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

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.

B. feces. C. fibroid tumors. D. fluid. : D. fluid. 5. A patient has been admitted to the hospital with vertebral fractures related to osteoporosis. She is in extreme pain. This type of pain would be classified as: A. deep somatic. B. visceral. C. cutaneous. D. referred. : A. deep somatic. 6. A patient has had three pregnancies and two live births. The nurse would record this information as gravida _____, para _____, AB _____. A. 3; 2; 1 B. 2; 2; 1 C. 3; 2; 0 D. 3; 3; 1 : A. 3; 2; 1 7. A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects:

A. scleroderma. B. Bell's palsy. C. damage to the trigeminal nerve. D. frostbite with resultant paresthesia to the cheeks. : C. damage to the trigeminal nerve. 8. A patient states that the pain medication is "not working" and rates his postoperative pain at a 10 on a 1 to 10 scale. Which of these assessment findings indicates an acute pain response to poorly controlled pain? A. Increased blood pressure and pulse B. Confusion

C. Hyperventilation D. Depression : A. Increased blood pressure and pulse 9. A patient with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the patient that the middle ear functions to:

A. interpret sounds as they enter the ear. B. conduct vibrations of sounds to the inner ear. C. maintain balance. D. increase amplitude of sound for the inner ear to function. : B. conduct vibrations of sounds to the inner ear. 10. A patient with lack of oxygen to his heart will have pain in his chest and possibly the shoulder, arms, or jaw. 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. B. There is a lesion in the dorsal root that is preventing the sensation from being transmitted normally. C. The sensory cortex does not have the ability to localize pain in the heart, so the pain is felt elsewhere. D. There is a problem with the sensory cortex and its ability to discriminate the location. : C. The sensory cortex does not have the ability to localize pain in the heart, so the pain is felt elsewhere. 11. A patient's laboratory data reveal an elevated thyroxine level. The nurse would proceed with an examination of the _____ gland.

A. adrenal B. parotid C. parathyroid D. thyroid : D. thyroid 12. A woman states that 2 weeks ago she had a urinary tract infection that was treated with an antibiotic. As a part of the interview, the nurse should ask, "Have you noticed:

A. a change in your urination patterns?" B. any changes in your desire for intercourse?" C. any excessive vaginal bleeding?" D. any unusual vaginal discharge or itching?" : D. any unusual vaginal discharge or itching?" 13. After completing an assessment of a 60-year-old man with a family history of colon cancer, the nurse discusses with him early detection measures for colon cancer. The nurse should mention the need for a(n):

A. annual proctoscopy. B. colonoscopy every 10 years. C. fecal test for blood every 6 months. D. digital rectal examinations every 2 years. : B. colonoscopy every 10 years 14. An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because:

A. there is a significant loss of subcutaneous fat. B. there is a thickening of the intervertebral disks. C. of the shortening of the vertebral column. D. long bones tend to shorten with age. : C. of the shortening of the vertebral column. 15. During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse's most appropriate response to this would be: A. "I would like some more information about the pain in your left breast." B. "Don't worry about the pain; breast cancer is not painful." C. "Breast pain is almost always the result of benign breast disease." D. "Oh, I had pain like that after my son was born; it turned out to be a blocked milk duct." : A. "I would like some more information about the pain in your left breast."

16. During an examination the nurse observes a female patient's vestibule and expects to see the:

A. paraurethral (Skene) and vestibular (Bartholin) glands. B. urethral meatus and vaginal orifice. C. vaginal orifice and vestibular (Bartholin) glands. D. urethral meatus and paraurethral (Skene) glands. : B. urethral meatus and vaginal orifice. 17. During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:

A. decreased in the elderly. B. stimulated by cranial nerves I and II. C. stimulated by cranial nerves III, IV, and VI. D. impaired in a patient with cataracts. : C. stimulated by cranial nerves III, IV, and VI. 18. Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called:

A. tendons. B. ligaments. C. bursa. D. cartilage. : B. ligaments. 19. In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is correct response to these findings? A. Nothing, because this is the appearance of normal tonsils. B. Obtain a throat culture on the patient for possible strep infection. C. Refer the patient to a throat specialist. D. Continue with assessment looking for any other abnormal findings. : A. Nothing, because this is the appearance of normal tonsils.

20. In performing a breast examination, the nurse knows that it is especially important to examine the upper outer quadrant of the breast. The reason for this is that the upper outer quadrant is:

A. the largest quadrant of the breast. B. where most of the suspensory ligaments attach. C. more prone to injury and calcifications than other locations in the breast. D. the location of most breast tumors. : D. the location of most breast tumors. 21. In performing an assessment of a woman's axillary lymph system, the nurse should assess which of these nodes?

A. Lateral, pectoral, axillary, and suprascapular nodes B. Central, lateral, pectoral, and subscapular nodes C. Pectoral, lateral, anterior, and sternal nodes D. Central, axillary, lateral, and sternal nodes : B. Central, lateral, pectoral, and subscapular nodes 22. The articulation of the mandible and the temporal bone is known as the:

A. condyle of the mandible. B. intervertebral foramen. C. temporomandibular joint. D. zygomatic arch of the temporal bone. : C. temporomandibular joint 23. The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor? A. An increased loss of elastin and a decrease in subcutaneous fat in the elderly B. An increase in elastin and a decrease in subcutaneous fat in the elderly C. Increased numbers of sweat and sebaceous glands in the elderly D. Increased vascularity of the skin in the elderly : A. An increased loss of elastin and a decrease in subcutaneous fat in the elderly

24. The nurse is examining a patient who is complaining of "feeling cold." Which is a mechanism of heat loss in the body? A. Radiation B. Exercise C. Food digestion D. Metabolism : A. Radiation 25. The nurse is examining a patient who tells the nurse, "I sure sweat a lot, especially on my face and feet but it doesn't have an odor." The nurse knows that this could be related to:

A. a disorder of the stratum germinativum. B. the eccrine glands. C. the apocrine glands. D. a disorder of the stratum corneum : B. the eccrine glands. 26. The nurse is performing an assessment on an adult. The adult's vital signs are normal and capillary refill time is 5 seconds. What should the nurse do next?

A. Suspect that the patient has a venous insufficiency problem. B. Consider this a delayed capillary refill time and investigate further. C. Consider this a normal capillary refill time that requires no further assessment. D. Ask the patient about a past history of frostbite. : B. Consider this a delayed capillary refill time and investigate further. 27. The nurse is performing an examination of the anus and rectum. Which of these statements is correct and important to remember during this examination?

A. There are no sensory nerves in the anal canal or rectum. B. The rectum is about 8 cm long. C. Above the anal canal, the rectum turns anteriorly.

D. The anorectal junction cannot be palpated. : D. The anorectal junction cannot be palpated. 28. The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed?

A. Quickly palpate a tender area to avoid any discomfort that the patient may experience. B. Start with light palpation to detect surface characteristics and to accustom the patient to being touched. C. Avoid palpation of reported "tender" areas because this may cause the patient pain. D. Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths. : B. Start with light palpation to detect surface characteristics and to accustom the patient to being touched. 29. The nurse is preparing to perform a physical assessment. Which statement is true about the inspection phase of the physical assessment?

A. Inspection requires a quick glance at the patient's body systems before proceeding on with palpation. B. Inspection takes time and reveals a surprising amount of information. C. Inspection may be somewhat uncomfortable for the expert practitioner. D. Inspection usually yields little information. : B. Inspection takes time and reveals a surprising amount of information. 30. The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope:

A. is often used to direct light onto the sinuses. B. uses a short, broad speculum to help visualize the ear. C. is used to examine the structures of the internal ear. D. directs light into the ear canal and onto the tympanic membrane. : D. directs light into the ear canal and onto the tympanic membrane. 31. The nurse is reviewing statistics regarding breast cancer. Which woman, aged 40 years in the United States, has the highest risk for development of breast cancer? A. African-American

B. Asian C. White D. American Indian : A. African-American 32. The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _____ artery.

A. ulnar B. deep palmar C. brachial D. radial : C. brachial 33. The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart? A. Intraluminal valves ensure unidirectional flow toward the heart. B. The high-pressure system of the heart helps to facilitate venous return. C. Contracting skeletal muscles milk blood distally toward the veins. D. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart. : A. Intraluminal valves ensure unidirectional flow toward the heart. 34. The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse is correct?

A. "Your breast milk is present immediately after delivery of the baby." B. "Breast milk is rich in protein and sugars (lactose) but has very little fat." C. "You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy." D. "The colostrum, which is present right after birth, does not contain the same nutrition as breast milk does." : C. "You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy." 35. The nurse is testing a patient's visual accommodation, which refers to which action?

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

A. psychological wellness. B. circulatory status. C. socioeconomic status. D. support systems. : B. circulatory status.

39. The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the:

A. outer meatus. B. auricle. C. concha. D. mastoid process. : B. auricle. 40. The nurse notices that a patient's palpebral fissures are not symmetrical. On examination, the nurse may find that there has been damage to cranial nerve:

A. V. B. VIII. C. VII. D. III. : C. VII. 41. The primary purpose of the ciliated mucous membrane in the nose is to:

A. filter coarse particles from inhaled air. B. warm the inhaled air. C. filter out dust and bacteria. D. facilitate movement of air through the nares. : C. filter out dust and bacteria. 42. When assessing a 75-year-old patient who has asthma, the nurse notes that he assumes a tripod position, leaning forward with arms braced on the chair. On the basis of this observation, the nurse should: A. recognize that a tripod position is often used when a patient is having respiratory difficulties. B. assume that the patient is eager and interested in participating in the interview. C. assume that the patient is having difficulty breathing and assist him to a supine position.

D. evaluate the patient for abdominal pain, which may be exacerbated in the sitting position. : A. recognize that a tripod position is often used when a patient is having respiratory difficulties. 43. When assessing the force, or strength, of a pulse, the nurse recalls that it:

A. demonstrates elasticity of the vessel wall. B. is usually recorded on a 0- to 2-point scale. C. is a reflection of the heart's stroke volume. D. reflects the blood volume in the arteries during diastole. : C. is a reflection of the heart's stroke volume. 44. When assessing the quality of a patient's pain, the nurse should ask which question?

A. "Is it a sharp pain or dull pain?" B. "When did the pain start?" C. "What does your pain feel like?" D. "Is the pain a stabbing pain?" : C. "What does your pain feel like?" 45. When beginning to assess a person's spirituality, which question by the nurse would be most appropriate?

A. "Do you believe in God?" B. "How does your spirituality relate to your health care decisions?" C. "Do you believe in the power of prayer?" D. "What religious faith do you follow?" : B. "How does your spirituality relate to your health care decisions?" 46. When examining a patient's eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system:

A. causes contraction of the ciliary body.

B. adjusts the eye for near vision. C. elevates the eyelid and dilates the pupil. D. causes pupillary constriction. : C. elevates the eyelid and dilates the pupil. 47. Which of the following statements is true regarding the internal structures of the breast? The breast is:

A. composed mostly of milk ducts, known as lactiferous ducts. B. composed of glandular tissue, which supports the breast by attaching to the chest wall. C. mainly muscle, with very little fibrous tissue. D. composed of fibrous, glandular, and adipose tissue. : D. composed of fibrous, glandular, and adipose tissue. 48. Which of these statements concerning areas of the brain is true?

A. Motor pathways of the spinal cord and brainstem synapse in the thalamus. B. The hypothalamus controls temperature and regulates sleep. C. The cerebellum is the center for speech and emotions. D. The basal ganglia are responsible for controlling voluntary movements. : B. The hypothalamus controls temperature and regulates sleep. 49. Which of these statements is true regarding the penis?

A. The penis is composed of two cylindrical columns of erectile tissue. B. The prepuce is the fold of foreskin covering the shaft of the penis. C. The corpus spongiosum expands into a cone of erectile tissue called the glans. D. The urethral meatus is located on the ventral side of the penis. : C. The corpus spongiosum expands into a cone of erectile tissue called the glans. 50. While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are:

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