Exam 1 Flashcards
During auscultation of the patient’s chest, how should the nurse position the stethoscope to minimize extraneous noises?
Position the head of the stethoscope between the second and third fingers and position it on the patient’s skin
When using a stethoscope during the physical exam, how should the stethoscope be positioned in the nurse’s ears to optimize hearing and comfort?
The earpieces should fit snugly in the ear canals
The earpieces should be angled toward the nose
When auscultating the patient’s lungs, how should the head of the stethoscope be held?
The diaphragm held firmly on the posterior lung fields
What action by the nurse is most appropriate to ensure an accurate pulse oximetry reading for a patient wearing fingernail polish?
Remove all the nail polish from the finger before placing the sensor probe
Which patient would the nurse anticipate having an inaccurate pulse oximetry reading?
An agitated patient thrashing in the bed
A patient with a sensor probe placed over nail polish
A patient with a sensor probe placed over the tip of the nose
When obtaining the pulse oximetry reading, what action will help verify the accuracy of the measurement?
Ensuring that the photodetectors in the probe are aligned before placing the sensor probe on the patient
If a nurse needs to repeat a blood pressure measurement, what is the most appropriate action to avoid a falsely high result?
Support the arm at heart level and wait at least 1 minute before repeating the blood pressure measurement
What action should the nurse take if the blood pressure obtained using an automatic cuff is significantly higher than the patient’s baseline?
Measure the blood pressure in the opposite arm and compare readings
Which actions help to prevent false blood pressure readings?
Select the correct cuff size for the limb being used
Support the arm at heart level during blood pressure measurement
What is the purpose of using the aperture and lenses of the ophthalmoscope?
To control focus during the eye examination
To compensate for myopia or hyperopia in the nurse or patient
To allow for light variations during the eye examination
To examine the retina for hemorrhage or lesions
Which ophthalmoscope setting should the nurse select to increase magnification and produce a larger field of view?
Select the positive numbers in the lens indicator
How should the nurse insert the otoscope speculum to best inspect the auditory canal and prevent injury in an adult patient?
Tilt the patient’s head slightly toward the opposite ear before inserting the otoscope speculum
What is the correct description of the use of the otoscope to examine the inside of the nose?
An otoscope using the shortest, widest speculum can be used to examine the nares of the nose.
What actions demonstrate proper positioning of the otoscope for assessment of a patient’s inner ear?
Holding the otoscope with the handle end in the upward position
Holding the otoscope against the patient’s head
Inserting the speculum into the patient’s ear
What statement demonstrates an understanding of the proper use of the percussion (reflex) hammer?
The percussion hammer should move in a swift arc and in a controlled direction during use.
What action is most appropriate to ensure the nurse achieves a full swinging motion while using a reflex hammer?
Hold the handle of the hammer loosely between thumb and index finger when swinging the hammer
How should the nurse position the patient to assess deep tendon reflexes?
Position the patient’s extremity so the tendon is slightly stretched
Manipulate the patient’s joint being tested away from you
When assessing vision of a small child, what visual acuity charts are appropriate?
Tumbling E
HOTV
LH symbols
What action best demonstrates proper use of the pocket visual acuity card when assessing patient’s near vision?
The patient holds the Rosenbaum chart 14 inches from the face.
What does a visual acuity measurement of 20/40 +2 mean?
The patient can read all the letters in the 20/40 line plus two letters in the 20/30 line correctly.
When assessing vibratory sensation, what action by the nurse is appropriate to activate the tuning fork?
Hold the tuning fork by the stem and tap the prongs against the heel of the hand
For which type of patient would the nurse use the tuning fork to further assess function?
Patient with loss of hearing
What should the nurse do if the patient is unable to feel the vibration of the tuning fork during assessment?
Move the tuning fork proximally until the vibratory sensation is felt
Order the steps to prepare the ophthalmoscope for use in an eye examination.
Seat the ophthalmoscope in the handle
Push downward
Turn the head in a clockwise direction
Lock the two pieces into place
Depress the on/off switch
Turn the rheostat control clockwise to desired light intensity
To ensure accurate findings, what information would the nurse verify prior to beginning inspection?
Overhead lighting and a lamp are available.
Which condition is necessary for accurate inspection?
Adequate time to complete exam
Which part of the hand is used to palpate the patient’s abdomen?
Finger pads
Which part of the hand would the nurse use to palpate pulsations?
Finger pads
During an abdominal assessment, palpation occurs after auscultation for what reason?
Palpation may increase intestinal activity.
Which tone would the nurse expect to hear when percussing over the stomach?
Tympany
Which tone would the nurse expect to hear when percussing over the lungs?
Resonance
Which tone would the nurse expect to hear when percussing over bone?
Flatness
What percussion tone would indicate air-filled (emphysematous) lungs?
Hyperresonance
Which techniques are required to conduct accurate percussion?
Downward snap the striking finger
Tap sharply and rapidly
Use the tip of the finger to strike
Have short fingernails
Which auscultation techniques are correct for auscultating the heart and lungs?
Isolate each sound and listen to it separately
Focus on the characteristics of each sound
Match the auscultation guidelines with correct rationale.
Have a quiet environment
P
revents distraction
Auscultate directly on skin
Avoids obscured sounds
Take time for auscultation
Important to identify characteristics
Listen to one sound at a time
Distinguishes between two sounds
What guidelines should the nurse follow to ensure that auscultation sounds are accurately heard?
Ensure that the stethoscope endpiece is firmly held against the skin
What components are included in a general inspection of the patient?
Overall color of skin
Symmetry of body
Obvious injuries
Which part of the hand is best used to assess for fremitus, or vibrations?
Ball of hand
Place the steps for indirect percussion technique in order.
Expose patient’s skin by removing gown as needed.
Place middle finger of nondominant hand firmly on patient’s skin.
Keep the remaining fingers of the nondominant hand fanned out and off the surface of the skin.
Snap the wrist of the dominant hand downward.
With dominant hand, strike the middle finger of nondominant hand.
At which developmental age do the legs grow faster than any other body part?
Child
What physical assessment findings in the older adult suggest skeletal muscle loss?
Increased fat
Loss of body weight
Which statement is correct concerning fetal growth and development?
Head growth predominates.
Which organ completes physical development more quickly than other body parts?
Brain
Which statement about infant brain development is true?
Disruption of brain development during infancy can affect brain function.
At what age does the head make up nearly 50% of the body?
2-month-old fetus
Which hormone helps regulate an individual’s height?
nsulin-like growth factor-1
Which hormone, regulated by insulin, stimulates cells that control connective tissue growth and ossification?
Insulin-like growth factor-1
Which hormone may influence appetite and food intake?
Ghrelin
Growth hormone–releasing hormone stimulates the pituitary gland to release which hormone?
Growth hormone
When a parent asks about a child’s bone growth, the nurse explains that which hormone is responsible for bone maturation and epiphyseal fusion?
Testosterone
Which hormones, secreted by the gonads, are responsible for maturation of genitalia during puberty?
Testosterone
Estrogen
Establishing a good rapport with the patient facilitates the nurse’s ability to obtain which information?
Details about a patient’s complaint
The patient’s expectations
Asking several consecutive yes/no questions should be avoided for which reason?
They may confuse the patient.
They discourage the patient from providing additional information.
A necessary part of establishing a good rapport with a patient is to understand the patient’s perspective on the condition and treatment plan. How does this help the history-taking process?
Prevents miscommunication and misinterpretations
Why is it important for the nurse to establish a good rapport by ensuring each patient-nurse interaction is unique?
To build trust
While preparing the patient room before beginning an interview, which steps should the nurse take to ensure patient comfort and establish good patient-nurse rapport?
Drawing the curtains
Adjusting the room temperature
Addressing immediate patient needs
Asking others to leave the room
Which steps should the nurse take to establish and maintain a good rapport with the patient?
Ensure patient comfort
Use effective communication
Use appropriate body language
Focus on the patient
Which appropriate actions taken by the nurse demonstrate that body language is important in establishing and maintaining a good rapport with the patient?
Sitting during the interview
Keeping an appropriate distance
Effective communication relies on the nurse implementing which communication techniques?
Courtesy
Comfort
Connection
Confidentiality
The nurse is communicating with a patient who recently received the diagnosis of a terminal illness. Which action by the nurse is an example of empathy?
Showing understanding and acceptance
The nurse is gathering a health history. Which question, asked by the nurse, would be most effective for obtaining details about the chief complaint?
“Please describe the pain.”
The nurse is gathering a health history. Which statement, made by the nurse, would be least effective for obtaining details about the patient’s smoking habits?
“You look like you smoke about a pack of cigarettes per day; is this accurate?”
During the health history, the patient tells the nurse he drinks four beers daily. Which statement, made by the nurse, is an example of reflecting?
“To clarify, you said you drink four beers daily?”
What is one limitation to most self-reporting pain scales relating to the patient’s perception of pain?
Very few include the patient’s emotional response.
When assessing a patient’s pain, the nurse should remember that which actions may increase the pain felt?
Moving
Coughing
Deep breathing
The nurse is examining a patient and identifies a facial mask of pain. What features characterize this expression?
Lackluster eyes
Wrinkled forehead
Grimace
Which patient behaviors are associated with pain?
Guarding
Head rocking
Scattered movement
Which body movements may indicate pain in a patient?
Rubbing
Pacing
Inability to keep the hands still
Which activities suggest that an infant is not in pain?
Lying quietly
Resting in a normal position
What patient characteristics should a nurse look at when observing an infant for pain?
Facial expression
Activity
Leg movement
Which pain scale is best to use for young children over the age of 3?
FACES
Match the patient with the most appropriate pain scale.
Older adult
Young children over 3 years
Infants
Self-report pain scale
FACES rating scale
CRIES scale
Which temperature, taken rectally, is outside the normal range for a healthy adult?
97° F
An increase in body temperature may be an indication of which condition?
Infection
Damage to the hypothalamus
Vasoconstriction
Contraction and relaxation of the skeletal muscles result in what temperature-regulating reaction?
Shivering
Which is the best method by which to measure temperature in a 5-month-old patient?
Tympanic
Which reason describes the benefit to using an electric thermometer to measure an adult patient’s temperature?
Quicker to use
Which method of temperature measurement is the most reliable?
Tympanic
The nurse is taking the pulse of an adult patient. Which description of pulse amplitude is characteristic of a normal pulse?
Strong
Which findings relating to a patient’s pulse are considered normal?
Regular rhythm
Strong amplitude
Contour with a smooth upstroke
Which characteristics of respiration are normal findings?
Breathing without effort
Breathing with regular rhythm
Abdominal movement with breathing
Quiet breathing
The best way to measure respirations is to count the breaths for __ seconds and multiply by 2.
30
Which respiratory rate (in breaths per minute) would the nurse characterize as bradypnea?
9
Select the blood pressure reading that falls outside of the normal range.
121/70
Which blood pressure response is expected when a patient rises from a sitting position?
A rise in diastolic pressure
Blood pressure follows a diurnal pattern, peaking at what time during the day?
Afternoon
Place the steps for measuring blood pressure in the order in which they are performed.
Determine palpable systolic pressure
Inflate cuff until it is 20 to 30 mm Hg above palpable systolic pressure
Deflate cuff to 2 to 3 mm Hg per second
Note the systolic sound
Note the second diastolic sound
What auscultatory landmark, identified after the systolic sound, marks the first diastolic sound?
Muffling of sounds
The correct method for measuring blood pressure includes inflating the cuff to 20 to 30 mmHg above the palpable systolic pressure and then deflating at what speed to identify the systolic pressure reading?
2 to 3 mmHg/sec
The pulse oximeter measures a patient’s blood oxygen based on which properties of hemoglobin?
Deoxygenated hemoglobin absorbs more red light than oxygenated hemoglobin.
Which body areas are best for measuring the blood oxygen levels of an adult patient?
Finger
Toe
Pinna
The pulse oximetry reading indicates which physiologic measure?
How much oxygen the blood is carrying
When preparing a dietary meal plan for a new patient, the nurse understands that which cultural factors may play a role in the patient’s food selection?
Food beliefs
Periods of required fasting
Culturally forbidden foods
Which aspects of a patient’s life that are influenced by culture may have an impact on patient care?
Health beliefs and practices
Communication
Dietary practices
Treatment preferences
The nurse is caring for a patient from an unfamiliar culture who states the intent to use an alternative therapy to treat a health condition. What is the nurse’s best response?
“What type of alternative treatment do you plan to use?”
Use of a medical interpreter to take a patient history in a non-English-speaking patient is preferred over use of the patient’s family member(s) for which reasons?
The ability of the interpreter to provide culturally sensitive advice
The interpreter’s knowledge of medical terminology
The interpreter’s understanding of patient rights
The tendency for a patient to withhold embarrassing or private information from family
When interviewing a patient through use of an interpreter, how should the nurse adjust the interviewing process?
Pause every one or two sentences to allow the interpreter to speak
The nurse is conducting a cultural assessment of a patient from an unfamiliar culture. What information would be helpful in establishing the patient’s faith-based influences and rituals?
Knowledge of whether the patient belongs to a religious organization
What factors encompass evidence-based practice?
Clinical expertise
Research findings
Clinical knowledge
patient preferences
Which factor is characterized as a societal dimension of acculturative stress?
Legal status
Discrimination
Political forces
Which condition is associated with deep somatic pain
tendinitis
Which observation would be considered correct when assessing the mobility of a patient walking across the room?
Gait
Which statement is true regarding acculturation?
Individuals adopt the culture of the majority
How would the nurse document pedal pulse of a patient which are determined to be full and bounding?
3+
The nurse would count the pulse of a patient with an irregular heart rate for how many seconds?
60
Which pieces of data are considered subjective?
Symptoms reported by the patient
After reviewing the medical record of on older patient diagnosed with kyphosis which aspect would the nurse include in the assessment related to this condition>
Posture
Which nurse is most likely to skip steps and arrive at a clinical judgment instantly during the nursing process?
The expert nurse
Which point would be the main focus of the electronic health record?
Conveying patient information
Which nursing intervention would help the nurse accurately measure the respiratory rate in an obese patient?
Feel the breaths by placing a hand on the patient’s abdomen.
Which phase of nociceptive pain signifies the conscious awareness of a painful sensation?
Perception
Arrange the assessments in sequential order during the routine physical examination of a patient excluding the abdominal assessment?
Inspection
Palpation
Percussion
Auscultation
Which assessment involves pinching a fold of skin under the clavicle
Turgor
Which point is the most important that the nurse should remember when measuring thigh BP
It is higher than in the arm
Which distance is considered the intimate zone?
0-1.5 ft
Which type of database is suitable for a short-term problem?
Problem-centered
In which stage of Piaget’s cognitive development theory is a child able to use structured grammar and language to communicate?
Preoperational
Which assessment finding would likely be the cause of a pulse oximeter not providing a reading when the nurse attempts to determine the patients oxygen saturation
Dark nail polish
Which feature would be characteristic of the preoperational state of Piaget’s theory?
Imaginative play
Which phase of the Korotkoff sounds would be documented as the systolic blood pressure reading?
1
Which indicates a potential social determinant of an individual’s health?
Educational level
In which part of the nursing process would the nurse gather the data from the medical record and the patient?
Assessment
Which statement represents the basic characteristic of culture?
Learned from birth
Shared by all members
Dynamic and ever changing
Adapted to specific conditions
When assessing a patient’s mobility which information would the nurse document if the patient has difficulty stopping during ambulation?
Propulsion
Which action would the nurse perform before initially inflating the cuff during a blood pressure assessment?
Palpate the brachial artery
Which describes the role of the novice nurse in respect to problem solving?
Use rules to guide performance
Arrange the phases of the nursing process in the order in which they are generally executed
Assessment
Diagnosis
Planning
Implementation
Evaluation
Which statement explains cultural competency in relation to the emerging majority?
Together the many minorities in the united states represent almost 40% of the total popluation
Which statement would indicate effective learning about BP cuff sizes?
A cuff size too narrow for a patient will give a false high BP
Which examination visualizes neurochemical changes in the brain caused by nociception?
Functional magnetic resonance imaging (FMRI)
Which seating arrangement would the nurse use with a patient during the interview?
Maintain equal-status seating with the patient
The study of how environment and behaviors impact gene expression would describe which concept?
Epigenetics
Which is the primary purpose of interviewing a patient?
To get the patient’s health history and current health status
Which type of qustion encourages a patient to focus on specific information?
Direct
Which statement about culture is the most correct
A complex system that includes attitudes beleifs roles and values of a group
Which component would the nurse include in the focused neurologic assessment for a patient who had a cerebrovascular accident?
Hand grips
Swallowing
Pupil size and reaction
Which intervention would the nurse perform first when assessing the patient admitted to the hospital from the emergency departement?
Introduce oneself
Which step would be appropriate to take before assessing a patient’s blood pressure?
Check that the patient’s feet are flat on the floor
Which response would the nurse’s statement indicate when a patient who is scheduled for a fasting blood test asks the nurse for a cup of juice, and the nurse responds. “You should avoid eating or drinking liquids or solids for 12 hours beofre the test because food may alter the blood test results.”?
Explanation
Which idea would the nurse educator be referencing when teaching about factors that influence a person’s health and well-being?
Social determinants of health
Which phase of nociceptive pain response involves the release of bradykinin and prostaglandins
Transduction
When the nurse views the mind body and spirit as interdependent and functioning as a whole whithin the environment wheich concept would this definition encompass?
Holistic health
The procdess of analyzing health data and drawing conclusions to identify diagnoses would describe which concept?
Diagnostic reasoning
Which route would the nurse use to assess temperature with an electronic thermometer with a red-tipped probe?
Rectal
Which assessment technique includes looking at the patient in a well-lighted room?
Inspection
Which organ would be considered the thermostat of the human body
Hypothalamus
Which is the foundation for evidence-based practice
Assessment
Which assessment skill would the nurse use to determine organ density during the physical examination of a patient?
Percussion
