when assessing the infant’s vital signs. A The parent should always be present to increase the child’s feeling of security and to understand normal growth and development. The timing of the examination should be 1 to 2 hours after feeding when the baby is neither too drowsy nor too hungry. Infants do not object to being nude; clothing should be removed, but a diaper should be left on a boy. 28. A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score when beginning the examination? a. Auscultate the lungs and heart while the infant is still sleeping. b. Examine the infant’s hips, because this procedure is uncomfortable. c. Begin with the assessment of the eye, and continue with the remainder of the examination in a head-to-toe approach. d. Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems. A When the infant is quiet or sleeping is an ideal time to assess the cardiac, respiratory, and abdominal systems. Assessment of the eye, ear, nose, and NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score statement because children at this age like to have choices d. Children at this age like to say, “No.” The examiner should not offer a choice when no choice is available D Children at this age like to say, “No.” Choices should not be offered when no choice is really available. If the child says, “No” and the nurse does it anyway, then the nurse loses trust. Autonomy is enhanced by offering a limited option, “Shall I listen to your heart next or your tummy?” 31. With which of these patients would it be most appropriate for the nurse to use games during the assessment, such as having the patient “blow out” the light on the penlight? a. Infant b. Preschool child NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score c. School-age child d. Adolescent B When assessing preschool children, using games or allowing them to play with the equipment to reduce their fears can be helpful. Such games are not appropriate for the other age groups. 32. The nurse is preparing to examine a 4-year-old child. Which action is appropriate for this age group? a. Explain the procedures in detail to alleviate the child’s anxiety. NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score b. Give the child feedback and reassurance during the examination. c. Do not ask the child to remove his or her clothes because children at this age are usually very private. d. Perform an examination of the ear, nose, and throat first, and then examine the thorax and abdomen. B With preschool children, short, simple explanations should be used. Children at this age are usually willing to undress. An examination of the head should be performed last. During the examination, needed feedback and reassurance should be given to the preschooler. NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score aging adults have hearing deficits. d. Arrange the sequence of the examination to allow as few position changes as possible. D When examining the older adult, arranging the sequence of the examination to allow as few position changes as possible is best. Physical touch is especially important with the older person because other senses may be diminished. 35. The most important step that the nurse can take to prevent the transmission of microorganisms in the hospital setting is to: a. Wear protective eye wear at all times. b. Wear gloves during any and all contact with patients. NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score c. Wash hands before and after contact with each patient. d. Clean the stethoscope with an alcohol swab between patients. C The most important step to decrease the risk of microorganism transmission is to wash hands promptly and thoroughly before and after physical contact with each patient. Stethoscopes should also be cleansed with an alcohol swab before and after each patient contact. The best routine is to combine stethoscope rubbing with hand hygiene each time hand hygiene is performed. 36. 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. NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score 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 nonintact skin, excretions containing visible blood, or expected contact with mucous membranes is present. C Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources and are intended for use for all patients, NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score 38. When examining an infant, the nurse should examine which area first? a. Ear b. Nose c. Throat d. Abdomen D The least-distressing steps are performed first, saving the invasive steps of the examination of the eye, ear, nose, and throat until last. 39. While auscultating heart sounds, the nurse hears a murmur. Which of these instruments should be used to assess this murmur? a. Electrocardiogram NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score b. Bell of the stethoscope c. Diaphragm of the stethoscope d. Palpation with the nurse’s palm of the hand B The bell of the stethoscope is best for soft, low-pitched sounds such as extra heart sounds or murmurs. The diaphragm of the stethoscope is best used for high-pitched sounds such as breath, bowel, and normal heart sounds. 40. During an examination of a patient’s abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drumlike quality of the sounds across the quadrants. This type of sound indicates: a. Constipation. b. Air-filled areas. NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score c. Presence of a tumor. d. Presence of dense organs. B A musical or drumlike sound (tympany) is heard when percussion occurs over an air- filled viscus, such as the stomach or intestines. 41. The nurse is preparing to examine a 6-year-old child. Which action is most appropriate? a. The thorax, abdomen, and genitalia are examined before the head. b. Talking about the equipment being used is avoided because doing so may increase the child’s anxiety. c. The nurse should keep in mind that a child at this age will have a NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score 1. The nurse is preparing to palpate the thorax and abdomen of a patient. Which of these statements describes the correct technique for this procedure? Select all that apply. a. Warm the hands first before touching the patient. b. For deep palpation, use one long continuous palpation when assessing the liver. c. Start with light palpation to detect surface characteristics. d. Use the fingertips to examine skin texture, swelling, pulsation, and presence of lumps. e. Identify any tender areas, and palpate them last. f. Use the palms of the hands to assess temperature of the NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score skin. A, C, D, E The hands should always be warmed before beginning palpation. Intermittent pressure rather than one long continuous palpation is used; any tender areas are identified and palpated last. Fingertips are used to examine skin texture, swelling, pulsation, and the presence of lumps. The dorsa (backs) of the hands are used to assess skin temperature because the skin on the dorsa is thinner than on the palms. NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score Chapter 2: 1. The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the: a. Auricle. b. Concha. c. Outer meatus. d. Mastoid process. A The external ear is called the auricle or pinna and consists of movable cartilage and skin. 2. The nurse is examining a patient’s ears and notices cerumen in the external canal. Which of these statements about cerumen is correct? a. Sticky honey-colored cerumen is a sign of infection. NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score 4. The nurse is reviewing the structures of the ear. Which of these statements concerning the eustachian tube is true? a. The eustachian tube is responsible for the production of cerumen. b. It remains open except when swallowing or yawning. c. The eustachian tube allows passage of air between the middle and outer ear. d. It helps equalize air pressure on both sides of the tympanic membrane. D The eustachian tube allows an equalization of air pressure on each side of the tympanic membrane so that the membrane does not rupture during, for example, altitude changes in an airplane. The tube is normally closed, but it opens with swallowing or yawning. NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score 5. A patient with a middle ear infection asks the nurse, “What does the middle ear do?” The nurse responds by telling the patient that the middle ear functions to: a. Maintain balance. b. Interpret sounds as they enter the ear. c. Conduct vibrations of sounds to the inner ear. d. Increase amplitude of sound for the inner NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score ear to function. C Among its other functions, the middle ear conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear. The other responses are not functions of the middle ear. 6. The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for conducting nerve impulses to the brain from the organ of Corti? a. I b. III c. VIII d. XI C The nerve impulses are conducted by the auditory portion of CN VIII to the brain. NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score d. Look for the source of the obstruction in the external ear. C A simple increase in amplitude may not enable the person to understand spoken words. Sensorineural hearing loss may be caused by presbycusis, which is a gradual nerve degeneration that occurs with aging and by ototoxic drugs, which affect the hair cells in the cochlea. 9. During an interview, the patient states he has the sensation that “everything around him is spinning.” The nurse recognizes that the portion of the ear responsible for this sensation is the: a. Cochlea. b. CN VIII. c. Organ of Corti. d. Labyrinth. D If the labyrinth ever becomes inflamed, then it feeds the wrong NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score information to the brain, creating a staggering gait and a strong, spinning, whirling sensation called vertigo. 10. A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these statements is correct regarding the significance of this in relation to the infant’s hearing? a. Rubella may affect the mother’s hearing but not the infant’s. b. Rubella can damage the infant’s organ of Corti, which will impair hearing. c. Rubella is only dangerous to the infant in the second trimester of pregnancy. d. Rubella can impair the development of CN VIII and thus affect hearing. B NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score If maternal rubella infection occurs during the first trimester, then it can damage the organ of Corti and impair hearing. 11. The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse? a. “It is unusual for a small child to have frequent ear infections unless something else is wrong.” b. “We need to check the immune system of your son to determine why he is having so NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score often sound “mixed up.” What might the nurse suspect as the cause for this change? a. Atrophy of the apocrine glands b. Cilia becoming coarse and stiff c. Nerve degeneration in the inner ear d. Scarring of the tympanic membrane C Presbycusis is a type of hearing loss that occurs in 60% of those older than 65 years of age, even in those living in a quiet environment. This sensorineural loss is gradual and caused by nerve degeneration in the inner ear. Words sound garbled, and the ability to localize sound is also impaired. This communication dysfunction is accentuated when background noise is present. NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score 14. During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? This finding: a. Is probably the result of lesions from eczema in his ear. b. Represents poor hygiene. c. Is a normal finding, and no further follow- up is necessary. d. Could be indicative of change in cilia; the nurse should assess for hearing loss. C Asians and Native Americans are more likely to have dry cerumen, whereas Blacks and Whites usually have wet cerumen. 15. The nurse is taking the history of a patient who may have a NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score perforated eardrum. What would be an important question in this situation? a. “Do you ever notice ringing or crackling in your ears?” b. “When was the last time you had your hearing checked?” c. “Have you ever been told that you have any type of hearing loss?” d. “Is there any relationship between the ear pain and the discharge you mentioned?” D Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then drainage occurs. 16. A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score these actions is correct? a. Tilting the person’s head forward during the examination b. Once the speculum is in the ear, releasing the traction c. Pulling the pinna up and back before inserting the speculum d. Using the smallest speculum to decrease the amount of discomfort C The pinna is pulled up and back on an adult or older child, which helps straighten the S- shape of the canal. Traction should not be released on the ear until the examination is completed and the otoscope is removed. NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score 19. The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal? a. If the drum has ruptured, then purulent drainage will result. b. Bloody or clear watery drainage can indicate a basal skull fracture. c. The auditory canal many be occluded from increased cerumen. d. Foreign bodies from the accident may NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score cause occlusion of the canal. B Frank blood or clear watery drainage (cerebrospinal leak) after a trauma suggests a basal skull fracture and warrants immediate referral. Purulent drainage indicates otitis externa or otitis media. 20. In performing a voice test to assess hearing, which of these actions would the nurse perform? a. Shield the lips so that the sound is muffled. b. Whisper a set of random numbers and letters, and then ask the patient to repeat them. c. Ask the patient to place his finger in his ear to occlude outside noise. d. Stand approximately 4 feet away NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score a. Immobility of the drum is a normal finding. b. An injected membrane would indicate an infection. c. The normal membrane may appear thick and opaque. d. The appearance of the membrane is identical to that of an adult. C During the first few days after the birth, the tympanic membrane of a newborn often appears thickened and opaque. It may look injected and have a mild redness from increased vascularity. The other statements are not correct. 23. The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? The infant: NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score a. Turns his or her head to localize the sound. b. Shows no obvious response to the noise. c. Shows a startle and acoustic blink reflex. d. Stops any movement, and appears to listen for the sound. A With a loud sudden noise, the nurse should notice the infant turning his or her head to localize the sound and to respond to his or her own name. A startle reflex and acoustic blink reflex is expected in newborns; at age 3 to 4 months, the infant stops any movement and appears to listen. 24. The nurse is performing an ear examination of an 80-year-old patient. Which of these findings would be considered normal? a. High-tone frequency loss NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score b. Increased elasticity of the pinna c. Thin, translucent membrane d. Shiny, pink tympanic membrane A A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging. The pinna loses elasticity, causing earlobes to be pendulous. The eardrum may be whiter in color and more opaque and duller in the older person than in the younger adult. 25. An assessment of a 23-year-old patient reveals the following: an auricle that is tender and NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score c. The tubes are permanently inserted during a surgical procedure. d. The purpose of the tubes is to decrease the pressure and allow for drainage. D Polyethylene tubes are surgically inserted into the eardrum to relieve middle ear pressure and to promote drainage of chronic or recurrent middle ear infections. Tubes spontaneously extrude in 6 months to 1 year. 28. In an individual with otitis externa, which of these signs would the nurse expect to find on assessment? a. Rhinorrhea NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score b. Periorbital edema c. Pain over the maxillary sinuses d. Enlarged superficial cervical nodes D The lymphatic drainage of the external ear flows to the parotid, mastoid, and superficial cervical nodes. The signs are severe swelling of the canal, inflammation, and tenderness. Rhinorrhea, periorbital edema, and pain over the maxillary sinuses do not occur with otitis externa. 29. When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in color and that air bubbles are visible behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that the child: NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score a. Most likely has serous otitis media. b. Has an acute purulent otitis media. c. Has evidence of a resolving cholesteatoma. d. Is experiencing the early stages of perforation. A An amber-yellow color to the tympanic membrane suggests serum or pus in the middle ear. Air or fluid or bubbles behind the tympanic membrane are often visible. The patient may have feelings of fullness, transient hearing loss, and a popping sound with swallowing. These findings most likely suggest that the child has serous otitis media. The other responses are not correct. 30. The nurse is performing an assessment on a 65-year-old man. He reports a crusty nodule behind the pinna. It intermittently bleeds and has not healed over the past 6 months. On physical assessment, the NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score patient who has had a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o’clock and landmarks visible. The nurse should: a. Refer the patient for the possibility of a fungal infection. b. Know that these are scars caused from frequent ear infections. c. Consider that these findings may represent the presence of blood in the middle ear. d. Be concerned about the ability to hear because of this abnormality on the tympanic membrane. B NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score Dense white patches on the tympanic membrane are sequelae of repeated ear infections. They do not necessarily affect hearing. 33. The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which one of these reflects the correct procedure? a. Pulling the pinna down b. Pulling the pinna up and back c. Slightly tilting the child’s head toward the examiner d. Instructing the child to touch his chin to his chest NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score A For an otoscopic examination on an infant or on a child under 3 years of age, the pinna is pulled down. The other responses are not part of the correct procedure. 34. The nurse is conducting a child safety class for new mothers. Which factor places young children at risk for ear infections? a. Family history b. Air conditioning c. Excessive cerumen d. Passive cigarette smoke D Exposure to passive and gestational smoke is a risk factor for ear infections in infants and children. 35. During an otoscopic examination, the nurse notices an area of black and white dots on the tympanic membrane and the ear canal wall. What NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score 37. During an examination, the patient states he is hearing a buzzing sound and says that it is “driving me crazy!” The nurse recognizes that this symptom indicates: a. Vertigo. b. Pruritus. c. Tinnitus. d. Cholesteatoma. C Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders. 38. During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, “It feels like the room is spinning!” The nurse notices that the patient is experiencing: a. Objective vertigo. NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score b. Subjective vertigo. c. Tinnitus. d. Dizziness. A With objective vertigo, the patient feels like the room spins; with subjective vertigo, the person feels like he or she is spinning. Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders. Dizziness is not the same as true vertigo; the person who is dizzy may feel unsteady and lightheaded. 39. A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, “I don’t know what the matter is. All of a sudden, I can’t hear you out of my left ear!” What should the nurse do next? a. Make note of this finding for the report to the next shift. NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score b. Prepare to remove cerumen from the patient’s ear. c. Notify the patient’s health care provider. d. Irrigate the ear with rubbing alcohol. C Any sudden loss of hearing in one or both ears that is not associated with an upper respiratory infection needs to be reported at once to the patient’s health care provider. Hearing loss associated with trauma is often sudden. Irrigating the ear or removing cerumen is not appropriate at this time. MULTIPLE RESPONSE NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score manubrium of the sternum. A The spinous process of C7 is the vertebra prominens and is the most prominent bony spur protruding at the base of the neck. Counting ribs and intercostal spaces on the posterior thorax is difficult because of the muscles and soft tissue. The vertebra prominens is easier to identify and is used as a starting point in counting thoracic processes and identifying landmarks on the posterior chest. 2. When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is: a. Observed in patients with kyphosis. b. Indicative of pectus excavatum. c. A normal finding in a healthy NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score adult. d. An expected finding in a patient with a barrel chest. C The right and left costal margins form an angle where they meet at the xiphoid process. Usually, this angle is 90 degrees or less. The angle increases when the rib cage is chronically overinflated, as in emphysema. 3. When assessing a patient’s lungs, the nurse recalls that the left lung: a. Consists of two lobes. b. Is divided by the horizontal fissure. c. Primarily consists of an upper lobe on the posterior chest. d. Is shorter than the right lung because of the underlying stomach. NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+ NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE RATED A+, Download to score A The left lung has two lobes, and the right lung has three lobes. The right lung is shorter than the left lung because of the underlying liver. The left lung is narrower than the right NURSING 2058Health Assessment Exam 2 study guide Q & AS BEST EXAM SOLUTION GUARANTEED SUCCESS LATEST UPDATE 2021/2023 RATED A+