Download NSG 6020 Midterm Questions With Complete Solutions: Nursing Assessment and Examination and more Exams Nursing in PDF only on Docsity!
NSG 6020 MidTerm Questions With Complete Solutions A patient tells the nurse that she has had abdominal pain for the past week. What would be the best response by the nurse? correct answer: "Can you point to where it hurts?" A patient's laboratory data reveal an elevated thyroxine level. The nurse would proceed with an examination of the: correct answer: Thyroid A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the examiner do first? correct answer: Auscultate the lungs and heart while the infant is still sleeping When preparing to examine a 6-year-old child, which action is most appropriate? correct answer: Start with the thorax, abdomen, and genitalia before examining the head. Avoid talking about the equipment being used because it may increase the child's anxiety. Keep in mind that a child this age will have a sense of modesty. Have the child undress from the waist up. 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble with reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that: correct answer: She may have macular degeneration
In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history? 1.Family history, hypertension, stress, age 2.Personality type, high cholesterol, diabetes, smoking 3.Smoking, hypertension, obesity, diabetes, high cholesterol 4.Alcohol consumption, obesity, diabetes, stress, high cholesterol correct answer: 3. Smoking, hypertension, obesity, diabetes, high cholesterol A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with: correct answer: a pneumothorax During a hearing assessment the nurse practitioner finds that sound lateralizes to the patient's left ear with the Weber test. What can the nurse practitioner conclude from this? correct answer: The patient has a conductive hearing loss in the right ear. Lateralization is a normal finding with the Weber test. The patient could have either a sensorineural or a conductive loss. A mistake has occurred; the test must be repeated. The most important reason to share information and offer brief teaching while performing the physical examination is to help: 1.the examiner feel more comfortable and gain control of the situation.
Which of the following statements regarding the aging adult and abdominal assessment is true? correct answer: the abdominal musculature is thinner In recording the childhood illnesses of a patient who denies having had any, which of the following notes by the nurse would be most accurate?
- Patient denies usual childhood illnesses.
- Patient states he was a "very healthy" child.
- Patient states sister had measles, but he didn't.
- Patient denies measles, mumps, rubella, chickenpox, pertussis, or strep throat. correct answer: 4. Patient denies measles, mumps, rubella, chickenpox, pertussis, or strep throat. A patient's thyroid is enlarged, and the nurse is preparing to auscultate the thyroid for the presence of a bruit. A bruit is a: correct answer: soft, whooshing, pulsatile sound best heard with the bell of the stethoscope. During an examination, the nurse knows that Paget's disease would be indicated by which of the following findings? correct answer: Paget's disease occurs more often in males and is characterized by bowed, long bones, sudden fractures, and enlarging skull bones that press on cranial nerves causing symptoms of headache, vertigo, tinnitus, and progressive deafness. A patient is unable to read the 20/100 line on the Snellen chart. The nurse practitioner would correct answer: refer the patient to an ophthalmologist or optometrist for further evaluation.
Which technique of assessment is used to determine the presence of crepitus, swelling, and pulsations? correct answer: Palpation During a cardiac assessment on an adult patient in the hospital for "chest pain," the nurse finds the following: jugular vein pulsations 4 cm above sternal angle when he is elevated at 45 degrees, BP 98/60, HR 130; ankle edema; difficulty in breathing when supine; and an S3 on auscultation. Which of the following best explains the cause of these findings? 1.Fluid overload 2.Atrial septal defect 3.Myocardial infarction 4.Heart failure correct answer: 4. heart failure Primary muscles of respiration include: correct answer: diaphragm & intercostals A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is correct answer: a hordeolum (stye). During an examination of a patient's abdomen, the nurse practitioner notes that the abdomen is rounded and firm to the touch. During percussion, the nurse practitioner notes a drum- like quality of the sound across the quadrants. This type of sound indicates: correct answer: air-filled areas.
unaffected side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, and pneumothorax. The nurse practitioner is examining a 2-year-old child and asks, "May I listen to your heart now?" Which critique of her technique is most accurate? correct answer: Children at this age like to say "No." The examiner should not offer a choice when there is none. A patient tells the nurse practitioner that he is very nervous, that he is nauseated, and that he "feels hot." This type of data would be: correct answer: Subjective During a hearing assessment the nurse practitioner finds that sound lateralizes to the patient's left ear with the Weber test. What can the nurse practitioner conclude from this? correct answer: the patient has conductive hearing loss in the right ear During an admission assessment, the nurse practitioner notices that a male patient has an enlarged and rather thick skull. The nurse practitioner suspects acromegaly and would further assess for correct answer: coarse facial features While performing a well-child assessment on a 5-year-old, the nurse practitioner notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0. cm in size, round, mobile, and nontender. The nurse practitioner suspects that this: correct answer: normal finding During an examination of a patient in her third trimester of pregnancy, the nurse practitioner notices that the patient's
thyroid gland is slightly enlarged. No enlargement had been noted previously. The nurse practitioner suspects that correct answer: The thyroid gland enlarges slightly during pregnancy owing to hyperplasia of the tissue and increased vascularity. What is responsible for the inspiratory splitting of S2? correct answer: Closure of aortic, then pulmonic valves A 25-year-old optical technician comes to your clinic for evaluation of fatigue. As part of your physical examination, you listen to her heart and hear a murmur only at the cardiac apex. Which valve is most likely to be involved, based on the location of the murmur? correct answer: Mitral A 58-year-old teacher presents to your clinic with a complaint of breathlessness with activity. The patient has no chronic conditions and does not take any medications, herbs, or supplements. Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems? correct answer: Orthopnea You are screening people at the mall as part of a health fair. The first person who comes for screening has a blood pressure of 132/85. How would you categorize this? correct answer: Prehypertension You are evaluating a 40-year-old banker for coronary heart disease risk factors. He has a history of hypertension, which is well-controlled on his current medications. He does not smoke; he does 45 minutes of aerobic exercise five times weekly. You are calculating his 10-year coronary heart disease risk. Which of
You are concerned that a patient has an aortic regurgitation murmur. Which is the best position to accentuate the murmur? correct answer: Upright, but leaning forward Where is the point of maximal impulse (PMI) normally located? correct answer: In the left 5th intercostal space, 7 to 9 cm lateral to the sternum Which of the following events occurs at the start of diastole? correct answer: Closure of the aortic valve Which is true of a third heart sound (S3)? correct answer: It is caused by rapid deceleration of blood against the ventricular wall. Which is true of splitting of the second heart sound? correct answer: It is best heard over the pulmonic area with the bell of the stethoscope In healthy adults over 20, how often should blood pressure, body mass index, waist circumference, and pulse be assessed, according to American Heart Association guidelines? correct answer: Every 2 years You find a bounding carotid pulse on a 62-year-old patient. Which murmur should you search out? correct answer: Aortic insufficiency To hear a soft murmur or bruit, which of the following may be necessary? correct answer: Asking the patient to hold her breath
Make sure the room is quiet when you perform the assessment Checking your stethoscope for air leaks (ALL) Which of the following may be missed unless the patient is placed in the left lateral decubitus position and auscultated with the bell? correct answer: Mitral stenosis murmur Opening snap of the mitral valve S3 and S4 gallops (all) How should you determine whether a murmur is systolic or diastolic? correct answer: Palpate the carotid pulse. You are listening carefully for S2 splitting. Which of the following will help? correct answer: Using the bell with light pressure over the 2nd left intercostal space A 78-year-old retired seamstress comes to the office for a routine check-up. She was obtained an ECG (electrocardiogram) because of her history of hypertension. She was diagnosed of a myocardial infarction, You ask her if she had any symptoms related to this. Which of the following symptoms would be more common in this patient's age group for an myocardial infarction? correct answer: Syncope A patient comes to the emergency room for evaluation of shortness of breath. To which anatomic region would you assign the symptom? correct answer: Cardiac patient presents for evaluation of a cough. Which of the following anatomic regions can be responsible for a cough? correct answer: Cardiac
following is actually an extra-articular structure? correct answer: Tendons Louise, a 60-year-old, complains of left knee pain associated with tenderness throughout, redness, and warmth over the joint. Which of the following is least helpful in determining if a joint problem is inflammatory? correct answer: Pain An infant presents with a heart rate of 180, a respiratory rate of 68, and an enlarged liver. What diagnosis does this suggest? correct answer: Heart failure You are assessing an infant and notice that his nares flare, he has a soft grunt with each breath, and the skin between his ribs is pulled inward with inhalation. What is the significance of these findings? correct answer: These are indicative of respiratory distress. Which of the following correlates with a sustained, high- amplitude point of maximal impulse (PMI)? correct answer: Hypertension A 68-year-old woman with hypertension and diabetes is seen by the nurse practitioner for a dry cough that worsens at night when she lies in bed. She has shortness of breath, which worsens when she exerts herself. The patient's pulse rate is 90/min and regular. The patient has gained 6 lbs over the past two months. She is on a nitroglycerine patch and furosemide daily. The explanation for her symptoms is: correct answer: Congestive heart failure
During a routine physical exam of a 90 year old woman, a low- pitched diastolic murmur grade II/VI is auscultated. It is located on the fifth intercostal space on the left side of the midclavicular line. Which is the following is the correct diagnosis? correct answer: Mitral stenosis You are performing a cardiac examination on a patient with shortness of breath and palpitations. You have the patient turn onto his left side in the left lateral decubitus position to listen to the heart. Which of the following valvular defects is best heard in this position? correct answer: Mitral A 78-year-old retired seamstress comes to the office for a routine check-up. You obtain an ECG (electrocardiogram) because of her history of hypertension. You diagnose a previous myocardial infarction and ask her if she had any symptoms related to this. Which of the following symptoms would be more common in this patient's age group for an acute myocardial infarction? correct answer: Syncope The nurse is participating in a health fair and performing cholesterol screens. One person has hypercholesterolemia. She is concerned about her risk for developing heart disease. Which of the following factors is used to estimate the 10-year risk of developing coronary heart disease correct answer: Gender - men have a higher risk than women excess fluid in pericardial cavity - caused by blunt trauma, pericarditis, myocardial rupture; life-threatening correct answer: cardiac tamponade
