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69 Cards in this Set

  • Front
  • Back
Jaundice is exhibited by a yellow skin color, indicating rising levels of bilirubin in the blood. Which of the following findings is indicative of true jaundice?
Choose one answer.
a. Yellow patches throughout the sclera
b. Yellow color of the sclera that extends up to the iris The yellow sclera of jaund
c. Skin that appears yellow when examined under low light
d. Yellow deposits on the palms and soles of the feet where jaundice first appears
B
During an examination, the patient states he is hearing a buzzing sound and says that it is “driving me crazy!” The nurse recognizes that this symptom is:
Choose one answer.
a. vertigo.
b. pruritus.
c. tinnitus.
d. cholesteatoma.
C
A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, “I quit smoking after my wife died 7 years ago.” However, the nurse notices an open package of cigarettes in his shirt pocket. Using confrontation, the nurse could say:
Choose one answer.
a. “Mr. K., I know that you are lying.”
b. “Mr. K., come on, tell me how much you smoke.”
c. “Mr. K., I didn’t realize your wife had died. It must be difficult for you at this time. Please tell me more about that.”
d. “Mr. K., you have said that you don’t smoke, but I see that you have an open package of cigarettes in your pocket.”
D
A 10-year-old is at the clinic for “a sore throat lasting 6 days.” The nurse is aware that which of the following would be most consistent with an acute infection?
Choose one answer.
a. Tonsils 1+ and pink
b. Tonsils 1+ with small plugs of white debris
c. Tonsils 3+ with large white spots
d. Tonsils 3+ without exudate
C
The client occludes one ear while the nurse whispers in the other ear from 30 cm (1 foot) away
Whisper or Voice test
A vibrating tuning fork is placed midline on top of the head and the client is asked where the sound is heard best
Weber Test
A vibrating tuning fork is placed on the mastoid process and then placed near the ear when the sound is no longer heard
Rinne Test
The nurse just noted from a patient’s medical record that the patient has a lesion that is confluent in nature. On examination, the nurse would expect to find:
Choose one answer.
a. lesions that run together.
b. annular lesions that have grown together.
c. lesions arranged in a line along a nerve route.
d. lesions that are grouped or clustered together.
A
During an interview, the patient states he has the sensation that “everything around him is spinning.” The nurse recognizes that the portion of the ear responsible for this sensation is:
Choose one answer.
a. the cochlea.
b. cranial nerve VIII.
c. the organ of Corti.
d. the bony labyrinth.
D
During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:
Choose one answer.
a. decreased in the elderly.
b. impaired in a patient with cataracts.
c. stimulated by cranial nerves I and II.
d. stimulated by cranial nerves III, IV, and VI.
D
When performing a physical assessment, the technique the nurse will use first is:
Choose one answer.
a. palpation.
b. inspection.
c. percussion.
d. auscultation.
B
A 17-year-old single mother is describing how difficult it is to raise a 2-year-old by herself. During the course of the interview she states, “I can’t believe my boyfriend left me to do this by myself! What a terrible thing to do to me!” Which of the following responses by the nurse uses empathy?
Choose one answer.
a. “You feel alone?”
b. “You can’t believe he left you alone.”
c. “It must be so hard to face this all alone.”
d. “I would be angry, too; raising a child alone is no picnic.”
C
The nurse is conducting a visual examination. Which of the following statements regarding visual pathways and visual fields is true?
Choose one answer.
a. The right side of the brain interprets vision for the right eye.
b. The image formed on the retina is upside down and reversed from its actual appearance in the outside world.
c. Light rays are refracted through the transparent media of the eye before striking the pupil.
d. The light impulses are conducted through the optic nerve to the temporal lobes of the brain.
B
A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice?
Choose one answer.
a. A trained interpreter
b. A male family member
c. A female family member
d. A volunteer college student from the foreign language studies department.
A
Which of the following is an example of a symptom?
Choose one answer.
a. Chest pain
b. Clammy skin
c. Serum potassium level 4.2 mEq/L
d. A temperature of 100° F
A
The nurse is assessing a patient’s headache pain. Which questions reflect one or more of the critical characteristics of symptoms that should be assessed? (Select all that apply.)
Choose at least one answer.
a. “Where is the headache pain?”
b. “Did you have these headaches as a child?”
c. “On a scale of 1 to 10, how bad is the pain?”
d. “How often do the headaches occur?”
e. “What makes the headaches better?”
f. “Do you have any family history of headaches?”
g. “What do you think is causing these headaches?”
A C D E G
Which technique of assessment is used to determine the presence of crepitus, swelling, and pulsations?
Choose one answer.
a. Palpation
b. Inspection
c. Percussion
d. Auscultation
A
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:
Choose one answer.
a. bulla.
b. wheal.
c. macule
d. papule
D
The nurse is taking a family history. Important diseases or problems to ask the patient about due to genetic risk include:
Choose one answer.
a. emphysema.
b. head trauma.
c. mental illness.
d. fractured bones.
C
When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of the following statements describes the most appropriate actions the examiner should take when performing a physical examination?
Choose one answer.
a. There is no need to wash one’s hands after removing gloves, as long as the gloves are still intact.
b. Wash hands at the beginning of the examination and any time that one leaves and re-enters the room.
c. Wash hands between the examination of each body system to prevent the spread of bacteria from one part of the body to another.
d. Wear gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.
B
A thorough skin assessment is very important because the skin holds information about:
Choose one answer.
a. support systems.
b. circulatory status.
c. socioeconomic status.
d. psychological wellness.
B
A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is:
Choose one answer.
a. caused by an excess of melanin pigment.
b. caused by an excess of apocrine glands in her feet.
c. caused by the complete absence of melanin pigment.
d. related to impetigo and that it can be treated with an ointment.
C
The nurse has discovered decreased skin turgor in a patient and knows that this is an expected finding in which of the following conditions?
Choose one answer.
a. Cases of severe obesity
b. During childhood growth spurts
c. In an individual who is severely dehydrated
d. With conditions of connective tissue disorders such as scleroderma
C
The nurse is preparing to percuss to assess the underlying:
Choose one answer.
a. tissue turgor.
b. tissue texture.
c. tissue density. d. tissue consistency.
C
A patient is being seen in the clinic for complaints of “fainting episodes that started last week.” How should the nurse proceed with the examination?
Choose one answer.
a. Take his blood pressure in both arms and thighs.
b. Assist him to a lying position and begin taking his blood pressure.
c. Record his blood pressure in the lying, sitting, and standing positions.
d. Record his blood pressure in the lying and sitting positions and average these numbers to obtain a mean blood pressure.
C
The nurse is assessing a patient’s skin during an office visit. What is the best technique to use to best assess the patient’s skin temperature?
Choose one answer.
a. Use the fingertips because they’re more sensitive to small changes in temperature.
b. Use the dorsal surface of the hand because the skin is thinner than on the palms.
c. Use the ulnar portion of the hand because there is increased blood supply that enhances temperature sensitivity.
d. Use the palmar surface of the hand because it is most sensitive to temperature variations because of increased nerve supply in this area.
B
Which statement is true regarding the diaphragm of the stethoscope?
Choose one answer.
a. Use the diaphragm to listen for high-pitched sounds.
b. Use the diaphragm to listen for low-pitched sounds.
c. Hold the diaphragm lightly against the person’s skin to block out low-pitched sounds.
d. Hold the diaphragm lightly against the person’s skin to listen for extra heart sounds and murmurs.
A
When performing a general survey, the examiner is:
Choose one answer.
a. observing the patient’s body stature and nutritional status.
b. interpreting the subjective information the patient has reported.
c. measuring the patient’s temperature, pulse, respirations, and blood pressure.
d. observing specific body systems while performing the physical assessment.
A
Tiny punctate hemorrhages, 1-3 mm, round and discrete, dark red, purple, or brown in color
Petechiae
A large patch of capillary bleeding into tissues
Eccyhmosis
Elevated cavity containing free fluid, up to 1 cm. Clear serum flows if wall is ruptured.
Vesicle
A hypertrophic scar
Keloid
Solid, elevated, hard or soft, larger than 1 cm
Nodule
Flat skin lesion less than 1 cm
Macule
A patient’s blood pressure is 118/82. He asks the nurse to explain “what the numbers mean.” The nurse’s best reply would be:
Choose one answer.
a. “The numbers are within normal range and nothing to worry about.”
b. “The bottom number is the diastolic pressure and reflects the stroke volume of the heart.”
c. “The top number is the systolic blood pressure and reflects the pressure on the arteries when the heart contracts.”
d. “The concept of blood pressure is difficult to understand. The main thing to be concerned about is the top number, or systolic blood pressure.”
C
The projections in the nasal cavity that increase the surface area are called the:
Choose one answer.
a. meatus.
b. septum.
c. turbinates.
d. Kiesselbach’s plexus.
C
The nurse should use which part of the hand to assess for vibration?
Choose one answer.
a. Ulnar surface
b. Finger pads
c. Dorsal surface
d. Palmar surface
A
A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble with reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that:
Choose one answer.
a. she may have macular degeneration.
b. her vision is normal for someone her age.
c. she has the beginning stages of cataract formation.
d. she has increased intraocular pressure or glaucoma.
A
When the retina is examined, which of the following is considered a normal finding?
Choose one answer.
a. An optic disc that is a yellow-orange color
b. Optic disc margins that are blurred around the edges
c. The presence of pigmented crescents in the macular area
d. The presence of the macula located on the nasal side of the retina
A
A patient’s vision is recorded as 20/30 when the Snellen eye chart is used. The nurse recognizes that these results indicate that:
Choose one answer.
a. at 30 feet the patient can read the entire chart.
b. the patient can read at 20 feet what a person with normal vision can read at 30 feet.
c. the patient can read the chart from 20 feet in the left eye and 30 feet in the right eye.
d. the patient can read from 30 feet what a person with normal vision can read from 20 feet.
B
Which of the following statements best describes the purpose of a health history?
Choose one answer.
a. To provide an opportunity for interaction between patient and nurse
b. To provide a form for obtaining the patient’s biographic information
c. To document the normal and abnormal findings of a physical assessment
d. To provide a database of subjective information about the patient’s past and current health
D
During an interview, a woman says, “I have decided that I can no longer allow my children to live with their father’s violence. I just can’t seem to leave him though.” Using interpretation, the nurse’s best response would be:
Choose one answer.
a. “You’re going to leave him?”
b. “If you’re afraid for your children, why can’t you leave?”
c. “It sounds as if you might be afraid of how your husband will respond.”
d. “It sounds as though you have made your decision. I think it is a good one.”
C
A nurse is taking complete health histories on all the patients attending a wellness workshop. On the history form, one of the written question asks, “You don’t smoke, drink, or take drugs, do you?” This question is an example of:
Choose one answer.
a. talking too much.
b. using confrontation.
c. using biased or leading questions.
d. using blunt language to deal with distasteful topics.
C
During an assessment, the nurse uses the CAGE test. The patient answers “yes” to two of the questions. What could this be indicating?
Choose one answer.
a. The patient is an alcoholic.
b. The patient is annoyed at the questions.
c. The patient should be examined thoroughly for possible alcohol withdrawal symptoms.
d. The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment.
D
During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be:
Choose one answer.
a. hard, tender and nonmobile
b. unilateral and nontender
c. tender and freely movable.
d. hard and nontender.
C
In a patient with acromegaly, the nurse will expect to observe:
Choose one answer.
a. heavy, flattened facial features.
b. growth retardation and a delayed onset of puberty.
c. overgrowth of bone in the face, head, hands, and feet.
d. increased height and weight and delayed sexual development.
C
The nurse is doing an assessment on a 21-year-old patient and notes that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient?
Choose one answer.
a. “Are you aware of having any allergies?”
b. “Do you have an elevated temperature?”
c. “Have you had any symptoms of a cold?”
d. “Have you been having frequent nosebleeds?
A
During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement?
Choose one answer.
a. Using gentle pressure, palpate with both hands to compare the two sides.
b. Using strong pressure, palpate with both hands to compare the two sides.
c. Gently pinch each node between one’s thumb and forefinger and move down the neck muscle.
d. Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern.
A
A patient tells the nurse that he has noticed that one of his nevi has started to burn and bleed. When assessing his skin, the nurse would pay special attention to the danger signs for pigmented lesions and would be concerned with which additional finding?
Choose one answer.
a. Color variation
b. Border regularity
c. Symmetry of lesions
d. Diameter less than 6 mm
A
In using the ophthalmoscope to assess a patient’s eyes, the nurse notes a red glow in the patient’s pupils. On the basis of this finding, the nurse would:
Choose one answer.
a. suspect that there is an opacity in the lens or cornea.
b. check the light source of the ophthalmoscope to verify that it is functioning.
c. consider this a normal reflection of the ophthalmoscope light off the inner retina.
d. continue with the ophthalmoscopic examination and refer the patient for further evaluation.
C
The nurse is testing a patient’s visual accommodation, which refers to:
Choose one answer.
a. pupillary constriction when looking at a near object.
b. pupillary dilation when looking at a far object.
c. changes in peripheral vision in response to light.
d. involuntary blinking in the presence of bright light.
A
Which of the following statements represents subjective data obtained from the patient regarding his skin?
Choose one answer.
a. Skin appears dry.
b. No obvious lesions
c. Denies color change
d. Lesion noted lateral aspect right arm
C
The nurse is palpating the sinus areas. If the findings are normal, the patient would report which sensation?
Choose one answer.
a. No sensation
b. Firm pressure
c. Pain during palpation
d. Pain sensation behind eyes
B
With which of the following patients would it be most appropriate to use games during the assessment, such as, having the patient “blow out” the light on the penlight?
Choose one answer.
a. An infant
b. A preschool child
c. A school-age child
d. An adolescent
B
A patient has a normal pupillary light reflex. The nurse recognizes that this indicates that:
Choose one answer.
a. the eyes converge to focus on the light.
b. light is reflected at the same spot in both eyes.
c. the eye focuses the image in the center of the pupil.
d. constriction of both pupils occurs in response to bright light.
D
The salivary gland that is located in the cheek in front of the ear is the:
Choose one answer.
a. parotid gland.
b. Stenson’s gland.
c. sublingual gland.
d. submandibular gland.
A
While performing the otoscopic exam of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and the light reflex is not visible. The most likely cause is:
Choose one answer.
a. fungal infection.
b. acute otitis media.
c. rupture of the drum.
d. blood behind the drum.
B
In response to a question regarding use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information?
Choose one answer.
a. This is necessary to determine the patient’s reliability.
b. Alcohol can interact with all medications and make some diseases worse.
c. The nurse needs to be able to teach the patient about the dangers of alcohol use.
d. It’s not really necessary to have this information unless there is an obvious drinking problem.
B
When examining the ear with an otoscope, the nurse remembers that the tympanic membrane should appear:
Choose one answer.
a. light pink with a slight bulge.
b. pearly gray and slightly concave.
c. pulled in at the base of the cone of light.
d. whitish with a small fleck of light in the superior portion.
B
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment of his skin, the nurse might expect to find the following:
Choose one answer.
a. anasarca.
b. scleroderma.
c. pedal erythema.
d. clubbing of the nails.
D
During an interview, the nurse states: “You mentioned shortness of breath. Tell me more about that.” Identify the verbal skill used with this statement.
Choose one answer.
a. Reflection
b. Facilitation
c. Direct question
d. Open-ended question
D
A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. He has noticed that his hair seems to be breaking off in patches and that he has some scaling on his head. The nurse would begin the examination suspecting:
Choose one answer.
a. tinea capitis.
b. tinea corporis.
c. toxic alopecia.
d. seborrheic dermatitis.
A
When incorporating the person’s spiritual values into the health history, which of the following questions illustrates the “community” portion of the FICA questions?
Choose one answer.
a. “Do you believe in God?”
b. “Are you a part of any religious or spiritual congregation?”
c. “Do you consider yourself to be a religious or spiritual person?”
d. "How does your religious faith influence the way you think about your health?”
B
During an examination, the nurse notes that a female patient has a round “moon” face, central trunk obesity, and a cervical hump. Her skin is fragile with bruises. The nurse notes that the patient has which condition?
Choose one answer.
a. Marfan’s syndrome
b. Gigantism
c. Cushing’s syndrome
d. Acromegaly
C
A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, “What causes these liver spots?” The nurse tells her:
Choose one answer.
a. “They are signs of decreased hematocrit related to anemia.”
b. “They are due to destruction of melanin in your skin from exposure to the sun.”
c. “They are clusters of melanocytes that appear after extensive sun exposure.”
d. “They are areas of hyperpigmentation related to decreased perfusion and vasoconstriction.”
C
Petechiae
Tiny punctate hemorrhages, 1-3 mm, round and discrete, dark red, purple, or brown in color
Ecchymosis (bruise)
A large patch of capillary beeding into tissues
Keloid
A hypertrophic scar
Vesicle
elevated cavity containing free fluid, up to 1 cm. Clear serum flows if wall is ruptured