Exam 1 Flashcards by Abigail Roark

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

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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

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When auscultating the patient’s lungs, how should the head of the stethoscope be held?

The diaphragm held firmly on the posterior lung fields

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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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

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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.

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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

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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

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When assessing vision of a small child, what visual acuity charts are appropriate?

Tumbling E

HOTV

LH symbols

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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.

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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.

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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

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For which type of patient would the nurse use the tuning fork to further assess function?

Patient with loss of hearing

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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

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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

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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.

Which respiratory rate (in breaths per minute) would the nurse characterize as bradypnea?

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?

The nurse would count the pulse of a patient with an irregular heart rate for how many seconds?

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?

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