Chapter 27 & 31

Question 1

An 85-year-old man has come in for a physical examination, and the nurse notices that he uses a cane. When documenting general appearance, the nurse should document this information under the section that covers:

Answer 1

Mobility

Question 2

The nurse is performing a vision examination. Which of these charts is most widely used for vision examinations?

Answer 2

Snellen

Question 3

After the health history has been obtained and before beginning the physical examination, the nurse should first ask the patient to:

Answer 3

Empty the bladder

Question 4

During a complete health assessment, how would the nurse test the patients hearing?

Answer 4

whisper test

Question 5

A patient states, Whenever I open my mouth real wide, I feel this popping sensation in front of my ears. To further examine this, the nurse would:

Answer 5

Place a finger on his temporomandibular joint, and ask him to open and close his mouth.

Question 6

The nurse has just completed an examination of a patients extraocular muscles. When documenting the findings, the nurse should document the assessment of which cranial nerves?

Answer 6

III, IV, and VI

Question 7

A patients uvula raises midline when she says ahh, and she has a positive gag reflex. The nurse has just tested which cranial nerves?

Answer 7

IX and X

Question 8

During an examination, the nurse notices that a patient is unable to stick out his tongue. Which cranial nerve is involved with the successful performance of this action?

Answer 8

XII

Question 9

A patient is unable to shrug her shoulders against the nurses resistant hands. What cranial nerve is involved with successful shoulder shrugging?

Answer 9

XI

Question 10

During an examination, a patient has just successfully completed the finger-to-nose and the rapid-alternating-movements tests and is able to run each heel down the opposite shin. The nurse will conclude that the patients __________ function is intact.

Answer 10

Cerebellar

Question 11

When the nurse performs the confrontation test, the nurse has assessed:

Answer 11

visual field

Question 12

Which statement is true regarding the complete physical assessment?

a. The male genitalia should be examined in the supine position.
b. The patient should be in the sitting position for examination of the head and neck.
c. The vital signs, height, and weight should be obtained at the end of the examination.
d. To promote consistency between patients, the examiner should not vary the order of the assessment.

Answer 12

B.) The patient should be in the sitting position for examination of the head and neck.

Question 13

Which of these is included in an assessment of general appearance?

Answer 13

Skin color

Question 14

The nurse should use which location for eliciting deep tendon reflexes?

Answer 14

Achilles

Question 15

During an inspection of a patients face, the nurse notices that the facial features are symmetric. This finding indicates which cranial nerve is intact?

Answer 15

VII

Question 16

During inspection of the posterior chest, the nurse should assess for:

Answer 16

Symmetry of shoulders and muscles.

Question 17

A patient tells the nurse, Sometimes I wake up at night and I have real trouble breathing. I have to sit up in bed to get a good breath. When documenting this information, the nurse would note:

Answer 17

Paroxysmal nocturnal dyspnea.

Question 18

During the examination of a patient, the nurse notices that the patient has several small, flat macules on the posterior portion of her thorax. These macules are less than 1 cm wide. Another name for these macules is:

Answer 18

Freckles

Question 19

During an examination, the nurse notices that a patients legs turn white when they are raised above the patients head. The nurse should suspect:

Answer 19

chronic arterial insufficiency

Question 20

The nurse has just recorded a positive iliopsoas test on a patient who has abdominal pain. This test is used to confirm a(n)

Answer 20

Perforated appendix

Question 21

The nurse will measure a patients near vision with which tool?

Answer 21

Jaeger card

Question 22

If the nurse records the results to the Hirschberg test, the nurse has:

Answer 22

Tested the corneal light reflex.

Question 23

During the examination of a patients mouth, the nurse observes a nodular bony ridge down the middle of the hard palate. The nurse would chart this finding as:

Answer 23

Torus palatinus.

Question 24

During examination, the nurse finds that a patient is unable to distinguish objects placed in his hand. The nurse would document:

Answer 24

Astereognosis.

Question 25

After the examination of an infant, the nurse documents opisthotonos. The nurse recognizes that this finding often occurs with:

Answer 25

Meningeal irritation.

Question 26

After assessing a female patient, the nurse notices flesh-colored, soft, pointed, moist, papules in a cauliflower-like patch around her introitus. This finding is most likely:

Answer 26

HPV

Question 27

While examining a 48-year-old patients eyes, the nurse notices that he had to move the handheld vision screener farther away from his face. The nurse would suspect:

Answer 27

Presbyopia

Question 28

The nurse is preparing to perform a functional assessment of an older patient and knows that a good approach would be to:

Answer 28

Observe the patients ability to perform the tasks.

Question 29

The nurse needs to assess a patients ability to perform activities of daily living (ADLs) and should choose which tool for this assessment?

Answer 29

Barthel Index

Question 30

The nurse is preparing to use the Lawton IADL instrument as part of an assessment. Which statement about the Lawton IADL instrument is true?

a. The nurse uses direct observation to implement this tool.
b. The Lawton IADL instrument is designed as a self-report measure of performance rather than ability.
c. This instrument is not useful in the acute hospital setting.
d. This tool is best used for those residing in an institutional setting.

Answer 30

B.) The Lawton IADL instrument is designed as a self report measure of performance rather than ability.

Question 31

When using the various instruments to assess an older persons ADLs, the nurse needs to remember that a disadvantage of these instruments includes:

Answer 31

Self or proxy reporting of functional activities.

Question 32

A patient will be ready to be discharged from the hospital soon, and the patients family members are concerned about whether the patient is able to walk safely outside alone. The nurse will perform which test to assess this?

Answer 32

Get Up and Go Test

Question 33

An 85-year-old man has been hospitalized after a fall at home, and his 86-year-old wife is at his bedside. She tells the nurse that she is his primary caregiver. The nurse should assess the caregiver for signs of possible caregiver burnout, such as:

Answer 33

Depression

Question 34

During a morning assessment, the nurse notices that an older patient is less attentive and is unable to recall yesterdays events. Which test is appropriate for assessing the patients mental status?

Answer 34

Mini-Cog

Question 35

The nurse is assessing the abilities of an older adult. Which activities are considered IADLs? Select all that apply.

a. Feeding oneself
b. Preparing a meal
c. Balancing a checkbook
d. Walking
e. Toileting
f. Grocery shopping

Answer 35

B,C,F