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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.

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

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

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

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

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

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

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

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

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

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

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

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

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