Module 3 Exam Mrs. Murray Flashcards
A nurse is assigned a patient in the GI unit. She is asking the patient about their history. Which of the following are questions that the nurse should ask? Select all that apply. (SLO 8)
A. “Have you been experiencing any nausea, vomiting, or cramping?”
B. “Do you drink alcohol? If so, how much?
C. “Why do you think your stomach hurts?”
D. “Do you take aspirin or ibuprofen? If so, how often?”
A,B,D
What are some of the expected findings when inspecting the abdomen? Select all that apply. A. Pink tone skin B. Cold, clammy skin C. Flat belly D. No pain or tenderness E. Absence of bowel sounds F. Striae
A, C, D, F
Which of the following are UNexpected findings when inspecting the abdomen? A. Pain and tenderness B. Warm, dry skin C. Bumps, masses, and lesions D. No bowel sounds E. Bowel sounds F. Striae
A, C, D
How long should you listen to the abdomen?
5 Minutes
Where should you listen to the abdomen?
The four quadrants
Put in order the steps to an Abdomen Physical Assessment.
- Palpate
- Auscultate
- Inspect
- Percussion
- Inspect
- Auscultate
- Percussion
- Palpate
How should you have a client positioned when giving an inspection of the abdomen?
Supine, with arms down and knees slightly bent
What does it mean if a patient has HYPOactive bowel sounds?
A. There is a lot of intestinal activity
B. Intestinal activity has slowed and is not as loud
C. Gurgling
B. Intestinal activity has slowed and is not as loud
A nurse is examining a patient’s abdomen. She hears high-pitched clicks and gurgles 5-35 times per minute. Is this an expected or unexpected finding?
Expected
What are borborygmi?
A. Growling
B. Wheezing
C. Friction rubs
A. growling
A patient is experiencing loud borborygmi (hyperactive sounds) which indicate increased GI motility. What are some of the possible causes for this? Select all that apply. A. Diarrhea B. Constipation C. Anxiety D. Bowel inflammation E. Reactions to certain foods F. Straie
A, C, D, E
Which of the following actions of inspecting the abdomen by a student nurse should be intervened by the RN? Select all that apply
A. Palpating the tender areas first.
B. Ausculating all four quadrants.
C. Palpating then auscultating the abdomen.
D. Auscultating the abdomen for five minutes.
A, C
What are wavelike movements that are visible in thin adults or in clients who have intestinal obstructions? A. Pulsations B. Peristalsis C. Hernias D. Straie
B. peristalsis
When is the most appropriate time to auscultate bowel sounds?
A. Before meals
B. After meals
C. In between meals
C. In between meals.
What should you EXPECT to hear when doing percussion over the abdomen?
A. Tympany
B. Peristalsis
C. Pulsations
A. Tympany
The nurse puts a patient’s foot through its passive range of motion by bending the toes and the foot downward. Which term describes this range of motion?
a. Flexion
b. Inversion
c. Dorsiflexion
d. Plantar flexion
d. plantar flexion
A nurse observes range of motion (ROM) while providing a complete bed bath for a patient. What is the reason behind this nursing action?
a. To measure joint mobility
b. To measure risk of pressure ulcers
c. To ensure proper body alignment
d. To determine the patient‘s tolerance of bathing
a. to measure joint mobility
The patient with hemiparesis- half of the body is numb needs passive range-of-motion (ROM) exercises to promote musculoskeletal health. Which precautions should be taken to ensure effective ROM exercises? Select all that apply.
a. Carry out movements slowly and smoothly
b. Be aware that ROM may cause mild pain
c. Never force a joint beyond its capacity
d. Repeat each movement ten times during a session
e. Perform exercises using head-to-toe sequence
a, c, e
A patient is diagnosed with expressive aphasia. What manifestation should the nurse expect to find during an assessment?
a. Inability to understand verbal speech
b. Inability to understand written words
c. Inability to hear spoken words
d. Inability to write or speak
d. inability to write or speak
A patient is brought to the emergency department following a road traffic accident. Which parameters should the nurse use to assess whether the patient is oriented? Select all that apply.
a. Time
b. Place
c. Person
d. Medical diagnosis
e. Laboratory results
a, b, c
The nurse teaches a patient about cranial nerves to help explain why the right side of the patient’s mouth droops instead of moving up into a smile. Which nerve does the nurse explain to the patient?
a. Facial (VII)
b. Trigeminal (V)
c. Hypoglossal (XII)
d. Spinal accessory (XI)
a. facial (vii)
What finding in the patient’s urinary report suggests the need for intervention? A) pH value of 7.4 B) Specific gravity of 1.1 C)Absence of red blood cells D)Protein value of 2 mg/100mL
B. specific gravity of 1.1
What are some reasons that may cause a change in mental or emotional functioning?
Age, injury, substance/ medication abuse, diseases/ disorders
Which activities can the nurse delegate to nursing assistive personnel (NAP)?Select all that apply.
a. Measuring oral intake and urine output
b. Replacing intravenous fluids as needed
c. Reporting a reddened area on the patient’s perineum
d. Changing a patient’s soiled bed linens
e. Reporting an electronic infusion device alarm
a, c, d, e
A patient had 200 mL of ice chips and 900 mL intravenous (IV) fluid during the nurse’s shift. Which total intake should the nurse record?
a. 700 mL
b. 900 mL
c. 1000 mL
d. 1100 mL
c. 1000 mL
Which measures should the nurse emphasize to prevent urinary infection in females?Select all that apply.
a. Proper handwashing
b. Use of indwelling catheters
c. Frequent sexual intercourse
d. Wiping from front to back after voiding
e. Adequate fluid intake
a, d, e
What are the two types of reflexes?
Deep tendon and Cutaneous
How many pairs of cranial nerves are there? A. 13 B. 12 C. 20 D. 10
B. 12
Definition: Exaggerated curvature of the thoracic spine. (hunchback)
A. Scoliosis
B. Lordosis
C. Kyphosis
C. Kyphosis
Definition: Exaggerated lateral curvature.
A. Scoliosis
B. Lordosis
C. Kyphosis
A. Scoliosis
Definition: Exaggerated curvature of lumbar spine.
A. Scoliosis
B. Lordosis
C. Kyphosis
B. Lordosis
What is the only way to get a sterile urine sample?
Catheter
When is the optimal time to conduct a Breast Self Exam? Select all that apply. A. Before menses begin B. 4 to 7 days after menses begin C. During menses D. Right after menstruation ends
B, D
How should you feel for lumps during a breast exam?
A. using the finger pads of your three middle fingers
B. the palms of your hands
C. lightly palpate using all fingers
A. using the finger pads of your three middle fingers
How should you systematically palpate during a breast exam?
A. From the sternum to the posterior axillary line, and from the clavicle to the bra line, including the areola, nipple, and tail of Spence.
B. From the posterior axillary line to the sternum, and from the bra line to the clavicle, including the areola, nipple, and tail of Spence.
A. From the sternum to the posterior axillary line, and from the clavicle to the bra line, including the areola, nipple, and tail of Spence.
Definition: Movement of an extremity toward the midline of the body. A. dorsiflexion B. adduction C. abduction
B. adduction
Definition: bending the foot and toes upward. A. dorsiflexion B. pronation C. supination
A. dorsiflexion
Definition: bending the foot and toes downward. A. dorsiflexion B. plantarflexion C. abduction
B. plantarflexion
Definition: turning a body part away from the midline. A. eversion B. inversion C. pronation
A. eversion
Definition: rotating a joint outward. A. external rotation B. internal rotation C. supination
A. external rotation
Definition: movement that decreases the angle between two adjacent bones. A. pronation B. extension C. flexion
C. flexion
Definition: movement that increases the angle between two adjacent bones. A. flexion B. extension C. eversion
B. extension
Definition: movement of a body part beyond its normal extended position. A. extension B. pronation C. hyperextension
C. hyperextension
Definition: movement of a body part so the ventral (front) surface faces up. A. supination B. pronation C. hyperextension
A. supination
Definition: movement of an extremity away from the midline of the body. A. abduction B. adduction C. supination
A. abduction
Definition: turning a body part toward the midline. A. eversion B. adduction C. inversion
C. inversion
Definition: rotating a joint outward. A. external rotation B. internal rotation C. supination
A. external rotation
Definition: rotating a joint inward. A. inversion B. eversion C. internal rotation
C. internal rotation
Definition:
Paralysis of all four limbs.
Quadriplegia
Definition:
Paralysis of the legs.
Paraplegia
Definition:
1/2 of the bodys hemisphere is paralyzed.
Hemiplegia
What is the one exception if the intake is greater than the output?
dehydration
What do antidiuretics do?
Help get rid of fluid.
What actions can you delegate to a UAP or CNA regarding intake and output?
They can help them go to the bathroom, they can measure urine output and intake.
Definition:
The tissues holding onto fluid.
Edema
Is jell-o measured when calculating input?
Yes
How are ice chips measured when calculating input?
They are half of their volume.
When measuring input, if you take all of your ounces (OX) and multiply them by ____ you can get them converted to mL.
30
1 cc = how many mL?
1 mL
What are some things you do NOT have to measure for input? Select all that apply. A. jell-o B. pudding C. yogurt D. ice chips
B, C
Which position eases the examination of the female genitalia and genital tract? A. Prone B. Lithotomy C. Dorsal recumbent D. Lateral recumbent
B. Lithotomy
Which of the following substances should NOT be in urine (abnormal findings)? Select all that apply. A. Protein B. Glucose C. Hemoglobin D. Ketones E.Bilirubin F. Bacteria G. White Blood Cells
All of them should not be in urine.
What should the specific gravity be for urine?
1.001- 1.035
What should the pH of urine be?
5.0-9.0
What color should urine be?
pale yellow to deep amber
What should the clarity of urine be?
translucent
How long should you have to wait for urine results?
24-48 hrs.
Should you obtain a urine sample prior to initiation of antibiotics?
Yes
If a patients urine is a very dark amber color, what does this indicate?
There could be something wrong with the liver.
If a patient's urine is CONSISTENTLY cloudy what could this be an indication of? Select all that apply. A. UTI B. Impaired liver function C. Diuresis D. Kidney disease
A, D
What should urine smell like?
Ammonia like
This term means relating to the kidneys.
A. renal
B. diuresis
C. oliguria
A. renal
Definition:
increased or excessive production of urine.
diuresis
Urinating frequently at night.
A. renal
B. diuresis
C. nocturia
C. nocturia
Passing abnormally large amounts of urine.
A. mensturation
B. polyuria
C. anuria
B. polyuria
the failure of the kidneys to produce urine.
A. anuria
B. polyuria
C. dysuria
A. anuria
painful or difficult urination.
A. polyuria
B. dysuria
C. nephron
B. dysuria
the production of abnormally small amounts of urine.
A. polyuria
B. dysuria
C. oliguria
C. oliguria
Definition:
This is a functional unit of the kidney.
nephron
when a woman’s period stops.
menopause
A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?
A. Place suction equipment at the client’s bedside.
B. Apply an eye patch to the clients right eye.
C. Avoid the use of warm water to clean the clients face.
D. Provide range of motion exercises to the client’s nevck and shoulders.
A. place suction equipment at the client’s bedside
A community health nurse is developing a pamphlet about breast self-examination (BSE) for a local health fair. Which of the following instructions should the nurse include?
A. Expect breast dimpling or discharge with age.
B. For those who have a menstrual cycle, perform a BSE every month, 2 to 3 days before menstruation.
C. Using the palm of the hand, feel for lumps in a circular motion
D. Breasts can be examined in the shower with soapy hands.
D. Breasts can be examined in the shower with soapy hands
A nurse is assessing a client’s cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II?
A. Ask the client to read a Snellen chart.
B. Listen to the client’s speech.
C. Ask the clienty to identify scented aromas.
D. Ask the client to clench his teeth.
A. Ask the client to read a Snellen chart
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse the client’s peristalsis is returning?
A. hypoactive bowel sounds in two quadrants.
B. request for a cup of tea and some toast
C. passage of flatus
D. abdominal distention
C. passage of flatus
A nurse is assessing a clients abdomen who reports stomach pain. Which of the following actions should the nurse take first? A. Auscualate B. Percuss C. Inspect D. Palpate
C. Inspect
A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel? Select all that apply.
A. Bathe a client who had an amputation 2 days ago.
B. Assist a client to ambulate using a gait belt.
C. Review a low-sodium diet for a client who has hypertension
D. Explain oral hygiene to a client receiving chemotherapy.
E. Feed a client who had a stroke 3 months ago.
A, B, and E.
A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider?
A. Urine output of 175 mL in the past 8 hrs.
B. Urine output of 2,200 mL in the past 24 hr.
C. First voided urine in the morning has a strong odor.
D. Urine is cloudy after sitting in the urinal for 6 hours.
A. urine output of 175 mL in the past 8 hrs.
A charge nurse is observing a nurse auscultating a client’s bowel sounds. Which of the following actions requires intervention by the charge nurse?
A. Clamps the NG tube during auscultation.
B. Performs auscultation between meals
C. Auscultates bowel sounds for 3 to 5 minutes.
D. Palpates the abdomen prior to performing auscultation.
D. Palpates the abdomen prior to performing auscultation.
A nurse is completing an 8 hour I & O record for a client who consumed 4 oz juice, 6 oz hot tea, 100 mL ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client’s record?
740 mL
A nurse is assessing a client’s cranial nerves as part of a neurological assessment. Which of the following actions should the nurse take to assess cranial nerve III?
A. Testing visual activity
B. Observing for facial symmetry
C. Eliciting the gag reflex
D. Checking the pupillary response to light.
D. checking the pupillary response to light
A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances? A. Steatorrhea B. Blood C. Bacteria D. Parasites
B. Blood
A nurse is assessing an older adult who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client? A. Lordosis B. Ankylosis C. Kyphosis D. Scoliosis
C. Kyphosis
A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse?
A. symmetrical convex sphere shape
B. concave umbilicus
C. bilateral bowel sounds in the lower quadrants
D. ecchymosis
D. ecchymosis
A nurse is assessing a client who has a urine output of 250 mL in a 24 hr. period. Which of the following descriptive terms should the nurse place in the clients electronical record? A. Enuresis B. Anuria C. Nocturia D. Oliguria
D. Oliguria
A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following? A. Urinary Tract Infection B. Urinary incontinence C. Urinary frequency D. Urinary retention
A. Urinary tract infection
Which of the following are functions of the GI tract? Select all that apply.
A. Digestion of food
B. Elimination of waste
C. Provision of oxygen to the organs
D. Circulation of blood
E. Production of lymphocytes to fight infections.
A, B
Which of the following abdominal organs releases insulin to regulate blood sugar? A. stomach B. pancreas C. gallbladder D. appendix
B. pancreas
Which of the following would be an appropriate question to collect subjective data about a client’s past health history?
A. “do you have any family members with liver disease?”
B. “have you noticed any changes in appetite or weight gain?”
C. “have you had any previous abdominal surgeries?”
C. Have you had any previous abdominal surgeries
Which of the following assessment findings are unexpected when inspecting the abdomen? Select all that apply. A. soft protrusion of the umbilicus B. silver-white striae C. scaphoid abdomen D. voluntary guarding E. prominent veins
A, E
Which of the following findings are expected when auscultating the abdomen?
A. silent abdomen
B. borborygmi
C. vascular sounds
D. bowel sounds heard every 1 to 5 minutes
B. borborygmi
Which of the following is an expected finding when palpating the abdomen? A. voluntary guarding B. rigidity C. tenderness D. superficial masses
A. voluntary guarding
You are teaching a client about recommendations to prevent the occurrence of colorectal cancer. Which of the following should be included in the teaching? Select all that apply.
A. Consume a diet high in fats and simple carbohydrates
B. Engage in moderate exercise for 30 min per day
C. Achieve and maintain a healthy weight within the recommended BMI.
D. Limit alcohol intake to 4 to 5 times per day.
E. Take a probiotic daily.
B, C
At which age should a client who is considered to have an average risk for colorectal cancer begin screenings? A. 50 B. 30 C. 40 D. 60
A. 50
Which of the following is an abnormal finding that should be documented and reported to the provider? A. abdominal distention B. silver striae C. abdominal symmetry D. borborygmi
A. abdominal distention
Which of the following client responses requires the nurse to asl additional open ended questions? Select all that apply.
A. “I’ve thrown up about 3 times today, and I feel awful. My stomach is so queasy and it hurts.”
B. “I feel a little warm, I have fever, and I also have body aches and pains”
C. “For lunch yesterday, I ate a salad that I made from the salad bar at the grocery store. I went out to dinner last night and ordered shrimp scampi”
D. “Now that I think about it, a coworker called in sick yesterday because she had the flu. I was surprised because she didn’t seem sick the day before yesterday.”
E. “No one who I had lunch with yesterday is sick.”
A, C, D
A nurse is assessing a client who reports pins and needles sensations to their right hand. Which of the following terms should the nurse use to describe the sensations? A. Proprioception B. Paresthesia C. Dysesthia D. Sprain
B. Paresthesia
Which of the following conditions involves the bones of the joint? A. Osteoarthritis B. Bursitis C. Effusion D. Gout
A. Osteoarthritis
A nurse is collecting data from an older adult client as part of a neurological examination. Which of the following findings should the nurse expect as changes associated with aging? Select all that apply. A. Slower light touch sensation B. Some vision and hearing decline C. Slower fine finger movements D. Some short-term memory decline E. Decreased risk of depression
A, B, C, D
A nurse, who is assessing a client’s neurologic system, should ask the client to close their eyes and identify which of the following items?
A. A word the nurse whispers 30 cm from the ear
B. A number the nurse traces on the palm of the hand
C. The vibration of a tuning fork the nurse places on the foot.
D. A familiar object the nurse places in their hand.
D. A familiar object the nurse places in their hand.
A nurse in a provider’s office is preparing to assess a young adult client’s musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all that apply.
A. Concave thoracic spine posteriorly
B. Exaggerated lumbar spine curvature
C. Concave lumbar spine posteriorly
D. Exaggerated thoracic curvature
E. Muscles slightly larger on the dominant side.
C & E
A nurse is performing a neurological examination for a client. Which of the following assessments should the nurse perform to test the clients balance? Select all that apply. A. Romberg Test B. Heel-to-toe-walk C. Snellen test D. Spinal accessory function E. Rosenbaum test
A & B
Definition; turbulence in a vessel A. guaiac B. Anuria C. Bruiting D. Aspirating
C. Bruiting
Definition:
Discoloration of the skin resulting from bleeding underneath, typically caused by bruising.
Ecchymosis
What are some signs of aspiration?
Coughing after drinking liquids
When documenting findings in the abdomen, what should you include?
Lesions, bruising, scarring, cuts, what quadrant they are in, how big they are, and what they look like.
Are dilated veins on the abdomen an abnormal or expected finding? If abnormal, should you notify the HCP?
Abnormal, and yes notify the HCP.
If a patient has jaundice, what does this indicate?
Issues with the liver.
Cyanosis indicates issues with….
Oxygen
What do ascites indicate issues with?
fluid
Is a pulsating mass on the abdomen and expected or unexpected finding? If unexpected, should you notify the HCP?
unexpected and yes notify.
What are some expected sounds of the abdomen?
gurgling, clicking, swishing
If the bladder feels mushy and bounces, what could this indicate?
Distention
