Question 1

What should the nurse do when preparing to complete an assessment for a 16-year-old patient?

Accepted Answer

The nurse should treat the patient as an individual, respecting their autonomy and privacy, especially at 16 years old, where they are developing independence and self-identity.

Question 2

What technique should the nurse implement for assessment of the carotid artery?

Accepted Answer

The nurse should palpate each carotid artery separately to assess for any abnormalities or differences in pulse strength. Massaging the arteries briskly can be harmful and increase the risk of stroke in patients with carotid artery disease. Using the diaphragm of the stethoscope is appropriate for auscultation of heart sounds, but not for assessing the carotid artery. Placing the patient in a supine position may help assess for jugular venous distension, but not the carotid artery.

Question 3

The nurse is preparing to examine a patient who has chronic lung disease.She realizes that the patient most likely will need to be in which position for the examination?

Accepted Answer

Patients with chronic lung disease often have difficulty breathing when lying flat, making sitting upright the most appropriate position for examination. This allows for maximum expansion of the lungs and ease of breathing.

Question 4

How should the nurse document an exaggeration of the posterior curvature of the thoracic spine found during the assessment of a 90-year-old patient?

Accepted Answer

Kyphosis is an exaggeration of the posterior curvature of the thoracic spine, commonly seen in elderly patients. Lordosis is an exaggeration of the anterior curvature of the lumbar spine, usually seen during pregnancy or in individuals with obesity. Osteoporosis is a condition characterized by low bone density and increased risk of fracture. Scoliosis is a lateral curvature of the spine, which may be present at birth or develop during childhood or adolescence.

Question 5

Which technique is most appropriate for a nurse to implement during the assessment of the abdomen?

Accepted Answer

Auscultating for 5 minutes over each quadrant allows the nurse to assess bowel sounds and any potential abnormalities in each area, without causing discomfort to the patient. Assessing painful areas first may cause unnecessary discomfort and may cause the patient to tense their abdominal muscles, hindering the examination. Positioning the patient in a supine position with the arms behind or over the head may also cause discomfort and may also cause the abdominal muscles to tense up. Palpating painful masses or organ enlargement deeply and firmly may cause pain and discomfort to the patient, and can also exacerbate any underlying conditions.

Question 6

In providing a physical assessment of an 88-year-old patient,the nurse should

Accepted Answer

Inclusion of a review of mental status is highly recommended when the nurse performs an examination of an older adult.Allow extra time,and be patient,relaxed,and unhurried with older adults.Do not assume that aging is always accompanied by illness or disability.Older adults are able to adapt to change and to maintain functional independence.Provide adequate space for an examination,particularly if the patient uses a mobility aid.

Question 7

The nurse is caring for a patient who is recovering from an acute myocardial infarction.While providing cardiac education,the nurse realizes that the patient needs more education when he

Accepted Answer

The patient needs more education because taking medication only when experiencing chest pain or a high heart rate is not typically how cardiac medications are prescribed. Regular, consistent use is often necessary to manage heart conditions effectively.

Question 8

Where is the pulmonic area for auscultation found?

Accepted Answer

The pulmonic area for auscultation is found in the second intercostal space on the left side, where the pulmonary artery is located.

Question 9

Which of the following is an expected outcome for a patient after cardiac assessment?

Accepted Answer

The point of maximal impulse (PMI) being palpable at the left fifth intercostal space at the midclavicular line is a normal finding in a cardiac assessment.

Question 10

While performing a cardiovascular assessment on a patient with suspected left-sided congestive heart failure,the nurse is unable to palpate the point of maximal impulse (PMI)with the patient lying supine.What might her next step be?

Accepted Answer

Having the patient turn onto his left side (left lateral decubitus position) can bring the heart closer to the chest wall, making the PMI easier to palpate.

Question 11

Measurement of the patient's ability to differentiate between sharp and dull sensations over the forehead tests which cranial nerve?

Accepted Answer

The trigeminal nerve is responsible for sensory innervation of the face, including the forehead. Testing the patient's ability to differentiate between sharp and dull sensations over the forehead is a test of the trigeminal nerve's sensory function. The abducens nerve controls lateral eye movement, the facial nerve controls facial expression and taste for the anterior two-thirds of the tongue, and the oculomotor nerve controls most of the extraocular muscles.

Question 12

Which of the following is an unexpected finding after a cardiac assessment?

Accepted Answer

Murmurs are sustained swishing or blowing sounds heard at the beginning,middle,or end of systole or diastole.They are caused by increased blood flow through a normal valve,forward flow through a stenotic valve or into a dilated vessel or chamber,or backward flow through a valve that fails to close.Expected outcomes following completion of procedure: Heart rate is between 60 and 100 beats per minute (adolescent through adult)and without extra sounds or murmurs;jugular veins distend when patient lies supine and flatten when patient is in sitting position;and point of maximal impulse (PMI)is palpable at fifth intercostal space at left midclavicular line in the adult.

Question 13

The nurse is assessing the patient by grasping a fold of skin on his forearm.She notices that the skin remains suspended for a longer than normal period.What could this indicate?

Accepted Answer

Grasping a fold of skin on the forearm and noticing that it remains suspended for a longer than normal period indicates poor skin turgor, which is commonly seen in dehydration.

Question 14

Which is the best position in which to place the patient to hear low-pitched cardiovascular sounds?

Accepted Answer

The left lateral recumbent position is the best position to hear low-pitched cardiovascular sounds, such as the S3 and S4 heart sounds, because it brings the heart closer to the chest wall. This position also decreases the interference of body sounds from the stomach and intestines.

Question 15

The general survey begins with a review of the patient's primary health problems and an evaluation of the patient's vital signs,height and weight,general behaviour,and appearance.It also provides information about the patient's illness,hygiene,skin condition,body image,and emotional state.Which of the following cannot be delegated to unregulated care providers (UCP)?

Accepted Answer

The answer of The general survey begins with a review...

Question 16

Which of the following may an unregulated care provider (UCP)be responsible for determining?

Accepted Answer

The answer of Which of the following may an unregulated...

Question 17

The patient is admitted with fever and acute lower abdominal pain.He has taken Tylenol but says he still feels feverish.Before taking the patient's temperature,the nurse may

Accepted Answer

The dorsum (back)of the hand is more sensitive to temperature variations.The pads of the fingertips detect subtle changes in texture,shape,size,consistency,and pulsation of body parts.Bimanual palpation involves one hand placed over the other while pressure is applied.The upper hand exerts downward pressure as the other hand feels the subtle characteristics of underlying organs and masses.Seek the assistance of a qualified instructor before attempting deep palpation.Percussion involves tapping the body with the fingertips to evaluate the size,borders,and consistency of body organs and to discover fluid in body cavities.

Question 18

The patient is diagnosed with Bell's palsy.The nurse assesses the patient and notices drooping of the patient's right eye and the right side of his mouth.When the functions of the following cranial nerves (CNs)are compared,the most likely cause of these symptoms would be a dysfunction of the

Accepted Answer

Bell's palsy is caused by dysfunction of the facial nerve (CN VII), which controls the muscles of facial expression, leading to drooping of the affected side of the face.

Question 19

Petechiae are noted on the patient as a result of the nurse finding

Accepted Answer

Petechiae are pinpoint-sized red dots that appear on the skin due to bleeding under the skin.

Question 20

The nurse is visiting the patient for the first time this shift.She introduces herself and asks the patient several questions related to his condition.While doing so,and without being obvious,she is looking at the colour of his eyes and is assessing his ears and nose for discharge and the symmetry of his mouth.Which assessment technique is the nurse using?

Accepted Answer

The nurse is using inspection, which involves visually examining the patient for any signs of abnormalities or changes in condition.

Quiz 8: Health Assessment