Question 1

The nurse is urgently called to the gymnasium regarding an injured student.The student is crying in severe pain with a malformed fractured lower leg.The proper sequence for the nurse's initial assessment is

Accepted Answer

Inspection is the use of vision and hearing to distinguish normal from abnormal findings.Light palpation determines areas of tenderness and skin temperature,moisture,and texture.Deep palpation is used to examine the condition of organs,such as those in the abdomen.Caution is the rule with deep palpation.Deep palpation is done after light palpation.Auscultation is used to evaluate sound.

Question 2

A parent calls the school nurse with questions regarding the recent school vision screening.Snellen chart examination revealed 20/60 for both eyes.Considering the visual acuity results,the nurse informs the parent that the child

Accepted Answer

Normal vision is 20/20.The larger the denominator,the poorer the patient's visual acuity.For example,a value of 20/60 means that the patient,when standing 20 feet away,can read a line that a person with normal vision can read from 60 feet away.Strabismus is a (congenital)condition in which both eyes do not focus on an object simultaneously: These eyes appear crossed.Acuity may not be affected.Presbyopia is impaired near vision that occurs in middle-aged and older adults and is caused by loss of elasticity of the lens.Cataracts develop slowly and progressively after age 35 or suddenly after trauma.

Question 3

A febrile preschool-aged child presents to the after-hours clinic.Varicella is diagnosed on the basis of the illness history and the presence of small,circumscribed skin lesions filled with serous fluid.The nurse documents the varicellar lesions as which type of skin lesion?

Accepted Answer

Vesicles are circumscribed,elevated skin lesions filled with serous fluid that measure less than 1 cm.Wheals are irregularly shaped,elevated areas of superficial localized edema that vary in size.They are common with bug bits and hives.Papules are palpable,circumscribed,solid elevations in the skin that are smaller than 1 cm.Pustules are elevations of skin similar to vesicles,but they are filled with pus.

Question 4

Objective physical data describe air moving through small airways over the lung's periphery.The expected inspiratory-to-expiratory phase of this normal vesicular breath sound is which of the following?

Accepted Answer

Vesicular breath sounds are normal breath sounds; the inspiratory phase is three times longer than the expiratory phase.Bronchovesicular breath sounds have an inspiratory phase equal to the expiratory phase.Bronchial breath sounds have an expiration phase longer than the inspiration phase at a 3:2 ratio.

Question 5

On admission,a patient weighs 250 pounds.The weight is recorded as 256 pounds on the second inpatient day.The nurse should evaluate the patient for

Accepted Answer

This patient has gained 6 pounds in a 24-hour period.A weight gain of 5 pounds (2.3 kg)or more in a day indicates fluid retention problems.A downward trend may indicate a reduction in nutritional reserves that may be caused by decreased intake such as anorexia or by fluid loss.

Question 6

A head and neck physical examination is completed on a 50-year-old female patient.All physical findings are normal except for fine brittle hair.Based on the physical findings,which of the following laboratory tests would the nurse expect to be ordered?

Accepted Answer

Thyroid disease can make hair thin and brittle.Liver function testing is indicated for a patient who has jaundice.Lead levels and a CBC are not indicated for the presence of brittle hair.

Question 7

Which is the best examination position for a complete geriatric physical examination on a weak patient with bilateral basilar pneumonia?

Accepted Answer

This is the most normally relaxed position.It will not compromise the patient's breathing because it is likely compromised with pneumonia.If the patient becomes short of breath easily,raise the head of the bed.This position would be easiest for an elderly weak person to get into position for an examination.Lateral recumbent and prone positions cause respiratory difficulty for any patient with respiratory difficulties.Sims' position is used for assessment of the rectum and the vagina.

Question 8

A male student comes to the college health clinic.He hesitantly describes that his testis has lumps.The nurse recognizes this as a potential sign of which of the following?

Accepted Answer

Irregular lumps of the testes may indicate testicular cancer.Testicular cancer is cancer that begins in the testicles.Testicular cancer is the most common form of cancer in men between the ages of 15 and 35 years.A hernia presents with bulging in the scrotum.Sexually transmitted infections often present with genital lesions.Use of diuretics,sedatives,or antihypertensives can cause difficulty in achieving erection or ejaculation but does not usually cause lumps.

Question 9

A nurse is a preceptor for a nurse who just graduated from nursing school.When caring for a patient,the new graduate nurse begins to explain to the patient the purpose of completing a physical assessment.Which of the following statements made by the new graduate nurse requires the preceptor to intervene?

Accepted Answer

Nursing assessment data are used to evaluate the effectiveness of all aspects of a patient's care,not just the patient's medical care.Assessment data help to evaluate the effectiveness of medications and to determine a patient's health care needs,including the need for patient education.Nurses also use assessment data to identify patients' psychosocial and cultural needs.

Question 10

During an annual gynecological examination,a college student discusses her upcoming college break at a tropical location.After the student receives an oral contraceptive prescription,the nurse identifies the importance of skin cancer prevention education by discussing which evidence-based prevention health topic?

Accepted Answer

Oral contraceptives can make the skin more sensitive to the sun.For this reason,the patient should be educated about the need for sun protection such as wide-brimmed hats,use of broad-spectrum sunscreen of SPF 15 or greater,not tanning during midday,and not using tanning beds.Broad-spectrum sunscreens should be applied 15 minutes before going into the sun and after swimming or perspiring.Tanning parlors,sunlamps,etc.,should be avoided.Sunscreens with SPF of 15 or greater should be used.

Question 11

The patient is a 50-year-old African American male who has come in for his routine annual physical.Which of the following preventive screenings does the nurse recommend?

Accepted Answer

Men need to have a digital rectal examination of the prostate every year beginning at 50 years of age.Ca125 blood tests are indicated for women at high risk for ovarian cancer.Because this patient is a man,Ca125 is not needed.Patients over the age of 65 need to have complete eye examinations yearly.Colonoscopy every 10 years is recommended in patients 50 years of age and older.

Question 12

Having misplaced his stethoscope,a nurse borrows a colleague's stethoscope.He next enters the patient's room and identifies himself,washes his hands with soap,and states the purpose of his visit.He performs proper identification of the patient before he auscultates her lungs.Which critical health assessment step was not performed?

Accepted Answer

Bacteria and viruses can be transferred from patient to patient when a stethoscope that is not clean is used.The stethoscope should be cleaned before use on each patient.Running water over the stethoscope does not kill bacteria.Betadine is an inappropriate cleaning solution and may damage the equipment.Hand sanitizer is not an approved cleaning product.

Question 13

A school nurse recognizes a belt buckle-shaped ecchymosis on a 7-year-old student.When privately asked about how the injury occurred,the student described falling on the playground.Upon suspecting abuse,the school nurse's best next action is which of the following?

Accepted Answer

Most states mandate a report to a social service center if nurses suspect abuse or neglect.When abuse is suspected,the nurse interviews the patient in private.Abuse of children,women,and older adults is a growing health problem.It is difficult to detect abuse because victims often will not complain or report that they are in an abusive situation.

Question 14

During a school physical examination,the nurse reviews the patient's current medical history.With a positive medical history of asthma,eczema,and allergic rhinitis,the nurse expects which physical finding on nasal examination?

Accepted Answer

Pale nasal mucosa with clear mucoid discharge indicates allergic rhinitis.Polyps are tumorlike growths.Yellow discharge would be seen with infection.Habitual use of intranasal cocaine and opioids causes puffiness and increased vascularity of the nasal mucosa.

Question 15

The nurse is caring for a female victim of rape.To perform the proper evaluation,the nurse should place the patient in which of the following positions?

Accepted Answer

Lithotomy is the position for examination of female genitalia.The lithotomy position provides for the maximum exposure of genitalia and allows the insertion of a vaginal speculum.Sitting does not allow adequate access for speculum insertion and is better used to visualize upper body parts.Dorsal recumbent is used to examine the head and neck,anterior thorax and lungs,breasts,axillae,heart,and abdomen.Knee-chest provides maximal exposure of the rectal area but is embarrassing and uncomfortable.

Question 16

An elderly patient is being seen for a chronic entropion.The nurse realizes that entropion places the patient at risk for which of the following?

Accepted Answer

The diagnosis of entropion can lead to lashes of the lids irritating the conjunctiva and cornea.Irritation can lead to infection.Ectropion is when the eyelid margins turn out so that the lashes do not irritate the conjunctiva.Exophthalmos is a bulging of the eyes and usually indicates hyperthyroidism.Strabismus,or crossing of the eyes,results from neuromuscular injury or inherited abnormalities.

Question 17

During a routine pediatric history and physical,the parents report that their child was a premature infant and was so small that he had to stay in the neonatal intensive care unit longer than usual.They state that the infant was yellow when born,and that he developed an infection that required "every antibiotic under the sun" to cure him.Considering the neonatal history,the nurse determines that it is especially important to perform a focused _____ examination.

Accepted Answer

Risk factors for hearing problems include low birth weight,nonbacterial intrauterine infection,and excessively high bilirubin levels.Hearing loss due to ototoxicity (injury to auditory nerves)can result from high maintenance doses of antibiotics.Cardiac,respiratory,and eye examinations are important assessments but are not relevant to this child's condition.

Question 18

During a sexually transmitted illness presentation to high school students,the nurse recommends the HPV vaccine series to prevent

Accepted Answer

Human papillomavirus (HPV)infection increases the person's risk for cervical cancer.HPV vaccine is recommended by the American Cancer Society for females aged 9 to 26 years.Vaginal discharge,painful or swollen perianal tissues,and genital lesions are signs and symptoms that may indicate a sexually transmitted infection.

Question 19

An advanced practice nurse is preparing to assess the external genitalia of a 25-year-old American woman of Chinese descent.Which of the following nursing actions does the nurse do first?

Accepted Answer

Patients who are Chinese American often believe that examination of the external genitalia is offensive.Before proceeding with the examination,the nurse first determines how the patient feels about the procedure and explains the procedure to answer any questions and to help the patient feel comfortable with the assessment.Once the patient is ready to have her external genitalia examined,the nurse places the patient in the lithotomy position and drapes the patient appropriately.Typically,nurses ask adolescents if they want a parent present during the examination.The patient in this question is 25 years old,so she is not an adolescent.Asking her if she would like her mother to be present is inappropriate.

Question 20

A nurse identifies Pediculosis humananus capitis.Considering the possible complications of treatment,the nurse knows to not use which of the following treatment products?

Accepted Answer

Products containing lindane,a toxic ingredient,often cause adverse reactions.Instruct patients who have head lice to shampoo thoroughly with pediculicide (shampoo available at drugstores)in cold water,comb thoroughly with a fine-toothed comb,and discard the comb.A dilute solution of vinegar and water helps loosen nits.

Quiz 78: Health Assessment and Physical Examination