Question 1

The nurse considers several new female patients to receive additional health education on the need for more frequent Pap smears and gynecological examinations.Which of the following assessment findings reveals the patient at highest risk for cervical cancer and thus having the greatest need for patient education?

Accepted Answer

Females considered to be at higher risk include those who smoke and are over 21 with weak immune systems,multiple sex partners,and a history of sexually transmitted infections.Of all the assessment findings listed,the 22-year-old smoker with multiple sexual partners has the greatest number of risk factors for cervical cancer.The other patients are at lower risk.

Question 2

During a routine physical examination of a 70-year-old patient,a blowing sound is auscultated over the carotid artery.The nurse notifies the medical provider of the unexpected physical finding known as

Accepted Answer

A bruit is the sound of turbulence of blood passing through a narrowed blood vessel.A bruit can reflect cardiovascular disease in the carotid artery of middle-aged to older adults'.Clubbing is due to insufficient oxygenation at the periphery resulting from conditions such as chronic emphysema and congenital heart disease; it is noted in the nails.Jugular venous distention,not bruit,is a possible sign of right-sided heart failure.Some patients with heart disease have distended jugular veins when sitting.Phlebitis is an inflammation of a vein that occurs commonly after trauma to the vessel wall,infection,immobilization,and prolonged insertion of IV catheters.It affects predominantly peripheral veins.

Question 3

The patient is a 54-year-old male with a medium frame.He weighs 148 pounds and is 5 feet 8 inches tall.The nurse realizes that this patient is

Accepted Answer

According to the Metropolitan Life Insurance Company Statistical Bulletin,a male of medium frame who is 5 feet 8 inches tall should weigh between 145 and 157 pounds.This patient is at his desired weight.He is not overweight,underweight,or obese.

Question 4

A patient in the emergency department is complaining of left lower abdominal pain.The comprehensive abdominal examination would include,in proper order,which of the following?

Accepted Answer

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

Question 5

A teen female patient reports intermittent abdominal pain for 12 hours.No dysuria is present.When performing an abdominal assessment,the nurse should

Accepted Answer

Black or tarry stools (melena)indicate gastrointestinal alteration.The nurse should caution patients about the dangers of excessive use of laxatives or enemas.Determine if the patient is pregnant,and note her last menstrual period.Pregnancy causes changes in abdominal shape and contour.Assess painful areas last to minimize discomfort and anxiety.

Question 6

The best term for breath sounds created by air moving through large lung airways is

Accepted Answer

Bronchovesicular breath sounds are created by air moving through large airways.Vesicular sounds are created by air moving through smaller airways.Bronchial sounds are created by air moving through the trachea close to the chest wall.Rhonchi are abnormal lung sounds that are loud,low-pitched,rumbling coarse sounds heard during inspiration or expiration that sometimes clear by coughing.

Question 7

The paramedics transport an adult involved in a motor vehicle accident to the emergency department.On physical examination,the patient's level of consciousness is reported as opening eyes to pain and responding with inappropriate words and flexion withdrawal to painful stimuli.The nurse correctly identifies the patient's Glasgow Coma Scale score as

Accepted Answer

According to the guidelines of the Glasgow Coma Scale,the patient has a score of 9.Opening eyes to pain is 2 points; inappropriate word use is 3 points; and flexion withdrawal is 4 points.The total for this patient is 2 + 3 + 4 = 9.

Question 8

In preparation for a rectal examination of a nonambulatory male patient,the patient is informed of the need to be placed in which position?

Accepted Answer

Nonambulatory patients are best examined in a side-lying Sims' position.Forward bending would require the patient to be able to stand upright.Knees to chest would be difficult to maintain in a nonambulatory male and is embarrassing and uncomfortable.Dorsal recumbent does not provide adequate access for a rectal examination and is used for abdominal assessment because it promotes relaxation of abdominal muscles.

Question 9

The patient presents to the clinic with dysuria and hematuria.How does the nurse proceed to assess for kidney inflammation?

Accepted Answer

With the patient sitting or standing erect,use direct or indirect percussion to assess for kidney inflammation.With the ulnar surface of the partially closed fist,percuss posteriorly the costovertebral angle at the scapular line.If the kidneys are inflamed,the patient feels tenderness during percussion.Use a systematic palpation approach for each quadrant of the abdomen to assess for muscular resistance,distention,abdominal tenderness,and superficial organs or masses.Light palpation would not detect kidney tenderness because the kidneys sit deep within the abdominal cavity.Posteriorly,the lower ribs and heavy back muscles protect the kidneys,so they cannot be palpated.Kidney inflammation will not cause abdominal movement.However,to inspect the abdomen for abnormal movement or shadows,the nurse should stand on the patient's right side and inspect from above the abdomen using direct light over the abdomen.

Question 10

A nurse is assessing a patient's hearing.Which of the following items does the nurse gather before conducting the assessment?

Accepted Answer

The nurse uses a tuning fork when conducting the Weber test to assess lateralization of sound and the Rinne test to assess air and bone conduction-two tests used to assess hearing.A current list of patient medications is needed to determine whether the patient is taking any medications,such as antibiotics,that could possibly cause ototoxicity.Cotton-tipped applicators are not used during an ear examination; instead they are sometimes used to assess the patient's ability to distinguish sharp from dull sensations.Ophthalmoscopes and Snellen charts are used during a visual examination.

Question 11

The school nurse is assessing the tympanic membranes of a 3-year-old child.Which of the following demonstrates proper technique?

Accepted Answer

Using the inverted otoscope grip while pulling the auricle downward is a common approach with child examinations because it prevents accidental movement of the otoscope deeper into the ear canal,as could occur with an unexpected pediatric reaction to the ear examination.The other techniques could result in injury to the child's tympanic membrane.

Question 12

A nurse suspects an abnormal thyroid shape during the physical examination.The nurse offers the patient a glass of water and observes her drinking to

Accepted Answer

This technique is used to visual an abnormally large thyroid gland.Normally,the thyroid cannot be visualized.An exostosis is a bony growth between the two palates that is noted when the oral cavity is examined.The patient's gag reflex is tested by placing a tongue depressor on the posterior tongue.The uvula and soft palate are visualized by using a penlight.Both structures should rise centrally as the patient says,"Ah."

Question 13

The patient has had a stroke that has affected her ability to speak,and she becomes extremely frustrated when she tries to speak.She responds correctly to questions and instructions but cannot form words coherently.This patient is showing signs of _____ aphasia.

Accepted Answer

The two types of aphasia are sensory (or receptive)and motor (or expressive).The patient cannot express herself in words and is showing signs of expressive aphasia.She responds correctly to questions and instructions,indicating that she does not have receptive or sensory aphasia.Patients sometimes suffer a combination of receptive and expressive aphasia,but this is not the case here.

Question 14

During a preschool readiness examination,the nurse prepares to perform visual acuity screenings.Given the children's age,the best equipment to test central vision is which of the following?

Accepted Answer

The E chart is used when an individual is unable to read,as would be the case for a preschool-aged child.A Snellen chart and a reading test are too advanced for a preschooler's education level.A penlight is used to check light perception.Shine a penlight into the eye,and then turn it off.If the patient notes when the light is turned on or off,light perception is intact.

Question 15

Asking an adult what the statement "A stitch in time saves nine" means to him is a mental status examination technique used to assess

Accepted Answer

For an individual to explain common phrases such as "A stitch in time saves nine" requires a higher level of intellectual function.Knowledge-based assessment is factual.Assess knowledge by asking how much the patient knows about his illness or the reason for seeking health care.To assess past memory,ask the patient to recall the maiden name of the patient's mother,a birthday,or a special date in history.It is best to ask open-ended questions rather than simple yes/no questions.Patients demonstrate immediate recall by repeating a series of numbers in the order in which they are presented or in reverse order.

Question 16

An elderly patient has been on high doses of antibiotics and is experiencing a sudden loss of hearing.The nurse should contact the health care provider and

Accepted Answer

Older adults are especially at risk for hearing loss due to ototoxicity (injury to auditory nerve)resulting from high maintenance doses of antibiotics (e.g.,aminoglycosides).Continuation of the medications is a physician responsibility.Older adults experience an inability to hear high-frequency sounds and consonants.Deterioration of the cochlea and thickening of the tympanic membrane cause older adults to gradually lose hearing acuity.

Question 17

The advanced practice nurse is conducting a comprehensive eye examination on an 80-year-old African American woman.Which of the following findings requires the nurse to contact the patient's physician for further examination?

Accepted Answer

Dilated pupils result from glaucoma,trauma,neurological disorders,eye medication,or withdrawal from opioids.Shining a beam of light through the pupil and onto the retina stimulates the third cranial nerve and causes the muscles of the iris to constrict.Any abnormality along the nerve pathways from the retina to the iris alters the ability of the pupils to react to light.A thin white ring along the margin of the iris,called an arcus senilis,is common with aging but is abnormal in anyone younger than age 40.The pupils are normally black,round,regular,and equal in size.The fundus of African American patients can be black.

Question 18

A teen patient is tearful and reports locating lumps in her breasts.Other history obtained is that she is currently menstruating.Physical examination reveals soft and movable cysts in both breasts that are painful to palpation.The nurse also notes that the patient's nipples are erect,but the areolae are wrinkled.The next nursing step is which of the following?

Accepted Answer

A common benign condition of the breast is benign (fibrocystic)breast disease.This patient has symptoms of fibrocystic disease,which include bilateral lumpy,painful breasts sometimes accompanied by nipple discharge.Symptoms are more apparent during the menstrual period.When palpated,the cysts (lumps)are soft,well differentiated,and movable.Deep cysts feel hard.Although a common condition,benign breast disease is not normal; therefore,the nurse does not tell the patient that this is a normal finding.During examination of the nipples and areolae,the nipple sometimes becomes erect with wrinkling of the areola.Therefore,consulting a breast surgeon to treat her nipples and areolae is not appropriate.

Question 19

During a genitourinary examination of a 30-year-old male patient,the nurse identifies a small amount of a white,thick substance on the patient's uncircumcised glans penis.The nurse's next step is to

Accepted Answer

A small amount of thick,white smegma sometimes collects under the foreskin in the uncircumcised male.Penile pain or swelling,genital lesions,and urethral discharge are signs and symptoms that may indicate STI.All men 15 years and older need to perform a male-genital self-examination monthly.The nurse needs to assess a patient's sexual history and use of safe sex habits.Sexual history reveals risks for STI and HIV.

Question 20

While assessing the skin of an 82-year-old male patient,a nurse discovers nonpainful ruby red papules on the patient's trunk.What is the nurse's next action?

Accepted Answer

The skin is normally free of lesions,except for common freckles or age-related changes such as skin tags,senile keratosis (thickening of skin),cherry angiomas (ruby red papules),and atrophic warts.Basal cell carcinoma is most common in sun-exposed areas and frequently occurs in a background of sun-damaged skin; it almost never spreads to other parts of the body.Squamous cell carcinoma is more serious than basal cell and develops on the outer layers of sun-exposed skin; these cells may travel to lymph nodes and throughout the body.Report abnormal lesions to the health care provider for further examination.Edema is an area of skin that becomes swollen or edematous from a buildup of fluid in the tissues.This has nothing to do with cherry angiomas.

Quiz 78: Health Assessment and Physical Examination