Question 1

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.See Chapter 16.

Question 2

After assessing a female patient,the nurse notices 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.See Chapter 26.

Question 3

While examining a 48-year-old patient's eyes,the nurse notices that he had to move the handheld 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 handheld vision screener card is moved farther away.See Chapter 14.

Question 4

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.See Chapter 20.

Question 5

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 occurs when the patient awakens from sleep with shortness of breath and needs to be upright to achieve comfort.See Chapter 18.

Question 6

The nurse notices that a patient has ulcerations on the tips of the toes and on the lateral aspect of the ankles.This finding indicates:

Accepted Answer

Ulcerations on the tips of the toes and lateral aspect of the ankles are indicative of arterial insufficiency.See Chapter 20.

Question 7

During an examination,the patient tells the nurse that she sometimes feels as if objects are spinning around her.The nurse would document 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 equilibratory apparatus.See Chapter 23.

Question 8

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

Accepted Answer

A macule is solely a lesion with color change,flat and circumscribed,less than 1 cm.Macules are also known as freckles.See Chapter 12.

Question 9

After the examination of an infant,the nurse documents 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.See Chapter 23

Question 10

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

Accepted Answer

A succussion splash,which is unrelated to peristalsis,is a very loud splash auscultated over the upper abdomen when the infant is rocked side to side.It indicates increased air and fluid in the stomach as seen with pyloric obstruction or large hiatus hernia.See Chapter 21.

Question 11

For the abdominal assessment,place these assessment techniques in the correct order,with A being performed first and E being performed last. 
A)Deep palpation, all quadrants
B)Light palpation, all quadrants
C)Auscultate bowel sounds
D)Inspect abdomen for contour, skin characteristics, and pulsations
E)Percuss all quadrants

Accepted Answer

The answer of For the abdominal assessment,place these assessment techniques...

Question 12

During an examination,the nurse notices that a patient's legs turn white when they are raised above the patient's head.The nurse should suspect:

Accepted Answer

Elevational pallor (marked)indicates arterial insufficiency.See Chapter 20.

Question 13

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 should document _____ sign.

Accepted Answer

Calf pain with these maneuvers is a positive Homans' sign,which occurs in some cases of deep vein thrombosis.See Chapter 20.

Question 14

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.One pregnancy was with twins.

Question 15

While recording in a patient's medical record,the nurse notices that a patient's Hematest results are positive.This means that there:

Accepted Answer

If a stool is Hematest positive,then it indicates the presence of occult blood.See Chapter 21.

Question 16

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

Accepted Answer

A perforated appendix irritates the obturator muscle,producing pain.See Chapter 21.

Question 17

Which of these actions is most appropriate to perform on a 9-month-old infant at a well-child checkup?

Accepted Answer

Until the age of 12 months,the infant should be assessed for Ortolani's sign.If Ortolani's sign is present,it could indicate the presence of a dislocated hip.The other tests are not appropriate for a 9-month-old child.

Question 18

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

Accepted Answer

The Jaeger card is used to measure near vision.See Chapter 14.

Question 19

During examination,the nurse finds that a patient is unable to distinguish objects placed in his hand.The nurse would document:

Accepted Answer

Astereognosis is the inability to identify correctly an object placed in the hand.See Chapter 23.

Question 20

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

Accepted Answer

The Hirschberg test assesses the corneal light reflex.See Chapter 14.

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