TBRQ Ch: 31 - Assessment

Question 1

The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship?

1. Appearance and behavior
2. Measurement of vital signs
3. Observing specific body systems
4. Conducting a detailed health history

Answer 1

Answer: 1.

The first part of the general survey is assessment of the appearance and behavior of the patient. As you are initiating the nurse-patient relationship, observe gender and race, age, signs of distress, body type, posture, gait, body movement, hygiene and grooming, dress, affect and mood, speech, and signs of patient abuse.

Question 2

The nurse is performing an abdominal assessment on a patient. In what order does the nurse perform the steps?

1. Percussion
2. Inspection
3. Auscultation
4. Palpation

Answer 2

Answer: 2, 3, 4, 1. 


The order of an abdominal examination differs slightly from previous assessments. Begin with inspection and follow with auscultation. By using auscultation before palpation there is less chance of altering the frequency and character of bowel sounds.

Question 3

While auscultating the adult patient’s lungs, the nurse hears loud, bubbly sounds during inspiration that did not disappear after the 607patient coughed. Which finding should the nurse document from the lung assessment?

1. Rhonchi
2. Coarse crackles
3. Sibilant wheeze
4. Pleural friction rub

Answer 3

Answer: 2. 


Coarse crackles are loud, bubbly sounds heard during inspiration that are not cleared with coughing. This is because of random, sudden reinflation of groups of alveoli and the disruption of the passage of air through the small airways. Crackles are most common in the dependent lobes such as the right and left lung bases.

Question 4

During assessment of the skin, the nurse assesses a lesion on the arm of the patient. The lesion is irregularly shaped, elevated with edema, and about 3 cm. What type of lesion does the patient have?

1. Nodule
2. Macule
3. Wheal
4. Pustule

Answer 4

Answer: 3.


A wheal is an irregularly shaped, elevated area or superficial localized edema. A wheal varies in size (e.g., hive, mosquito bite). A 1-cm firm, solid mass describes a nodule. A flat, brown area measuring 0.5 cm is a macule. A pus-filled circumscribed elevation of the skin is a pustule.

Question 5

The nurse is assessing a patient who returned 1 hour ago from surgery for an abdominal hysterectomy. Which assessment finding would require immediate follow-up?

1. Auscultation of an apical heart rate of 76
2. Absence of bowel sounds on abdominal assessment
3. Respiratory rate of 8 breaths/min
4. Palpation of dorsalis pedis pulses with strength of +2

Answer 5

Answer: 4. 


The tricuspid area is located at the fourth or fifth intercostal space along the sternum.

Question 6

Which statement made by the patient indicates an understanding about teaching related to early detection of colorectal cancer?

1. “I’ll make sure to schedule my colonoscopy annually after the age of 60.”
2. “I’ll make sure to have a computed tomography (CT) colonoscopy every 5 years.”
3. “I’ll make sure to have a flexible sigmoidoscopy every year once I turn 55.”
4. “I’ll make sure to have a fecal occult blood test annually once I turn 50.”

Answer 6

Answer: 4.

American Cancer Society guidelines state that for people of average risk, beginning at the age of 50, an annual fecal occult blood test is recommended. Flexible sigmoidoscopy and colonoscopy are recommended every 5 years in this population. A computed tomography (CT) colonoscopy is used every 5 years if recommended by the health care provider.

Question 7

The nurse is teaching a patient to prevent heart disease. Which information should the nurse include? (Select all that apply.)

1. Limit intake of cholesterol to less than 400 mg/day.
2. Talk with your health care provider about taking a daily low dose of aspirin.
3. Work with your health care provider to develop a regular exercise program.
4. Limit daily intake of fats to less than 25% to 35% of total calories.
5. Review strategies to encourage the patient to quit smoking.

Answer 7

Answer: 2, 3, 4, 5.


Teaching about prevention of heart disease focuses on risk factor reduction. Smoking, lack of regular aerobic exercise, and a diet high in fats (which contributes to higher cholesterol levels) are three major risk factors that can be modified. Quitting smoking, regular exercise, and a diet with lower fat intake are preventive measures. Low-dose aspirin has been shown to be beneficial in reducing the risk of heart disease.

Question 8

How should the patient be positioned to best palpate for lumps or tumors during an examination of the right breast?

1. Supine with both arms overhead with palms upward
2. Sitting with hands clasped just above the umbilicus
3. Supine with the right arm abducted and hand under the head and neck
4. Lying on the right side, adducting the right arm on the side of the body

Answer 8

Answer: 3. 


The supine position with one arm under the head allows the breast tissue to flatten evenly against the chest wall. This allows for better palpation for lumps or tumors.

Question 9

The nurse is assessing the cranial nerves. Match the cranial nerve with its related function.
Cranial Nerves	Cranial Nerve Function
1. XII Hypoglossal
2. V Trigeminal
3. VI Adducens
4. IV Trochlear
5. X Vagus
a. Motor innervation to the muscles of the jaw
b. Lateral movement of the eyeballs
c. Sensation of the pharynx
d. Downward, inward eye movements
e. Position of the tongue

Answer 9

Answer:

1e, 2a, 3b, 4d, 5c

Question 10

The nurse is teaching a patient how to perform a testicular self-examination. Which statement made by the patient indicates a need for further teaching?

1. “I’ll recognize abnormal lumps because they are very painful.”
2. “I’ll start performing testicular self-examination monthly after I turn 15.”
3. “I’ll perform the self-examination in front of a mirror.”
4. “I’ll gently roll the testicle between my fingers.”

Answer 10

Answer: 1


The examination should be performed monthly in all men 15 years of age and older. Feel for small, pea-size lumps on the front and side of the testicle. Abnormal lumps are usually painless.

Question 11

The nurse is observing the student nurse perform a respiratory assessment on a patient. Which action by the student nurse requires the nurse to intervene?

1. The student stands at a midline position behind the patient observing for position of the spine and scapula.
2. The student palpates the thoracic muscles for masses, pulsations, or abnormal movements.
3. The student places the bell of the stethoscope on the anterior chest wall to auscultate breath sounds.
4. The student places the palm of the hand over the intercostal spaces and asks the patient to say “ninety-nine.”

Answer 11

Answer: 3.


Breath sounds should be auscultated using the diaphragm of the stethoscope. Auscultate in a systematic pattern over the posterior and anterior chest wall.

Question 12

The nurse plans to assess the patient’s memory. Which task should the nurse ask the patient to perform?

1. “Tell me where you are.”
2. “What can you tell me about your illness?”
3. “Repeat these numbers back to me: 7…5…8.”
4. “What does this mean: ‘A stitch in time saves nine?’”

Answer 12

Answer: 3. 


Asking a patient to recall and repeat a series of numbers assesses immediate recall and recent and remote memory. The other tasks assess orientation, knowledge, judgment, and abstract reasoning.

Question 13

A patient has undergone surgery for a femoral artery bypass. The surgeon’s orders include assessment of dorsalis pedis pulses. The nurse will use which of the following techniques to assess the pulses? (Select all that apply.)

1. Place the fingers behind and below the medial malleolus.
2. Have the patient slightly flex the knee with the foot resting on the bed.
3. Have the patient relax the foot while lying supine.
4. Palpate the groove lateral to the flexor tendon of the wrist.
5. Palpate along the top of the foot in a line with the groove between extensor tendons of great and first toes.

Answer 13

Answer: 3, 5.


To palpate the dorsalis pedis pulses (located in the feet), ask the patient to relax the foot, and then palpate along the top of the foot in a line with the groove between the extensor tendons of the toe of the great and first toes. Placing fingers behind the medial malleolus is a technique for assessing the posterior tibial pulse. Having a patient slightly flex the knee is a technique for assessing the popliteal artery behind the knee. Palpation of the groove lateral to the flexor tendon of the wrist is the technique to assess the radial artery.

Question 14

The faith community nurse is teaching the community center women’s group about breast cancer risk factors. Which factors does the nurse include? (Select all that apply.)

1. First child at the age of 26 years
2. Menopause onset at the age of 49 years
3. Family history with BRCA1 inherited gene mutation
4. Age over 40 years
5. Onset of menses before the age of 12
6. Recent use of oral contraceptives

Answer 14

Answer: 3, 4, 5, 6. 


These are all risk factors for development of breast cancer. Onset of menopause after the age of 55, not at the age of 49, is a risk factor. First child after the age of 30, not birth of a child at 26, is a risk factor.