Question 1

While recording in a patient's chart,the nurse notes that a patient's hematest results have been positive.This means that:

Accepted Answer

If a stool is hematest positive,it indicates the presence occult blood.

Question 2

During an examination,the patient tells the nurse that she sometimes feels as if objects are spinning around her.The nurse would note that she occasionally experiences:

Accepted Answer

Vertigo is the sensation of moving around in space (subjective)or of having objects move about the person (objective)and is a result of a disturbance of equilibrator apparatus.

Question 3

During the examination of a patient,the nurse notes that the patient has several small,flat macules on her posterior thorax.These macules are less than 1 cm wide.Another name for these macules is:

Accepted Answer

A macule is solely a color change,flat and circumscribed,less than 1 cm.

Question 4

The nurse has just recorded a positive obturator test on a patient who has abdominal pain.This test is used to confirm:

Accepted Answer

A perforated appendix irritates the obturator muscle,producing pain.

Question 5

If the nurse records the results to the Hirschberg test,the nurse has:

Accepted Answer

The Hirschberg test assesses the corneal light reflex.

Question 6

A female patient tells the nurse that she has four children and has had three pregnancies.How should the nurse document this?

Accepted Answer

Gravida refers to the number of pregnancies,and para refers to the number of children.

Question 7

Which of the following is most appropriate to perform on a 9-month-old well child?

Accepted Answer

Until the age of 12 months,the infant should be assessed for Ortolani's sign.To perform this maneuver,flex the infant's knees,holding your thumbs on the inner mid thighs and your fingers outside on the hips touching the greater trochanter.Adduct the legs until your thumbs touch and abduct the legs until the knees touch the table.If Ortolani's sign is present,it could indicate the presence of a dislocated hip.

Question 8

The nurse will measure a patient's near vision with which tool?

Accepted Answer

The Jaeger card is used to measure near vision.

Question 9

The nurse documents that a patient has coarse,thickened skin and brown discoloration over the lower legs.Pulses are present.This finding is probably the result of:

Accepted Answer

Chronic venous insufficiency would present as firm brawny edema,coarse thickened skin,normal pulses,and brown discoloration.

Question 10

When the nurse flexes the patient's knee and gently compresses the gastrocnemius muscle anteriorly against the tibia,the patient indicates that he is having calf pain.The nurse would document:

Accepted Answer

Calf pain with these maneuvers is a positive Homan's sign,which occurs in some cases of deep vein thrombosis.

Question 11

While examining a 48-year-old patient's eyes,the nurse notes that he had to move the hand-held vision screener farther away from his face.The nurse would suspect:

Accepted Answer

Presbyopia,the decrease in power of accommodation with aging,is suggested when the hand-held vision screener card is moved farther away.

Question 12

After the examination of an infant,the nurse notes opisthotonos.The nurse recognizes that this finding often occurs with:

Accepted Answer

Opisthotonos is a form of spasm in which the head is arched back,and there is stiffness of the neck and extension of the arms and legs.It occurs with meningeal or brainstem irritation.

Question 13

The nurse notes that a patient has ulcerations on the tips of the toes and on the lateral ankles.This finding would indicate:

Accepted Answer

Ulcerations on the tips of the toes and lateral ankles are indicative of arterial insufficiency.

Question 14

After assessing a female patient,the nurse notes flesh-colored,soft,pointed,moist,papules in a cauliflower-like patch around her introitus.This finding is most likely:

Accepted Answer

Human papillomavirus appears in a flesh-colored,soft,moist,cauliflower-like patch of papules.

Question 15

During the examination of a patient's mouth,the nurse observes a nodular bony ridge down the middle of the hard palate.The nurse would chart this finding as:

Accepted Answer

A normal variation of the hard palate is a nodular bony ridge down the middle of the hard palate,a torus palatinus.

Question 16

The nurse is documenting the assessment of an infant.During the abdominal assessment,the nurse noted a very loud splash auscultated over the upper abdomen when the nurse rocked her from side to side.This finding would indicate:

Accepted Answer

Succussion splash: unrelated to peristalsis,this very loud splash auscultated over the upper abdomen when the infant is rocked side to side indicates increased air and fluid in the stomach as seen with pyloric obstruction or large hiatus hernia.

Question 17

A patient tells the nurse that "sometimes I wake up at night and I have real trouble breathing.I have to sit up in bed to get a good breath." When documenting this information,the nurse would note:

Accepted Answer

Paroxysmal nocturnal dyspnea-awakens from sleep with shortness of breath and needs to be upright to achieve comfort.

Quiz 27: The Complete Health Assessment: Putting It All Together