Health Assessment (Final Exam Review; Jarvis 6th Ed.

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1. A 45-year-old mother of two children is seen at the clinic for complaints of "losing my urine when I sneeze." The nurse documents that she is experiencing:

A. enuresis. B. stress incontinence. C. urinary frequency. D. urge incontinence. : B. stress incontinence. 2. A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says he "can't always tell where the sound is coming from" and the words often sound "mixed up." What might the nurse suspect as the cause for this change? A. Cilia becoming coarse and stiff B. Nerve degeneration in the inner ear C. Scarring of the tympanic membrane D. Atrophy of the apocrine glands : B. Nerve degeneration in the inner ear 3. A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting she gets "really dizzy" and feels like she is going to fall over. The nurse's best response would be:

A. "I'll refer you for a complete neurologic examination." B. "Have you been extremely tired lately?" C. "You need to get up slowly when you've been lying or sitting." D. "You probably just need to drink more liquids." : C. "You need to get up slowly when you've been lying or sitting" 4. A nurse notices that a patient has ascites, which indicates the presence of:

A. flatus.

fibroid tumors. 3. 6. : C. Increased blood pressure and pulse B. Bell's palsy. 3. 3. 5. damage to the trigeminal nerve. 2. 1 C. D. 8. : D. The nurse would record this information as gravida _____. 1 : A. 1 7. cutaneous. The nurse suspects: A. A patient has had three pregnancies and two live births. C. 3. Which of these assessment findings indicates an acute pain response to poorly controlled pain? A. fluid. A patient has been admitted to the hospital with vertebral fractures related to osteoporosis. referred. 2. scleroderma. deep somatic. feces. D.B. A. C. : A. 0 D. 2. damage to the trigeminal nerve. D. visceral. deep somatic. 2. C. She is in extreme pain. A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. para _____. frostbite with resultant paresthesia to the cheeks. 1 B. Confusion . B. 2. AB _____. This type of pain would be classified as: A. fluid. A patient states that the pain medication is "not working" and rates his postoperative pain at a 10 on a 1 to 10 scale. 3. B.

The sensory cortex does not have the ability to localize pain in the heart. conduct vibrations of sounds to the inner ear. : B. Hyperventilation D. B. arms. B. adrenal B. There is a lesion in the dorsal root that is preventing the sensation from being transmitted normally. 11. conduct vibrations of sounds to the inner ear. Depression : A. parathyroid D. thyroid : D. As a part of the interview. interpret sounds as they enter the ear.C. so the pain is felt elsewhere. A patient's laboratory data reveal an elevated thyroxine level. so the pain is felt elsewhere. 10. A. D. A patient with a middle ear infection asks the nurse. thyroid 12. maintain balance. There is a problem with the sensory cortex and its ability to discriminate the location. The nurse knows that the statement that best explains why this occurs is which of these? A. The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing pain. D. or jaw. A patient with lack of oxygen to his heart will have pain in his chest and possibly the shoulder. Increased blood pressure and pulse 9. C. "What does the middle ear do?" The nurse responds by telling the patient that the middle ear functions to: A. The nurse would proceed with an examination of the _____ gland. A woman states that 2 weeks ago she had a urinary tract infection that was treated with an antibiotic. increase amplitude of sound for the inner ear to function. the nurse should ask. The sensory cortex does not have the ability to localize pain in the heart. C. "Have you noticed: . parotid C. : C.

any excessive vaginal bleeding?" D. "Oh. breast cancer is not painful. there is a significant loss of subcutaneous fat. The nurse should explain that decreased height occurs with aging because: A. any unusual vaginal discharge or itching?" 13. C. An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages." B. there is a thickening of the intervertebral disks. D. After completing an assessment of a 60-year-old man with a family history of colon cancer. : B. "Don't worry about the pain. digital rectal examinations every 2 years. colonoscopy every 10 years. of the shortening of the vertebral column. "Breast pain is almost always the result of benign breast disease. a patient states that she has noticed pain in her left breast. it turned out to be a blocked milk duct. of the shortening of the vertebral column. any unusual vaginal discharge or itching?" : D. I had pain like that after my son was born. During a breast health interview. a change in your urination patterns?" B. "I would like some more information about the pain in your left breast." C. any changes in your desire for intercourse?" C. 15. "I would like some more information about the pain in your left breast. C. D. long bones tend to shorten with age. The nurse should mention the need for a(n): A. the nurse discusses with him early detection measures for colon cancer." D. annual proctoscopy." : A. B. colonoscopy every 10 years 14.A." . fecal test for blood every 6 months. B. The nurse's most appropriate response to this would be: A. : C.

and VI. and VI. Refer the patient to a throat specialist. : B. What is correct response to these findings? A. urethral meatus and paraurethral (Skene) glands. D. because this is the appearance of normal tonsils. granular in appearance. Nothing. tendons. During an examination the nurse observes a female patient's vestibule and expects to see the: A. : C. D. the nurse keeps in mind that movement of the extraocular muscles is: A. and appear to have deep crypts.16. B. C. impaired in a patient with cataracts. Nothing. B. 19. the nurse notices that they are involuted. C. In assessing the tonsils of a 30 year old. stimulated by cranial nerves III. 18. B. decreased in the elderly. paraurethral (Skene) and vestibular (Bartholin) glands. : B. Continue with assessment looking for any other abnormal findings. urethral meatus and vaginal orifice. ligaments. stimulated by cranial nerves I and II. : A. . D. IV. D. because this is the appearance of normal tonsils. 17. stimulated by cranial nerves III. ligaments. bursa. During ocular examinations. urethral meatus and vaginal orifice. Obtain a throat culture on the patient for possible strep infection. vaginal orifice and vestibular (Bartholin) glands. IV. Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called: A. B. C. C. cartilage.

temporomandibular joint 23. Increased vascularity of the skin in the elderly : A. zygomatic arch of the temporal bone. more prone to injury and calcifications than other locations in the breast. and subscapular nodes 22. the location of most breast tumors. anterior. Pectoral. axillary. D. : D. Increased numbers of sweat and sebaceous glands in the elderly D. In performing a breast examination. lax. : C. the location of most breast tumors. the largest quadrant of the breast. The articulation of the mandible and the temporal bone is known as the: A. axillary. The reason for this is that the upper outer quadrant is: A. and sternal nodes : B. pectoral. and sternal nodes D. pectoral. 21. In performing an assessment of a woman's axillary lymph system. Central. and dry. lateral. where most of the suspensory ligaments attach. C. An increased loss of elastin and a decrease in subcutaneous fat in the elderly . An increase in elastin and a decrease in subcutaneous fat in the elderly C. temporomandibular joint. C. An increased loss of elastin and a decrease in subcutaneous fat in the elderly B. lateral. Central. This finding would be related to which factor? A. and subscapular nodes C. thin. B.20. Lateral. condyle of the mandible. lateral. The nurse is bathing an 80-year-old man and notices that his skin is wrinkled. Central. intervertebral foramen. the nurse should assess which of these nodes? A. D. B. the nurse knows that it is especially important to examine the upper outer quadrant of the breast. pectoral. and suprascapular nodes B. lateral.

. Metabolism : A. The nurse is performing an assessment on an adult. Consider this a delayed capillary refill time and investigate further. Exercise C. There are no sensory nerves in the anal canal or rectum. Radiation 25. Above the anal canal. the eccrine glands. 27. Consider this a delayed capillary refill time and investigate further. Ask the patient about a past history of frostbite. a disorder of the stratum germinativum. What should the nurse do next? A. the rectum turns anteriorly. 26. Consider this a normal capillary refill time that requires no further assessment. The nurse is performing an examination of the anus and rectum. B. The nurse is examining a patient who is complaining of "feeling cold. The nurse is examining a patient who tells the nurse. The rectum is about 8 cm long. : B. Suspect that the patient has a venous insufficiency problem." The nurse knows that this could be related to: A. Food digestion D. C." Which is a mechanism of heat loss in the body? A. the apocrine glands. D. Radiation B. C. a disorder of the stratum corneum : B. the eccrine glands. Which of these statements is correct and important to remember during this examination? A. C. especially on my face and feet but it doesn't have an odor. The adult's vital signs are normal and capillary refill time is 5 seconds.24. B. D. B. "I sure sweat a lot.

directs light into the ear canal and onto the tympanic membrane. : B. C. is used to examine the structures of the internal ear. broad speculum to help visualize the ear. D. Avoid palpation of reported "tender" areas because this may cause the patient pain. 30.D. African-American . Which woman. directs light into the ear canal and onto the tympanic membrane. The anorectal junction cannot be palpated. : D. B. D. Inspection may be somewhat uncomfortable for the expert practitioner. Inspection usually yields little information. encouraging the patient to relax and take deep breaths. B. Which statement is true regarding the otoscope? The otoscope: A. uses a short. Which statement is true about the inspection phase of the physical assessment? A. Inspection takes time and reveals a surprising amount of information. Quickly palpate a tender area to avoid any discomfort that the patient may experience. 29. B. Begin the assessment with deep palpation. Inspection takes time and reveals a surprising amount of information. aged 40 years in the United States. is often used to direct light onto the sinuses. The nurse is preparing to assess a patient's abdomen by palpation. The nurse is reviewing statistics regarding breast cancer. Inspection requires a quick glance at the patient's body systems before proceeding on with palpation. The nurse is preparing to use an otoscope for an examination. C. Start with light palpation to detect surface characteristics and to accustom the patient to being touched. : D. 31. C. Start with light palpation to detect surface characteristics and to accustom the patient to being touched. 28. D. has the highest risk for development of breast cancer? A. : B. The nurse is preparing to perform a physical assessment. The anorectal junction cannot be palpated. How should the nurse proceed? A.

"You may notice a thick. American Indian : A. does not contain the same nutrition as breast milk does. Intraluminal valves ensure unidirectional flow toward the heart.B. yellow fluid expressed from your breasts as early as the fourth month of pregnancy. The major artery supplying the arm is the _____ artery. : A. which refers to which action? . brachial 33. A. The nurse is reviewing the blood supply to the arm. which is present right after birth. yellow fluid expressed from your breasts as early as the fourth month of pregnancy. radial : C. D. deep palmar C. The nurse is teaching a pregnant woman about breast milk. The nurse is reviewing venous blood flow patterns. White D. Asian C." 35." B. B." : C. Which statement by the nurse is correct? A. The high-pressure system of the heart helps to facilitate venous return." D. ulnar B. "Your breast milk is present immediately after delivery of the baby. Contracting skeletal muscles milk blood distally toward the veins. Intraluminal valves ensure unidirectional flow toward the heart. The nurse is testing a patient's visual accommodation. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart? A. African-American 32. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart. "Breast milk is rich in protein and sugars (lactose) but has very little fat. C. "You may notice a thick." C. "The colostrum. 34. brachial D.

Pupillary constriction when looking at a near object 36. Avoid touching the nasal septum with the speculum. C. D. circulatory status. "We need to determine areas of tenderness before using percussion and palpation. The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen.A. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? A. socioeconomic status." 38. ." : A. Pupillary constriction when looking at a near object : D. 37." B. : A. "It prevents distortion of bowel sounds that might occur after percussion and palpation." D. support systems. Avoid touching the nasal septum with the speculum. Involuntary blinking in the presence of bright light B. B. Keep the speculum tip medial to avoid touching the floor of the nares." C. Pupillary dilation when looking at a far object D. "This prevents distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation. Which of these techniques is correct? A. D. "It allows the patient more time to relax and therefore be more comfortable with the physical examination. C. B. Insert the speculum at least 3 cm into the vestibule. "It prevents distortion of bowel sounds that might occur after percussion and palpation. Changes in peripheral vision in response to light C. circulatory status. psychological wellness. The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person's: A. Gently displace the nose to the side that is being examined. The nurse is using an otoscope to assess the nasal cavity. : B.

auricle. : B. VII. On the basis of this observation. assume that the patient is eager and interested in participating in the interview. VII. V. mastoid process. C. C. recognize that a tripod position is often used when a patient is having respiratory difficulties. The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. B. the nurse may find that there has been damage to cranial nerve: A. VIII. This portion of the ear is called the: A. facilitate movement of air through the nares. 41. B. C. filter coarse particles from inhaled air. B. auricle. : C. outer meatus. : C. the nurse should: A.39. On examination. C. leaning forward with arms braced on the chair. . 40. warm the inhaled air. assume that the patient is having difficulty breathing and assist him to a supine position. D. The primary purpose of the ciliated mucous membrane in the nose is to: A. D. filter out dust and bacteria. concha. B. III. The nurse notices that a patient's palpebral fissures are not symmetrical. D. When assessing a 75-year-old patient who has asthma. filter out dust and bacteria. 42. the nurse notes that he assumes a tripod position.

"Do you believe in God?" B. D. recognize that a tripod position is often used when a patient is having respiratory difficulties. When beginning to assess a person's spirituality. : A. is a reflection of the heart's stroke volume. . When examining a patient's eyes. is a reflection of the heart's stroke volume. is usually recorded on a 0. the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system: A. "Do you believe in the power of prayer?" D. "Is the pain a stabbing pain?" : C. "When did the pain start?" C. When assessing the quality of a patient's pain.to 2-point scale. or strength. of a pulse. "How does your spirituality relate to your health care decisions?" C. "How does your spirituality relate to your health care decisions?" 46.D. the nurse should ask which question? A. which question by the nurse would be most appropriate? A. the nurse recalls that it: A. causes contraction of the ciliary body. "What religious faith do you follow?" : B. reflects the blood volume in the arteries during diastole. When assessing the force. "Is it a sharp pain or dull pain?" B. B. : C. 44. which may be exacerbated in the sitting position. "What does your pain feel like?" D. 43. evaluate the patient for abdominal pain. C. demonstrates elasticity of the vessel wall. "What does your pain feel like?" 45.

47. : C. The nurse would suspect that these are: . : B. elevates the eyelid and dilates the pupil. adjusts the eye for near vision. C. causes pupillary constriction. known as lactiferous ducts. : D. and adipose tissue. The corpus spongiosum expands into a cone of erectile tissue called the glans. The prepuce is the fold of foreskin covering the shaft of the penis. elevates the eyelid and dilates the pupil. and adipose tissue. with very little fibrous tissue. C. D. glandular. Which of these statements concerning areas of the brain is true? A. Which of these statements is true regarding the penis? A. mainly muscle. The cerebellum is the center for speech and emotions. The hypothalamus controls temperature and regulates sleep. The hypothalamus controls temperature and regulates sleep. B. glandular. : C.B. which supports the breast by attaching to the chest wall. D. The penis is composed of two cylindrical columns of erectile tissue. The corpus spongiosum expands into a cone of erectile tissue called the glans. The urethral meatus is located on the ventral side of the penis. C. The basal ganglia are responsible for controlling voluntary movements. composed mostly of milk ducts. D. composed of fibrous. B. While examining a patient. 48. the nurse observes abdominal pulsations between the xiphoid and umbilicus. composed of fibrous. 50. B. composed of glandular tissue. 49. C. Motor pathways of the spinal cord and brainstem synapse in the thalamus. D. Which of the following statements is true regarding the internal structures of the breast? The breast is: A.

A. pulsations of the inferior vena cava. : D. increased peristalsis from a bowel obstruction.com/_cb1m4 . B. normal abdominal aortic pulsations. normal abdominal aortic pulsations. D. Jarvis 6th Ed.)Study online at quizlet. Health Assessment (Final Exam Review. pulsations of the renal arteries. C.

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