weekly quiz qestions Flashcards
How should the nurse document mild, slight non-pitting edema present at the ankles of a pregnant patient?
1+ on a 0-4+ scale
A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has?
dysphagia
The nurse is reviewing an assessment of a patient’s peripheral pulses and notices that the documentation states that the radial pulses are “2+.” The nurse recognizes that this reading indicates what type of pulse?
A) Bounding
B) Normal
C) Weak
D) Absent
B) Normal
Pages: 506-507. When documenting the force, or amplitude, of pulses, 3+ indicates an increased, full, or bounding pulse, 2+ indicates a normal pulse, 1+ indicates a weak pulse, and 0 indicates an absent pulse.
The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should:
examine the tender area last
Just before going home, a new mother asks the nurse about the infant’s umbilical cord. Which statements is correct?
It should fall off by 10-14 days
The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to:
hyperactive bowel sounds
The nurse is performing a peripheral vascular assessment on a bedridden patient and notices the following findings in the right leg: increased warmth, swelling, tenderness, tenderness to palpation, and a positive Homan’s sign. The nurse should:
seek emergency referral because of the risk of pulmonary embolism
The nurse notices that the patient has had a black, tarry stool and recalls that a possible cause would be:
gastrointestinal bleeding
A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is:
A) diarrhea.
B) peritonitis.
C) laxative use.
D) gastroenteritis.
B) peritonitis.
Page: 561. Diminished or absent bowel sounds signal decreased motility from inflammation as seen with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction.
A patient’s abdomen is bulging and stretched in appearance. The nurse should describe this finding as:
protuberant
When auscultating over a patient’s femoral arteries the nurse notices the presence of a bruit on the left side. The nurse knows that:
bruits occur with turbulent blood flow, indicating partial occlusion.
During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient’s abdomen. Before reporting this finding as “silent bowel sounds” the nurse should listen for at least:
A) 1 minute.
B) 5 minutes.
C) 10 minutes.
D) 2 minutes in each quadrant.
B) 5 minutes.
Pages: 539-540. Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding bowel sounds are completely absent.
During an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is experiencing:
Raynaud’s disease/phenomenom
A nurse notices that a patient has ascites, which indicates the presence of: A) fluid. B) feces. C) flatus. D) fibroid tumors.
A) fluid
Ascites is free fluid in the peritoneal cavity, and occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer.
A patients has a positive Homen’s sign. The nurse knows that a positive Homen’s sign may indicate:
deep vein thrombosis
A 67-year old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing:
claudication
The nurse is watching a new graduate nurse perform auscultation of a patient’s abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?
A) “We need to determine areas of tenderness before using percussion and palpation.”
B) “It prevents distortion of bowel sounds that might occur after percussion and palpation.”
C) “It allows the patient more time to relax and therefore be more comfortable with the physical examination.”
D) “This prevents distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation.”
B) “It prevents distortion of bowel sounds that might occur after percussion and palpation.”
Auscultation is performed first (after inspection) because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.
During an abdominal assessment, the nurse elicits tenderness on light palpation in the lower right quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures?
appendix
The nurse is reviewing risk factors for venous disease. Which of these situations best describes a person at highest risk for development of venous disease?
A) Woman in her second month of pregnancy
B) Person who has been on bed rest for 4 days
C) Person with a 30-year, 1 pack per day smoking history
D) Elderly person taking anticoagulant medication
B) person who has been on bed rest for 4 days
At risk for venous disease are people who undergo prolonged standing, sitting, or bed rest. Hypercoagulable (not anticoagulated) states and vein wall trauma also place the person at risk for venous disease. Obesity and pregnancy are also risk factors, but not the early months of pregnancy.
During an assessment, the nurse notices that a patient’s left arm is swollen from the shoulder down to the fingers, with non-pitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. The nurse suspects which problem?
lymphedema
During an assessment of a 26 year old at the clinic for a “spot on my lip I think is cancer” the nurse notices a group of clear vesicles with an erythematous base around them located at the lip/skin border. The patient mentions that she just returned form Hawaii. What would be the most appropriate response from the nurse?
Tell the patient it is most likely herpes simplex 1 and will heal in 4 to 10 days.
A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he has?
Bell’s Palsy
A 19 yr old college student is brought tho the ED with a severe headache he describes as “like nothing I have ever had before” Hie temp 104 F and he has a stiff neck. The nurse looks for other signs and symptoms of what?
meningitis
During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects what?
A) Rickets
B) Dehydration
C) Mental retardation
D) Increased intracranial pressure
B. dehydration
Depressed and sunken fontanels occur with dehydration or malnutrition. Mental retardation and rickets have no effect on fontanels. Increased intracranial pressure would cause tense or bulging, and possibly pulsating fontanels.
A patient’s lab data reveal an elevated thyroxine level. The nurse would proceed to examine what gland?
thyroid
The nurse suspects that a patient has hyperthyroidism and laboratory data indicate that the patient’s thyroxine and tri-iodothyronine hormone levels are elevated. Which of these findings would the nurse most likely find on examination?
A) Tachycardia
B) Constipation
C) Rapid dyspnea
D) Atrophied nodular thyroid
A) Tachycardia
Thyroxine and tri-iodothyronine are thyroid hormones that stimulate the rate of cellular metabolism, resulting in tachycardia. With an enlarged thyroid as in hyperthyroidism, the nurse might expect to find diffuse enlargement (goiter) or a nodular lump, but not an atrophied gland. Dyspnea and constipation are not findings associated with hyperthyroidism.
Nurse is palpating sinus areas. If they are normal the patient will report what sensation?
firm pressure
Patient presents with excruciating headache on one side of head, around his eye, forehead and cheek. They last 1/2 - 2 hours and happen once or twice a day. The nurse suspects what?
cluster headaches
A woman comes to the clinic and states, “I’ve been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry.” The nurse will assess for other signs and symptoms of:
A) cachexia.
B) Parkinson’s syndrome.
C) myxedema.
D) scleroderma.
C) myxedema.
Pages: 276-277. Myxedema (hypothyroidism) is a deficiency of thyroid hormone that, when severe, causes a nonpitting edema or myxedema. The patient will have a puffy edematous face especially around eyes (periorbital edema), coarse facial features, dry skin, and dry, coarse hair and eyebrows. See Table 13-4, Abnormal Facial Appearances with Chronic Illnesses, for descriptions of the other responses.
A male patient with a history of AIDS has come in for an examination and states, “I think that I have the mumps.” The nurse would begin by examing what?
parotid gland
A 92 yr old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?
dysphagia
The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern what would the nurse say?
This is a fungal infection caused by all the antibiotics you’ve received.
During an examination of a female patient, the nurse notes lymphadenopathy and suspects and acute infection. Acutely infected lymph nodes would feel how?
firm but freely movable
A patient has been diagnosed with strep throat. The nurse is aware that without treatment, what complication may occur?
rheumatic fever
During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for what?
coarse facial features
A patient presents with complete paralysis to the right side of her face. She states that she cannot wrinkle her forehead, raise eyebrow, close eye, whistle, or show teeth. The nurse suspects Bell’s palsy and knows that it indicates what?
paralysis of cranial nerve VII
A patient complains that while studying for an examination he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. The nurse suspects that he may be suffering from what?
migraine headaches
During a check up, a 22 yr old woman tells the nurse that she uses an over the counter nasal spray because of her allergies. She also states that it does not work as well as it used to when she started using it. The best response by the nurse would be what?
“Using these nasal medications irritates the lining of the nose and may cause rebound swelling”
During a well baby check, the nurse notices that a 1 week old infant’s face looks small compared with his cranium, which seems enlarged. On further examination, the nurse also notices dilated scalp veins and down cast “setting sun” eyes. What condition does the nurse suspect?
hydrocephaly
During an assessment of a 20 yr old patient with a 3 day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of what?
dehydration
A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain would the nurse be concerned about with these findings?
Cerebellum
A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination on him. During the tests of cognitive function the nurse would expect that he:
will be oriented to place and person but may not be certain of the date
During a mental status examination, the nurse wants to assess a patient’s affect. The nurse should ask the patient which question?
A) “How do you feel today?”
B) “Would you please repeat the following words?”
C) “Have these medications had any effect on your pain?”
D) “Has this pain affected your ability to get dressed by yourself?”
A) “How do you feel today?”
Page: 74. Judge mood and affect by body language and facial expression and by asking directly, “How do you feel today?” or “How do you usually feel?” The mood should be appropriate to the person’s place and condition and should change appropriately with topics.
During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This is an example of:
compulsive disorder
The nurse is testing the function of cranial nerve XI. Which of these best describes the response the nurse should expect if the nerve is intact? The patient:
moves the head and shoulders against resistance with equal strength
The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to:
give him the Four Unrelated Words Test
The nurse is reviewing a patient’s medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma?
6
When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as a(n):
A) ataxia.
B) lack of coordination.
C) negative Homans’ sign.
D) positive Romberg sign.
D) positive Romberg sign.
Page: 638. Abnormal findings for Romberg test include swaying, falling, and widening base of feet to avoid falling. Positive Romberg sign is loss of balance that is increased by closing of the eyes. Ataxia is uncoordinated or unsteady gait. Homans’ sign is used to test the legs for deep vein thrombosis.
During an examination, the nurse can assess mental status by which activity?
A) Examining the patient’s electroencephalogram
B) Observing the patient as he or she performs an IQ test
C) Observing the patient and inferring health or dysfunction
D) Examining the patient’s response to a specific set of questions
C) Observing the patient and inferring health or dysfunction
Page: 71. Mental status cannot be scrutinized directly like the characteristics of skin or heart sounds. Its functioning is inferred through assessment of an individual’s behaviors, such as consciousness, language, mood and affect, and other aspects.
A patient drifts off to sleep when she is not being stimulated. The nurse can arouse her easily when calling her name, but she remains drowsy during the conversation. The best description of this
patient’s level of consciousness would be:
lethargic
A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not _____ four unrelated words _____.
recall; after a 30-minute delay
The nurse is assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented?
“I know that my name is John. I am at the hospital in Spokane. I couldn’t tell you what date it is, but I know that it is February of a new year—2010
The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status?
A) Mental status assessment diagnoses specific psychiatric disorders.
B) Mental disorders occur in response to everyday life stressors.
C) Mental status functioning is inferred through assessment of an individual’s behaviors.
D) Mental status can be assessed directly, just like other systems of the body (e.g., cardiac and breath sounds).
C) Mental status functioning is inferred through assessment of an individual’s behaviors.
Page: 71. Mental status functioning is inferred through assessment of an individual’s behaviors. It cannot be assessed directly like characteristics of the skin or heart sounds.
A patient describes feeling an unreasonable, irrational fear of snakes. It is so persistent that he can no longer comfortably even look at pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. The nurse recognizes that he:
has a snake phobia
During the history, a patient tells the nurse that “it feels like the room is spinning around me.” The nurse would document this as:
vertigo
The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment?
A) Cranial nerves, motor function, and sensory function
B) Deep tendon reflexes, vital signs, and coordinated movements
C) Level of consciousness, motor function, pupillary response, and vital signs
D) Mental status, deep tendon reflexes, sensory function, and pupillary response
C) Level of consciousness, motor function, pupillary response, and vital signs
Pages: 660-661. Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process. These people must be monitored closely for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure. The nurse should use an abbreviation of the neurologic examination in the following sequence: level of consciousness, motor function, pupillary response, and vital signs.
Which of these individuals would the nurse consider at highest risk for a suicide attempt?
Elderly man who tells the nurse that he is going to “join his wife in heaven” tomorrow and plans to use a gun
During a mental status assessment, which question by the nurse would best assess a person’s judgment?
A) “Do you feel that you are being watched, followed, or controlled?”
B) “Tell me about what you plan to do once you are discharged from the hospital.”
C) “What does the statement, ‘People in glass houses shouldn’t throw stones,’ mean to you?”
D) “What would you do if you found a stamped, addressed envelope lying on the sidewalk?”
B) “Tell me about what you plan to do once you are discharged from the hospital.”
Pages: 76-77. A person exercises judgment when he or she can compare and evaluate the alternatives in a situation and reach an appropriate course of action. Rather than testing the person’s response to a hypothetical situation (as illustrated in the option with the envelope), the nurse should be more interested in the person’s judgment about daily or long-term goals, the likelihood of acting in response to delusions or hallucinations and the capacity for violent or suicidal behavior.
During an assessment of a 22-year-old woman who has a head injury from a car accident 4 hours ago, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated and nonreactive, left pupil is 4 mm and reacts to light. What does finding this suggest?
A) Injury to the right eye
B) Increased intracranial pressure
C) Test was not performed accurately
D) Normal response after a head injury
B) Increased intracranial pressure
Pages: 662-663. In a brain-injured person, a sudden, unilateral, dilated, and nonreactive pupil is ominous. Cranial nerve III runs parallel to the brainstem. When increasing intracranial pressure pushes the brainstem down (uncal herniation), it puts pressure on cranial nerve III, causing pupil dilation. The other responses are incorrect.
While obtaining a history of a 3-month-old infant from the mother, the nurse asks about the infant’s ability to suck and grasp the mother’s finger. What is the nurse assessing?
Reflexes
A 70-year-old woman tells the nurse that every time she gets up in the morning or after she’s been sitting she gets “really dizzy” and feels like she is going to fall over. The nurse’s best response would be
“You need to get up slowly when you’ve been lying or sitting”
During an assessment of the cranial nerves, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these cranial nerves?
Motor component of VII
A patient has been diagnosed with a ganglion cyst over the dorsum of his left wrist. He asks the nurse, “What is this thing?” The nurse’s best answer would be,
“It is a common benign tumor”
During a neonatal examination, the nurse notices that the newborn infant has six toes. This finding is documented as:
During a neonatal examination, the nurse notices that the newborn infant has six toes. This finding is documented as:
A) unidactyly.
B) syndactyly.
C) polydactyly.
D) multidactyly.
C) polydactyly
The nurse is teaching a class on osteoporosis prevention to a group of postmenopausal woman. A participant shows that she needs more instruction when she states.
“I will start swimming to increase my weight-bearing exercise.”
A patient states, “I can hear a crunching or grating sound when I kneel.” She also states that “it is very difficult to get out of bed in the morning because of stiffness and pain in my joints.” The nurse should assess for signs of what problem?
Crepitation
The nurse should use which test to check for large amounts of fluid around the patella?
Ballottement
An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because:
of the shortening of the vertebral column
The nurse has completed the musculoskeletal examination of a patient’s knee and has found a positive bulge sign. The nurse interprets this finding to indicate:
swelling from fluid in the suprapatellar pouch
A 14-year-old boy who has been diagnosed with Osgood-Schlatter disease reports painful swelling just below the knee for the past 5 months. Which response by the nurse is appropriate?
“Your disease is due to repeated stress on the patellar tendon. It is usually self-limited, and your symptoms should resolve with rest.”
A patient has been diagnosed with osteoporosis and asks the nurse, “What is osteoporosis?” The nurse explains to the patient that osteoporosis is defined as:
loss of bone density
A patient is being assessed for range of joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called:
adduction
A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform which movement? A) flexion. B) abduction. C) adduction. D) extension.
A) flexion.
Flexion, or bending a limb at a joint, would be required to move the hand to the mouth. Extension is straightening a limb at a joint. Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body.
A woman who is 8 months pregnant comments that she has noticed a change in posture and is having lower back pain. The nurse tells her that during pregnancy women have a posture shift to compensate for the enlarging fetus. This shift in posture is known as: A) lordosis. B) scoliosis. C) ankylosis. D) kyphosis.
A) lordosis.
Lordosis compensates for the enlarging fetus, which would shift the center of balance forward. This shift in balance in turn creates strain on the low back muscles, felt as low back pain during late pregnancy by some women. Scoliosis is lateral curvature of portions of the spine; ankylosis is extreme flexion of the wrist, as seen with severe rheumatoid arthritis; and kyphosis is an enhanced thoracic curvature of the spine.
The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen’s test. To perform this test, the nurse should instruct the patient to:
A) dorsiflex the foot.
B) plantarflex the foot.
C) hold both hands back to back while flexing the wrists 90 degrees for 60 seconds.
D) hyperextend the wrists with the palmar surface of both hands touching and wait for 60 seconds.
C) hold both hands back to back while flexing the wrists 90 degrees for 60 seconds.
For the Phalen’s test, the nurse should ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand. The Phalen’s test reproduces numbness and burning in a person with carpal tunnel syndrome. The other actions are not correct for testing for carpal tunnel syndrome.
What statement is true regarding the vertebra prominens? The vertebra prominens is:
A. opposite the interior border of the scapula.
B. usually not palpable in most individuals.
C. located next to the manubrium of the sternum.
D. the spinous process of C7.
D. the spinous process of C7.
A 40-year-old man has come into the clinic with complaints of “extreme tenderness in my toes.” The nurse notices that his toes are slightly swollen, reddened, and warm to the touch. His complaints would suggest:
acute gout
A patient tells the nurse that “all my life I’ve been called ‘knock knees.’” The nurse knows that another term for “knock knees” is:
genu valgum
A patient who has had rheumatoid arthritis for years comes to the clinic to ask about changes in her fingers. The nurse will assess for signs of what problems? A) Heberden's nodes B) Bouchard's nodules C) Swan neck deformities D) Dupuytren's contractures
C) Swan neck deformities
A patient is complaining of pain in his joints that is worse in the morning, is better after he has moved around for awhile, and then gets worse again if he sits for long periods of time. The nurse should assess for other signs of what problem?
A) Tendinitis
B) Osteoarthritis
C) Rheumatoid arthritis
D) Intermittent claudication
C) Rheumatoid arthritis
When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale?
5
The nurse is examining a 3-month-old infant. While holding the thumbs on the infant’s inner mid thighs and the fingers outside on the hips, touching the greater trochanter, the nurse adducts the legs until the nurse’s thumbs touch and then abducts the legs until the infant’s knees touch the table. The nurse does not notice any “clunking” sounds and is confident to record a:
A) positive Allis test.
B) negative Allis test.
C) positive Ortolani’s sign.
D) negative Ortolani’s sign.
D. negative Ortolani’s sign
Nodule
Solid, elevated, hard or soft, larger than 1 cm. May extend deeper into dermis than papule. Examples: xanthoma, fibroma, intradermal nevi.
Keloid
A hypertrophic scar. The resulting skin level is elevated by excess scar tissue, which is invasive beyond the site of original injury. May increase long after healing occurs. Looks smooth, rubbery, and “clawlike” and has a higher incidence among African Americans.
Papule
Something you can feel (i.e., solid, elevated, circumscribed, less than 1 cm diameter) caused by superficial thickening in the epidermis. Examples: elevated nevus (mole), lichen planus, molluscum, wart (verruca).
Macule
Solely a color change, flat and circumscribed, of less than 1 cm. Examples: freckles, flat nevi, hypopigmentation, petechiae, measles, scarlet fever.
Wheal
Superficial, raised, transient and erythematous; slightly irregular shape due to edema (fluid held diffusely in the tissues). Examples: mosquito bite, allergic reaction, dermographism.
Zosteriform
Shapes/configurations of lesions, examples
linear arrangement along a unilateral nerve route (e.g., herpes zoster)
Grouped
Shapes/configuration of lesions, examples
cluster of lesions (e.g., vesicles of contact dermatitis)
Elevated skin lesions that are greater than 1 cm in diameter are called: A. bullae. B. papules. C. nodules. D. furuncles.
C. nodules.
The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse would report this as a: A. nodule. B. bulla. C. papule. D. vesicle.
C. papule
