Chapter 21 FA Davis questions

The nurse is reassessing a patient's abdomen. Which reason is correct as to why the nurse alters the normal order of physical assessment techniques?

1. Percussion of the abdomen is last because it is the most painful assessment.

2. Inspection of the abdomen can occur at the beginning or end of the assessment.

3. Palpation of the abdomen before auscultation will alter bowel sounds.

4. Olfaction is used because of the passage of flatus after palpation

3. Palpation of the abdomen before auscultation will alter bowels sounds

The nurse is reassessing a patient. Which nonverbal behavior by the patient requires that the nurse seek clarification?

1. The patient closes their eyes when the nurse examines the genitalia.

2. The patient comments about the temperature of the examining room.

3. The patient grimaces and pulls away when a joint is palpated.

4. The patient frowns when the nurse asks about family relationships

3. The patient grimaces and pulls away when a joint is palpated.

The licensed practical nurse/licensed vocational nurse (LPN/LVN) reviews the registered nurse's (RN's) assessment notes on a newly admitted patient. For which assessment finding will the LPN/LVN need in order to acquire clarification from the RN?

1. The temperature, texture, and moisture of the patient's skin.

2. The presence of muscle tenderness or rigidity.

3. The level of pain voiced by the patient during abdominal palpation.

4. The quality of the femoral and popliteal pulses.

3. The level of pain voiced by the patient during abdominal palpation

The nurse is reassessing a patient's apical pulse prior to the administration of cardiac medication. Which action by the nurse is inappropriate?

1. Placing the patient on the left side if the patient is unable to sit up

2. Putting the stethoscope at the left fifth intercostal space

3. Listening to the posterior aspect of the thoracic cavity

4. Counting the heartbeats at the left midclavicular line

3. Listening to the posterior aspect of the thoracic cavity

The nurse is admitting a patient to a long-term care facility. Which reasons does the nurse recognize as the need for the physical assessment during admission? Select all that apply.

1. It provides a baseline against which future changes can be compared.

2. It provides validation of the patient's condition for third-party reimbursement.

3. It is used to identify real or potential problems the patient has or may develop.

4. It is used to evaluate the effectiveness of nursing interventions.

5. It provides information about specific body systems that may need further assessment.

1. It provides a baseline against which future changes can be compared.

3. It is used to identify real or potential problems the patient has or may develop

4. It is used to evaluate the effectiveness of nursing interventions.

5. It provides information about specific body systems that may need further assessment

Part of the assessment process involves an interview by the admitting nurse. Which information will be included in the interview portion of assessment? Select all that apply.

1. Medical history.

2. Personal identity.

3. Food and drug allergies.

4. Details about current condition.

5. Patient expectations of hospitalization.

1. Medical history.

2. Personal identity.

3. Food and drug allergies.

4. Details about current condition.

5. Patient expectations of hospitalization.

The nurse is aware that the neurological assessment of a patient includes vital sign evaluation. Which vital signs are related to functions of the central nervous system? Select all that apply.

1. Oxygen saturation.

2. Temperature.

3. Pulse rate.

4. Blood pressure.

5. Respiration rate.

2. Temperature.

3. Pulse rate.

4. Blood pressure.

5. Respiration rate.

The nurse is preparing to review the physical assessment performed on a newly admitted patient. Which purpose of the physical assessment will the nurse identify as inaccurate?

1. It provides guidelines for decisions about medical treatment.

2. It establishes a baseline of the patient's current condition for comparison.

3. It uses data to evaluate the effectiveness of nursing interventions.

4. It identifies real or potential problems for which the patient is at risk.

1. It provides guidelines for decisions about medical treatment.

The new graduate nurse states, "I am always fearful that I will forget part of the physical assessment process." Which assistance does the experienced nurse provide?

1. "Start at the top and move downward to the toes, then do the arms and legs."

2. "I begin with the part of the body associated with the symptoms shared by the patient."

3. "Everyone has their own technique so just find an order that makes sense to you."

4. "Write everything down and go back if you need to find missing information."

1. "Start at the top and move downward to the toes, then do the arms and legs."

The nurse is providing care for a patient from a culture whose members are extremely modest and sensitive about being touched. Which statement by the nurse indicates cultural respect for this patient?

1. "Can you suggest how I can check you physically without touching your body?'

2. "The ability to monitor what is going on will be much easier if you are in a gown."

3. "I suggest that we come to some understanding about your culture and your physical care."

4. "May I place my hands under your clothing and touch your abdomen to evaluate the pain?"

4. "May I place my hands under your clothing and touch your abdomen to evaluate the pain?"

The nurse is preparing to interview an older adult patient. Which assessment is most important for the nurse to perform prior to the interview?

1. Vital sign readings.

2. Visual acuity.

3. Level of consciousness.

4. Ability to hear.

3. Level of consciousness.

The nurse at a pediatric clinic is preparing to weigh an infant. Which action by the nurse will interfere with acquiring an accurate weight?

1. Placing a cover on the scale after the scale is calibrated

2. Undressing the infant following facility policy about the diaper

3. Putting the infant supine on the cradle of the scale

4. Holding a protective hand one to two inches above the infant

1. Placing a cover on the scale after the scale is calibrated

Which olfaction assessment is most common among medical health-care providers?

1. Cerumen with a mousey odor related to an infection from Proteus.

2. The differentiation between the smell of strep and other infections.

3. The odor of normal menstrual flow in a non-medical setting.

4. The odor of acetone on the breath of a patient with diabetes mellitus.

4. The odor of acetone on the breath of a patient with diabetes mellitus.

The nurse is reassessing a patient and acquires the scale pictured below. Which assessment can be obtained with the use of this scale?

1. Skin lesion size.

2. Dressing drainage size.

3. Pupil size.

4. Kidney stone size.

3. Pupil size.

The nurse is caring for a patient who returned 2 hr ago following throat surgery. Which focused assessment finding will cause the greatest concern for the nurse?

1. Hoarseness when speaking

2. A pain level of 8 on a scale of 0 to 10

3. A response elicited by touch and verbal stimuli

4. Frequent swallowing movements

4. Frequent swallowing movements

The licensed practical nurse/licensed vocational nurse (LPN/LVN) is using the skill of palpation during the reassessment of a patient. Which conditions will the nurse expect to find with palpation? Select all that apply.

1. A fatty tumor beneath the skin on the arm.

2. A pulse deficit between the left and right foot.

3. Pitting edema in the lower extremities.

4. A liver mass related to a medical diagnosis.

5. Muscle rigidity in a seizing neck muscle.

1. A fatty tumor beneath the skin on the arm.

2. A pulse deficit between the left and right foot.

3. Pitting edema in the lower extremities.

5. Muscle rigidity in a seizing neck muscle.

The nurse is preparing to interview a patient admitted to the hospital. Which is the nurse's most important objective during the interviewing process?

1. To foster rapport and communication with the patient

2. To obtain personal and medical history from the patient

3. To learn about the symptoms that caused the patient to seek medical help

4. To become aware of the patient's expectations for hospitalization

1. To foster rapport and communication with the patient

The nurse is performing an abdominal reassessment on a patient who had abdominal surgery under general anesthesia. Which is the correct conclusion if the nurse counts 22 clicks and gurgles after auscultating the patient's abdomen for 1 min?

1. Bowel sounds support a clear liquid diet.

2. The bowel is exhibiting normal activity.

3. Bowel sounds are indicative of a blockage.

4. The bowel is still affected by the anesthesia.

2. The bowel is exhibiting normal activity.

The nurse in an adult clinic is assessing a patient who just arrived. Which assessment of the patient's general appearance indicates physical distress?

1. Facial expression with wide eyes

2. Breathing through the mouth

3. Unkempt physical appearance

4. Slow response to verbal stimuli

2. Breathing through the mouth

The nurse is reviewing a comprehensive assessment on a newly admitted patient. Which assessment information does the nurse associate with the patient's physical examination?

1. The patient's description of previous surgeries.

2. The patient's stated reason for seeking medical care.

3. The patient's response to palpation of a painful growth.

4. The patient's expression of distress over hospitalization.

3. The patient's response to palpation of a painful growth.

The nurse is reassessing a patient admitted to the hospital. When inspecting the patient's mouth, the nurse notes that the patient has no teeth. The patient states, "I have dentures but they hurt my mouth so I didn't even bring them." Which action should the nurse take?

1. Inspect the patient's mouth for sores.

2. Seek an order for a mechanically soft diet.

3. Ask if a family member can bring the dentures.

4. Inquire if the patient has consulted a dentist.

2. Seek an order for a mechanically soft diet.

The nurse is preparing to reassess a patient's initial shift assessment. Which physical assessment technique is least likely to be used by the nurse?

1. Palpation

2. Percussion

3. Auscultation

4. Olfaction

2. Percussion

Which of the following may cause cheilitis? Select all that apply.

1. Carbon monoxide

2. Wind chapping

3. Anemia

4. Sun exposure

5. Anaphylaxis

2. Wind chapping

4. Sun exposure

5. Anaphylaxis

When assessing a patient's eyes, the nurse can shine a light into one of the patient's eyes and both pupils should have a rapid constriction that is simultaneous and equal. This action is known as which of the following?

1. Consensual reflex

2. Accommodation response

3. PERRLA

4. Ptosis

1. Consensual reflex

The nurse is providing care for a patient scheduled for surgery to amputate gangrenous toes from the left foot. During the shift assessment, the nurse checks pedal pulses, skin color and warmth, and the level of pain. Which finding would prompt the nurse to perform an additional assessment?

1. The patient's right lower leg and ankle are swollen.

2. The pedal pulses to the left foot are lower than 12 hr earlier.

3. The right lower extremity is pink in color and warm to the touch.

4. The level of pain in the left lower extremity is a level 6 on a 0 to 10 scale.

1. The patient's right lower leg and ankle are swollen.

The nurse is preparing to reassess a patient's neurological status. Which reason is why the nurse verbally explains the assessment process to a patient who is comatose?

1. It helps the nurse to remain organized.

2. Family members will repeat the behavior.

3. The sense of hearing may still be present.

4. It demonstrates respect for the patient

3. The sense of hearing may still be present.

When the nurse first enters a patient's room, the process of inspection begins. Which conclusion by the nurse can be solely identified through the process of inspection? Select all that apply.

1. The patient needs assistance with personal care.

2. The patient is sweating due to the room temperature.

3. The patient is tall but also overweight.

4. The patient is experiencing respiratory distress.

5. The patient is not connected to tubing or equipment.

1. The patient needs assistance with personal care.

The nurse enters a patient's room and discovers the patient sitting on the side of the bed and leaning forward over the bedside table. Which condition does the nurse associate with the patient's position?

1. Orthopnea

2. Lethargy

3. Dysphagia

4. Hypoxia

1. Orthopnea

The nurse is performing a reassessment of a patient's breath sounds. Which action by the nurse is correct during this assessment?

1. Listening to the posterior chest wall prior to listening to the anterior wall

2. Listening to the apex of the lungs before auscultating the lateral aspects

3. Listening to the left side of the chest before listening to the right side

4. Listening to a minimum of two breaths at each auscultation site

2. Listening to the apex of the lungs before auscultating the lateral aspects

The nurse is newly hired on the cardiac stepdown unit, and is reviewing the principles of evaluating the apical pulse. Which conclusions made by the nurse about the apical pulse are correct? Select all that apply.

1. The first sound, S1, is louder and represents the "lubb" sound.

2. The apical pulse is taken for 1 full min as a standard of practice.

3. The apical pulse is best heard right of the sternum at the second intercostal space.

4. An S2 sound is longer and represents a conduction delay.

5. Evenly spaced beats indicates that the cardiac rhythm is regular.

1. The first sound, S1, is louder and represents the "lubb" sound.

2. The apical pulse is taken for 1 full min as a standard of practice.

5. Evenly spaced beats indicates that the cardiac rhythm is regular.

The nurse is performing a focused assessment at the beginning of the shift on a patient diagnosed with pneumonia. Which patient assessment is least informative for the nurse?

1. Oxygen saturation level.

2. Level of consciousness.

3. Bilateral breath sounds.

4. Skin color and warmth.

4. Skin color and warmth.

The nurse is working as a summer camp nurse. While accompanying campers on a hike, a hiker falls and is injured. The nurse has no medical equipment available. Which assessment process is the nurse least likely to use?

1. Tactile skills to determine the presence of internal injuries.

2. Critical thinking in order to determine the safest way to assess and care for the hiker.

3. Visualization to identify the location and severity of physical injuries.

4. Auditory skills to receive and process the hiker's subjective input.

1. Tactile skills to determine the presence of internal injuries.

The nurse is caring for multiple patients in an acute care setting. Which client is unlikely to require a daily weight assessment?

1. A patient with a suppressed appetite from medication.

2. A patient who is being treated for generalized edema.

3. A patient with a medical history of heart disease.

4. A patient who is on fluid restrictions for kidney disease.

1. A patient with a suppressed appetite from medication.

The licensed practical nurse/licensed vocational nurse (LPN/LVN) accompanies the health-care provider who is physically assessing a patient. Which assessment information does the nurse understand the health-care provider acquires with the use of percussion?

1. The extent of a disease within the body.

2. The intensity of pain in specific organs.

3. The detection of malfunction of internal organs.

4. The location and size of organs within the body.

4. The location and size of organs within the body.

The nurse is assigned to care for a patient who is hospitalized. Which patient finding did the nurse most likely find with the use of a stethoscope?

1. Eructation.

2. Carotid bruit.

3. Wheezing.

4. Passing flatus.

2. Carotid bruit.

The nurse is reviewing the admission notes for a newly admitted patient. Which assessment finding is recognized as a symptom of the patient's condition?

1. The patient grimaces when the muscles of the arms and legs are palpated.

2. The patient needs assistance when getting up and down from exam table.

3. The patient reports generalized muscle tenderness and fever.

4. The patient's skin is pink in color, warm and dry to the touch, and intact.

3. The patient reports generalized muscle tenderness and fever.

The nurse is working in a clinic that focuses on the care of patients with respiratory conditions. Which adventitious breath sounds will the nurse recognize as causing the concern? Select all that apply.

1. Crackles that will not clear with a cough.

2. Rhonchi that sounds like snoring and gurgling.

3. Wheezes heard on inspiration and expiration.

4. Stridor present in a toddler in the emergency room.

5. Pleural friction rub present after being in the cold.

2. Rhonchi that sounds like snoring and gurgling.

4. Stridor present in a toddler in the emergency room.

The nurse in a health-care provider's office is preparing to perform a vision test for a patient. Which action will the nurse take in the performance of this assessment?

1. Move to a smaller line if the patient has no more than three errors in the tested line.

2. If the patient wears corrective lenses, they should be worn during the exam.

3. Place the patient at a distance from the chart where vision is best.

4. Have the patient place the palm firmly over the eye not being tested.

2. If the patient wears corrective lenses, they should be worn during the exam.

The nurse is preparing to reassess a patient at the beginning of the shift. For which assessment will the nurse need to acquire equipment?

1.Evaluation of pupil size

2.Monitoring respiratory efforts

3.Inspection of the tympanic membrane

4. Performance of muscle movement

3.Inspection of the tympanic membrane

The licensed practical nurse/licensed vocational nurse (LPN/LVN) is reassessing an assigned patient. For which assessment will the LPN/LVN use the skill of palpation?

1. To reassess the location of the liver

2. To reassess for dependent edema

3. To reassess for a bladder distention

4. To reassess for appendix tenderness

2. To reassess for dependent edema

The nurse in an acute care setting is identifying specific times when physical reassessment is performed. Which times has the nurse identified correctly? Select all that apply.

1. When the nurse feels, or a patient states, that things seem uncertain or wrong.

2. Right before the patient is discharged from the care setting.

3. When the nurse needs to evaluate the effectiveness of the patient's plan of care.

4. At the beginning of the first shift of each day in order to document patient progression.

5. Before the health-care provider arrives so that the nurse can relay information about recent changes.

1. When the nurse feels, or a patient states, that things seem uncertain or wrong.

3. When the nurse needs to evaluate the effectiveness of the patient's plan of care.

When the nurse first enters a patient's room, the process of inspection begins. Which conclusion by the nurse can be solely identified through the process of inspection? Select all that apply.

1. The patient needs assistance with personal care.

2. The patient is sweating due to the room temperature.

3. The patient is tall but also overweight.

4. The patient is experiencing respiratory distress.

5. The patient is not connected to tubing or equipment.

1. The patient needs assistance with personal care.

The nurse works in a medical clinic. Which actions will the nurse perform in anticipation of the health-care provider assessing the patient's ears and nose? Select all that apply.

1.Check the otoscope for a functioning light bulb.

2.Have the patient blow their nose before inspection.

3.Assure the availability of speculum covers.

4. Clean the lens of the ophthalmoscope.

5. Measure the patient's ear canal and nares.

1.Check the otoscope for a functioning light bulb.

3.Assure the availability of speculum covers.

When a nurse uses the assessment skill of olfaction, which condition can be revealed by the odor of a patient's breath? Select all that apply.

1.Gum disease or sinus infection from halitosis.

2. Kidney disease by the odor of ammonia.

3. Imbalanced diet by an earthy smell.

4. Stomach irritation from a citrus smell.

5. High stress levels causing a sour odor.

1.Gum disease or sinus infection from halitosis.

2. Kidney disease by the odor of ammonia.

5. High stress levels causing a sour odor.

The nurse is providing care for a patient who suddenly develops abdominal pain at a level of 7 on a scale of 0 to 10. Which resource will the nurse use to evaluate the patient's condition?

1. The patient's health-care provider to ascertain if the development of pain is significant.

2. The physical assessment notes acquired at the time of admission.

3. The patient's significant other for information about previous pain.

4. The patient's previous nurse to learn if the pain is reoccurring.

2. The physical assessment notes acquired at the time of admission.

The nurse in the emergency department is assessing an older adult patient. Which assessment technique used by the nurse will prompt a suspicion of physical abuse?

1. The patient is reluctant to talk to the nurse.

2. The nurse acquires a set of vital signs.

3.The patient appears fearful of family members.

4. The nurse detects odors of urine and feces.

4. The nurse detects odors of urine and feces.

The nurse is preparing to perform a head-to-toe assessment on a patient. Which action by the nurse is performed first?

1. Ensure the patient's privacy.

2. Gather all the necessary equipment.

3. Suggest that the patient use the bathroom.

4. Explain the purpose of the assessment.

2. Gather all the necessary equipment.

The nurse is reassessing a patient. The nurse begins assessment at the patient's head and neck. Which action does the nurse perform first?

1. Observes the patient's pupil reaction

2. Checks the patient's skin color

3. Inspects the patient's oral membranes

4. Evaluates the patient's swallowing

2. Checks the patient's skin color

During the reassessment of a patient's chest, the patient states, "I have been coughing up stuff that is kind of foamy and pink in color." Which patient diagnosis does the nurse relate to the character of the patient's sputum?

1. Bacterial pneumonia.

2. Tuberculosis.

3. Chronic pulmonary disease.

4. Congestive heart failure.

4. Congestive heart failure.