Physical Examination And Health Assessment 9th Edition By Carolyn Jarvis, Ann Eckhardt Test Bank / All Chapters 1-32 / 2024

PhysicalExaminationandHealthAssessment9thEditionbyCarolynJarvis,AnnEckhardtTestBank/AllChapters1-32/FullComplete2023/2024TestBankforPhysicalExaminationandHealthAssessment,9thEdition,CarolynJarvis,ISBN:9780323510806LatestUpdatePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)2STUVIA.COMChapter01:Evidence-BasedAssessmentMULTIPLECHOICE1.Aftercompletinganinitialassessmentofapatient,thenursehaschartedthathisrespirationsareeupneicandhispulseis58beatsperminute.Thesetypesofdatawouldbe:a.Objective.b.Reflective.c.Subjective.d.Introspective.ANS:AObjectivedataarewhatthehealthprofessionalobservesbyinspecting,percussing,palpating,andauscultatingduringthephysicalexamination.Subjectivedataiswhatthepersonsaysabouthimorherselfduringhistorytaking.Thetermsreflectiveandintrospectivearenotusedtodescribedata.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare2.ApatienttellsthenursethatheisverynervNouUsR,SisINnaGuTsBea.CteOdM,andfeelshot.Thesetypesofdatawouldbe:a.Objective.b.Reflective.c.Subjective.d.Introspective.ANS:CSubjectivedataarewhatthepersonsaysabouthimorherselfduringhistorytaking.Objectivedataarewhatthehealthprofessionalobservesbyinspecting,percussing,palpating,andauscultatingduringthephysicalexamination.Thetermsreflectiveandintrospectivearenotusedtodescribedata.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare3.Thepatientsrecord,laboratorystudies,objectivedata,andsubjectivedatacombinetoformthe:a.Database.b.Admittingdata.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)3STUVIA.COMc.Financialstatement.d.Dischargesummary.ANS:ATogetherwiththepatientsrecordandlaboratorystudies,theobjectiveandsubjectivedataformthedatabase.Theotheritemsarenotpartofthepatientsrecord,laboratorystudies,ordata.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare4.Whenlisteningtoapatientsbreathsounds,thenurseisunsureofasoundthatisheard.Thenursesnextactionshouldbeto:a.Immediatelynotifythepatientsphysician.b.Documentthesoundexactlyasitwasheard.c.Validatethedatabyaskingacoworkertolistentothebreathsounds.d.Assessagainin20minutestonotewhetherthesoundisstillpresent.NURSINGTB.COMANS:CWhenunsureofasoundheardwhilelisteningtoapatientsbreathsounds,thenursevalidatesthedatatoensureaccuracy.Ifthenursehaslessexperienceinanarea,thenheorsheasksanexperttolisten.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare5.Thenurseisconductingaclassfornewgraduatenurses.Duringtheteachingsession,thenurseshouldkeepinmindthatnovicenurses,withoutabackgroundofskillsandexperiencefromwhichtodraw,aremorelikelytomaketheirdecisionsusing:a.Intuition.b.Asetofrules.c.Articlesinjournals.d.Advicefromsupervisors.ANS:BNovicenursesoperatefromasetofdefined,structuredrules.Theexpertpractitionerusesintuitivelinks.DIF:CognitiveLevel:Understanding(Comprehension)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)4STUVIA.COMMSC:ClientNeeds:General6.Thenurseisreviewinginformationaboutevidence-basedpractice(EBP).WhichstatementbestreflectsEBP?a.EBPreliesontraditionforsupportNoUfRbSesINtpGrTacBt.iCceOsM.b.EBPissimplytheuseofbestpracticetechniquesforthetreatmentofpatients.c.EBPemphasizestheuseofbestevidencewiththecliniciansexperience.d.ThepatientsownpreferencesarenotimportantwithEBP.ANS:CEBPisasystematicapproachtopracticethatemphasizestheuseofbestevidenceincombinationwiththecliniciansexperience,aswellaspatientpreferencesandvalues,whenmakingdecisionsaboutcareandtreatment.EBPismorethansimplyusingthebestpracticetechniquestotreatpatients,andquestioningtraditionisimportantwhennocompellingandsupportiveresearchevidenceexists.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare7.Expertnurseslearntoattendtoapatternofassessmentdataandactwithoutconsciouslylabelingit.Theseresponsesarereferredtoas:a.Intuition.b.Thenursingprocess.c.Clinicalknowledge.d.Diagnosticreasoning.ANS:AIntuitionischaracterizedbypatternrecognitionexpertnurseslearntoattendtoapatternofassessmentdataandactwithoutconsciouslylabelingit.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:General8.Thenurseisconductingaclassonprioritysettingforagroupofnewgraduatenurses.Whichisanexampleofafirst-levelpriorityproblem?a.Patientwithpostoperativepainb.NewlydiagnosedpatientwithdiabeteswhoneedsdiabeticteachingPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)5STUVIA.COMc.Individualwithasmalllacerationonthesoleofthefootd.IndividualwithshortnessofbreathandrespiratorydistressANS:DFirst-levelpriorityproblemsarethosethatareemergent,lifethreatening,andimmediate(e.g.,establishinganairway,supportingbreathing,maintainingcirculation,monitoringabnormalvitalsigns).DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare9.Whenconsideringprioritysettingofproblems,thenursekeepsinmindthatsecond-levelpriorityproblemsincludewhichoftheseaspects?a.Lowself-esteemb.Lackofknowledgec.Abnormallaboratoryvaluesd.SeverelyabnormalvitalsignsANS:CNURSINGTB.COMSecond-levelpriorityproblemsarethosethatrequirepromptinterventiontoforestallfurtherdeterioration(e.g.,mentalstatuschange,acutepain,abnormallaboratoryvalues,riskstosafetyorsecurity).DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare10.Whichcriticalthinkingskillhelpsthenurseseerelationshipsamongthedata?a.Validationb.Clusteringrelatedcuesc.Identifyinggapsindatad.DistinguishingrelevantfromirrelevantANS:BClusteringrelatedcueshelpsthenurseseerelationshipsamongthedata.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCarePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)6STUVIA.COM11.Thenurseknowsthatdevelopingappropriatenursinginterventionsforapatientreliesontheappropriatenessofthediagnosis.a.Nursingb.Medicalc.Admissiond.CollaborativeANS:AAnaccuratenursingdiagnosisprovidesthebasisfortheselectionofnursinginterventionstoachieveoutcomesforwhichthenurseisaccountable.Theotheritemsdonotcontributetothedevelopmentofappropriatenursinginterventions.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare12.Thenursingprocessisasequentialmethodofproblemsolvingthatnursesuseandincludeswhichsteps?a.Assessment,treatment,planning,evaluation,discharge,andfollow-upNURSINGTB.COMb.Admission,assessment,diagnosis,treatment,anddischargeplanningc.Admission,diagnosis,treatment,evaluation,anddischargeplanningd.Assessment,diagnosis,outcomeidentification,planning,implementation,andevaluationANS:DThenursingprocessisamethodofproblemsolvingthatincludesassessment,diagnosis,outcomeidentification,planning,implementation,andevaluation.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare13.Anewlyadmittedpatientisinacutepain,hasnotbeensleepingwelllately,andishavingdifficultybreathing.Howshouldthenurseprioritizetheseproblems?a.Breathing,pain,andsleepb.Breathing,sleep,andpainc.Sleep,breathing,andpainPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)7STUVIA.COMd.Sleep,pain,andbreathingANS:AFirst-levelpriorityproblemsareimmediatepriorities,rememberingtheABCs(airway,breathing,andcirculation),followedbysecond-levelproblems,andthenthird-levelproblems.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare14.Whichofthesewouldbeformulatedbyanurseusingdiagnosticreasoning?a.Nursingdiagnosisb.Medicaldiagnosisc.Diagnostichypothesisd.DiagnosticassessmentANS:CDiagnosticreasoningcallsforthenursetoformulateadiagnostichypothesis;thenursingprocesscallsforanursingdiagnosis.NURSINGTB.COMDIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:General15.BarrierstoincorporatingEBPinclude:a.Nurseslackofresearchskillsinevaluatingthequalityofresearchstudies.b.Lackofsignificantresearchstudies.c.Insufficientclinicalskillsofnurses.d.Inadequatephysicalassessmentskills.ANS:AAsindividuals,nurseslackresearchskillsinevaluatingthequalityofresearchstudies,areisolatedfromothercolleagueswhoareknowledgeableinresearch,andoftenlackthetimetovisitthelibrarytoreadresearch.Theotherresponsesarenotconsideredbarriers.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:General16.Whatstepofthenursingprocessincludesdatacollectionbyhealthhistory,physicalexamination,andinterview?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)8STUVIA.COMa.Planningb.Diagnosisc.Evaluationd.AssessmentANS:DDatacollection,includingperformingthehealthhistory,physicalexamination,andinterview,istheassessmenstepofthenursingprocess.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General17.Duringastaffmeeting,nursesdiscusstheproblemswithaccessingresearchstudiestoincorporateevidence-basedclinicaldecisionmakingintotheirpractice.Whichsuggestionbythenursemanagerwouldbesthelptheseproblems?a.Formacommitteetoconductresearchstudies.b.PostpublishedresearchstudiesonNthUeRuSnINitsGbTuBll.eCtOinMboards.c.Encouragethenursestovisitthelibrarytoreviewstudies.d.Teachthenurseshowtoconductelectronicsearchesforresearchstudies.ANS:DFacilitatingsupportforEBPwouldincludeteachingthenurseshowtoconductelectronicsearches;timetovisitthelibrarymaynotbeavailableformanynurses.Actuallyconductingresearchstudiesmaybehelpfulinthelong-runbutnotanimmediatesolutiontoreviewingexistingresearch.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare18.Whenreviewingtheconceptsofhealth,thenurserecallsthatthecomponentsofholistichealthincludewhichofthese?a.Diseaseoriginatesfromtheexternalenvironment.b.Theindividualhumanisaclosedsystem.c.Nursesareresponsibleforapatientshealthstate.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)9STUVIA.COMd.Holistichealthviewsthemind,body,andspiritasinterdependent.ANS:DConsiderationofthewholepersonistheessenceofholistichealth,whichviewsthemind,body,andspiritasinterdependent.Thebasisofdiseaseoriginatesfromboththeexternalenvironmentandfromwithintheperson.Boththeindividualhumanandtheexternalenvironmentareopensystems,continuallychangingandadapting,andeachpersonisresponsibleforhisorherownpersonalhealthstate.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare19.Thenurserecognizesthattheconceptofpreventionindescribinghealthisessentialbecause:a.Diseasecanbepreventedbytreatingtheexternalenvironment.b.ThemajorityofdeathsamongAmericansunderage65yearsarenotpreventable.c.Preventionplacestheemphasisonthelinkbetweenhealthandpersonalbehavior.d.Themeanstopreventionisthroughtreatmentprovidedbyprimaryhealthcarepractitioners.ANS:CAnaturalprogressiontopreventionroundsouNtUthReSpIrNesGeTnBtc.CoOncMeptofhealth.Guidelinestopreventionplacetheemphasisonthelinkbetweenhealthandpersonalbehavior.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:General20.Thenurseisperformingaphysicalassessmentonanewlyadmittedpatient.Anexampleofobjectiveinformationobtainedduringthephysicalassessmentincludesthe:a.Patientshistoryofallergies.b.Patientsuseofmedicationsathome.c.Lastmenstrualperiod1monthago.d.25cmscarontherightlowerforearm.ANS:DObjectivedataarethepatientsrecord,laboratorystudies,andconditionthatthehealthprofessionalobservesbyinspecting,percussing,palpating,andauscultatingduringthephysicalexamination.Theotherresponsesreflectsubjectivedata.DIF:CognitiveLevel:Applying(Application)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)10STUVIA.COMMSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare21.Avisitingnurseismakinganinitialhomevisitforapatientwhohasmanychronicmedicalproblems.Whichtypeofdatabaseismostappropriatetocollectinthissetting?a.Afollow-updatabasetoevaluatechangesatappropriateintervalsb.Anepisodicdatabasebecauseofthecontinuing,complexmedicalproblemsofthispatientc.Acompletehealthdatabasebecauseofthenursesprimaryresponsibilityformonitoringthepatientshealthd.AnemergencydatabasebecauseoftheneedtocollectinformationandmakeaccuratediagnosesrapidlyANS:CThecompletedatabaseiscollectedinaprimarycaresetting,suchasapediatricorfamilypracticeclinic,independentorgroupprivatepractice,collegehealthservice,womenshealthcareagency,visitingnurseagency,orcommunityhealthagency.Inthesesettings,thenurseisthefirsthealthprofessionaltoseethepatientandhastheprimaryresponsibilityformonitoringthepersonshealthcare.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare22.WhichsituationismostappropriateduringNwUhRiScIhNtGheTBnu.CrsOeMperformsafocusedorproblem-centeredhistory?a.Patientisadmittedtoalong-termcarefacility.b.Patienthasasuddenandsevereshortnessofbreath.c.Patientisadmittedtothehospitalforsurgerythefollowingday.d.Patientinanoutpatientclinichascoldandinfluenza-likesymptoms.ANS:DInafocusedorproblem-centereddatabase,thenursecollectsaminidatabase,whichissmallerinscopethanthecompleteddatabase.Thisminidatabaseprimarilyconcernsoneproblem,onecuecomplex,oronebodysystem.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare23.Apatientisattheclinictohaveherbloodpressurechecked.Shehasbeencomingtotheclinicweeklysinceshechangedmedications2monthsago.Thenurseshould:a.Collectafollow-updatabaseandthencheckherbloodpressure.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)11STUVIA.COMb.Askhertoreadherhealthrecordandindicateanychangessinceherlastvisit.c.Checkonlyherbloodpressurebecausehercompletehealthhistorywasdocumented2monthsago.d.Obtainacompletehealthhistorybeforecheckingherbloodpressurebecausemuchofherhistoryinformationmayhavechanged.ANS:AAfollow-updatabaseisusedinallsettingstofollowupshort-termorchronichealthproblems.Theotherresponsesarenotappropriateforthesituation.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare24.Apatientisbroughtbyambulancetotheemergencydepartmentwithmultipletraumasreceivedinanautomobileaccident.Heisalertandcooperative,buthisinjuriesarequitesevere.Howwouldthenurseproceedwithdatacollection?a.Collecthistoryinformationfirst,thenperformthephysicalexaminationandinstitutelife-savingmeasures.b.Simultaneouslyaskhistoryquestionswhileperformingtheexaminationandinitiatinglife-savingmeasures.NURSINGTB.COMc.Collectallinformationonthehistoryform,includingsocialsupportpatterns,strengths,andcopingpatterns.d.Performlife-savingmeasuresanddelayaskinganyhistoryquestionsuntilthepatientistransferredtotheintensivecareunit.ANS:BTheemergencydatabasecallsforarapidcollectionofthedatabase,oftenconcurrentlycompiledwithlife-savingmeasures.Theotherresponsesarenotappropriateforthesituation.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare25.A42-year-oldpatientofAsiandescentisbeingseenattheclinicforaninitialexamination.Thenurseknowsthatincludingculturalinformationinhishealthassessmentisimportantto:a.Identifythecauseofhisillness.b.Makeaccuratediseasediagnoses.c.Provideculturalhealthrightsfortheindividual.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)12STUVIA.COMd.Provideculturallysensitiveandappropriatecare.ANS:DTheinclusionofculturalconsiderationsinthehealthassessmentisofparamountimportancetogatheringdatathatareaccurateandmeaningfulandtointerveningwithculturallysensitiveandappropriatecare.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity26.Inthehealthpromotionmodel,thefocusofthehealthprofessionalincludes:a.Changingthepatientsperceptionsofdisease.b.Identifyingbiomedicalmodelinterventions.c.Identifyingnegativehealthactsoftheconsumer.d.Helpingtheconsumerchooseahealthierlifestyle.ANS:DInthehealthpromotionmodel,thefocusofthehealthprofessionalisonhelpingtheconsumerchooseahealthierlifestyle.NURSINGTB.COMDIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:HealthPromotionandMaintenance27.Thenursehasimplementedseveralplannedinterventionstoaddressthenursingdiagnosisofacutepain.Whichwouldbethenextappropriateaction?a.Establishpriorities.b.Identifyexpectedoutcomes.c.Evaluatetheindividualscondition,andcompareactualoutcomeswithexpectedoutcomes.d.Interpretdata,andthenidentifyclustersofcuesandmakeinferences.ANS:CEvaluationisthenextstepaftertheimplementationphaseofthenursingprocess.Duringthisstep,thenurseevaluatestheindividualsconditionandcomparestheactualoutcomeswithexpectedoutcomes.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare28.Whichstatementbestdescribesaproficientnurse?Aproficientnurseisonewho:PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)13STUVIA.COMa.Haslittleexperiencewithaspecifiedpopulationandusesrulestoguideperformance.b.Hasanintuitivegraspofaclinicalsituationandquicklyidentifiestheaccuratesolution.c.Seesactionsinthecontextofdailyplansforpatients.d.Understandsapatientsituationasawholeratherthanalistoftasksandrecognizesthelong-termgoalsforthepatient.ANS:DTheproficientnurse,withmoretimeandexperiencethanthenovicenurse,isabletounderstandapatientsituationasawholeratherthanasalistoftasks.Theproficientnurseisabletoseehowtodaysnursingactionscanapplytothepointthenursewantsthepatienttoreachatafuturetime.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:GeneralMULTIPLERESPONSE1.Thenurseisreviewingdatacollectedafteranassessment.Ofthedatalistedbelow,whichwouldbeconsideredrelatedcuesthatwouldbeclusteredtogetherduringdataanalysis?Selectallthatapply.a.InspiratorywheezesnotedinleftlowerlobesNURSINGTB.COMb.Hypoactivebowelsoundsc.Nonproductivecoughd.Edema,+2,notedonlefthande.Patientreportsdyspneauponexertionf.Rateofrespirations16breathsperminuteANS:A,C,E,FClusteringrelatedcueshelpthenurserecognizerelationshipsamongthedata.Thecuesrelatedtothepatientsrespiratorystatus(e.g.,wheezes,cough,reportofdyspnea,respirationrateandrhythm)areallrelated.Cuesrelatedtobowelsandperipheraledemaarenotrelatedtotherespiratorycues.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCareMATCHINGPutthefollowingpatientsituationsinorderaccordingtothelevelofpriority.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)14STUVIA.COMa.Apatientnewlydiagnosedwithtype2diabetesmellitusdoesnotknowhowtocheckhisownbloodglucoselevelswithaglucometer.b.Ateenagerwhowasstungbyabeeduringasoccermatchishavingtroublebreathing.c.Anolderadultwithaurinarytractinfectionisalsoshowingsignsofconfusionandagitation.1.a=First-levelpriorityproblem2.b=Second-levelpriorityproblem3.c=Third-levelpriorityproblem1.ANS:BDIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCareNOT:First-levelpriorityproblemsareimmediatepriorities,suchastroublebreathing(remembertheairway,breathing,circulationpriorities).Second-levelpriorityproblemsarenextinurgency,butnotlife-threatening.Third-levelpriorities(e.g.,patienteducation)areimportanttoapatientshealthbutcanbeaddressedaftermoreurgenthealthproblemsareaddressed.2.ANS:CDIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCareNOT:First-levelpriorityproblemsareimmediatepriorities,suchastroublebreathing(remembertheairway,breathing,circulationpriorities).Second-levelpriorityproblemsarenextinurgency,butnotlife-threatening.Third-levelpriorities(e.g.,patienteducation)NarUeRimSIpNoGrtTanBt.CtoOaMpatientshealthbutcanbeaddressedaftermoreurgenthealthproblemsareaddressed.3.ANS:ADIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCareNOT:First-levelpriorityproblemsareimmediatepriorities,suchastroublebreathing(remembertheairway,breathing,circulationpriorities).Second-levelpriorityproblemsarenextinurgency,butnotlife-threatening.Third-levelpriorities(e.g.,patienteducation)areimportanttoapatientshealthbutcanbeaddressedaftermoreurgenthealthproblemsareaddressed.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)15STUVIA.COMChapter02:CulturalAssessmentMULTIPLECHOICE1.Thenurseisreviewingthedevelopmentofculture.Whichstatementiscorrectregardingthedevelopmentofonesculture?Cultureis:a.Geneticallydeterminedonthebasisofracialbackground.b.Learnedthroughlanguageacquisitionandsocialization.c.Anonspecificphenomenonandisadaptivebutunnecessary.d.Biologicallydeterminedonthebasisofphysicalcharacteristics.ANS:BCultureislearnedfrombirththroughlanguageacquisitionandsocialization.Itisnotbiologicallyorgeneticallydeterminedandislearnedbytheindividual.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity2.Duringaclassontheaspectsofculture,thenursesharesthatculturehasfourbasiccharacteristics.Whichstatementcorrectlyreflectsoneofthesecharacteristics?NURSINGTB.COMa.Culturesarestaticandunchanging,despitechangesaroundthem.b.Culturesareneverspecific,whichmakesthemhardtoidentify.c.Cultureismostclearlyreflectedinapersonslanguageandbehavior.d.Cultureadaptstospecificenvironmentalfactorsandavailablenaturalresources.ANS:DCulturehasfourbasiccharacteristics.Cultureadaptstospecificconditionsrelatedtoenvironmentalandtechnicalfactorsandtotheavailabilityofnaturalresources,anditisdynamicandeverchanging.Cultureislearnedfrombirththroughtheprocessoflanguageacquisitionandsocialization,butitisnotmostclearlyreflectedinoneslanguageandbehavior.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrity3.Duringaseminaronculturalaspectsofnursing,thenurserecognizesthatthedefinitionstatingthespecificanddistinctknowledge,beliefs,skills,andcustomsacquiredbymembersofasocietyreflectswhichterm?a.MoresPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)16STUVIA.COMb.Normsc.Cultured.SociallearningANS:CTheculturethatdevelopsinanygivensocietyisalwaysspecificanddistinctive,encompassingalloftheknowledge,beliefs,customs,andskillsacquiredbymembersofthesociety.Theothertermsdonotfitthegivendefinition.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PsychosocialIntegrity4.Whendiscussingtheuseofthetermsubculture,thenurserecognizesthatitisbestdescribedas:a.Fittingasmanypeopleintothemajoritycultureaspossible.b.Definingsmallgroupsofpeoplewhodonotwanttobeidentifiedwiththelargerculture.c.Singlingoutgroupsofpeoplewhosufferdifferentialandunequaltreatmentasaresultofculturalvariations.NURSINGTB.COMd.Identifyingfairlylargegroupsofpeoplewithsharedcharacteristicsthatarenotcommontoallmembersofaculture.ANS:DWithincultures,groupsofpeoplesharedifferentbeliefs,values,andattitudes.Differencesoccurbecauseofethnicity,religion,education,occupation,age,andgender.Whensuchgroupsfunctionwithinalargeculture,theyarereferredtoassubculturalgroups.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity5.WhenreviewingthedemographicsofethnicgroupsintheUnitedStates,thenurserecallsthatthelargestandfastestgrowingpopulationis:a.Hispanic.b.Black.c.Asian.d.AmericanIndian.ANS:APHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)17STUVIA.COMHispanicsarethelargestandfastestgrowingpopulationintheUnitedStates,followedbyAsians,Blacks,AmericanIndiansandAlaskanatives,andothergroups.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General6.Duringanassessment,thenursenoticesthatapatientishandlingasmallcharmthatistiedtoaleatherstriparoundhisneck.Whichactionbythenurseisappropriate?a.Askthepatientabouttheitemanditssignificance.b.Askthepatienttolocktheitemwithothervaluablesinthehospitalssafe.c.Tellthepatientthatafamilymembershouldtakevaluableshome.d.Noactionisnecessary.ANS:AThenurseshouldinquireabouttheamuletsmeaning.Amulets,suchascharms,areoftenconsideredanimportantmeansofprotectionfromevilspiritsbysomecultures.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrityNURSINGTB.COM7.Thenursemanagerisexplainingculturallycompetentcareduringastaffmeeting.Whichstatementaccuratelydescribestheconceptofculturallycompetentcare?Thecaregiver:a.Isabletospeakthepatientsnativelanguage.b.Possessessomebasicknowledgeofthepatientsculturalbackground.c.Appliestheproperbackgroundknowledgeofapatientsculturalbackgroundtoprovidethebestpossiblehealthcare.d.Understandsandattendstothetotalcontextofthepatientssituation.ANS:DCulturallycompetentimpliesthatthecaregiverunderstandsandattendstothetotalcontextoftheindividualssituation.Thiscompetencyincludesawarenessofimmigrationstatus,stressfactors,othersocialfactors,andculturalsimilaritiesanddifferences.Itdoesnotrequirethecaregivertospeakthepatientsnativelanguage.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrity8.Thenurserecognizesthatanexampleofapersonwhoisheritageconsistentwouldbea:a.Womanwhohasadaptedherclothingtotheclothingstyleofhernewcountry.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)18STUVIA.COMb.Womanwhofollowsthetraditionsthathermotherfollowedregardingmeals.c.Manwhoisnotsureofhisancestorscountryoforigin.d.Childwhoisnotabletospeakhisparentsnativelanguage.ANS:BSomeonewhoisheritageconsistentlivesalifestylethatreflectshisorhertraditionalheritage,notthenormsandcustomsofthenewcountry.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity9.Afteraclassoncultureandethnicity,thenewgraduatenursereflectsacorrectunderstandingoftheconceptofethnicitywithwhichstatement?a.Ethnicityisdynamicandeverchanging.b.Ethnicityisthebeliefinahigherpower.c.Ethnicitypertainstoasocialgroupwithinthesocialsystemthatclaimssharedvaluesandtraditions.NURSINGTB.COMd.Ethnicityislearnedfrombirththroughtheprocessesoflanguageacquisitionandsocialization.ANS:CEthnicitypertainstoasocialgroupwithinthesocialsystemthatclaimstohavevariabletraits,suchasacommongeographicorigin,migratorystatus,religion,race,language,values,traditions,symbols,orfoodpreferences.Cultureisdynamic,everchanging,andlearnedfrombirththroughtheprocessesoflanguageacquisitionandsocialization.Religionisthebeliefinahigherpower.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity10.Thenurseiscomparingtheconceptsofreligionandspirituality.Whichofthefollowingisanappropriatecomponentofonesspirituality?a.BeliefinandtheworshipofGodorgodsb.Attendanceataspecificchurchorplaceofworshipc.Personaleffortmadetofindpurposeandmeaninginlifed.BeingcloselytiedtoonesethnicbackgroundPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)19STUVIA.COMANS:CSpiritualityreferstoeachpersonsuniquelifeexperiencesandhisorherpersonalefforttofindpurposeandmeaninginlife.Theotherresponsesapplytoreligion.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity11.AwomanwhohaslivedintheUnitedStatesforayearaftermovingfromEuropehaslearnedtospeakEnglishandisalmostfinishedwithhercollegestudies.ShenowdresseslikeherpeersandsaysthatherfamilyinEuropewouldhardlyrecognizeher.Thisnurserecognizesthatthissituationillustrateswhichconcept?a.Assimilationb.Heritageconsistencyc.Biculturalismd.AcculturationANS:AAssimilationistheprocessbywhichapersondevelopsanewculturalidentityandbecomeslikemembersofthedominantculture.Thisconceptdoesnotreflectheritageconsistency.Biculturalismisadualpatternofidentification;acculturationistheprocessofadaptingtoandacquiringanotherculture.NURSINGTB.COMDIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity12.Thenurseisconductingaheritageassessment.Whichquestionismostappropriateforthisassessment?a.Whatisyourreligion?b.Doyoumostlyparticipateinthereligioustraditionsofyourfamily?c.Doyousmoke?d.Doyouhaveahistoryofheartdisease?ANS:BAskingquestionsaboutparticipationinthereligioustraditionsoffamilyenablesthenursetoassessapersonsheritage.Simplyaskingaboutonesreligion,smokinghistory,orhealthhistorydoesnotreflectheritage.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity13.InthemajoritycultureofAmerica,coughing,sweating,anddiarrheaaresymptomsofanillness.ForsomeindividualsofMexican-Americanorigin,however,thesesymptomsareanormalpartofliving.Thenurserecognizesthatthisdifferenceistrue,probablybecauseMexican-Americans:PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)20STUVIA.COMa.Havelessefficientimmunesystemsandareoftenill.b.Considerthesesymptomspartofnormalliving,notsymptomsofillhealth.c.ComefromMexico,andcoughingisnormalandhealthythere.d.Areusuallyinalowersocioeconomicgroupandaremorelikelytobesick.ANS:BThenurseneedstoidentifythemeaningofhealthtothepatient,rememberingthatconceptsarederived,inpart,fromthewayinwhichmembersoftheculturalgroupdefinehealth.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity14.Thenurseisreviewingtheoriesofillness.Thegermtheory,whichstatesthatmicroscopicorganismssuchasbacteriaandvirusesareresponsibleforspecificdiseaseconditions,isabasicbeliefofwhichtheoryofillness?a.Holisticb.Biomedicalc.Naturalisticd.MagicoreligiousNURSINGTB.COMANS:BAmongthebiomedicalexplanationsfordiseaseisthegermtheory,whichstatesthatmicroscopicorganismssuchasbacteriaandvirusesareresponsibleforspecificdiseaseconditions.Thenaturalistic,orholistic,perspectiveholdsthattheforcesofnaturemustbekeptinnaturalbalance.Themagicoreligiousperspectiveholdsthatsupernaturalforcesdominateandcauseillnessorhealth.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity15.AnAsian-Americanwomanisexperiencingdiarrhea,whichisbelievedtobecoldoryin.Thenurseexpectsthatthewomanislikelytotrytotreatitwith:a.Foodsthatarehotoryang.b.ReadingsandEasternmedicinemeditations.c.Highdosesofmedicinesbelievedtobecold.d.Notreatmentistriedbecausediarrheaisanexpectedpartoflife.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)21STUVIA.COMANS:AYinfoodsarecoldandyangfoodsarehot.Coldfoodsareeatenwithahotillness,andhotfoodsareeatenwithacoldillness.Theotherexplanationsdonotreflecttheyin/yangtheory.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity16.ManyAsiansbelieveintheyin/yangtheory,whichisrootedintheancientChinesephilosophyofTao.WhichstatementmostaccuratelyreflectshealthinanAsianwiththisbelief?a.Apersonisabletoworkandproduce.b.Apersonishappy,stable,andfeelsgood.c.Allaspectsofthepersonareinperfectbalance.d.Apersonisabletocareforothersandfunctionsocially.ANS:CManyAsiansbelieveintheyin/yangtheory,inwhichhealthisbelievedtoexistwhenallaspectsofthepersonareinperfectbalance.Theotherstatementsdonotdescribethistheory.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrityNURSINGTB.COM17.Illnessisconsideredpartoflifesrhythmiccourseandisanoutwardsignofdisharmonywithin.Thisstatementmostaccuratelyreflectstheviewsaboutillnessfromwhichtheory?a.Naturalisticb.Biomedicalc.Reductionistd.MagicoreligiousANS:AThenaturalisticperspectivestatesthatthelawsofnaturecreateimbalances,chaos,anddisease.FromtheperspectiveoftheChinese,forexample,illnessisnotconsideredanintroducingagent;rather,illnessisconsideredapartoflifesrhythmiccourseandanoutwardsignofdisharmonywithin.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrityPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)22STUVIA.COM18.Anindividualwhotakesthemagicoreligiousperspectiveofillnessanddiseaseislikelytobelievethathisorherillnesswascausedby:a.Germsandviruses.b.Supernaturalforces.c.Eatingimbalancedfoods.d.Animbalancewithinhisorherspiritualnature.ANS:BThebasicpremiseofthemagicoreligiousperspectiveisthattheworldisseenasanarenainwhichsupernaturaforcesdominate.Thefateoftheworldandthoseinitdependsontheactionsofsupernaturalforcesforgoodorevil.Theotheranswersdonotreflectthemagicoreligiousperspective.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity19.IfanAmericanIndianwomanhascometotheclinictoseekhelpwithregulatingherdiabetes,thenthenursecanexpectthatshe:a.Willcomplywiththetreatmentprescribed.NURSINGTB.COMb.Hasobviouslygivenupherbeliefinnaturalisticcausesofdisease.c.Mayalsobeseekingtheassistanceofashamanormedicineman.d.Willneedextrahelpindealingwithherillnessandmaybeexperiencingacrisisoffaith.ANS:CWhenself-treatmentisunsuccessful,theindividualmayturntothelayorfolkhealingsystems,tospiritualorreligioushealing,ortoscientificbiomedicine.Inadditiontoseekinghelpfromabiomedicalorscientifichealthcareprovider,patientsmayalsoseekhelpfromfolkorreligioushealers.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrity20.AnolderMexican-Americanwomanwithtraditionalbeliefshasbeenadmittedtoaninpatientcareunit.Aculturallysensitivenursewould:a.Contactthehospitaladministratoraboutthebestcourseofaction.b.Automaticallygetacuranderoforher,becauserequestingoneherselfisnotculturallyappropriate.c.FurtherassessthepatientsculturalbeliefsandofferthepatientassistanceincontactingacuranderoPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)23STUVIA.COMorpriestifshedesires.d.AskthefamilywhattheywouldliketodobecauseMexican-Americanstraditionallygivecontrolofdecisionmakingtotheirfamilies.ANS:CInadditiontoseekinghelpfromthebiomedicalorscientifichealthcareprovider,patientsmayalsoseekhelpfromfolkorreligioushealers.Somepeople,suchasthoseofMexican-AmericanorAmerican-Indianorigins,maybelievethatthecureisincompleteunlessthebody,mind,andspiritarealsohealed(althoughthedivisionofthepersonintopartsisaWesternconcept).DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrity21.A63-year-oldChinese-Americanmanentersthehospitalwithcomplaintsofchestpain,shortnessofbreath,andpalpitations.Whichstatementmostaccuratelyreflectsthenursesbestcourseofaction?a.Thenurseshouldfocusonperformingafullcardiacassessment.b.Thenurseshouldfocusonpsychosomaticcomplaintsbecausethepatienthasjustlearnedthathiswifehascancer.c.Thispatientisnotinanydangeratpresent;therefore,thenurseshouldsendhimhomewithinstructionstocontacthisphysician.NURSINGTB.COMd.Itisunclearwhatishappeningwiththispatient;consequently,thenurseshouldperformanassessmentinboththephysicalandthepsychosocialrealms.ANS:DWideculturalvariationsexistinthemannerinwhichcertainsymptomsanddiseaseconditionsareperceived,diagnosed,labeled,andtreated.Chinese-Americanssometimesconvertmentalexperiencesorstatesintobodilysymptoms(e.g.,complainingofcardiacsymptomsbecausethecenterofemotionintheChinesecultureistheheart).DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrity22.Symptoms,suchaspain,areofteninfluencedbyapersonsculturalheritage.Whichofthefollowingisatruestatementregardingpain?a.Nursesattitudestowardtheirpatientspainareunrelatedtotheirownexperienceswithpain.b.Nursesneedtorecognizethatmanyculturespracticesilentsufferingasaresponsetopain.c.Anursesareaofclinicalpracticewillmostlikelydeterminehisorherassessmentofapatientspain.d.AnursesyearsofclinicalexperienceandcurrentpositionarestrongindicatorsofhisorherPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)24STUVIA.COMresponsetopatientpain.ANS:BSilentsufferingisapotentialresponsetopaininmanycultures.Thenursesassessmentofpainneedstobeembeddedinaculturalcontext.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity23.Thenurseisreviewingconceptsofculturalaspectsofpain.Whichstatementistrueregardingpain?a.Allpatientswillbehavethesamewaywheninpain.b.Justaspatientsvaryintheirperceptionsofpain,sowilltheyvaryintheirexpressionsofpain.c.Culturalnormshaveverylittletodowithpaintolerance,becausepaintoleranceisalwaysbiologicallydetermined.d.Apatientsexpressionofpainislargelydependentontheamountoftissueinjuryassociatedwiththepain.ANS:BInadditiontoexpectingvariationsinpainpercNeUpRtioSnINaGndTBto.CleOraMnce,thenurseshouldexpectvariationsintheexpressionofpain.Itiswellknownthatindividualsturntotheirsocialenvironmentforvalidationandcomparison.Theotherstatementsareincorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity24.Duringaclassonreligionandspirituality,thenurseisaskedtodefinespirituality.Whichansweriscorrect?Spirituality:a.Isapersonalsearchtodiscoverasupremebeing.b.Isanorganizedsystemofbeliefsconcerningthecause,nature,andpurposeoftheuniverse.c.Isabeliefthateachpersonexistsforeverinsomeform,suchasabeliefinreincarnationortheafterlife.d.Arisesoutofeachpersonsuniquelifeexperienceandhisorherpersonalefforttofindpurposeinlife.ANS:DSpiritualityarisesoutofeachpersonsuniquelifeexperienceandhisorherpersonalefforttofindpurposeandmeaninginlife.Theotherdefinitionsreflecttheconceptofreligion.DIF:CognitiveLevel:Understanding(Comprehension)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)25STUVIA.COMMSC:ClientNeeds:PsychosocialIntegrity25.Thenurserecognizesthatworkingwithchildrenwithadifferentculturalperspectivemaybeespeciallydifficultbecause:a.Childrenhavespiritualneedsthatareinfluencedbytheirstagesofdevelopment.b.Childrenhavespiritualneedsthataredirectreflectionsofwhatisoccurringintheirhomes.c.Religiousbeliefsrarelyaffecttheparentsperceptionsoftheillness.d.Parentsareoftenthedecisionmakers,andtheyhavenoknowledgeoftheirchildrensspiritualneeds.ANS:AIllnessduringchildhoodmaybeanespeciallydifficultclinicalsituation.Children,aswellasadults,havespiritualneedsthatvaryaccordingtothechildsdevelopmentallevelandthereligiousclimatethatexistsinthefamily.Theotherstatementsarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity26.A30-year-oldwomanhasrecentlymovedtotheUnitedStateswithherhusband.Theyarelivingwiththewomanssisteruntiltheycangetahomeoftheirown.Whencompanyarrivestovisitwiththewomanssister,thewomanfeelssuddenlyshyandretreatstotNhUeRbaScINkGbeTdBr.oCoOmMtohideuntilthecompanyleaves.SheexplainsthatherreactiontoguestsissimplybecauseshedoesnotknowhowtospeakperfectEnglish.Thiswomancouldbeexperiencing:a.Cultureshock.b.Culturaltaboos.c.Culturalunfamiliarity.d.Culturedisorientation.ANS:ACultureshockisatermusedtodescribethestateofdisorientationorinabilitytorespondtothebehaviorofadifferentculturalgroupbecauseofitssuddenstrangeness,unfamiliarity,andincompatibilitywiththeindividualsperceptionsandexpectations.Theothertermsarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrity27.Afterasymptomisrecognized,thefirsteffortattreatmentisoftenself-care.Whichofthefollowingstatementsaboutself-careistrue?Self-careis:a.Notrecognizedasvaluablebymosthealthcareproviders.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)26STUVIA.COMb.Usuallyineffectiveandmaydelaymoreeffectivetreatment.c.Alwayslessexpensivethanbiomedicalalternatives.d.Influencedbytheaccessibilityofover-the-countermedicines.ANS:DAfterasymptomisidentified,thefirsteffortattreatmentisoftenself-care.Theavailabilityofover-the-countermedications,therelativelyhighliteracylevelofAmericans,andtheinfluenceofthemassmediaincommunicatinghealth-relatedinformationtothegeneralpopulationhavecontributedtothehighpercentageofcasesofself-treatment.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity28.Thenurseisreviewingthehot/coldtheoryofhealthandillness.Whichstatementbestdescribesthebasictenetsofthistheory?a.Thecausationofillnessisbasedonsupernaturalforcesthatinfluencethehumorsofthebody.b.Herbsandmedicinesareclassifiedontheirphysicalcharacteristicsofhotandcoldandthehumorsofthebody.NURSINGTB.COMc.Thefourhumorsofthebodyconsistofblood,yellowbile,spiritualconnectedness,andsocialaspectsoftheindividual.d.Thetreatmentofdiseaseconsistsofaddingorsubtractingcold,heat,dryness,orwetnesstorestorethebalanceofthehumorsofthebody.ANS:DThehot/coldtheoryofhealthandillnessisbasedonthefourhumorsofthebody:blood,phlegm,blackbile,andyellowbile.Thesehumorsregulatethebasicbodilyfunctions,describedintermsoftemperature,dryness,andmoisture.Thetreatmentofdiseaseconsistsofaddingorsubtractingcold,heat,dryness,orwetnesstorestorethebalanceofthehumors.Theotherstatementsarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity29.Inthehot/coldtheory,illnessesarebelievedtobecausedbyhotorcoldenteringthebody.Whichofthesepatientconditionsismostconsistentwithacoldcondition?a.Patientwithdiabetesandrenalfailureb.Teenagerwithanabscessedtoothc.ChildwithsymptomsofitchingandarashPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)27STUVIA.COMd.OldermanwithgastrointestinaldiscomfortANS:DIllnessesbelievedtobecausedbycoldenteringthebodyincludeearache,chestcramps,gastrointestinaldiscomfort,rheumatism,andtuberculosis.Thoseillnessesbelievedtobecausedbyheat,oroverheating,includesorethroats,abscessedteeth,rashes,andkidneydisorders.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrity30.Whenprovidingculturallycompetentcare,nursesmustincorporateculturalassessmentsintotheirhealthassessments.WhichstatementismostappropriatetousewheninitiatinganassessmentofculturalbeliefswithanolderAmerican-Indianpatient?a.AreyouoftheChristianfaith?b.Doyouwanttoseeamedicineman?c.Howoftendoyouseekhelpfrommedicalproviders?d.Whatculturalorspiritualbeliefsareimportanttoyou?ANS:DNURSINGTB.COMThenurseneedstoassesstheculturalbeliefsandpracticesofthepatient.AmericanIndiansmayseekassistancefromamedicinemanorshaman,butthenurseshouldnotassumethis.Anopen-endedquestionregardingculturalandspiritualbeliefsisbestusedinitiallywhenperformingaculturalassessment.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrity31.Duringaclassonculturalpractices,thenursehearsthetermculturaltaboo.Whichstatementillustratestheconceptofaculturaltaboo?a.Believingthatillnessisapunishmentofsinb.Tryingprayerbeforeseekingmedicalhelpc.Refusingtoacceptbloodproductsaspartoftreatmentd.StatingthatachildsbirthdefectistheresultoftheparentssinsANS:CCulturaltaboosarepracticesthataretobeavoided,suchasreceivingbloodproducts,eatingpork,andconsumingcaffeine.Theotheranswersdonotreflectculturaltaboos.DIF:CognitiveLevel:Applying(Application)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)28STUVIA.COMMSC:ClientNeeds:PsychosocialIntegrity32.Thenurserecognizesthatcategoriessuchasethnicity,gender,andreligionillustratetheconceptof:a.Family.b.Cultures.c.Spirituality.d.Subcultures.ANS:DWithincultures,groupsofpeoplesharedifferentbeliefs,values,andattitudes.Differencesoccurbecauseofethnicity,religion,education,occupation,age,andgender.Whensuchgroupsfunctionwithinalargeculture,theyarereferredtoassubculturalgroups.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity33.Thenurseisreviewingconceptsrelatedtoonesheritageandbeliefs.Thebeliefindivineorsuperhumanpower(s)tobeobeyedandworshippedasthecreator(s)andruler(s)oftheuniverseisknownas:a.Culture.b.Religion.c.Ethnicity.d.Spirituality.NURSINGTB.COMANS:BReligionisdefinedasanorganizedsystemofbeliefsconcerningthecause,nature,andpurposeoftheuniverse,especiallybeliefinortheworshipofGodorgods.Spiritualityisbornoutofeachpersonsuniquelifeexperiencesandhisorherpersonaleffortstofindpurposeandmeaninginlife.Ethnicitypertainstoasocialgroupwithinthesocialsystemthatclaimstopossessvariabletraits,suchasacommongeographicorigin,religion,race,andothers.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PsychosocialIntegrity34.Whenplanningaculturalassessment,thenurseshouldincludewhichcomponent?a.Familyhistoryb.ChiefcomplaintPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)29STUVIA.COMc.Medicalhistoryd.Health-relatedbeliefsANS:DHealth-relatedbeliefsandpracticesareonecomponentofaculturalassessment.Theotheritemsreflectotheraspectsofthepatientshistory.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity35.WhichofthefollowingreflectsthetraditionalhealthandillnessbeliefsandpracticesofthoseofAfricanheritage?Healthis:a.Beingrewardedforgoodbehavior.b.Thebalanceofthebodyandspirit.c.Maintainedbywearingjadeamulets.d.Beinginharmonywithnature.ANS:DNURSINGTB.COMThebeliefthathealthisbeinginharmonywithnaturereflectsthehealthbeliefsofthoseofAfricanheritages.TheotherexamplesrepresentIberianandCentralandSouthAmericanheritages,American-Indianheritages,andAsianheritages.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrityMULTIPLERESPONSE1.Thenurseisreviewingaspectsofculturalcare.Whichstatementsillustrateproperculturalcare?Selectallthatapply.a.Examinethepatientwithinthecontextofonesownculturalhealthandillnesspractices.b.Selectquestionsthatarenotcomplex.c.Askquestionsrapidly.d.Touchpatientswithintheculturalboundariesoftheirheritage.e.Pacequestionsthroughoutthephysicalexamination.ANS:B,D,EPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)30STUVIA.COMPatientsshouldbeexaminedwithinthecontextoftheirownculturalhealthandillnesspractices.Questionsshouldbesimplystatedandnotrapidlyasked.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrity2.Thenurseisaskingquestionsaboutapatientshealthbeliefs.Whichquestionsareappropriate?Selectallthatapply.a.Whatisyourdefinitionofhealth?b.Doesyourfamilyhaveahistoryofcancer?c.Howdoyoudescribeillness?d.Whatdidyourmotherdotokeepyoufromgettingsick?e.Haveyoueverhadanysurgeries?f.Howdoyoukeepyourselfhealthy?ANS:A,C,D,FThequestionslistedareappropriatequestionsNfoUrRaSnINasGseTsBs.mCeOnMtofapatientshealthbeliefsandpractices.Thequestionsregardingfamilyhistoryandsurgeriesarepartofthepatientsphysicalhistory,notthepatientshealthbeliefs.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrityPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)31STUVIA.COMChapter03:TheInterviewMULTIPLECHOICE1.Thenurseisconductinganinterviewwithawomanwhohasrecentlylearnedthatsheispregnantandwhohascometotheclinictodaytobeginprenatalcare.Thewomanstatesthatsheandherhusbandareexcitedaboutthepregnancybuthaveafewquestions.Shelooksnervouslyatherhandsduringtheinterviewandsighsloudly.Consideringtheconceptofcommunication,whichstatementdoesthenurseknowtobemostaccurate?Thewomanis:a.Excitedaboutherpregnancybutnervousaboutthelabor.b.Exhibitingverbalandnonverbalbehaviorsthatdonotmatch.c.Excitedaboutherpregnancy,butherhusbandisnotandthisisupsettingtoher.d.Notexcitedaboutherpregnancybutbelievesthenursewillnegativelyrespondtoherifshestatesthis.ANS:BCommunicationisallbehaviors,consciousandunconscious,verbalandnonverbal.Allbehaviorshavemeaning.Herbehaviordoesnotimplythatsheisnervousaboutlabor,upsetbyherhusband,orworriedaboutthenursesresponse.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrityNURSINGTB.COM2.Receivingisapartofthecommunicationprocess.Whichreceiverismostlikelytomisinterpretamessagesentbyahealthcareprofessional?a.Well-adjustedadolescentwhocameinforasportsphysicalb.Recoveringalcoholicwhocameinforabasicphysicalexaminationc.Manwhosewifehasjustbeendiagnosedwithlungcancerd.ManwithahearingimpairmentwhousessignlanguagetocommunicateandwhohasaninterpreterwithhimANS:CThereceiverattachesmeaningdeterminedbyhisorherexperiences,culture,self-concept,andcurrentphysicalandemotionalstates.Themanwhosewifehasjustbeendiagnosedwithlungcancermaybeexperiencingemotionsthataffecthisreceiving.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrity3.Thenursemakeswhichadjustmentinthephysicalenvironmenttopromotethesuccessofaninterview?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)32STUVIA.COMa.Reducesnoisebyturningofftelevisionsandradiosb.Reducesthedistancebetweentheinterviewerandthepatientto2feetorlessc.Providesadimlightthatmakestheroomcozyandhelpsthepatientrelaxd.ArrangesseatingacrossadeskortabletoallowthepatientsomepersonalspaceANS:AThenurseshouldreducenoisebyturningoffthetelevision,radio,andotherunnecessaryequipment,becausemultiplestimuliareconfusing.Theinterviewerandpatientshouldbeapproximately4to5feetapart;theroomshouldbewell-lit,enablingtheinterviewerandpatienttoseeeachotherclearly.Havingatableordeskinbetweenthetwopeoplecreatestheideaofabarrier;equal-statusseating,ateyelevel,isbetter.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity4.Inaninterview,thenursemayfinditnecessarytotakenotestoaidhisorhermemorylater.Whichstatementistrueregardingnote-taking?a.Note-takingmayimpedethenursesobservationofthepatientsnonverbalbehaviors.b.Note-takingallowsthepatienttocNonUtRinSuIeNaGtThBis.CoOrMherownpaceasthenurserecordswhatissaid.c.Note-takingallowsthenursetoshiftattentionawayfromthepatient,resultinginanincreasedcomfortlevel.d.Note-takingallowsthenursetobreakeyecontactwiththepatient,whichmayincreasehisorherlevelofcomfort.ANS:ATheuseofhistoryformsandnote-takingmaybeunavoidable.However,thenursemustbeawarethatnote-takingduringtheinterviewhasdisadvantages.Itbreakseyecontacttoooftenandshiftstheattentionawayfromthepatient,whichdiminisheshisorhersenseofimportance.Note-takingmayalsointerruptthepatientsnarrativeflow,anditimpedestheobservationofthepatientsnonverbalbehavior.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity5.Thenurseasks,Iwouldliketoaskyousomequestionsaboutyourhealthandyourusualdailyactivitiessothatwecanbetterplanyourstayhere.Thisquestionisfoundatthephaseoftheinterviewprocess.a.Summaryb.ClosingPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)33STUVIA.COMc.Bodyd.OpeningorintroductionANS:DWhengatheringacompletehistory,thenurseshouldgivethereasonfortheinterviewduringtheopeningorintroductionphaseoftheinterview,notduringorattheendoftheinterview.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity6.Awomanhasjustenteredtheemergencydepartmentafterbeingbatteredbyherhusband.Thenurseneedstogetsomeinformationfromhertobegintreatment.Whatisthebestchoiceforanopeningphaseoftheinterviewwiththispatient?a.Hello,Nancy,mynameisMrs.C.b.Hello,Mrs.H.,mynameisMrs.C.Itsureiscoldtoday!c.Mrs.H.,mynameisMrs.C.Howareyou?d.Mrs.H.,mynameisMrs.C.Illneedtoaskyouafewquestionsaboutwhathappened.NURSINGTB.COMANS:DAddressthepersonbyusinghisorhersurname.Thenurseshouldintroducehimorherselfandgivethereasonfortheinterview.Friendlysmalltalkisnotneededtobuildrapport.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity7.Duringaninterview,thenursestates,Youmentionedhavingshortnessofbreath.Tellmemoreaboutthat.Whichverbalskillisusedwiththisstatement?a.Reflectionb.Facilitationc.Directquestiond.Open-endedquestionANS:DTheopen-endedquestionasksfornarrativeinformation.Itstatesthetopictobediscussedbutonlyingeneralterms.Thenurseshoulduseittobegintheinterview,tointroduceanewsectionofquestions,andwheneverthpersonintroducesanewtopic.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)34STUVIA.COMDIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity8.Apatienthasfinishedgivingthenurseinformationaboutthereasonheisseekingcare.Whenreviewingthedata,thenursefindsthatsomeinformationaboutpasthospitalizationsismissing.Atthispoint,whichstatementbythenursewouldbemostappropriatetogatherthesedata?a.Mr.Y.,atyourage,surelyyouhavebeenhospitalizedbefore!b.Mr.Y.,IjustneedpermissiontogetyourmedicalrecordsfromCountyMedical.c.Mr.Y.,youmentionedthatyouhavebeenhospitalizedonseveraloccasions.Wouldyoutellmemoreaboutthat?d.Mr.Y.,Ijustneedtogetsomeadditionalinformationaboutyourpasthospitalizations.Whenwasthelasttimeyouwereadmittedforchestpain?ANS:DThenurseshouldusedirectquestionsafterthepersonsopeningnarrativetofillinanydetailsheorsheleftout.Thenursealsoshouldusedirectquestionswhenspecificfactsareneeded,suchaswhenaskingaboutpasthealthproblemsorduringthereviewofsystems.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrityNURSINGTB.COM9.Inusingverbalresponsestoassistthepatientsnarrative,someresponsesfocusonthepatientsframeofreferenceandsomefocusonthehealthcareprovidersperspective.Anexampleofaverbalresponsethatfocusesonthehealthcareprovidersperspectivewouldbe:a.Empathy.b.Reflection.c.Facilitation.d.Confrontation.ANS:DWhenthehealthcareproviderusestheresponseofconfrontation,theframeofreferenceshiftsfromthepatientsperspectivetotheperspectiveofthehealthcareprovider,andthehealthcareproviderstartstoexpresshisorherownthoughtsandfeelings.Empathy,reflection,andfacilitationresponsesfocusonthepatientsframeofreference.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PsychosocialIntegrity10.Whentakingahistoryfromanewlyadmittedpatient,thenursenoticesthatheoftenpausesandexpectantlyPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)35STUVIA.COMlooksatthenurse.Whatwouldbethenursesbestresponsetothisbehavior?a.Besilent,andallowhimtocontinuewhenheisready.b.Smileathimandsay,Dontworryaboutallofthis.Imsurewecanfindoutwhyyourehavingthesepains.c.Leanbackinthechairandask,Youarelookingatmekindoffunny;thereisntanythingwrong,isthere?d.Standupandsay,Icanseethatthisinterviewisuncomfortableforyou.Wecancontinueitanothertime.ANS:ASilentattentivenesscommunicatesthatthepersonhastimetothinkandtoorganizewhatheorshewishestosaywithoutaninterruptionfromthenurse.Healthprofessionalsmostofteninterruptthisthinkingsilence.Theotherresponsesarenotconducivetoidealcommunication.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity11.Awomanisdiscussingtheproblemssheishavingwithher2-year-oldson.Shesays,Hewontgotosleepatnight,andduringthedayhehasseveralfits.Igetsoupsetwhenthathappens.Thenursesbestverbalresponsewouldbe:a.Goon,Imlistening.NURSINGTB.COMb.Fits?Tellmewhatyoumeanbythis.c.Yes,itcanbeupsettingwhenachildhasafit.d.Dontbeupsetwhenhehasafit;every2yearoldhasfits.ANS:BThenurseshoulduseclarificationwhenthepersonswordchoiceisambiguousorconfusing(e.g.,Tellmewhatyoumeanbyfits.).Clarificationisalsousedtosummarizethepersonswordsortosimplifythewordstomakethemclearer;thenurseshouldthenaskifheorsheisontherighttrack.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity12.A17-year-oldsinglemotherisdescribinghowdifficultitistoraisea3-year-oldchildbyherself.Duringthecourseoftheinterviewshestates,Icantbelievemyboyfriendleftmetodothisbymyself!Whataterriblethingtodotome!Whichoftheseresponsesbythenurseusesempathy?a.Youfeelalone.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)36STUVIA.COMb.Youcantbelieveheleftyoualone?c.Itmustbesohardtofacethisallalone.d.Iwouldbeangry,too;raisingachildaloneisnopicnic.ANS:CAnempatheticresponserecognizesthefeelingandputsitintowords.Itnamesthefeeling,allowsitsexpression,andstrengthensrapport.Otherempatheticresponsesare,Thismustbeveryhardforyou,Iunderstand,orsimplyplacingyourhandonthepersonsarm.Simplyreflectingthepersonswordsoragreeingwiththepersonisnotanempatheticresponse.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity13.Amanhasbeenadmittedtotheobservationunitforobservationafterbeingtreatedforalargecutonhisforehead.Asthenurseworksthroughtheinterview,oneofthestandardquestionshastodowithalcohol,tobacco,anddruguse.Whenthenurseaskshimabouttobaccouse,hestates,Iquitsmokingaftermywifedied7yearsago.However,thenursenoticesanopenpackofcigarettesinhisshirtpocket.Usingconfrontation,thenursecouldsay:a.Mr.K.,Iknowthatyouarelying.b.Mr.K.,comeon,tellmehowmuchyousmoke.NURSINGTB.COMc.Mr.K.,Ididntrealizeyourwifehaddied.Itmustbedifficultforyouatthistime.Pleasetellmemoreaboutthat.d.Mr.K.,youhavesaidthatyoudontsmoke,butIseethatyouhaveanopenpackofcigarettesinyourpocket.ANS:DInthecaseofconfrontation,acertainaction,feeling,orstatementhasbeenobserved,andthenursenowfocusesthepatientsattentiononit.Thenurseshouldgivehonestfeedbackaboutwhatisseenorfelt.Confrontationmayfocusonadiscrepancy,orthenursemayconfrontthepatientwhenpartsofthestoryareinconsistent.Theotherstatementsarenotappropriate.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity14.Thenursehasusedinterpretationregardingapatientsstatementoractions.Afterusingthistechnique,itwouldbebestforthenurseto:a.Apologize,becauseusinginterpretationcanbedemeaningforthepatient.b.Allowtimeforthepatienttoconfirmorcorrecttheinference.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)37STUVIA.COMc.Continuewiththeinterviewasthoughnothinghashappened.d.Immediatelyrestatethenursesconclusiononthebasisofthepatientsnonverbalresponse.ANS:BInterpretationisnotbasedondirectobservationasisconfrontation,butitisbasedononesinferenceorconclusion.Thenurserisksmakingthewronginference.Ifthisisthecase,thenthepatientwillcorrectit.However,eveniftheinferenceiscorrect,interpretationhelpspromptfurtherdiscussionofthetopic.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrity15.Duringaninterview,awomansays,IhavedecidedthatIcannolongerallowmychildrentolivewiththeirfathersviolence,butIjustcantseemtoleavehim.Usinginterpretation,thenursesbestresponsewouldbe:a.Youaregoingtoleavehim?b.Ifyouareafraidforyourchildren,thenwhycantyouleave?c.Itsoundsasifyoumightbeafraidofhowyourhusbandwillrespond.d.Itsoundsasthoughyouhavemadeyourdecision.Ithinkitisagoodone.NURSINGTB.COMANS:CThisstatementisnotbasedononesinferenceorconclusion.Itlinksevents,makesassociations,orimpliescause.Interpretationalsoascribesfeelingsandhelpsthepersonunderstandhisorherownfeelingsinrelationtotheverbalmessage.Theotherstatementsdonotreflectinterpretation.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity16.Apregnantwomanstates,IjustknowlaborwillbesopainfulthatIwontbeabletostandit.Iknowitsoundsawful,butIreallydreadgoingintolabor.Thenurserespondsbystating,Oh,dontworryaboutlaborsomuch.Ihavebeenthroughit,andalthoughitispainful,manygoodmedicationsareavailabletodecreasethepain.Whichstatementistrueregardingthisresponse?Thenursesreplywasa:a.Therapeuticresponse.Bysharingsomethingpersonal,thenursegiveshopetothiswoman.b.Nontherapeuticresponse.Byprovidingfalsereassurance,thenurseactuallycutofffurtherdiscussionofthewomansfears.c.Therapeuticresponse.Byprovidinginformationaboutthemedicationsavailable,thenurseisgivinginformationtothewoman.d.Nontherapeuticresponse.Thenurseisessentiallygivingthemessagetothewomanthatlaborcannotbetoleratedwithoutmedication.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)38STUVIA.COMANS:BByprovidingfalseassuranceorreassurance,thiscouragebuilderrelievesthewomansanxietyandgivesthenursethefalsesenseofhavingprovidedcomfort.However,forthewoman,providingfalseassuranceorreassuranceactuallyclosesoffcommunication,trivializesheranxiety,andeffectivelydeniesanyfurthertalkofit.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrity17.Duringavisittotheclinic,apatientstates,ThedoctorjusttoldmehethoughtIoughttostopsmoking.HedoesntunderstandhowhardIvetried.Ijustdontknowthebestwaytodoit.WhatshouldIdo?Thenursesmostappropriateresponseinthiscasewouldbe:a.IdquitifIwereyou.Thedoctorreallyknowswhatheistalkingabout.b.Wouldyoulikesomeinformationaboutthedifferentwaysapersoncanquitsmoking?c.Stoppingyourdependenceoncigarettescanbeverydifficult.Iunderstandhowyoufeel.d.Whyareyouconfused?Didntthedoctorgiveyoutheinformationaboutthesmokingcessationprogramweoffer?ANS:BClarificationshouldbeusedwhenthepersonsNwUoRrSdIcNhGoTicBe.CisOaMmbiguousorconfusing.Clarificationisalsousedtosummarizethepersonswordsortosimplifythewordstomakethemclearer;thenurseshouldthenaskifheorsheisontherighttrack.Theotherresponsesgiveunwantedadviceordonotofferahelpfulresponse.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity18.Asthenurseentersapatientsroom,thenursefindshercrying.Thepatientstatesthatshehasjustfoundoutthatthelumpinherbreastiscancerandsays,Imsoafraidof,um,youknow.Thenursesmosttherapeuticresponsewouldbetosayinagentlemanner:a.Youreafraidyoumightloseyourbreast?b.No,Imnotsurewhatyouaretalkingabout.c.Illwaithereuntilyougetyourselfundercontrol,andthenwecantalk.d.Icanseethatyouareveryupset.Perhapsweshoulddiscussthislater.ANS:AReflectionechoesthepatientswords,repeatingpartofwhatthepersonhasjustsaid.Reflectioncanalsohelpexpressthefeelingsbehindapersonswords.DIF:CognitiveLevel:Applying(Application)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)39STUVIA.COMMSC:ClientNeeds:PsychosocialIntegrity19.Anurseistakingcompletehealthhistoriesonallofthepatientsattendingawellnessworkshop.Onthehistoryform,oneofthewrittenquestionsasks,Youdontsmoke,drink,ortakedrugs,doyou?Thisquestionisanexampleof:a.Talkingtoomuch.b.Usingconfrontation.c.Usingbiasedorleadingquestions.d.Usingbluntlanguagetodealwithdistastefultopics.ANS:CThisquestionisanexampleofusingleadingorbiasedquestions.Asking,Youdontsmoke,doyou?impliesthatoneanswerisbetterthananother.Ifthepersonwantstopleasesomeone,thenheorsheiseitherforcedtoanswerinawaythatcorrespondstohisorherimpliedvaluesorismadetofeelguiltywhenadmittingtheotheranswer.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity20.Whenobservingapatientsverbalandnonverbalcommunication,thenursenoticesadiscrepancy.Whichstatementistrueregardingthissituation?TheNnUurRsSeIsNhGouTlBd.:COMa.Asksomeonewhoknowsthepatientwelltohelpinterpretthisdiscrepancy.b.Focusonthepatientsverbalmessage,andtrytoignorethenonverbalbehaviors.c.Trytointegratetheverbalandnonverbalmessagesandtheninterpretthemasanaverage.d.Focusonthepatientsnonverbalbehaviors,becausetheseareoftenmorereflectiveofapatientstruefeelings.ANS:DWhennonverbalandverbalmessagesarecongruent,theverbalmessageisreinforced.Whentheyareincongruent,thenonverbalmessagetendstobethetrueonebecauseitisunderlessconsciouscontrol.Thusstudyingthenonverbalmessagesofthepatientsandexaminersandunderstandingtheirmeaningsareimportant.Theotherstatementsarenottrue.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity21.Duringaninterview,aparentofahospitalizedchildissittinginanopenposition.Astheinterviewerbeginstodiscusshissonstreatment,however,hesuddenlycrosseshisarmsagainsthischestandcrosseshislegs.Thischangedposturewouldsuggestthattheparentis:PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)40STUVIA.COMa.Simplychangingpositions.b.Morecomfortableinthisposition.c.Tiredandneedsabreakfromtheinterview.d.Uncomfortabletalkingabouthissonstreatment.ANS:DThepersonspositionisnoted.Anopenpositionwiththeextensionoflargemusclegroupsshowsrelaxation,physicalcomfort,andawillingnesstoshareinformation.Aclosedpositionwiththearmsandlegscrossedtendstolookdefensiveandanxious.Anychangeinpostureshouldbenoted.Ifapersoninarelaxedpositionsuddenlytenses,thenthischangeinposturesuggestspossiblediscomfortwiththenewtopic.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrity22.Amotherbringsher28-month-olddaughterintotheclinicforawell-childvisit.Atthebeginningofthevisit,thenursefocusesattentionawayfromthetoddler,butastheinterviewprogresses,thetoddlerbeginstowarmupandissmilingshylyatthenurse.Thenursewillbemostsuccessfulininteractingwiththetoddlerifwhichisdonenext?a.Ticklethetoddler,andgethertolaugh.NURSINGTB.COMb.Stoopdowntoherlevel,andaskheraboutthetoysheisholding.c.Continuetoignoreheruntilitistimeforthephysicalexamination.d.Askthemothertoleaveduringtheexaminationofthetoddler,becausetoddlersoftenfusslessiftheirparentisnotinview.ANS:BAlthoughmostofthecommunicationiswiththeparent,thenurseshouldnotcompletelyignorethechild.Makingcontactwillhelpeasethetoddlerlaterduringthephysicalexamination.Thenurseshouldbeginbyaskingaboutthetoysthechildisplayingwithoraboutaspecialdollorteddybearbroughtfromhome.Doesyourdollhaveaname?orWhatcanyourtruckdo?Stoopdowntomeetthechildathisorhereyelevel.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity23.Duringanexaminationofa3-year-oldchild,thenursewillneedtotakeherbloodpressure.Whatmightthenursedototrytogainthechildsfullcooperation?a.Tellthechildthatthebloodpressurecuffisgoingtogiveherarmabighug.b.Tellthechildthatthebloodpressurecuffisasleepandcannotwakeup.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)41STUVIA.COMc.Givethebloodpressurecuffanameandrefertoitbythisnameduringtheassessment.d.Tellthechildthatbyusingthebloodpressurecuff,wecanseehowstronghermusclesare.ANS:DTakethetimetogiveashort,simpleexplanationwithaconcreteexplanationforanyunfamiliarequipmentthatwillbeusedonthechild.Preschoolersareanimistic;theyimagineinanimateobjectscancomealiveandhavehumancharacteristics.Thusabloodpressurecuffcanwakeupandbiteorpinch.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity24.A16-year-oldboyhasjustbeenadmittedtotheunitforovernightobservationafterbeinginanautomobileaccident.Whatisthenursesbestapproachtocommunicatingwithhim?a.Useperiodsofsilencetocommunicaterespectforhim.b.Betotallyhonestwithhim,eveniftheinformationisunpleasant.c.Tellhimthateverythingthatisdiscussedwillbekepttotallyconfidential.d.Useslanglanguagewhenpossibletohelphimopenup.NURSINGTB.COMANS:BSuccessfulcommunicationwithanadolescentispossibleandcanberewarding.Theguidelinesaresimple.Thefirstconsiderationisonesattitude,whichmustbeoneofrespect.Second,communicationmustbetotallyhonest.Anadolescentsintuitionishighlytunedandcandetectphoninessorthewithholdingofinformation.Alwaystellhimorherthetruth.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity25.A75-year-oldwomanisattheofficeforapreoperativeinterview.Thenurseisawarethattheinterviewmaytakelongerthaninterviewswithyoungerpersons.Whatisthereasonforthis?a.Anagedpersonhasalongerstorytotell.b.Anagedpersonisusuallylonelyandlikestohavesomeonewithwhomtotalk.c.Agedpersonslosemuchoftheirmentalabilitiesandrequirelongertimetocompleteaninterview.d.Asapersonages,heorsheisunabletohear;thustheinterviewerusuallyneedstorepeatmuchofwhatissaid.ANS:APHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)42STUVIA.COMTheinterviewusuallytakeslongerwitholderadultsbecausetheyhavealongerstorytotell.Itisnotnecessarilytruethatallolderadultsarelonely,havelostmentalabilities,orarehardofhearing.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity26.Thenurseisinterviewingamalepatientwhohasahearingimpairment.Whattechniqueswouldbemostbeneficialincommunicatingwiththispatient?a.Determinethecommunicationmethodheprefers.b.Avoidusingfacialandhandgesturesbecausemosthearing-impairedpeoplefindthisdegrading.c.Requestasignlanguageinterpreterbeforemeetingwithhimtohelpfacilitatethecommunication.d.Speakloudlyandwithexaggeratedfacialmovementwhentalkingwithhimbecausedoingsowillhelphimlipread.ANS:AThenurseshouldaskthedeafpersonthepreferredwaytocommunicatebysigning,lipreading,orwriting.Ifthepersonpreferslipreading,thenthenurseshouldbesuretofacehimsquarelyandhavegoodlightingonthenursesface.Thenurseshouldnotexaggeratelipmovementsbecausethisdistortswords.Similarly,shoutingdistortsthereceptionofahearingaidthepersonmaywear.Thenurseshouldspeakslowlyandsupplementhisorhervoicewithappropriatehandgesturesorpantomime.NURSINGTB.COMDIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity27.Duringaprenatalcheck,apatientbeginstocryasthenurseasksheraboutpreviouspregnancies.Shestatesthatsheisrememberingherlastpregnancy,whichendedinmiscarriage.Thenursesbestresponsetohercryingwouldbe:a.Imsosorryformakingyoucry!b.Icanseethatyouaresadrememberingthis.Itisallrighttocry.c.WhydontIstepoutforafewminutesuntilyourefeelingbetter?d.Icanseethatyoufeelsadaboutthis;whydontwetalkaboutsomethingelse?ANS:BAbeginningexaminerusuallyfeelshorrifiedwhenthepatientstartscrying.Whenthenursesayssomethingthatmakesthepersoncry,thenurseshouldnotthinkheorshehashurttheperson.Thenursehassimplyhitonanimportanttopic;therefore,movingontoanewtopicisessential.Thenurseshouldallowthepersontocryandtoexpresshisorherfeelingsfully.Thenursecanofferatissueandwaituntilthecryingsubsidestotalk.DIF:CognitiveLevel:Applying(Application)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)43STUVIA.COMMSC:ClientNeeds:PsychosocialIntegrity28.Afemalenurseisinterviewingamanwhohasrecentlyimmigrated.Duringthecourseoftheinterview,heleansforwardandthenfinallymoveshischaircloseenoughthathiskneesarenearlytouchingthenursesknees.Thenursebeginstofeeluncomfortablewithhisproximity.Whichstatementmostcloselyreflectswhatthenurseshoulddonext?a.Thenurseshouldtrytorelax;thesebehaviorsareculturallyappropriateforthisperson.b.Thenurseshoulddiscreetlymovehisorherchairbackuntilthedistanceismorecomfortable,andthencontinuewiththeinterview.c.Thesebehaviorsareindicativeofsexualaggression,andthenurseshouldconfrontthispersonabouthisbehaviors.d.Thenurseshouldlaughbuttellhimthatheorsheisuncomfortablewithhisproximityandaskhimtomoveaway.ANS:ABoththepatientsandthenursessenseofspatialdistancearesignificantthroughouttheinterviewandphysicalexamination,withculturallyappropriatedistancezonesvaryingwidely.Someculturalgroupsvalueclosephysicalproximityandmayperceiveahealthcareproviderwhoisdistancinghimorherselfasbeingaloofandunfriendly.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrityNURSINGTB.COM29.AfemaleAmericanIndianhascometotheclinicforfollow-updiabeticteaching.Duringtheinterview,thenursenoticesthatshenevermakeseyecontactandspeaksmostlytothefloor.Whichstatementistrueregardingthissituation?a.Thewomanisnervousandembarrassed.b.Shehassomethingtohideandisashamed.c.Thewomanisshowinginconsistentverbalandnonverbalbehaviors.d.Sheisshowingthatsheiscarefullylisteningtowhatthenurseissaying.ANS:DEyecontactisperhapsamongthemostculturallyvariablenonverbalbehaviors.Asian,AmericanIndian,Indochinese,Arabian,andAppalachianpeoplemayconsiderdirecteyecontactimpoliteoraggressive,andtheymayaverttheireyesduringtheinterview.AmericanIndiansoftenstareatthefloorduringtheinterview,whichisaculturallyappropriatebehavior,indicatingthatthelistenerispayingcloseattentiontothespeaker.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrityPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)44STUVIA.COM30.Thenurseisperformingahealthinterviewonapatientwhohasalanguagebarrier,andnointerpreterisavailable.Whichisthebestexampleofanappropriatequestionforthenursetoaskinthissituation?a.Doyoutakemedicine?b.Doyousterilizethebottles?c.Doyouhavenauseaandvomiting?d.Youhavebeentakingyourmedicine,haventyou?ANS:AInasituationduringwhichalanguagebarrierexistsandnointerpreterisavailable,simplewordsshouldbeused,avoidingmedicaljargon.Theuseofcontractionsandpronounsshouldalsobeavoided.Nounsshouldberepeatedlyused,andonetopicatatimeshouldbediscussed.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrity31.Amanarrivesattheclinicforhisannualwellnessphysical.Heisexperiencingnoacutehealthproblems.Whichquestionorstatementbythenurseismostappropriatewhenbeginningtheinterview?a.Howisyourfamily?b.Howisyourjob?c.Tellmeaboutyourhypertension.NURSINGTB.COMd.Howhasyourhealthbeensinceyourlastvisit?ANS:DOpen-endedquestionsareusedforgatheringnarrativeinformation.Thistypeofquestioningshouldbeusedtobegintheinterview,tointroduceanewsectionofquestions,andwheneverthepersonintroducesanewtopic.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity32.Thenursemakesthiscommenttoapatient,Iknowitmaybehard,butyoushoulddowhatthedoctororderedbecausesheistheexpertinthisfield.Whichstatementiscorrectaboutthenursescomment?a.Thiscommentisinappropriatebecauseitshowsthenursesbias.b.Thiscommentisappropriatebecausemembersofthehealthcareteamareexpertsintheirareaofpatientcare.c.ThistypeofcommentpromotesdependencyandinferiorityonthepartofthepatientandisbestPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)45STUVIA.COMavoidedinaninterviewsituation.d.Usingauthoritystatementswhendealingwithpatients,especiallywhentheyareundecidedaboutanissue,isnecessaryattimes.ANS:CUsingauthorityresponsespromotesdependencyandinferiority.Avoidingtheuseofauthorityisbest.Althoughthehealthcareproviderandpatientdonothaveequalprofessionalknowledge,bothhaveequallyworthyrolesinthehealthprocess.Theotherstatementsarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity33.AfemalepatientdoesnotspeakEnglishwell,andthenurseneedstochooseaninterpreter.Whichofthefollowingwouldbethemostappropriatechoice?a.Trainedinterpreterb.Malefamilymemberc.Femalefamilymemberd.VolunteercollegestudentfromtheforeignlanguagestudiesdepartmentNURSINGTB.COMANS:AWheneverpossible,thenurseshoulduseatrainedinterpreter,preferablyonewhoknowsmedicalterminology.Ingeneral,anolder,morematureinterpreterispreferredtoayounger,lessexperiencedone,andthesamegenderispreferredwhenpossible.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity34.Duringafollow-upvisit,thenursediscoversthatapatienthasnotbeentakinghisinsulinonaregularbasis.Thenurseasks,Whyhaventyoutakenyourinsulin?Whichstatementisanappropriateevaluationofthisquestion?a.Thisquestionmayplacethepatientonthedefensive.b.Thisquestionisaninnocentsearchforinformation.c.Discussinghisbehaviorwithhiswifewouldhavebeenbetter.d.Adirectquestionisthebestwaytodiscoverthereasonsforhisbehavior.ANS:APHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)46STUVIA.COMTheadultsuseofwhyquestionsusuallyimpliesblameandcondemnationandplacesthepersononthedefensive.Theotherstatementsarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrity35.Thenurseisnearingtheendofaninterview.Whichstatementisappropriateatthistime?a.Didweforgetsomething?b.Isthereanythingelseyouwouldliketomention?c.Ineedtogoontothenextpatient.Illbeback.d.WhileImhere,letstalkaboutyourupcomingsurgery.ANS:BThisquestionoffersthepersonafinalopportunityforself-expression.Nonewtopicshouldbeintroduced.Theotherquestionsarenotappropriate.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity36.DuringtheinterviewportionofdatacollecNtiUoRn,StIhNeGnTuBrs.CeOcoMllectsdata.a.Physicalb.Historicalc.Objectived.SubjectiveANS:DTheinterviewisthefirst,andreallythemostimportant,partofdatacollection.Duringtheinterview,thenursecollectssubjectivedata;thatis,whatthepersonsaysabouthimorherself.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PsychosocialIntegrity37.Duringaninterview,thenursewouldexpectthatmostoftheinterviewwilltakeplaceatwhatdistance?a.Intimatezoneb.PersonaldistancePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)47STUVIA.COMc.Socialdistanced.PublicdistanceANS:CSocialdistance,4to12feet,isusuallythedistancecategoryformostoftheinterview.Publicdistance,over12feet,istoomuchdistance;theintimatezoneisinappropriate,andthepersonaldistancewillbeusedforthephysicalassessment.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity38.Afemalenurseisinterviewingamalepatientwhoisnearthesameageasthenurse.Duringtheinterview,thepatientmakesanovertlysexualcomment.Thenursesbestreactionwouldbe:a.Stopthatimmediately!b.Oh,youaretoofunny.Letskeepgoingwiththeinterview.c.DoyoureallythinkIwouldbeinterested?d.Itmakesmeuncomfortablewhenyoutalkthatway.Pleasestop.NURSINGTB.COMANS:DThenursesresponsemustmakeitclearthatsheisahealthprofessionalwhocanbestcareforthepersonbymaintainingaprofessionalrelationship.Atthesametime,thenurseshouldcommunicatethatheorsheacceptsthepersonandunderstandsthepersonsneedtobeself-assertivebutthatsexualadvancescannotbetolerated.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrityMULTIPLERESPONSE1.Thenurseisconductinganinterview.Whichofthesestatementsistrueregardingopen-endedquestions?Selectallthatapply.a.Open-endedquestionselicitcoldfacts.b.Theyallowforself-expression.c.Open-endedquestionsbuildandenhancerapport.d.Theyleaveinteractionsneutral.e.Open-endedquestionscallforshortone-totwo-wordanswers.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)48STUVIA.COMf.Theyareusedwhennarrativeinformationisneeded.ANS:B,C,FOpen-endedquestionsallowforself-expression,buildandenhancerapport,andobtainnarrativeinformation.Thesefeaturesenhancecommunicationduringaninterview.Theotherstatementsareappropriateforclosedordirectquestions.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity2.Thenurseisconductinganinterviewinanoutpatientclinicandisusingacomputertorecorddata.Whicharethebestusesofthecomputerinthissituation?Selectallthatapply.a.Collectthepatientsdatainadirect,face-to-facemanner.b.Enterallthedataasthepatientstatesthem.c.Askthepatienttowaitasthenurseentersthedata.d.Typethedataintothecomputerafterthenarrativeisfullyexplored.e.Allowthepatienttoseethemonitorduringtyping.NURSINGTB.COMANS:A,D,ETheuseofacomputercanbecomeabarrier.Thenurseshouldbegintheinterviewasusualbygreetingthepatient,establishingrapport,andcollectingthepatientsnarrativestoryinadirect,face-to-facemanner.Onlyafterthenarrativeisfullyexploredshouldthenursetypedataintothecomputer.Whentyping,thenurseshouldpositionthemonitorsothatthepatientcanseeit.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrityPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)49STUVIA.COMChapter04:TheCompleteHealthHistoryMULTIPLECHOICE1.Thenurseispreparingtoconductahealthhistory.Whichofthesestatementsbestdescribesthepurposeofahealthhistory?a.Toprovideanopportunityforinteractionbetweenthepatientandthenurseb.Toprovideaformforobtainingthepatientsbiographicinformationc.Todocumentthenormalandabnormalfindingsofaphysicalassessmentd.ToprovideadatabaseofsubjectiveinformationaboutthepatientspastandcurrenthealthANS:DThepurposeofthehealthhistoryistocollectsubjectivedatawhatthepersonsaysabouthimorherself.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare2.Whenthenurseisevaluatingthereliabilityofapatientsresponses,whichofthesestatementswouldbecorrect?Thepatient:NURSINGTB.COMa.Hasahistoryofdrugabuseandthereforeisnotreliable.b.Providedconsistentinformationandthereforeisreliable.c.Smiledthroughoutinterviewandthereforeisassumedreliable.d.Wouldnotanswerquestionsconcerningstressandthereforeisnotreliable.ANS:BAreliablepersonalwaysgivesthesameanswers,evenwhenquestionsarerephrasedorarerepeatedlaterintheinterview.Theotherstatementsarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare3.A59-year-oldpatienttellsthenursethathehasulcerativecolitis.Hehasbeenhavingblackstoolsforthelast24hours.Howwouldthenursebestdocumenthisreasonforseekingcare?a.J.M.isa59-year-oldmanseekingtreatmentforulcerativecolitis.b.J.M.cameintothecliniccomplainingofhavingblackstoolsforthepast24hours.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)50STUVIA.COMc.J.M.isa59-year-oldmanwhostatesthathehasulcerativecolitisandwantsitchecked.d.J.M.isa59-year-oldmanwhostatesthathehasbeenhavingblackstoolsforthepast24hours.ANS:DThereasonforseekingcareisabriefspontaneousstatementinthepersonsownwordsthatdescribesthereasonforthevisit.Itstatesone(possiblytwo)signsorsymptomsandtheirduration.Itisenclosedinquotationmarkstoindicatethepersonsexactwords.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare4.Apatienttellsthenursethatshehashadabdominalpainforthepastweek.Whatwouldbethenursesbestresponse?a.Canyoupointtowhereithurts?b.Welltalkmoreaboutthatlaterintheinterview.c.Whathaveyouhadtoeatinthelast24hours?d.Haveyoueverhadanysurgeriesonyourabdomen?NURSINGTB.COMANS:AAfinalsummaryofanysymptomthepersonhasshouldinclude,alongwithsevenothercriticalcharacteristics,Location:specific.Thepersonisaskedtopointtothelocation.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare5.A29-year-oldwomantellsthenursethatshehasexcruciatingpaininherback.Whichwouldbethenursesappropriateresponsetothewomansstatement?a.Howdoesyourfamilyreacttoyourpain?b.Thepainmustbeterrible.Youprobablypinchedanerve.c.Ivehadbackpainmyself,anditcanbeexcruciating.d.Howwouldyousaythepainaffectsyourabilitytodoyourdailyactivities?ANS:DThesymptomofpainisdifficulttoquantifybecauseofindividualinterpretation.Withpain,adjectivesshouldbeavoidedandthepatientshouldbeaskedhowthepainaffectshisorherdailyactivities.Theotherresponsesarenotappropriate.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)51STUVIA.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare6.Inrecordingthechildhoodillnessesofapatientwhodenieshavinghadany,whichnotebythenursewouldbemostaccurate?a.Patientdeniesusualchildhoodillnesses.b.Patientstateshewasaveryhealthychild.c.Patientstateshissisterhadmeasles,buthedidnt.d.Patientdeniesmeasles,mumps,rubella,chickenpox,pertussis,andstrepthroat.ANS:DChildhoodillnessesincludemeasles,mumps,rubella,chickenpox,pertussis,andstrepthroat.Avoidrecordingusualchildhoodillnessesbecauseanillnesscommoninthepersonschildhoodmaybeunusualtoday(e.g.,measles).DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare7.Afemalepatienttellsthenursethatshehashadsixpregnancies,withfourlivebirthsattermandtwospontaneousabortions.HerfourchildrenaresNtiUllRliSvIiNngG.THBo.CwOwMouldthenurserecordthisinformation?a.P-6,B-4,(S)Ab-2b.Grav6,Term4,(S)Ab-2,Living4c.Patienthashadfourlivingbabies.d.Patienthasbeenpregnantsixtimes.ANS:BObstetrichistoryincludesthenumberofpregnancies(gravidity),numberofdeliveriesinwhichthefetusreachedterm(term),numberofpretermpregnancies(preterm),numberofincompletepregnancies(abortions),andnumberofchildrenliving(living).Thisisrecorded:GravTermPretermAbLiving.Foranyincompletepregnancies,thedurationisrecordedandwhetherthepregnancyresultedinaspontaneous(S)oraninduced(I)abortion.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare8.Apatienttellsthenursethatheisallergictopenicillin.Whatwouldbethenursesbestresponsetothisinformation?a.Areyouallergictoanyotherdrugs?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)52STUVIA.COMb.Howoftenhaveyoureceivedpenicillin?c.Illwriteyourallergyonyourchartsoyouwontreceiveanypenicillin.d.Describewhathappenstoyouwhenyoutakepenicillin.ANS:DNoteboththeallergen(medication,food,orcontactagent,suchasfabricorenvironmentalagent)andthereaction(rash,itching,runnynose,wateryeyes,ordifficultybreathing).Withadrug,thissymptomshouldnotbeasideeffectbutatrueallergicreaction.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare9.Thenurseistakingafamilyhistory.Importantdiseasesorproblemsaboutwhichthepatientshouldbespecificallyaskedinclude:a.Emphysema.b.Headtrauma.c.Mentalillness.d.Fracturedbones.NURSINGTB.COMANS:CQuestionsconcerninganyfamilyhistoryofheartdisease,highbloodpressure,stroke,diabetes,obesity,blooddisorders,breastandovariancancers,coloncancer,sicklecellanemia,arthritis,allergies,alcoholordrugaddiction,mentalillness,suicide,seizuredisorder,kidneydisease,andtuberculosisshouldbeasked.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare10.Thereviewofsystemsprovidesthenursewith:a.Physicalfindingsrelatedtoeachsystem.b.Informationregardinghealthpromotionpractices.c.Anopportunitytoteachthepatientmedicalterms.d.Informationnecessaryforthenursetodiagnosethepatientsmedicalproblem.ANS:BPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)53STUVIA.COMThepurposesofthereviewofsystemsareto:(1)evaluatethepastandcurrenthealthstateofeachbodysystem,(2)doublecheckfactsincaseanysignificantdatawereomittedinthepresentillnesssection,and(3)evaluatehealthpromotionpractices.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare11.Whichofthesestatementsrepresentssubjectivedatathenurseobtainedfromthepatientregardingthepatientsskin?a.Skinappearsdry.b.Nolesionsareobvious.c.Patientdeniesanycolorchange.d.Lesionisnotedonthelateralaspectoftherightarm.ANS:CThehistoryshouldbelimitedtopatientstatementsorsubjectivedatafactorsthatthepersonsayswereorwerenotpresent.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareENnUvRirSoInNmGeTnBt:.CMOaMnagementofCare12.Thenurseisobtainingahistoryfroma30-year-oldmalepatientandisconcernedabouthealthpromotionactivities.Whichofthesequestionswouldbeappropriatetousetoassesshealthpromotionactivitiesforthispatient?a.Doyouperformtesticularself-examinations?b.Haveyouevernoticedanypaininyourtesticles?c.Haveyouhadanyproblemswithpassingurine?d.Doyouhaveanyhistoryofsexuallytransmitteddiseases?ANS:AHealthpromotionforamanwouldincludetheperformanceoftesticularself-examinations.Theotherquestionsareaskingaboutpossiblediseaseorillnessissues.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare13.Whichoftheseresponsesmightthenurseexpectduringafunctionalassessmentofapatientwhoselegisinacast?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)54STUVIA.COMa.Ibrokemyrightleginacaraccident2weeksago.b.Thepainisdecreasing,butIstillneedtotakeacetaminophen.c.IcheckthecolorofmytoeseveryeveningjustlikeIwastaught.d.Imabletotransfermyselffromthewheelchairtothebedwithouthelp.ANS:DFunctionalassessmentmeasuresapersonsself-careabilityintheareasofgeneralphysicalhealthorabsenceofillness.Theotherstatementsconcernhealthorillnessissues.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare14.Inresponsetoaquestionaboutstress,a39-year-oldwomantellsthenursethatherhusbandandmotherbothdiedinthepastyear.Whichresponsebythenurseismostappropriate?a.Thishasbeenadifficultyearforyou.b.Idontknowhowanyonecouldhandlethatmuchstressin1year!c.WhatdidyoudotocopewiththelNoUssRoSfINboGthTBy.oCuOrMhusbandandmother?d.Thatisalotofstress;nowletsgoontothenextsectionofyourhistory.ANS:CQuestionsaboutcopingandstressmanagementincludequestionsregardingthekindsofstressesinoneslife,especiallyinthelastyear,anychangesinlifestyleoranycurrentstress,methodstriedtorelievestress,andwhetherthesemethodshavebeenhelpful.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare15.Inresponsetoaquestionregardingtheuseofalcohol,apatientasksthenursewhythenurseneedstoknow.Whatisthereasonforneedingthisinformation?a.Thisinformationisnecessarytodeterminethepatientsreliability.b.Alcoholcaninteractwithallmedicationsandcanmakesomediseasesworse.c.Thenurseneedstobeabletoteachthepatientaboutthedangersofalcoholuse.d.Thisinformationisnotnecessaryunlessadrinkingproblemisobvious.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)55STUVIA.COMANS:BAlcoholadverselyinteractswithallmedicationsandisafactorinmanysocialproblemssuchaschildorsexualabuse,automobileaccidents,andassaults;alcoholalsocontributestomanyillnessesanddiseaseprocesses.Therefore,assessingforsignsofhazardousalcoholuseisimportant.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare16.Themotherofa16-month-oldtoddlertellsthenursethatherdaughterhasanearache.Whatwouldbeanappropriateresponse?a.Maybesheisjustteething.b.Iwillcheckherearforanearinfection.c.Areyousuresheisreallyhavingpain?d.Describewhatsheisdoingtoindicatesheishavingpain.ANS:DWithaveryyoungchild,theparentisasked,Howdoyouknowthechildisinpain?Ayoungchildpullingathisorherearsshouldalertparentstothechildsearpain.Statementsaboutteethingandquestioningwhetherthechildisreallyhavingpaindonotexplorethesymptoms,whichshouldbedonebeforeaphysicalexamination.NURSINGTB.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare17.Duringanassessmentofapatientsfamilyhistory,thenurseconstructsagenogram.Whichstatementbestdescribesagenogram?a.Listofdiseasespresentinapersonsnearrelativesb.Graphicfamilytreethatusessymbolstodepictthegender,relationship,andageofimmediatefamilymembersc.Drawingthatdepictsthepatientsfamilymembersuptofivegenerationsbackd.DescriptionofthehealthofapersonschildrenandgrandchildrenANS:BAgenogram(orpedigree)isagraphicfamilytreethatusessymbolstodepictthegender,relationship,andageofimmediatebloodrelativesinatleastthreegenerations(parents,grandparents,siblings).Theotheroptionsdonotdescribeagenogram.DIF:CognitiveLevel:Applying(Application)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)56STUVIA.COMMSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare18.A5-year-oldboyisbeingadmittedtothehospitaltohavehistonsilsremoved.Whichinformationshouldthenursecollectbeforethisprocedure?a.Childsbirthweightb.Ageatwhichhecrawledc.Whetherthechildhashadthemeaslesd.ChildsreactionstoprevioushospitalizationsANS:DHowthechildreactedtoprevioushospitalizationsandanycomplicationsshouldbeassessed.Ifthechildreactedpoorly,thenheorshemaybeafraidnowandwillneedspecialpreparationfortheexaminationthatistofollow.Theotheritemsarenotsignificantfortheprocedure.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare19.Aspartofthehealthhistoryofa6-year-oldboyataclinicforasportsphysicalexamination,thenursereviewshisimmunizationrecordandnotesthathislastmeasles-mumps-rubella(MMR)vaccinationwasat15monthsofage.Whatrecommendationshouldthenursemake?NURSINGTB.COMa.NofurtherMMRimmunizationsareneeded.b.MMRvaccinationneedstoberepeatedat4to6yearsofage.c.MMRimmunizationneedstoberepeatedevery4yearsuntilage21years.d.Arecommendationcannotbemadeuntilthephysicianisconsulted.ANS:BBecauseofrecentoutbreaksofmeaslesacrosstheUnitedStates,theAmericanAcademyofPediatrics(2006)recommendstwodosesoftheMMRvaccine,oneat12to15monthsofageandoneatage4to6years.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare20.Inobtainingareviewofsystemsonahealthy7-year-oldgirl,thehealthcareproviderknowsthatitwouldbeimportanttoincludethe:a.Lastglaucomaexamination.b.Frequencyofbreastself-examinations.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)57STUVIA.COMc.Dateofherlastelectrocardiogram.d.Limitationsrelatedtoherinvolvementinsportsactivities.ANS:DWhenreviewingthecardiovascularsystem,thehealthcareprovidershouldaskwhetheranyactivityislimitedorwhetherthechildcankeepupwithherpeers.Theotheritemsarenotappropriateforachildthisage.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare21.Whenthenurseasksforadescriptionofwholiveswithachild,themethodofdiscipline,andthesupportsystemofthechild,whatpartoftheassessmentisbeingperformed?a.Familyhistoryb.Reviewofsystemsc.Functionalassessmentd.ReasonforseekingcareANS:CNURSINGTB.COMFunctionalassessmentincludesinterpersonalrelationshipsandhomeenvironment.Familyhistoryincludesillnessesinfamilymembers;areviewofsystemsincludesquestionsaboutthevariousbodysystems;andthereasonforseekingcareistherationaleforrequestinghealthcare.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare22.Thenurseisobtainingahealthhistoryonan87-year-oldwoman.Whichofthefollowingareasofquestioningwouldbemostusefulatthistime?a.Obstetrichistoryb.Childhoodillnessesc.Generalhealthforthepast20yearsd.CurrenthealthpromotionactivitiesANS:DItisimportantforthenursetorecognizepositivehealthmeasures,suchaswhatthepersonhasbeendoingtohelphimorherselfstaywellandtolivetoanolderage.Theotherresponsesarenotpertinenttoapatientofthisage.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)58STUVIA.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare23.Thenurseisperformingareviewofsystemsona76-year-oldpatient.Whichofthesestatementsiscorrectforthissituation?a.Thequestionsaskedareidenticalforallages.b.Theinterviewerwillstartincorporatingdifferentquestionsforpatients70yearsofageandolder.c.Questionsthatarereflectiveofthenormaleffectsofagingareadded.d.Atthisage,areviewofsystemsisnotnecessarythefocusshouldbeoncurrentproblems.ANS:CThehealthhistoryincludesthesameformatasthatdescribedfortheyoungeradult,aswellassomeadditionalquestions.Theseadditionalquestionsaddresswaysinwhichtheactivitiesofdailylivingmayhavebeenaffectedbythenormalagingprocessesorbytheeffectsofchronicillnessordisability.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare24.A90-year-oldpatienttellsthenursethathecannotrememberthenamesofthemedicationsheistakingorforwhatreasonheistakingthem.AnapproprNiaUteRrSeIsNpGonTsBe.CfrOomMthenursewouldbe:a.Canyoutellmewhattheylooklike?b.Dontworryaboutit.Youareonlytakingtwomedications.c.Howlonghaveyoubeentakingeachofthepills?d.Wouldyouhaveafamilymemberbringinyourmedications?ANS:DThepersonmaynotknowthedrugnameorpurpose.Whenthisoccurs,askthepersonorafamilymembertobringinthedrugtobeidentified.Theotherresponseswouldnothelptoidentifythemedications.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare25.Thenurseisperformingafunctionalassessmentonan82-year-oldpatientwhorecentlyhadastroke.Whichofthesequestionswouldbemostimportanttoask?a.Doyouwearglasses?b.Areyouabletodressyourself?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)59STUVIA.COMc.Doyouhaveanythyroidproblems?d.Howmanytimesadaydoyouhaveabowelmovement?ANS:BFunctionalassessmentmeasureshowapersonmanagesday-to-dayactivities.Fortheolderperson,themeaningofhealthbecomesthoseactivitiesthattheycanorcannotdo.Theotherresponsesdonotrelatetofunctionalassessment.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare26.Thenurseispreparingtodoafunctionalassessment.Whichstatementbestdescribesthepurposeofafunctionalassessment?a.Thefunctionalassessmentassesseshowtheindividualiscopingwithlifeathome.b.Itdetermineshowchildrenaremeetingdevelopmentalmilestones.c.Thefunctionalassessmentcanidentifyanyproblemswithmemorytheindividualmaybeexperiencing.NURSINGTB.COMd.Ithelpsdeterminehowapersonismanagingday-to-dayactivities.ANS:DThefunctionalassessmentmeasureshowapersonmanagesday-to-dayactivities.Theotheranswersdonotreflectthepurposeofafunctionalassessment.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare27.Thenurseisaskingapatientforhisreasonforseekingcareandasksaboutthesignsandsymptomsheisexperiencing.Whichoftheseisanexampleofasymptom?a.Chestpainb.Clammyskinc.Serumpotassiumlevelat4.2mEq/Ld.Bodytemperatureof100FANS:AAsymptomisasubjectivesensation(e.g.,chestpain)thatapersonfeelsfromadisorder.AsignisanobjectivePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)60STUVIA.COMabnormalitythattheexaminercandetectonphysicalexaminationorinlaboratoryreports,asillustratedbytheotherresponses.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare28.Apatientisdescribinghissymptomstothenurse.Whichofthesestatementsreflectsadescriptionofthesettingofhissymptoms?a.Itisasharp,burningpaininmystomach.b.IalsohavethesweatsandnauseawhenIfeelthispain.c.Ithinkthispainistellingmethatsomethingbadiswrongwithme.d.ThispainhappenseverytimeIsitdowntousethecomputer.ANS:DThesettingdescribeswherethepersonisorwhatthepersonisdoingwhenthesymptomstarts.Describingthepainassharpandburningreflectsthecharacterorqualityofthepain;statingthatthepainistellingthepatientthatsomethingbadiswrongwithhimreflectsthepatientsperceptionofthepain;anddescribingthesweatsandnauseareflectsassociatedfactorsthatoccurwiththepain.DIF:CognitiveLevel:Analyzing(Analysis)NURSINGTB.COMMSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare29.Duringanassessment,thenurseusestheCAGEtest.Thepatientanswersyestotwoofthequestions.Whatcouldthisbeindicating?a.Thepatientisanalcoholic.b.Thepatientisannoyedatthequestions.c.Thepatientshouldbethoroughlyexaminedforpossiblealcoholwithdrawalsymptoms.d.Thenurseshouldsuspectalcoholabuseandcontinuewithamorethoroughsubstanceabuseassessment.ANS:DTheCAGEtestisknownasthecutdown,annoyed,guilty,andeye-openertest.IfapersonanswersyestotwoormoreofthefourCAGEquestions,thenthenurseshouldsuspectalcoholabuseandcontinuewithamorecompletesubstanceabuseassessment.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare30.Thenurseisincorporatingapersonsspiritualvaluesintothehealthhistory.WhichofthesequestionsPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)61STUVIA.COMillustratesthecommunityportionoftheFICA(faithandbelief,importanceandinfluence,community,andaddressingorapplyingincare)questions?a.DoyoubelieveinGod?b.Areyouapartofanyreligiousorspiritualcongregation?c.Doyouconsideryourselftobeareligiousorspiritualperson?d.Howdoesyourreligiousfaithinfluencethewayyouthinkaboutyourhealth?ANS:BThecommunityisassessedwhenthenurseaskswhetherapersonispartofareligiousorspiritualcommunityorcongregation.Theotherareasassessedarefaith,influence,andaddressinganyreligiousorspiritualissuesorconcerns.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare31.Thenurseispreparingtocompleteahealthassessmentona16-year-oldgirlwhoseparentshavebroughthertotheclinic.Whichinstructionwouldbeappropriatefortheparentsbeforetheinterviewbegins?a.Pleasestayduringtheinterview;youcananswerforherifshedoesnotknowtheanswer.NURSINGTB.COMb.Itwouldhelptointerviewthethreeofyoutogether.c.WhileIinterviewyourdaughter,willyoupleasestayintheroomandcompletethesefamilyhealthhistoryquestionnaires?d.WhileIinterviewyourdaughter,willyoustepouttothewaitingroomandcompletethesefamilyhealthhistoryquestionnaires?ANS:DThegirlshouldbeinterviewedalone.Theparentscanwaitoutsideandfilloutthefamilyhealthhistoryquestionnaires.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare32.ThenurseisassessinganewpatientwhohasrecentlyimmigratedtotheUnitedStates.Whichquestionisappropriatetoaddtothehealthhistory?a.WhydidyoucometotheUnitedStates?b.WhendidyoucometotheUnitedStatesandfromwhatcountry?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)62STUVIA.COMc.Whatmadeyouleaveyournativecountry?d.Areyouplanningtoreturntoyourhome?ANS:BBiographicdata,suchaswhenthepersonenteredtheUnitedStatesandfromwhatcountry,areappropriateadditionstothehealthhistory.Theotheranswersdonotreflectappropriatequestions.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrityMULTIPLERESPONSE1.Thenurseisassessingapatientsheadachepain.Whichquestionsreflectoneormoreofthecriticalcharacteristicsofsymptomsthatshouldbeassessed?Selectallthatapply.a.Whereistheheadachepain?b.Didyouhavetheseheadachesasachild?c.Onascaleof1to10,howbadisthepain?d.Howoftendotheheadachesoccur?NURSINGTB.COMe.Whatmakestheheadachesfeelbetter?f.Doyouhaveanyfamilyhistoryofheadaches?ANS:A,C,D,EThemnemonicPQRSTUmayhelpthenurseremembertoaddressthecriticalcharacteristicsthatneedtobeassessed:(1)P:provocativeorpalliative;(2)Q:qualityorquantity;(3)R:regionorradiation;(4)S:severityscale;(5)T:timing;and(6)U:understandthepatientsperception.Asking,Whereisthepain?reflectsregion.Askingthepatienttoratethepainona1to10scalereflectsseverity.AskingHowoftenreflectstiming.Askingwhatmakesthepainbetterreflectsprovocative.Theotheroptionsreflecthealthhistoryandfamilyhistory.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare2.Thenurseisconductingadevelopmentalhistoryona5-year-oldchild.Whichquestionsareappropriatetoasktheparentsforthispartoftheassessment?Selectallthatapply.a.Howmuchjunkfooddoesyourchildeat?b.Howmanyteethhashelost,andwhendidhelosethem?c.Isheabletotiehisshoelaces?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)63STUVIA.COMNURSINGTB.COMd.Doeshetakeachildrensvitamin?e.Canhetelltime?f.Doeshehaveanyfoodallergies?ANS:B,C,EQuestionsabouttoothloss,abilitytotelltime,andabilitytotieshoelacesareappropriatequestionsforadevelopmentalassessment.Questionsaboutjunkfoodintakeandvitaminsarepartofanutritionalhistory.Questionsaboutfoodallergiesarenotpartofadevelopmentalhistory.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCarePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)64STUVIA.COMChapter05:MentalStatusAssessmentMULTIPLECHOICE1.Duringanexamination,thenursecanassessmentalstatusbywhichactivity?a.Examiningthepatientselectroencephalogramb.Observingthepatientasheorsheperformsanintelligencequotient(IQ)testc.Observingthepatientandinferringhealthordysfunctiond.ExaminingthepatientsresponsetoaspecificsetofquestionsANS:CMentalstatuscannotbedirectlyscrutinizedlikethecharacteristicsofskinorheartsounds.Itsfunctioningisinferredthroughanassessmentofanindividualsbehaviors,suchasconsciousness,language,moodandaffect,andotheraspects.PTS:1DIF:CognitiveLevel:Understanding(Comprehension)2.Thenurseisassessingthementalstatusofachild.Whichstatementaboutchildrenandmentalstatusistrue?a.Allaspectsofmentalstatusinchildrenareinterdependent.NURSINGTB.COMb.Childrenarehighlylabileandunstableuntiltheageof2years.c.Childrensmentalstatusislargelyafunctionoftheirparentsleveloffunctioninguntiltheageof7years.d.Achildsmentalstatusisimpossibletoassessuntilthechilddevelopstheabilitytoconcentrate.ANS:ASeparatingandtracingthedevelopmentofonlyoneaspectofmentalstatusisdifficult.Allaspectsareinterdependent.Forexample,consciousnessisrudimentaryatbirthbecausethecerebralcortexisnotyetdeveloped.Theinfantcannotdistinguishtheselffromthemothersbody.Theotherstatementsarenottrue.PTS:1DIF:CognitiveLevel:Understanding(Comprehension)3.Thenurseisassessinga75-year-oldman.Asthenursebeginsthementalstatusportionoftheassessment,thenurseexpectsthatthispatient:a.Willhavenodecreaseinanyofhisabilities,includingresponsetime.b.Willhavedifficultyontestsofremotememorybecausethisabilitytypicallydecreaseswithage.c.Maytakealittlelongertorespond,buthisgeneralknowledgeandabilitiesshouldnothavePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)65STUVIA.COMdeclined.d.Willexhibithadadecreaseinhisresponsetimebecauseofthelossoflanguageandadecreaseingeneralknowledge.ANS:CTheagingprocessleavestheparametersofmentalstatusmostlyintact.Generalknowledgedoesnotdecrease,andlittleornolossinvocabularyoccurs.Responsetimeisslowerthaninayouth.Ittakesalittlelongerforthebraintoprocessinformationandtoreacttoit.Recentmemory,whichrequiressomeprocessing,issomewhatdecreasedwithaging,butremotememoryisnotaffected.PTS:1DIF:CognitiveLevel:Analyzing(Analysis)4.Whenassessingagingadults,thenurseknowsthatoneofthefirstthingsthatshouldbeassessedbeforemakingjudgmentsabouttheirmentalstatusis:a.Presenceofphobiasb.Generalintelligencec.Presenceofirrationalthinkingpatternsd.Sensory-perceptiveabilitiesANS:DNURSINGTB.COMAge-relatedchangesinsensoryperceptioncanaffectmentalstatus.Forexample,visionloss(asdetailedinChapter15)mayresultinapathy,socialisolation,anddepression.Hearingchangesarecommoninolderadults,whichproducesfrustration,suspicion,andsocialisolationandmakesthepersonappearconfused.PTS:1DIF:CognitiveLevel:Analyzing(Analysis)5.Thenurseispreparingtoconductamentalstatusexamination.Whichstatementistrueregardingthementalstatusexamination?a.Apatientsfamilyisthebestresourceforinformationaboutthepatientscopingskills.b.Gatheringmentalstatusinformationduringthehealthhistoryinterviewisusuallysufficient.c.Integratingthementalstatusexaminationintothehealthhistoryinterviewtakesanenormousamountofextratime.d.Togetagoodideaofthepatientsleveloffunctioning,performingacompletementalstatusexaminationisusuallynecessary.ANS:BThefullmentalstatusexaminationisasystematiccheckofemotionalandcognitivefunctioning.Thestepsdescribed,however,rarelyneedtobetakenintheirentirety.Usually,onecanassessmentalstatusthroughthePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)66STUVIA.COMcontextofthehealthhistoryinterview.PTS:1DIF:CognitiveLevel:Applying(Application)6.Awomanbringsherhusbandtotheclinicforanexamination.Sheisparticularlyworriedbecauseafterarecentfall,heseemstohavelostagreatdealofhismemoryofrecentevents.Whichstatementreflectsthenursesbestcourseofaction?a.Performacompletementalstatusexamination.b.Referhimtoapsychometrician.c.Plantointegratethementalstatusexaminationintothehistoryandphysicalexamination.d.Reassurehiswifethatmemorylossafteraphysicalshockisnormalandwillsoonsubside.ANS:APerformingacompletementalstatusexaminationisnecessarywhenanyabnormalityinaffectorbehaviorisdiscoveredorwhenfamilymembersareconcernedaboutapersonsbehavioralchanges(e.g.,memoryloss,inappropriatesocialinteraction)oraftertrauma,suchasaheadinjury.PTS:1DIF:CognitiveLevel:Applying(Application)7.Thenurseisconductingapatientinterview.Whichstatementmadebythepatientshouldthenursemorefullyexploreduringtheinterview?NURSINGTB.COMa.Isleeplikeababy.b.Ihavenohealthproblems.c.Ineverdidtoogoodinschool.d.Iamnotcurrentlytakinganymedications.ANS:CIneverymentalstatusexamination,thefollowingfactorsfromthehealthhistorythatcouldaffectthefindingsshouldbenoted:anyknownillnessesorhealthproblems,suchasalcoholismorchronicrenaldisease;currentmedications,thesideeffectsofwhichmaycauseconfusionordepression;theusualeducationalandbehaviorallevel,notingthislevelasthepatientsnormalbaselineandnotexpectingalevelofperformanceonthementalstatusexaminationtoexceedit;andresponsestopersonalhistoryquestions,indicatingcurrentstress,socialinteractionpatterns,andsleephabits.PTS:1DIF:CognitiveLevel:Analyzing(Analysis)8.Apatientisadmittedtotheunitafteranautomobileaccident.Thenursebeginsthementalstatusexaminationandfindsthatthepatienthasdysarthricspeechandislethargic.Thenursesbestapproachregardingthisexaminationisto:a.Plantodefertherestofthementalstatusexamination.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)67STUVIA.COMb.Skipthelanguageportionoftheexamination,andproceedontoassessingmoodandaffect.c.Conductanin-depthspeechevaluation,anddeferthementalstatusexaminationtoanothertime.d.Proceedwiththeexamination,andassessthepatientforsuicidalthoughtsbecausedysarthriaisoftenaccompaniedbyseveredepression.ANS:AInthementalstatusexamination,thesequenceofstepsformsahierarchyinwhichthemostbasicfunctions(consciousness,language)areassessedfirst.Thefirststepsmustbeaccuratelyassessedtoensurevalidityofthestepsthatfollow.Forexample,ifconsciousnessisclouded,thenthepersoncannotbeexpectedtohavefullattentionandtocooperatewithnewlearning.Iflanguageisimpaired,thenasubsequentassessmentofnewlearningorabstractreasoning(anythingthatrequireslanguagefunctioning)cangiveerroneousconclusions.PTS:1DIF:CognitiveLevel:Analyzing(Analysis)9.A19-year-oldwomancomestotheclinicattheinsistenceofherbrother.Sheiswearingblackcombatbootsandablacklacenightgownoverthetopofherotherclothes.Herhairisdyedpinkwithblackstreaksthroughout.Shehasseveralpiercedholesinhernaresandearsandiswearinganearringthroughhereyebrowandheavyblackmakeup.Thenurseconcludesthat:a.Sheprobablydoesnothaveanyproblems.b.SheisonlytryingtoshockpeopleNanUdRtShIaNtGhTerBd.CreOsMsshouldbeignored.c.Shehasamanicsyndromebecauseofherabnormaldressandgrooming.d.Moreinformationshouldbegatheredtodecidewhetherherdressisappropriate.ANS:DGroomingandhygieneshouldbenotedthepersoniscleanandwellgroomed,hairisneatandclean,womenhavemoderateornomakeup,andmenareshavedortheirbeardsormoustachesarewellgroomed.Careshouldbetakenwheninterpretingclothingthatisdisheveled,bizarre,orinpoorrepairbecausethesesometimesreflectthepersonseconomicstatusoradeliberatefashiontrend.PTS:1DIF:CognitiveLevel:Applying(Application)10.Apatienthasbeenintheintensivecareunitfor10days.Hehasjustbeenmovedtothemedical-surgicalunit,andtheadmittingnurseisplanningtoperformamentalstatusexamination.Duringthetestsofcognitivefunction,thenursewouldexpectthathe:a.Maydisplaysomedisruptioninthoughtcontent.b.Willstate,Iamsorelievedtobeoutofintensivecare.c.Willbeorientedtoplaceandperson,butthepatientmaynotbecertainofthedate.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)68STUVIA.COMd.Mayshowevidenceofsomecloudingofhislevelofconsciousness.ANS:CThenursecandiscerntheorientationofcognitivefunctionthroughthecourseoftheintervieworcandirectlyandtactfullyask,Somepeoplehavetroublekeepingupwiththedateswhileinthehospital.Doyouknowtodaysdate?Manyhospitalizedpeoplehavetroublewiththeexactdatebutarefullyorientedontheremainingitems.PTS:1DIF:CognitiveLevel:Analyzing(Analysis)11.Duringamentalstatusexamination,thenursewantstoassessapatientsaffect.Thenurseshouldaskthepatientwhichquestion?a.Howdoyoufeeltoday?b.Wouldyoupleaserepeatthefollowingwords?c.Havethesemedicationshadanyeffectonyourpain?d.Hasthispainaffectedyourabilitytogetdressedbyyourself?ANS:AJudgemoodandaffectbybodylanguageandfacialexpressionandbydirectlyasking,Howdoyoufeeltoday?orHowdoyouusuallyfeel?ThemoodshouldNbUeRaSpIpNrGopTrBia.CteOtMothepersonsplaceandconditionandshouldappropriatelychangewiththetopics.PTS:1DIF:CognitiveLevel:Applying(Application)12.Thenurseisplanningtoassessnewmemorywithapatient.Thebestwayforthenursetodothiswouldbeto:a.AdministertheFACTtest.b.Askhimtodescribehisfirstjob.c.GivehimtheFourUnrelatedWordsTest.d.Askhimtodescribewhattelevisionshowhewaswatchingbeforecomingtotheclinic.ANS:CAskquestionsthatcanbecorroborated,whichscreensfortheoccasionalpersonwhoconfabulatesormakesupanswerstofillinthegapsofmemoryloss.TheFourUnrelatedWordsTestteststhepersonsabilitytolaydownnewmemoriesandisahighlysensitiveandvalidmemorytest.PTS:1DIF:CognitiveLevel:Applying(Application)13.A45-year-oldwomanisattheclinicforamentalstatusassessment.IngivinghertheFourUnrelatedWordsTest,thenursewouldbeconcernedifshecouldnotfourunrelatedwords.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)69STUVIA.COMa.Invent;within5minutesb.Invent;within30secondsc.Recall;aftera30-minutedelayd.Recall;aftera60-minutedelayANS:CTheFourUnrelatedWordsTestteststhepersonsabilitytolaydownnewmemories.Itisahighlysensitiveandvalidmemorytest.Itrequiresmoreeffortthantherecallofpersonalorhistoricevents.Tothepersonsay,Iamgoingtosayfourwords.Iwantyoutorememberthem.InafewminutesIwillaskyoutorecallthem.After5minutes,askforthefourwords.Thenormalresponseforpersonsunder60yearsisanaccuratethree-orfour-wordrecallaftera5-,10-,and30-minutedelay.PTS:1DIF:CognitiveLevel:Analyzing(Analysis)14.Duringamentalstatusassessment,whichquestionbythenursewouldbestassessapersonsjudgment?a.Doyoufeelthatyouarebeingwatched,followed,orcontrolled?b.Tellmewhatyouplantodoonceyouaredischargedfromthehospital.NURSINGTB.COMc.Whatdoesthestatement,Peopleinglasshousesshouldntthrowstones,meantoyou?d.Whatwouldyoudoifyoufoundastamped,addressedenvelopelyingonthesidewalk?ANS:BApersonexercisesjudgmentwhenheorshecancompareandevaluatethealternativesinasituationandreachanappropriatecourseofaction.Ratherthantestingthepersonsresponsetoahypotheticalsituation(asillustratedintheoptionwiththeenvelope),thenurseshouldbemoreinterestedinthepersonsjudgmentaboutdailyorlong-termgoals,thelikelihoodofactinginresponsetodelusionsorhallucinations,andthecapacityfoviolentorsuicidalbehavior.PTS:1DIF:CognitiveLevel:Applying(Application)15.Whichoftheseindividualswouldthenurseconsiderathighestriskforasuicideattempt?a.Manwhojokesaboutdeathb.Womanwho,duringapastepisodeofmajordepression,attemptedsuicidec.Adolescentwhojustbrokeupwithherboyfriendandstatesthatshewouldliketokillherselfd.OlderadultmanwhotellsthenursethatheisgoingtojoinhiswifeinheaventomorrowandplanstouseagunPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)70STUVIA.COMANS:DWhenthepersonexpressesfeelingsofsadness,hopelessness,despair,orgrief,assessinganypossibleriskofphysicalharmtohimorherselfisimportant.Theinterviewshouldbeginwithmoregeneralquestions.Ifthenursehearsaffirmativeanswers,thenheorsheshouldcontinuewithmorespecificquestions.Aprecisesuicideplantotakeplaceinthenext24to48hourswithuseofalethalmethodconstituteshighrisk.PTS:1DIF:CognitiveLevel:Applying(Application)16.Thenurseisperformingamentalstatusassessmentona5-year-oldgirl.Herparentsareundergoingabitterdivorceandareworriedabouttheeffectitishavingontheirdaughter.Whichactionorstatementmightleadthenursetobeconcernedaboutthegirlsmentalstatus?a.Sheclingstohermotherwheneverthenurseisintheroom.b.Sheappearsangryandwillnotmakeeyecontactwiththenurse.c.Hermotherstatesthatshehasbeguntorideatricyclearoundtheiryard.d.Hermotherstatesthatherdaughterpreferstoplaywithtoddlersinsteadofkidsherownagewhileindaycare.ANS:DThementalstatusassessmentofinfantsandchildrencoversbehavioral,cognitive,andpsychosocialdevelopmentandexamineshowthechildiscopingwithhisorherenvironment.Essentially,thenurseshouldfollowthesameAssociationforBehavioralanNdUCRoSgInNiGtivTeBT.ChOerMapies(ABCT)guidelinesasthosefortheadult,withspecialconsiderationfordevelopmentalmilestones.Thebestexaminationtechniquearisesfromathoroughknowledgeofthedevelopmentalmilestones(describedinChapter2).Abnormalitiesareoftenproblemsofomission(e.g.,thechilddoesnotachieveamilestoneasexpected).PTS:1DIF:CognitiveLevel:Applying(Application)17.Thenurseisassessingorientationina79-year-oldpatient.Whichoftheseresponseswouldleadthenursetoconcludethatthispatientisoriented?a.IknowmynameisJohn.IcouldnttellyouwhereIam.Ithinkitis2010,though.b.IknowmynameisJohn,buttotellyouthetruth,Igetkindofconfusedaboutthedate.c.IknowmynameisJohn;IguessImatthehospitalinSpokane.No,Idontknowthedate.d.IknowmynameisJohn.IamatthehospitalinSpokane.Icouldnttellyouwhatdateitis,butIknowthatitisFebruaryofanewyear2010.ANS:DManyagingpersonsexperiencesocialisolation,lossofstructurewithoutajob,achangeinresidence,orsomeshort-termmemoryloss.Thesefactorsaffectorientation,andthepersonmaynotprovidetheprecisedateorcompletenameoftheagency.Youmayconsideragingpersonsorientediftheygenerallyknowwheretheyareandthepresentperiod.Theyshouldbeconsideredorientedtotimeiftheyearandmontharecorrectlystated.Orientationtoplaceisacceptedwiththecorrectidentificationofthetypeofsetting(e.g.,hospital)andthePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)71STUVIA.COMnameofthetown.PTS:1DIF:CognitiveLevel:Applying(Application)18.ThenurseisperformingtheDenverIIscreeningtestona12-month-oldinfantduringaroutinewell-childvisit.ThenurseshouldtelltheinfantsparentsthattheDenverII:a.Teststhreeareasofdevelopment:cognitive,physical,andpsychologicalb.Willindicatewhetherthechildhasaspeechdisordersothattreatmentcanbegin.c.Isascreeninginstrumentdesignedtodetectchildrenwhoareslowindevelopment.d.Isatesttodetermineintellectualabilityandmayindicatewhetherproblemswilldeveloplaterinschool.ANS:CTheDenverIIisascreeninginstrumentdesignedtodetectdevelopmentaldelaysininfantsandpreschoolers.Ittestsfourfunctions:grossmotor,language,finemotor-adaptive,andpersonal-social.TheDenverIIisnotanintelligencetest;itdoesnotpredictcurrentorfutureintellectualability.Itisnotdiagnostic;itdoesnotsuggesttreatmentregimens.PTS:1DIF:CognitiveLevel:Applying(Application)19.Apatientdriftsofftosleepwhensheisnotbeingstimulated.Thenursecaneasilyarouseherbycallinghername,butthepatientremainsdrowsyduringtNheUcRoSnIvNeGrsTaBti.oCnO.MThebestdescriptionofthispatientslevelofconsciousnesswouldbe:a.Lethargicb.Obtundedc.Stuporousd.SemialertANS:ALethargic(orsomnolent)iswhenthepersonisnotfullyalert,driftsofftosleepwhennotstimulated,andcanbearousedwhencalledbynameinanormalvoicebutlooksdrowsy.Heorsheappropriatelyrespondstoquestionsorcommands,butthinkingseemsslowandfuzzy.Heorsheisinattentiveandlosesthetrainofthought.Spontaneousmovementsaredecreased.PTS:1DIF:CognitiveLevel:Understanding(Comprehension)20.Apatienthashadacerebrovascularaccident(stroke).Heistryingveryhardtocommunicate.Heseemsdriventospeakandsays,Ibuyobiegetspirdingandtakemytrain.Whatisthebestdescriptionofthispatientsproblem?a.GlobalaphasiaPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)72STUVIA.COMb.Brocasaphasiac.Echolaliad.WernickesaphasiaANS:DThistypeofcommunicationillustratesWernickesorreceptiveaphasia.Thepersoncanhearsoundsandwordsbutcannotrelatethemtopreviousexperiences.Speechisfluent,effortless,andwellarticulated,butithasmanyparaphasias(wordsubstitutionsthataremalformedorwrong)andneologisms(made-upwords)andoftenlackssubstantivewords.Speechcanbetotallyincomprehensible.Often,agreaturgetospeakispresent.Repetition,reading,andwritingalsoareimpaired.Echolaliaisanimitationortherepetitionofanotherpersonswordsorphrases.PTS:1DIF:CognitiveLevel:Applying(Application)21.Apatientrepeatedlyseemstohavedifficultycomingupwithaword.Hesays,Iwasonmywaytowork,andwhenIgotthere,thethingthatyoustepintothatgoesupintheairwassofullthatIdecidedtotakethestairs.Thenursewillnoteonhischartthatheisusingorexperiencing:a.Blockingb.Neologismc.Circumlocutiond.CircumstantialityNURSINGTB.COMANS:CCircumlocutionisaroundaboutexpression,substitutingaphrasewhenonecannotthinkofthenameoftheobject.PTS:1DIF:CognitiveLevel:Understanding(Comprehension)22.Duringanexamination,thenursenotesthatapatientisexhibitingflightofideas.Whichstatementbythepatientisanexampleofflightofideas?a.Mystomachhurts.Hurts,spurts,burts.b.Kiss,wood,reading,ducks,onto,maybe.c.Takethispill?Thepillisred.Iseered.Redvelvetissoft,softasababysbottom.d.Iwashmyhands,washthem,washthem.Iusuallygotothesinkandwashmyhands.ANS:CPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)73STUVIA.COMFlightofideasisdemonstratedbyanabruptchange,rapidskippingfromtopictotopic,andpracticallycontinuousflowofacceleratedspeech.Topicsusuallyhaverecognizableassociationsorareplaysonwords.PTS:1DIF:CognitiveLevel:Understanding(Comprehension)23.Apatientdescribesfeelinganunreasonable,irrationalfearofsnakes.Hisfearissopersistentthathecannolongercomfortablylookatevenpicturesofsnakesandhasmadeanefforttoidentifyalltheplaceshemightencounterasnakeandavoidsthem.Thenurserecognizesthathe:a.Hasasnakephobia.b.Isahypochondriac;snakesareusuallyharmless.c.Hasanobsessionwithsnakes.d.Hasadelusionthatsnakesareharmful,whichmuststemfromanearlytraumaticincidentinvolvingsnakes.ANS:AAphobiaisastrong,persistent,irrationalfearofanobjectorsituation;thepersonfeelsdriventoavoidit.PTS:1DIF:CognitiveLevel:Applying(Application)24.Apatienthasbeendiagnosedwithschizophrenia.Duringarecentinterview,heshowsthenurseapictureofamanholdingadecapitatedhead.Hedescribesthispictureashorrifyingbutthenlaughsloudlyatthecontent.Thisbehaviorisadisplayof:a.Confusionb.Ambivalencec.Depersonalizationd.InappropriateaffectNURSINGTB.COMANS:DAninappropriateaffectisanaffectclearlydiscordantwiththecontentofthepersonsspeech.PTS:1DIF:CognitiveLevel:Analyzing(Analysis)25.Duringreporting,thenursehearsthatapatientisexperiencinghallucinations.Whichisanexampleofahallucination?a.Manbelievesthathisdeadwifeistalkingtohim.b.Womanhearsthedoorbellringandgoestoanswerit,butnooneisthere.c.Childseesamanstandinginhiscloset.Whenthelightsareturnedon,itisonlyadrycleaningbag.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)74STUVIA.COMd.Manbelievesthatthedoghascurleduponthebed,butwhenhegetscloserheseesthatitisablanket.ANS:AHallucinationsaresensoryperceptionsforwhichnoexternalstimuliexist.Theymaystrikeanysense:visual,auditory,tactile,olfactory,orgustatory.PTS:1DIF:CognitiveLevel:Remembering(Knowledge)26.A20-year-oldconstructionworkerhasbeenbroughtintotheemergencydepartmentwithheatstroke.Hehasdeliriumasaresultofafluidandelectrolyteimbalance.Forthementalstatusexamination,thenurseshouldfirstassessthepatients:a.Affectandmoodb.Memoryandaffectc.Languageabilitiesd.LevelofconsciousnessandcognitiveabilitiesANS:DNURSINGTB.COMDeliriumisadisturbanceofconsciousness(i.e.,reducedclarityofawarenessoftheenvironment)withreducedabilitytofocus,sustain,orshiftattention.Deliriumisnotanalterationinmood,affect,orlanguageabilities.PTS:1DIF:CognitiveLevel:Understanding(Comprehension)27.Apatientstates,Ifeelsosadallofthetime.IcantfeelhappyevendoingthingsIusedtoliketodo.Healsostatesthatheistired,sleepspoorly,andhasnoenergy.Todifferentiatebetweenadysthymicdisorderandamajordepressivedisorder,thenurseshouldaskwhichquestion?a.Haveyouhadanyweightchanges?b.Areyouhavinganythoughtsofsuicide?c.Howlonghaveyoubeenfeelingthisway?d.Areyouhavingfeelingsofworthlessness?ANS:CMajordepressivedisorderischaracterizedbyoneormoremajordepressiveepisodes,thatis,atleast2weeksofdepressedmoodorlossofinterestaccompaniedbyatleastfouradditionalsymptomsofdepression.Dysthymicdisorderischaracterizedbyatleast2yearsofdepressedmoodformoredaysthannot,accompaniedbyadditionaldepressivesymptoms.PTS:1DIF:CognitiveLevel:Analyzing(Analysis)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)75STUVIA.COM28.A26-year-oldwomanwasrobbedandbeatenamonthago.Sheisreturningtotheclinictodayforafollow-upassessment.Thenursewillwanttoaskherwhichoneofthesequestions?a.Howarethingsgoingwiththetrial?b.Howarethingsgoingwithyourjob?c.Tellmeaboutyourrecentengagement!d.Areyouhavinganydisturbingdreams?ANS:DInposttraumaticstressdisorder,thepersonhasbeenexposedtoatraumaticevent.Thetraumaticeventispersistentlyreexperiencedbyrecurrentandintrusive,distressingrecollectionsoftheevent,includingimages,thoughts,orperceptions;recurrentdistressingdreamsoftheevent;andactingorfeelingasifthetraumaticeventwererecurring.PTS:1DIF:CognitiveLevel:Applying(Application)29.Thenurseisperformingamentalstatusexamination.Whichstatementistrueregardingtheassessmentofmentalstatus?a.Mentalstatusassessmentdiagnosesspecificpsychiatricdisorders.NURSINGTB.COMb.Mentaldisordersoccurinresponsetoeverydaylifestressors.c.Mentalstatusfunctioningisinferredthroughtheassessmentofanindividualsbehaviors.d.Mentalstatuscanbedirectlyassessed,similartoothersystemsofthebody(e.g.,heartsounds,breathsounds).ANS:CMentalstatusfunctioningisinferredthroughtheassessmentofanindividualsbehaviors.Itcannotbedirectlyassessedlikethecharacteristicsoftheskinorheartsounds.PTS:1DIF:CognitiveLevel:Understanding(Comprehension)30.A23-year-oldpatientintheclinicappearsanxious.Herspeechisrapid,andsheisfidgetyandinconstantmotion.Whichofthesequestionsorstatementswouldbemostappropriateforthenursetouseinthissituationtoassessattentionspan?a.Howdoyouusuallyfeel?Isthisnormalbehaviorforyou?b.Iamgoingtosayfourwords.Inafewminutes,Iwillaskyoutorecallthem.c.Describethemeaningofthephrase,Lookingthroughrose-coloredglasses.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)76STUVIA.COMd.Pickupthepencilinyourlefthand,moveittoyourrighthand,andplaceitonthetable.ANS:DAttentionspanisevaluatedbyassessingtheindividualsabilitytoconcentrateandcompleteathoughtortaskwithoutwandering.Givingaseriesofdirectionstofollowisonemethodusedtoassessattentionspan.PTS:1DIF:CognitiveLevel:Applying(Application)31.Thenurseisplanninghealthteachingfora65-year-oldwomanwhohashadacerebrovascularaccident(stroke)andhasaphasia.Whichofthesequestionsismostimportanttousewhenassessingmentalstatusinthispatient?a.Pleasecountbackwardfrom100byseven.b.Iwillnamethreeitemsandaskyoutorepeattheminafewminutes.c.PleasepointtoarticlesintheroomandpartsofthebodyasInamethem.d.Whatwouldyoudoifyoufoundastamped,addressedenvelopeonthesidewalk?ANS:CAdditionaltestsforpersonswithaphasiaincludewordcomprehension(askingtheindividualtopointtoarticlesintheroomorpartsofthebody),reading(askingthepersontoreadavailableprint),andwriting(askingthepersontomakeupandwriteasenNteUncReS)I.NGTB.COMPTS:1DIF:CognitiveLevel:Applying(Application)32.A30-year-oldfemalepatientisdescribingfeelingsofhopelessnessanddepression.Shehasattemptedself-mutilationandhasahistoryofsuicideattempts.Shedescribesdifficultysleepingatnightandhaslost10poundsinthepastmonth.Whichofthesestatementsorquestionsisthenursesbestresponseinthissituation?a.Doyouhaveaweapon?b.Howdootherpeopletreatyou?c.Areyoufeelingsohopelessthatyoufeellikehurtingyourselfnow?d.Peopleoftenfeelhopeless,butthefeelingsresolvewithinafewweeks.ANS:CWhenthepersonexpressesfeelingsofhopelessness,despair,orgrief,assessingtheriskofphysicalharmtohimorherselfisimportant.Thisprocessbeginswithmoregeneralquestions.Iftheanswersareaffirmative,thentheassessmentcontinueswithmorespecificquestions.PTS:1DIF:CognitiveLevel:Applying(Application)33.Thenurseisprovidinginstructionstonewlyhiredgraduatesfortheminimentalstateexamination(MMSE).Whichstatementbestdescribesthisexamination?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)77STUVIA.COMa.Scoresbelow30indicatecognitiveimpairment.b.TheMMSEisagoodtooltoevaluatemoodandthoughtprocesses.c.Thisexaminationisagoodtooltodetectdeliriumanddementiaandtodifferentiatethesefrompsychiatricmentalillness.d.TheMMSEisusefultoolforaninitialevaluationofmentalstatus.Additionaltoolsareneededtoevaluatecognitionchangesovertime.ANS:CTheMMSEisaquick,easytestof11questionsandisusedforinitialandserialevaluationsandcandemonstrateaworseningoranimprovementofcognitionovertimeandwithtreatment.Itevaluatescognitivefunctioning,notmoodorthoughtprocesses.MMSEisagoodscreeningtooltodetectdementiaanddeliriumandtodifferentiatethesefrompsychiatricmentalillness.PTS:1DIF:CognitiveLevel:Understanding(Comprehension)34.Thenursediscoversspeechproblemsinapatientduringanassessment.Thepatienthasspontaneousspeech,butitismostlyabsentorisreducedtoafewstereotypicalwordsorsounds.Thisfindingreflectswhichtypeofaphasia?a.Globalb.Brocasc.Dysphonicd.WernickesNURSINGTB.COMANS:AGlobalaphasiaisthemostcommonandsevereformofaphasia.Spontaneousspeechisabsentorreducedtoafewstereotypedwordsorsounds,andprognosisforlanguagerecoveryispoor.Dysphonicaphasiaisnotavalidcondition.PTS:1DIF:CognitiveLevel:Understanding(Comprehension)35.Apatientrepeats,Ifeelhot.Hot,cot,rot,tot,got.Imaspot.Thenursedocumentsthisasanillustrationof:a.Blockingb.Clangingc.Echolaliad.NeologismPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)78STUVIA.COMANS:BClangingiswordchoicebasedonsound,notmeaning,andincludesnonsenserhymesandpuns.PTS:1DIF:CognitiveLevel:Understanding(Comprehension)36.Duringaninterview,thenursenotesthatthepatientgetsupseveraltimestowashherhandseventhoughtheyarenotdirty.Thisbehaviorisanexampleof:a.Socialphobiab.Compulsivedisorderc.Generalizedanxietydisorderd.PosttraumaticstressdisorderANS:BRepetitivebehaviors,suchashandwashing,arebehaviorsthatthepersonfeelsdriventoperforminresponsetoanobsession.Thebehaviorsareaimedatpreventingorreducingdistressorpreventingsomedreadedeventorsituation.PTS:1DIF:CognitiveLevel:Understanding(Comprehension)37.ThenurseisadministeringaMini-Cogtesttoanolderadultwoman.Whenaskedtodrawaclockshowingthetimeof10:45,thepatientdrewaclockwitNhUthReSnINumGTbeBr.sCoOuMtoforderandwithanincorrecttime.Thisresulindicateswhichfinding?a.Cognitiveimpairmentb.Amnesiac.Deliriumd.Attention-deficitdisorderANS:ATheMini-Cogisanewerinstrumentthatscreensforcognitiveimpairment,oftenfoundwithdementia.Theresultofanabnormaldrawingofaclockandtimeindicatesacognitiveimpairment.PTS:1DIF:CognitiveLevel:Analyzing(Analysis)38.Duringmorningrounds,thenurseasksapatient,Howareyoutoday?Thepatientresponds,Youtoday,youtoday,youtoday!andmumblesthewords.Thisspeechpatternisanexampleof:a.Echolaliab.ClangingPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)79STUVIA.COMc.Wordsaladd.PerseverationANS:AEcholaliaoccurswhenapersonimitatesorrepeatsanotherswordsorphrases,oftenwithamumbling,mocking,oramechanicaltone.PTS:1DIF:CognitiveLevel:Applying(Application)MULTIPLERESPONSE1.Thenurseisassessingapatientwhoisadmittedwithpossibledelirium.Whichofthesearemanifestationsofdelirium?Selectallthatapply.a.Developsoverashortperiod.b.Personisexperiencingapraxia.c.Personisexhibitingmemoryimpairmentordeficits.d.Occursasaresultofamedicalcondition,suchassystemicinfection.e.Personisexperiencingagnosia.NURSINGTB.COMANS:A,C,DDeliriumisadisturbanceofconsciousnessthatdevelopsoverashortperiodandmaybeattributabletoamedicalcondition.Memorydeficitsmayalsooccur.Apraxiaandagnosiaoccurwithdementia.PTS:1DIF:CognitiveLevel:Applying(Application)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)80STUVIA.COMChapter06:SubstanceUseAssessmentMULTIPLECHOICE1.Awomanhascometotheclinictoseekhelpwithasubstanceabuseproblem.Sheadmitstousingcocainejustbeforearriving.Whichoftheseassessmentfindingswouldthenurseexpecttofindwhenexaminingthiswoman?a.Dilatedpupils,pacing,andpsychomotoragitationb.Dilatedpupils,unsteadygait,andaggressivenessc.Pupilconstriction,lethargy,apathy,anddysphoriad.Constrictedpupils,euphoria,anddecreasedtemperatureANS:AAcocaineusersappearanceincludespupillarydilation,tachycardiaorbradycardia,elevatedorloweredbloodpressure,sweating,chills,nausea,vomiting,andweightloss.Thepersonsbehaviorincludeseuphoria,talkativeness,hypervigilance,pacing,psychomotoragitation,impairedsocialoroccupationalfunctioning,fighting,grandiosity,andvisualortactilehallucinations.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhNysUioRlSoIgNicGATBda.CpOtaMtion2.Thenurseisassessingapatientwhohasbeenadmittedforcirrhosisoftheliver,secondarytochronicalcoholuse.Duringthephysicalassessment,thenurselooksforcardiacproblemsthatareassociatedwithchronicuseofalcohol,suchas:a.Hypertension.b.Ventricularfibrillation.c.Bradycardia.d.Mitralvalveprolapse.ANS:AEvenmoderatedrinkingleadstohypertensionandcardiomyopathy,withanincreaseinleftventricularmass,dilationofventricles,andwallthinning.Ventricularfibrillation,bradycardia,andmitralvalveprolapsearenotassociatedwithchronicheavyuseofalcohol.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation3.Thenurseisconductingaclassonalcoholandtheeffectsofalcoholonthebody.Howmanystandarddrinks(eachcontaining14gramsofalcohol)perdayinmenareassociatedwithincreaseddeathsfromcirrhosis,cancersofthemouth,esophagus,andinjuries?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)81STUVIA.COMa.2b.4c.6d.8ANS:BInmen,alcoholconsumptionofatleastfourstandarddrinksperdayisassociatedwithincreaseddeathsfromlivercirrhosis,cancersofthemouth,esophagusandotherareas,anddeathsfrominjuriesandotherexternalcauses.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential4.Duringasessiononsubstanceabuse,thenurseisreviewingstatisticswiththeclass.Forpersonsaged12yearsandolder,whichillicitsubstancewasmostcommonlyused?a.Crackcocaineb.Heroinc.Marijuanad.HallucinogensNURSINGTB.COMANS:CInpersonsage12yearsandolderwhoreportedusingduringthepastmonth,marijuana(hashish)wasthemostcommonlyusedillicitdrugreported.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation5.Awomanwhohasjustdiscoveredthatsheispregnantisintheclinicforherfirstobstetricvisit.Sheasksthenurse,Howmanydrinksadayissafeformybaby?Thenursesbestresponseis:a.Youshouldlimityourdrinkingtoonceortwiceaweek.b.Itsokaytohaveuptotwoglassesofwineaday.c.Aslongasyouavoidgettingdrunk,youshouldbesafe.d.Noamountofalcoholhasbeendeterminedtobesafeduringpregnancy.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)82STUVIA.COMANS:DNoamountofalcoholhasbeendeterminedtobesafeforpregnantwomen.Thepotentialadverseeffectsofalcoholuseonthefetusarewellknown;womenwhoarepregnantshouldbescreenedforalcoholuse,andabstinenceshouldberecommended.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:SafetyandInfectionControl6.Whenreviewingtheuseofalcoholbyolderadults,thenursenotesthatolderadultshaveseveralcharacteristicsthatcanincreasetheriskofalcoholuse.Whichwouldincreasethebioavailabilityofalcoholinthebloodforlongerperiodsintheolderadult?a.Increasedmusclemassb.Decreasedliverandkidneyfunctioningc.Decreasedbloodpressured.IncreasedcardiacoutputANS:BDecreasedliverandkidneyfunctioningincreasesthebioavailabilityofalcoholinthebloodforlongerperiods.Agingpeopleexperiencedecreasedmusclemass(notincreased),whichalsoincreasesthealcoholconcentrationinthebloodbecausethealcoholNiUsRdiSsItNriGbuTtBed.CtOoMlesstissueovertime.Bloodpressureandcardiacoutputarenotfactorsregardingbioavailability.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation7.Duringanassessment,thenurseasksafemalepatient,Howmanyalcoholicdrinksdoyouhaveaweek?Whichanswerbythepatientwouldindicateat-riskdrinking?a.Imayhaveoneortwodrinksaweek.b.Iusuallyhavethreeorfourdrinksaweek.c.Illhaveaglassortwoofwineeverynowandthen.d.Ihavesevenoreightdrinksaweek,butInevergetdrunk.ANS:DForwomen,havingsevenormoredrinksaweekorthreeormoredrinksperoccasionisconsideredat-riskdrinking,accordingtotheNationalInstituteonAlcoholAbuseandAlcoholism.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotentialPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)83STUVIA.COM8.Thenurseisaskinganadolescentaboutillicitsubstanceabuse.Theadolescentanswers,Yes,Iveusedmarijuanaatpartieswithmyfriends.Whatisthenextquestionthenurseshouldask?a.Whoarethesefriends?b.Doyourparentsknowaboutthis?c.Whenwasthelasttimeyouusedmarijuana?d.Isthisaregularhabit?ANS:CIfapatientadmitstotheuseofillicitsubstances,thenthenurseshouldask,Whenwasthelasttimeyouuseddrugs?andHowmuchdidyoutakethattime?Theotherquestionsmaybeconsideredaccusatoryandarenotconducivetogatheringinformation.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance9.Thenursehascompletedanassessmentonapatientwhocametotheclinicforaleginjury.Asaresultoftheassessment,thenursehasdeterminedthatthepatienthasat-riskalcoholuse.Whichactionbythenurseismostappropriateatthistime?a.RecordtheresultsoftheassessmeNntU,aRnSdINnGotTifBy.CthOeMphysicianoncall.b.State,Youaredrinkingmorethanismedicallysafe.Istronglyrecommendthatyouquitdrinking,andImwillingtohelpyou.c.State,Itappearsthatyoumayhaveadrinkingproblem.HereisthetelephonenumberofourlocalAlcoholicsAnonymouschapter.d.Givethepatientinformationaboutalocalrehabilitationclinic.ANS:BIfanassessmenthasdeterminedthatthepatienthasat-riskdrinkingbehavior,thenthenurseshouldgiveashortbutclearstatementofassistanceandconcern.Simplygivingoutatelephonenumberorreferraltoagenciesmaynotbeenough.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:SafetyandInfectionControl10.Apatientisbroughttotheemergencydepartment.Heisrestless,hasdilatedpupils,issweating,hasarunnynoseandtearingeyes,andcomplainsofmuscleandjointpains.Hisgirlfriendthinkshehasinfluenza,butshebecameconcernedwhenhistemperaturewentupto39.4C.Sheadmitsthathehasbeenaheavydruguser,buthehasbeentryingtostoponhisown.Thenursesuspectsthatthepatientisexperiencingwithdrawalsymptomsfromwhichsubstance?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)84STUVIA.COMa.Alcoholb.Heroinc.Crackcocained.SedativesANS:BWithdrawalsymptomsofopiates,suchasheroin,aresimilartotheclinicalpictureofinfluenzaandincludesymptomssuchasdilatedpupils,lacrimation,runnynose,tachycardia,fever,restlessness,muscleandjointpains,andothersymptoms.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:SafetyandInfectionControl11.Thenurseisreviewingaspectsofsubstanceabuseinpreparationforaseminar.Whichofthesestatementsillustratestheconceptoftolerancetoanillicitsubstance?Theperson:a.Hasaphysiologicdependenceonasubstance.b.Requiresanincreasedamountofthesubstancetoproducethesameeffect.NURSINGTB.COMc.Requiresdailyuseofthesubstancetofunctionandisunabletostopusingit.d.Experiencesasyndromeofphysiologicsymptomsifthesubstanceisnotused.ANS:BTheconceptoftolerancetoasubstanceindicatesthatthepersonrequiresanincreasedamountofthesubstancetoproducethesameeffect.Abuseindicatesthatthepersonneedstousethesubstancedailytofunction,andthepersonisunabletostopusingit.Dependenceisanactualphysiologicdependenceonthesubstance.Withdrawaloccurswhencessationofthesubstanceproducesasyndromeofphysiologicsymptoms.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationMULTIPLERESPONSE1.ApatientwithaknownhistoryofheavyalcoholusehasbeenadmittedtotheICUafterhewasfoundunconsciousoutsideabar.Thenursecloselymonitorshimforsymptomsofwithdrawal.Whichofthesesymptomsmayoccurduringthistime?Selectallthatapply.a.Bradycardiab.Coarsetremorofthehandsc.TransienthallucinationsPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)85STUVIA.COMd.Somnolencee.SweatingANS:B,C,ESymptomsofuncomplicatedalcoholwithdrawalstartshortlyafterthecessationofdrinking,peakatthesecondday,andimprovebythefourthorfifthday.Symptomsincludecoarsetremorsofthehands,tongue,andeyelids;anorexia;nauseaandvomiting;autonomichyperactivity(e.g.,tachycardia,sweating,elevatedbloodpressure);andtransienthallucinations,amongothersymptoms.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare2.Apatientvisitstheclinictoaskaboutsmokingcessation.Hehassmokedheavilyfor30yearsandwantstostopcoldturkey.Heasksthenurse,WhatsymptomscanIexpectifIdothis?Whichofthesesymptomsshouldthenursesharewiththepatientaspossiblesymptomsofnicotinewithdrawal?Selectallthatapply.a.Headachesb.Hungerc.SleepinessNURSINGTB.COMd.Restlessnesse.Nervousnessf.SweatingANS:A,B,D,ESymptomsofnicotinewithdrawalincludevasodilation,headaches,anger,irritability,frustration,anxiety,nervousness,awakeningatnight,difficultyconcentrating,depression,hunger,impatience,andthedesiretosmoke.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)86STUVIA.COMChapter07:DomesticandFamilyViolenceAssessmentMULTIPLECHOICE1.Asamandatoryreporterofelderabuse,whichmustbepresentbeforeanurseshouldnotifytheauthorities?a.Statementsfromthevictimb.Statementsfromwitnessesc.Proofofabuseand/orneglectd.Suspicionofelderabuseand/orneglectANS:DManyhealthcareworkersareundertheerroneousassumptionthatproofisrequiredbeforenotificationofsuspectedabusecanoccur.Onlythesuspicionofelderabuseorneglectisnecessary.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:SafetyandInfectionControl2.Duringahomevisit,thenursenoticesthatanolderadultwomaniscaringforherbedriddenhusband.Thewomanstatesthatthisisherduty,shedoesthebestshecan,andherchildrencometohelpwhentheyareintown.HerhusbandisunabletocareforhimseNlfU,aRnSdINshGeTaBp.pCeOaMrsthin,weak,andexhausted.Thenursenoticesthatseveralofhisprescriptionmedicationbottlesareempty.Thissituationisbestdescribedbytheterm:a.Physicalabuse.b.Financialneglect.c.Psychologicalabuse.d.Unintentionalphysicalneglect.ANS:DUnintentionalphysicalneglectmayoccur,despitegoodintentions,andisthefailureofafamilymemberorcaregivertoprovidebasicgoodsorservices.Physicalabuseisdefinedasviolentactsthatresultorcouldresultininjury,pain,impairment,ordisease.Financialneglectisdefinedasthefailuretousetheassetsoftheolderpersontoprovideservicesneededbyhimorher.Psychologicalabuseisdefinedasbehaviorsthatresultinmentalanguish.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:SafetyandInfectionControl3.Thenurseisawarethatintimatepartnerviolence(IPV)screeningshouldoccurwithwhichsituation?a.WhenIPVissuspectedPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)87STUVIA.COMb.Whenawomanhasanunexplainedinjuryc.Asaroutinepartofeachhealthcareencounterd.WhenahistoryofabuseinthefamilyisknownANS:CManynursingprofessionalorganizationshavecalledforroutine,universalscreeningforIPVtoassistwomeningettinghelpfortheproblem.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:SafetyandInfectionControl4.WhichstatementisbestforthenursetousewhenpreparingtoadministertheAbuseAssessmentScreen?a.Wearerequiredbylawtoaskthesequestions.b.Weneedtotalkaboutwhetheryoubelieveyouhavebeenabused.c.Weareaskingthesequestionsbecausewesuspectthatyouarebeingabused.d.WeneedtoaskthefollowingquesNtiUonRsSbINecGaTusBe.CdOomMesticviolenceissocommoninoursociety.ANS:DSuchanintroductionalertsthewomanthatquestionsaboutdomesticviolencearecomingandensuresthewomanthatsheisnotbeingsingledoutforthesequestions.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:SafetyandInfectionControl5.Whichtermreferstoawoundproducedbythetearingorsplittingofbodytissue,usuallyfrombluntimpactoverabonysurface?a.Abrasionb.Contusionc.Lacerationd.HematomaANS:CThetermlacerationreferstoawoundproducedbythetearingorsplittingofbodytissue.Anabrasioniscausedbytherubbingoftheskinormucousmembrane.AcontusionisinjurytotissueswithoutbreakageofPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)88STUVIA.COMskin,andahematomaisalocalizedcollectionofextravasatedblood.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:SafetyandInfectionControl6.Duringanexamination,thenursenoticesapatternedinjuryonapatientsback.Whichofthesewouldcausesuchaninjury?a.Bluntforceb.Frictionabrasionc.Stabbingfromakitchenknifed.WhippingfromanextensioncordANS:DApatternedinjuryisaninjurycausedbyanobjectthatleavesadistinctpatternontheskinororgan.Theotheractionsdonotcauseapatternedinjury.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:SafetyandInfectionControl7.WhendocumentingIPVandelderabuse,thNeUnRurSsIeNsGhToBul.dCOinMclude:a.Photographicdocumentationoftheinjuries.b.Summaryoftheabusedpatientsstatements.c.Verbatimdocumentationofeverystatementmade.d.Generaldescriptionofinjuriesintheprogressnotes.ANS:ADocumentationofIPVandelderabusemustincludedetailednonbiasedprogressnotes,theuseofinjurymaps,andphotographicdocumentation.Writtendocumentationneedstobeverbatim,withinreason.Noteverystatementcanbedocumented.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:SafetyandInfectionControl8.AfemalepatienthasdeniedanyabusewhenansweringtheAbuseAssessmentScreen,butthenursehasnoticedsomeotherconditionsthatareassociatedwithIPV.Examplesofsuchconditionsinclude:a.Asthma.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)89STUVIA.COMb.Confusion.c.Depression.d.Frequentcolds.ANS:CDepressionisoneoftheconditionsthatisparticularlyassociatedwithIPV.Abusedwomenalsohavebeenfoundtohavemorechronichealthproblems,suchasneurologic,gastrointestinal,andgynecologicsymptoms;chronicpain;andsymptomsofsuicidalityandposttraumaticstressdisorder.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:SafetyandInfectionControl9.Thenurseisusingthedangerassessment(DA)tooltoevaluatetheriskofhomicide.Whichofthesestatementsbestdescribesitsuse?a.TheDAtoolistobeadministeredbylawenforcementpersonnel.b.TheDAtoolshouldbeusedineveryassessmentofsuspectedabuse.c.Thenumberofyesanswersindicatesthewomansunderstandingofhersituation.NURSINGTB.COMd.Thehigherthenumberofyesanswers,themoreseriousthedangerofthewomanssituation.ANS:DNopredeterminedcutoffscoresexistontheDA.Thehigherthenumberyesanswers,themoreseriousthedangerofthewomanssituation.Theuseofthistoolisnotlimitedtolawenforcementpersonnelandisnotrequiredineverycaseofsuspectedabuse.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:SafetyandInfectionControl10.Thenurseisassessingbruisingonaninjuredpatient.Whichcolorindicatesanewbruisethatislessthan2hoursold?a.Redb.Purple-bluec.Greenish-brownd.Brownish-yellowANS:APHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)90STUVIA.COMAnewbruiseisusuallyredandwilloftendevelopapurpleorpurple-blueappearance12to36hoursafterblunt-forcetrauma.Thecolorofbruises(andecchymoses)generallyprogressesfrompurple-bluetobluish-greentogreenish-browntobrownish-yellowbeforefadingaway.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:SafetyandInfectionControl11.Thenursesuspectsabusewhena10-year-oldchildistakentotheurgentcarecenterforaleginjury.Thebestwaytodocumentthehistoryandphysicalfindingsisto:a.Documentwhatthechildscaregivertellsthenurse.b.Usethewordsthechildhassaidtodescribehowtheinjuryoccurred.c.Recordwhatthenurseobservesduringtheconversation.d.Relyonphotographsoftheinjuries.ANS:BWhendocumentingthehistoryandphysicalfindingsofsuspectedchildabuseandneglect,usethewordsthechildhassaidtodescribehowhisorherinjuryoccurred.Remember,theabusermaybeaccompanyingthechild.DIF:CognitiveLevel:Applying(Application)NURSINGTB.COMMSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare12.Duringaninterview,awomanhasansweredyestotwooftheAbuseAssessmentScreenquestions.Whatshouldthenursesaynext?a.Ineedtoreportthisabusetotheauthorities.b.Tellmeaboutthisabuseinyourrelationship.c.Soyouwereabused?d.Doyouknowwhatcausedthisabuse?ANS:BIfawomananswersyestoanyoftheAbuseAssessmentScreenquestions,thenthenurseshouldaskquestionsdesignedtoassesshowrecentandhowserioustheabusewas.Askingthewomananopen-endedquestion,suchastellmeaboutthisabuseinyourrelationshipisagoodwaytostart.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare13.Thenurseisexamininga3-year-oldchildwhowasbroughttotheemergencydepartmentafterafall.Whichbruise,iffound,wouldbeofmostconcern?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)91STUVIA.COMa.Bruiseonthekneeb.Bruiseontheelbowc.Bruisingontheabdomend.BruiseontheshinANS:CStudieshaveshownthatchildrenwhoarewalkingoftenhavebruisesoverthebonyprominencesofthefrontotheirbodies.Otherstudieshavefoundthatbruisinginatypicalplacessuchasthebuttocks,hands,feet,andabdomenwereexceedinglyrareandshouldarouseconcern.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCareMULTIPLERESPONSE1.Thenurseassessesanolderwomanandsuspectsphysicalabuse.Whichquestionsareappropriateforscreeningforabuse?Selectallthatapply.a.Hasanyonemadeyouafraid,touchedyouinwaysthatyoudidnotwant,orhurtyouphysically?b.Areyoubeingabused?NURSINGTB.COMc.Haveyoureliedonpeopleforanyofthefollowing:bathing,dressing,shopping,banking,ormeals?d.Haveyoubeenupsetbecausesomeonetalkedtoyouinawaythatmadeyoufeelshamedorthreatened?e.Haveyoureliedonpeopleforanyofthefollowing:bathing,dressing,shopping,banking,ormeals?ANS:A,C,D,EDirectlyaskingAreyoubeingabused?isnotanappropriatescreeningquestionforabusebecausethewomancouldeasilysayno,andnofurtherinformationwouldbeobtained.TheotherquestionsareamongthequestionsrecommendedbytheElderAbuseSuspicionIndex(EASI)whenscreeningforelderabuse.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCarePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)92STUVIA.COMChapter08:AssessmentTechniquesandSafetyintheClinicalSettingMULTIPLECHOICE1.Whenperformingaphysicalassessment,thefirsttechniquethenursewillalwaysuseis:a.Palpation.b.Inspection.c.Percussion.d.Auscultation.ANS:BTheskillsrequisiteforthephysicalexaminationareinspection,palpation,percussion,andauscultation.Theskillsareperformedoneatatimeandinthisorder(withtheexceptionoftheabdominalassessment,duringwhichauscultationtakesplacebeforepalpationandpercussion).Theassessmentofeachbodysystembeginswithinspection.Afocusedinspectiontakestimeandyieldsasurprisingamountofinformation.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare2.ThenurseispreparingtoperformaphysicaNlUasRseSsIsNmGeTnBt..CWOhMichstatementistrueaboutthephysicalassessment?Theinspectionphase:a.Usuallyyieldslittleinformation.b.Takestimeandrevealsasurprisingamountofinformation.c.Maybesomewhatuncomfortablefortheexpertpractitioner.d.Requiresaquickglanceatthepatientsbodysystemsbeforeproceedingwithpalpation.ANS:BAfocusedinspectiontakestimeandyieldsasurprisingamountofinformation.Initially,theexaminermayfeeluncomfortable,staringatthepersonwithoutalsodoingsomething.Afocusedassessmentissignificantlymorethanaquickglance.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare3.Thenurseisassessingapatientsskinduringanofficevisit.Whatpartofthehandandtechniqueshouldbeusedtobestassessthepatientsskintemperature?a.Fingertips;theyaremoresensitivetosmallchangesintemperature.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)93STUVIA.COMb.Dorsalsurfaceofthehand;theskinisthinneronthissurfacethanonthepalms.c.Ulnarportionofthehand;increasedbloodsupplyinthisareaenhancestemperaturesensitivity.d.Palmarsurfaceofthehand;thissurfaceisthemostsensitivetotemperaturevariationsbecauseofitsincreasednervesupplyinthisarea.ANS:BThedorsa(backs)ofthehandsandfingersarebestfordeterminingtemperaturebecausetheskinisthinneronthedorsalsurfacesthanonthepalms.Fingertipsarebestforfine,tactilediscrimination.Theotherresponsesarenotusefulforpalpation.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare4.Whichofthesetechniquesusesthesenseoftouchtoassesstexture,temperature,moisture,andswellingwhenthenurseisassessingapatient?a.Palpationb.Inspectionc.Percussiond.AuscultationNURSINGTB.COMANS:APalpationusesthesenseoftouchtoassessthepatientforthesefactors.Inspectioninvolvesvision;percussionassessesthroughtheuseofpalpablevibrationsandaudiblesounds;andauscultationusesthesenseofhearing.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare5.Thenurseispreparingtoassessapatientsabdomenbypalpation.Howshouldthenurseproceed?a.Palpationofreportedlytenderareasareavoidedbecausepalpationintheseareasmaycausepain.b.Palpatingatenderareaisquicklyperformedtoavoidanydiscomfortthatthepatientmayexperience.c.Theassessmentbeginswithdeeppalpation,whileencouragingthepatienttorelaxandtotakedeepbreaths.d.Theassessmentbeginswithlightpalpationtodetectsurfacecharacteristicsandtoaccustomthepatienttobeingtouched.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)94STUVIA.COMANS:DLightpalpationisinitiallyperformedtodetectanysurfacecharacteristicsandtoaccustomthepersontobeingtouched.Tenderareasshouldbepalpatedlast,notfirst.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare6.Thenursewouldusebimanualpalpationtechniqueinwhichsituation?a.Palpatingthethoraxofaninfantb.Palpatingthekidneysanduterusc.Assessingpulsationsandvibrationsd.AssessingthepresenceoftendernessandpainANS:BBimanualpalpationrequirestheuseofbothhandstoenveloporcapturecertainbodypartsororganssuchasthekidneys,uterus,oradnexa.Theothersituationsarenotappropriateforbimanualpalpation.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareENnUvRirSoInNmGeTnBt:.CMOaMnagementofCare7.Thenurseispreparingtopercusstheabdomenofapatient.Thepurposeofthepercussionistoassesstheoftheunderlyingtissue.a.Turgorb.Texturec.Densityd.ConsistencyANS:CPercussionyieldsasoundthatdepictsthelocation,size,anddensityoftheunderlyingorgan.Turgorandtextureareassessedwithpalpation.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare8.Thenurseisreviewingpercussiontechniqueswithanewlygraduatednurse.Whichtechnique,ifusedbythenewnurse,indicatesthatmorereviewisneeded?a.PercussingonceovereachareaPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)95STUVIA.COMb.Quicklyliftingthestrikingfingeraftereachstrokec.Strikingwiththefingertip,notthefingerpadd.Usingthewristtomakethestrikes,notthearmANS:AForpercussion,thenurseshouldpercusstwotimesovereachlocation.Thestrikingfingershouldbequicklyliftedbecausearestingfingerdampsoffvibrations.Thetipofthestrikingfingershouldmakecontact,notthepadofthefinger.Thewristmustberelaxedandisusedtomakethestrikes,notthearm.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare9.Whenpercussingovertheliverofapatient,thenursenoticesadullsound.Thenurseshould:a.Considerthisanormalfinding.b.Palpatethisareaforanunderlyingmass.c.Repositionthehands,andattempttopercussinthisareaagain.NURSINGTB.COMd.Considerthisfindingasabnormal,andreferthepatientforadditionaltreatment.ANS:APercussionoverrelativelydenseorgans,suchastheliverorspleen,willproduceadullsound.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare10.Thenurseisunabletoidentifyanychangesinsoundwhenpercussingovertheabdomenofanobesepatient.Whatshouldthenursedonext?a.Askthepatienttotakedeepbreathstorelaxtheabdominalmusculature.b.Considerthisfindingasnormal,andproceedwiththeabdominalassessment.c.Increasetheamountofstrengthusedwhenattemptingtopercussovertheabdomen.d.Decreasetheamountofstrengthusedwhenattemptingtopercussovertheabdomen.ANS:CPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)96STUVIA.COMThethicknessofthepersonsbodywallwillbeafactor.Thenurseneedsastrongerpercussionstrokeforpersonswithobeseorverymuscularbodywalls.Theforceoftheblowdeterminestheloudnessofthenote.Theotheractionsarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare11.Thenursehearsbilateralloud,long,andlowtoneswhenpercussingoverthelungsofa4-year-oldchild.Thenurseshould:a.Palpateovertheareaforincreasedpainandtenderness.b.Askthechildtotakeshallowbreaths,andpercussovertheareaagain.c.Immediatelyreferthechildbecauseofanincreasedamountofairinthelungs.d.Considerthisfindingasnormalforachildthisage,andproceedwiththeexamination.ANS:DPercussionnotesthatareloudinamplitude,lowinpitch,ofaboomingquality,andlongindurationarenormaloverachildslung.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareENnUvRirSoInNmGeTnBt:.CMOaMnagementofCare12.Apatienthassuddenlydevelopedshortnessofbreathandappearstobeinsignificantrespiratorydistress.Aftercallingthephysicianandplacingthepatientonoxygen,whichoftheseactionsisthebestforthenursetotakewhenfurtherassessingthepatient?a.Countthepatientsrespirations.b.Bilaterallypercussthethorax,notinganydifferencesinpercussiontones.c.Callforachestx-raystudy,andwaitfortheresultsbeforebeginninganassessment.d.Inspectthethoraxforanynewmassesandbleedingassociatedwithrespirations.ANS:BPercussionisalwaysavailable,portable,andoffersinstantfeedbackregardingchangesinunderlyingtissuedensity,whichmayyieldcluesofthepatientsphysicalstatus.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare13.Thenurseisteachingaclassonbasicassessmentskills.Whichofthesestatementsistrueregardingthestethoscopeanditsuse?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)97STUVIA.COMa.Slopeoftheearpiecesshouldpointposteriorly(towardtheocciput).b.Althoughthestethoscopedoesnotmagnifysound,itdoesblockoutextraneousroomnoise.c.Fitandqualityofthestethoscopearenotasimportantasitsabilitytomagnifysound.d.Idealtubinglengthshouldbe22inchestodampenthedistortionofsound.ANS:BThestethoscopedoesnotmagnifysound,butitdoesblockoutextraneousroomsounds.Theslopeoftheearpiecesshouldpointforwardtowardtheexaminersnose.Longtubingwilldistortsound.Thefitandqualityofthestethoscopearebothimportant.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare14.Thenurseispreparingtouseastethoscopeforauscultation.Whichstatementistrueregardingthediaphragmofthestethoscope?Thediaphragm:a.Isusedtolistenforhigh-pitchedsounds.b.Isusedtolistenforlow-pitchedsounds.NURSINGTB.COMc.Shouldbelightlyheldagainstthepersonsskintoblockoutlow-pitchedsounds.d.Shouldbelightlyheldagainstthepersonsskintolistenforextraheartsoundsandmurmurs.ANS:AThediaphragmofthestethoscopeisbestforlisteningtohigh-pitchedsoundssuchasbreath,bowel,andnormalheartsounds.Itshouldbefirmlyheldagainstthepersonsskin,firmlyenoughtoleavearing.Thebellofthestethoscopeisbestforsoft,low-pitchedsoundssuchasextraheartsoundsormurmurs.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare15.Beforeauscultatingtheabdomenforthepresenceofbowelsoundsonapatient,thenurseshould:a.Warmtheendpieceofthestethoscopebyplacingitinwarmwater.b.Leavethegownonthepatienttoensurethatheorshedoesnotgetchilledduringtheexamination.c.Ensurethatthebellsideofthestethoscopeisturnedtotheonposition.d.Checkthetemperatureoftheroom,andofferblanketstothepatientifheorshefeelscold.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)98STUVIA.COMANS:DTheexaminationroomshouldbewarm.Ifthepatientshivers,thentheinvoluntarymusclecontractionscanmakeitdifficulttoheartheunderlyingsounds.Theendofthestethoscopeshouldbewarmedbetweentheexaminershands,notwithwater.Thenurseshouldneverlistenthroughagown.Thediaphragmofthestethoscopeshouldbeusedtoauscultateforbowelsounds.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare16.Thenursewillusewhichtechniqueofassessmenttodeterminethepresenceofcrepitus,swelling,andpulsations?a.Palpationb.Inspectionc.Percussiond.AuscultationANS:APalpationappliesthesenseoftouchtoassesstexture,temperature,moisture,organlocationandsize,aswellasanyswelling,vibrationorpulsation,rigidityorspasticity,crepitation,presenceoflumpsormasses,andthepresenceoftendernessorpain.NURSINGTB.COMDIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare17.Thenurseispreparingtouseanotoscopeforanexamination.Whichstatementistrueregardingtheotoscope?Theotoscope:a.Isoftenusedtodirectlightontothesinuses.b.Usesashort,broadspeculumtohelpvisualizetheear.c.Isusedtoexaminethestructuresoftheinternalear.d.Directslightintotheearcanalandontothetympanicmembrane.ANS:DTheotoscopedirectslightintotheearcanalandontothetympanicmembranethatdividestheexternalandmiddleear.Ashort,broadspeculumisusedtovisualizethenares.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCarePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)99STUVIA.COM18.Anexaminerisusinganophthalmoscopetoexamineapatientseyes.Thepatienthasastigmatismandisnearsighted.Theuseofwhichofthesetechniqueswouldindicatethattheexaminationisbeingcorrectlyperformed?a.Usingthelargefullcircleoflightwhenassessingpupilsthatarenotdilatedb.Rotatingthelensselectordialtotheblacknumberstocompensateforastigmatismc.Usingthegridonthelensaperturedialtovisualizetheexternalstructuresoftheeyed.RotatingthelensselectordialtobringtheobjectintofocusANS:DTheophthalmoscopeisusedtoexaminetheinternaleyestructures.Itcancompensatefornearsightednessorfarsightedness,butitwillnotcorrectforastigmatism.Thegridisusedtoassesssizeandlocationoflesionsonthefundus.Thelargefullspotoflightisusedtoassessdilatedpupils.Rotatingthelensselectordialbringstheobjectintofocus.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare19.Thenurseisunabletopalpatetherightradialpulseonapatient.Thebestactionwouldbeto:a.AuscultateovertheareawithafetNosUcRopSeIN.GTB.COMb.Useagoniometertomeasurethepulsations.c.UseaDopplerdevicetocheckforpulsationsoverthearea.d.Checkforthepresenceofpulsationswithastethoscope.ANS:CDopplerdevicesareusedtoaugmentpulseorbloodpressuremeasurements.Goniometersmeasurejointrangeofmotion.Afetoscopeisusedtoauscultatefetalhearttones.Stethoscopesareusedtoauscultatebreath,bowelandheartsounds.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare20.Thenurseispreparingtoperformaphysicalassessment.Thecorrectactionbythenurseisreflectedbywhichstatement?Thenurse:a.Performstheexaminationfromtheleftsideofthebed.b.Examinestenderorpainfulareasfirsttohelprelievethepatientsanxiety.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)100STUVIA.COMc.Followsthesameexaminationsequence,regardlessofthepatientsageorcondition.d.Organizestheassessmenttoensurethatthepatientdoesnotchangepositionstoooften.ANS:DThestepsoftheassessmentshouldbeorganizedtoensurethatthepatientdoesnotchangepositionstoooften.Thesequenceofthestepsoftheassessmentmaydiffer,dependingontheageofthepersonandtheexaminerspreference.Tenderorpainfulareasshouldbeassessedlast.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare21.Amanisattheclinicforaphysicalexamination.Hestatesthatheisveryanxiousaboutthephysicalexamination.Whatstepscanthenursetaketomakehimmorecomfortable?a.Appearunhurriedandconfidentwhenexamininghim.b.Stayintheroomwhenheundressesincaseheneedsassistance.c.Askhimtochangeintoanexamininggownandtotakeoffhisundergarments.d.Defermeasuringvitalsignsuntiltheendoftheexamination,whichallowshimtimetobecomecomfortable.NURSINGTB.COMANS:AAnxietycanbereducedbyanexaminerwhoisconfident,self-assured,considerate,andunhurried.Familiarandrelativelynonthreateningactions,suchasmeasuringthepersonsvitalsigns,willgraduallyaccustomthepersontotheexamination.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare22.Whenperformingaphysicalexamination,safetymustbeconsideredtoprotecttheexaminerandthepatienagainstthespreadofinfection.Whichofthesestatementsdescribesthemostappropriateactionthenurseshouldtakewhenperformingaphysicalexamination?a.Washingoneshandsafterremovingglovesisnotnecessary,aslongastheglovesarestillintact.b.Handsarewashedbeforeandaftereveryphysicalpatientencounter.c.Handsarewashedbeforetheexaminationofeachbodysystemtopreventthespreadofbacteriafromonepartofthebodytoanother.d.Glovesarewornthroughouttheentireexaminationtodemonstratetothepatientconcernregardingthespreadofinfectiousdiseases.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)101STUVIA.COMANS:BThenurseshouldwashhisorherhandsbeforeandaftereveryphysicalpatientencounter;aftercontactwithblood,bodyfluids,secretions,andexcretions;aftercontactwithanyequipmentcontaminatedwithbodyfluids;andafterremovinggloves.Handsshouldbewashedaftergloveshavebeenremoved,eveniftheglovesappeartobeintact.Glovesshouldbewornwhenpotentialcontactwithanybodyfluidsispresent.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:SafetyandInfectionControl23.Thenurseisexaminingapatientslowerlegandnoticesadrainingulceration.Whichoftheseactionsismostappropriateinthissituation?a.Washinghands,andcontactingthephysicianb.Continuingtoexaminetheulceration,andthenwashinghandsc.Washinghands,puttingongloves,andcontinuingwiththeexaminationoftheulcerationd.Washinghands,proceedingwithrestofthephysicalexamination,andthencontinuingwiththeexaminationofthelegulcerationANS:CTheexaminershouldweargloveswhenthepotentialcontactwithanybodyfluidsispresent.Inthissituation,thenurseshouldwashhisorherhands,putonNgUloRvSeIsN,GanTdBc.CoOntMinueexaminingtheulceration.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:SafetyandInfectionControl24.Duringtheexamination,offeringsomebriefteachingaboutthepatientsbodyortheexaminersfindingsisoftenappropriate.Whichoneofthesestatementsbythenurseismostappropriate?a.Youratrialdysrhythmiasareundercontrol.b.Youhavepittingedemaandmildvaricosities.c.Yourpulseis80beatsperminute,whichiswithinthenormalrange.d.Imusingmystethoscopetolistenforanycrackles,wheezes,orrubs.ANS:CThesharingofsomeinformationbuildsrapport,aslongasthepatientisabletounderstandtheterminology.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare25.ThenursekeepsinmindthatthemostimportantreasontoshareinformationandtoofferbriefteachingPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)102STUVIA.COMwhileperformingthephysicalexaminationistohelpthe:a.Examinerfeelmorecomfortableandtogaincontrolofthesituation.b.Examinertobuildrapportandtoincreasethepatientsconfidenceinhimorher.c.Patientunderstandhisorherdiseaseprocessandtreatmentmodalities.d.Patientidentifyquestionsabouthisorherdiseaseandthepotentialareasofpatienteducation.ANS:BSharinginformationbuildsrapportandincreasesthepatientsconfidenceintheexaminer.Italsogivesthepatientalittlemorecontrolinasituationduringwhichfeelingcompletelyhelplessisoftenpresent.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare26.ThenurseisexamininganinfantandpreparestoelicittheMororeflexatwhichtimeduringtheexamination?a.Whentheinfantissleepingb.Attheendoftheexaminationc.Beforeauscultationofthethoraxd.HalfwaythroughtheexaminationNURSINGTB.COMANS:BTheMoroorstartlereflexiselicitedattheendoftheexaminationbecauseitmaycausetheinfanttocry.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare27.Whenpreparingtoperformaphysicalexaminationonaninfant,thenurseshould:a.Havetheparentremoveallclothingexceptthediaperonaboy.b.Instructtheparenttofeedtheinfantimmediatelybeforetheexamination.c.Encouragetheinfanttosuckonapacifierduringtheabdominalexamination.d.Asktheparenttoleavetheroombrieflywhenassessingtheinfantsvitalsigns.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)103STUVIA.COMANS:ATheparentshouldalwaysbepresenttoincreasethechildsfeelingofsecurityandtounderstandnormalgrowthanddevelopment.Thetimingoftheexaminationshouldbe1to2hoursafterfeedingwhenthebabyisneithertoodrowsynortoohungry.Infantsdonotobjecttobeingnude;clothingshouldberemoved,butadiapershouldbeleftonaboy.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare28.A6-month-oldinfanthasbeenbroughttothewell-childclinicforacheck-up.Sheiscurrentlysleeping.Whatshouldthenursedofirstwhenbeginningtheexamination?a.Auscultatethelungsandheartwhiletheinfantisstillsleeping.b.Examinetheinfantships,becausethisprocedureisuncomfortable.c.Beginwiththeassessmentoftheeye,andcontinuewiththeremainderoftheexaminationinahead-to-toeapproach.d.Waketheinfantbeforebeginninganyportionoftheexaminationtoobtainthemostaccurateassessmentofbodysystems.ANS:AWhentheinfantisquietorsleepingisanideaNltUimReSItNoGasTsBes.CsOthMecardiac,respiratory,andabdominalsystems.Assessmentoftheeye,ear,nose,andthroatareinvasiveproceduresthatshouldbeperformedattheendoftheexamination.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare29.A2-year-oldchildhasbeenbroughttotheclinicforawell-childcheckup.Thebestwayforthenursetobegintheassessmentisto:a.Asktheparenttoplacethechildontheexaminingtable.b.Havetheparentremoveallofthechildsclothingbeforetheexamination.c.Allowthechildtokeepasecurityobjectsuchasatoyorblanketduringtheexamination.d.Initiallyfocustheinteractionsonthechild,essentiallyignoringtheparentuntilthechildstrusthasbeenobtained.ANS:CThebestplacetoexaminethetoddlerisontheparentslap.Toddlersunderstandsymbols;therefore,asecurityobjectishelpful.Initially,thefocusismoreontheparent,whichallowsthechildtoadjustgraduallyandtobecomefamiliarwithyou.A2-year-oldchilddoesnotliketotakeoffhisorherclothes.Therefore,asktheparenttoundressonebodypartatatime.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)104STUVIA.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare30.Thenurseisexamininga2-year-oldchildandasks,MayIlistentoyourheartnow?Whichcritiqueofthenursestechniqueismostaccurate?a.Askingquestionsenhancesthechildsautonomyb.Askingthechildforpermissionhelpsdevelopasenseoftrustc.Thisquestionisanappropriatestatementbecausechildrenatthisageliketohavechoicesd.Childrenatthisageliketosay,No.TheexaminershouldnotofferachoicewhennochoiceisavailableANS:DChildrenatthisageliketosay,No.Choicesshouldnotbeofferedwhennochoiceisreallyavailable.Ifthechildsays,Noandthenursedoesitanyway,thenthenurselosestrust.Autonomyisenhancedbyofferingalimitedoption,ShallIlistentoyourheartnextoryourtummy?DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare31.WithwhichofthesepatientswoulditbemNoUstRaSpINprGoTprBia.CteOfMorthenursetousegamesduringtheassessment,suchashavingthepatientblowoutthelightonthepenlight?a.Infantb.Preschoolchildc.School-agechildd.AdolescentANS:BWhenassessingpreschoolchildren,usinggamesorallowingthemtoplaywiththeequipmenttoreducetheirfearscanbehelpful.Suchgamesarenotappropriatefortheotheragegroups.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare32.Thenurseispreparingtoexaminea4-year-oldchild.Whichactionisappropriateforthisagegroup?a.Explaintheproceduresindetailtoalleviatethechildsanxiety.b.Givethechildfeedbackandreassuranceduringtheexamination.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)105STUVIA.COMc.Donotaskthechildtoremovehisorherclothesbecausechildrenatthisageareusuallyveryprivate.d.Performanexaminationoftheear,nose,andthroatfirst,andthenexaminethethoraxandabdomen.ANS:BWithpreschoolchildren,short,simpleexplanationsshouldbeused.Childrenatthisageareusuallywillingtoundress.Anexaminationoftheheadshouldbeperformedlast.Duringtheexamination,neededfeedbackandreassuranceshouldbegiventothepreschooler.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare33.Whenexamininga16-year-oldmaleteenager,thenurseshould:a.Discusshealthteachingwiththeparentbecausetheteenisunlikelytobeinterestedinpromotingwellness.b.Askhisparenttostayintheroomduringthehistoryandphysicalexaminationtoansweranyquestionsandtoalleviatehisanxiety.c.TalktohimthesamemannerasonNeUwRoSuINldGtaTlBk.CtoOaMyoungerchildbecauseateenslevelofunderstandingmaynotmatchhisorherspeech.d.Providefeedbackthathisbodyisdevelopingnormally,anddiscussthewidevariationamongteenagersontherateofgrowthanddevelopment.ANS:DDuringtheexamination,theadolescentneedsfeedbackthathisorherbodyishealthyanddevelopingnormally.Theadolescenthasakeenawarenessofbodyimageandoftencompareshimorherselfwithpeers.Apprisetheadolescentofthewidevariationamongteenagersontherateofgrowthanddevelopment.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare34.Whenexamininganolderadult,thenurseshouldusewhichtechnique?a.Avoidtouchingthepatienttoomuch.b.Attempttoperformtheentirephysicalexaminationduringonevisit.c.Speakloudlyandslowlybecausemostagingadultshavehearingdeficits.d.Arrangethesequenceoftheexaminationtoallowasfewpositionchangesaspossible.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)106STUVIA.COMANS:DWhenexaminingtheolderadult,arrangingthesequenceoftheexaminationtoallowasfewpositionchangesaspossibleisbest.Physicaltouchisespeciallyimportantwiththeolderpersonbecauseothersensesmaybediminished.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare35.Themostimportantstepthatthenursecantaketopreventthetransmissionofmicroorganismsinthehospitalsettingisto:a.Wearprotectiveeyewearatalltimes.b.Wearglovesduringanyandallcontactwithpatients.c.Washhandsbeforeandaftercontactwitheachpatient.d.Cleanthestethoscopewithanalcoholswabbetweenpatients.ANS:CThemostimportantsteptodecreasetheriskofmicroorganismtransmissionistowashhandspromptlyandthoroughlybeforeandafterphysicalcontactwitheachpatient.Stethoscopesshouldalsobecleansedwithanalcoholswabbeforeandaftereachpatientcontact.ThebestroutineistocombinestethoscoperubbingwithhandhygieneeachtimehandhygieneisperfoNrmUeRdS.INGTB.COMDIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:SafetyandInfectionControl36.WhichofthesestatementsistrueregardingtheuseofStandardPrecautionsinthehealthcaresetting?a.StandardPrecautionsapplytoallbodyfluids,includingsweat.b.Usealcohol-basedhandrubifhandsarevisiblydirty.c.StandardPrecautionsareintendedforusewithallpatients,regardlessoftheirriskorpresumedinfectionstatus.d.StandardPrecautionsaretobeusedonlywhennonintactskin,excretionscontainingvisibleblood,orexpectedcontactwithmucousmembranesispresent.ANS:CStandardPrecautionsaredesignedtoreducetheriskoftransmissionofmicroorganismsfrombothrecognizedandunrecognizedsourcesandareintendedforuseforallpatients,regardlessoftheirriskorpresumedinfectionstatus.StandardPrecautionsapplytobloodandallotherbodyfluids,secretionsandexcretionsexceptsweatregardlessofwhethertheycontainvisibleblood,nonintactskin,ormucousmembranes.Handsshouldbewashedwithsoapandwaterifvisiblysoiledwithbloodorbodyfluids.Alcohol-basedhandrubscanbeusedifhandsarenotvisiblysoiled.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)107STUVIA.COMDIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:SafetyandInfectionControl37.Thenurseispreparingtoassessahospitalizedpatientwhoisexperiencingsignificantshortnessofbreath.Howshouldthenurseproceedwiththeassessment?a.Thepatientshouldliedowntoobtainanaccuratecardiac,respiratory,andabdominalassessment.b.Athoroughhistoryandphysicalassessmentinformationshouldbeobtainedfromthepatientsfamilymember.c.Acompletehistoryandphysicalassessmentshouldbeimmediatelyperformedtoobtainbaselineinformation.d.Bodyareasappropriatetotheproblemshouldbeexaminedandthentheassessmentcompletedaftertheproblemhasresolved.ANS:DBothalteringthepositionofthepatientduringtheexaminationandcollectingaminidatabasebyexaminingthebodyareasappropriatetotheproblemmaybenecessaryinthissituation.Anassessmentmaybecompletedlaterafterthedistressisresolved.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareENnUvRirSoInNmGeTnBt:.CMOaMnagementofCare38.Whenexamininganinfant,thenurseshouldexaminewhichareafirst?a.Earb.Nosec.Throatd.AbdomenANS:DTheleast-distressingstepsareperformedfirst,savingtheinvasivestepsoftheexaminationoftheeye,ear,nose,andthroatuntillast.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare39.Whileauscultatingheartsounds,thenursehearsamurmur.Whichoftheseinstrumentsshouldbeusedtoassessthismurmur?a.ElectrocardiogramPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)108STUVIA.COMb.Bellofthestethoscopec.Diaphragmofthestethoscoped.PalpationwiththenursespalmofthehandANS:BThebellofthestethoscopeisbestforsoft,low-pitchedsoundssuchasextraheartsoundsormurmurs.Thediaphragmofthestethoscopeisbestusedforhigh-pitchedsoundssuchasbreath,bowel,andnormalheartsounds.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare40.Duringanexaminationofapatientsabdomen,thenursenotesthattheabdomenisroundedandfirmtothetouch.Duringpercussion,thenursenotesadrumlikequalityofthesoundsacrossthequadrants.Thistypeofsoundindicates:a.Constipation.b.Air-filledareas.c.Presenceofatumor.d.Presenceofdenseorgans.NURSINGTB.COMANS:BAmusicalordrumlikesound(tympany)isheardwhenpercussionoccursoveranair-filledviscus,suchasthestomachorintestines.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare41.Thenurseispreparingtoexaminea6-year-oldchild.Whichactionismostappropriate?a.Thethorax,abdomen,andgenitaliaareexaminedbeforethehead.b.Talkingabouttheequipmentbeingusedisavoidedbecausedoingsomayincreasethechildsanxiety.c.Thenurseshouldkeepinmindthatachildatthisagewillhaveasenseofmodesty.d.Thechildisaskedtoundressfromthewaistup.ANS:CPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)109STUVIA.COMA6-year-oldchildhasasenseofmodesty.Thechildshouldundresshimorherself,leavingunderpantsonandusingagownordrape.Aschool-agechildiscurioustoknowhowequipmentworks,andthesequenceshouldprogressfromthechildsheadtothetoes.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare42.Duringauscultationofapatientsheartsounds,thenursehearsanunfamiliarsound.Thenurseshould:a.Documentthefindingsinthepatientsrecord.b.Wait10minutes,andauscultatethesoundagain.c.Askthepatienthowheorsheisfeeling.d.Askanothernursetodoublecheckthefinding.ANS:DIfanabnormalfindingisnotfamiliar,thenthenursemayaskanotherexaminertodoublecheckthefinding.Theotherresponsesdonothelpidentifytheunfamiliarsound.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCareNURSINGTB.COMMULTIPLERESPONSE1.Thenurseispreparingtopalpatethethoraxandabdomenofapatient.Whichofthesestatementsdescribesthecorrecttechniqueforthisprocedure?Selectallthatapply.a.Warmthehandsfirstbeforetouchingthepatient.b.Fordeeppalpation,useonelongcontinuouspalpationwhenassessingtheliver.c.Startwithlightpalpationtodetectsurfacecharacteristics.d.Usethefingertipstoexamineskintexture,swelling,pulsation,andpresenceoflumps.e.Identifyanytenderareas,andpalpatethemlast.f.Usethepalmsofthehandstoassesstemperatureoftheskin.ANS:A,C,D,EThehandsshouldalwaysbewarmedbeforebeginningpalpation.Intermittentpressureratherthanonelongcontinuouspalpationisused;anytenderareasareidentifiedandpalpatedlast.Fingertipsareusedtoexamineskintexture,swelling,pulsation,andthepresenceoflumps.Thedorsa(backs)ofthehandsareusedtoassessskintemperaturebecausetheskinonthedorsaisthinnerthanonthepalms.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)110STUVIA.COMNURSINGTB.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCarePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)111STUVIA.COMChapter09:GeneralSurveyandMeasurementMULTIPLECHOICE1.Thenurseisperformingageneralsurvey.Whichactionisacomponentofthegeneralsurvey?a.Observingthepatientsbodystatureandnutritionalstatusb.Interpretingthesubjectiveinformationthepatienthasreportedc.Measuringthepatientstemperature,pulse,respirations,andbloodpressured.ObservingspecificbodysystemswhileperformingthephysicalassessmentANS:AThegeneralsurveyisastudyofthewholepersonthatincludesobservingthepatientsphysicalappearance,bodystructure,mobility,andbehavior.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare2.Whenmeasuringapatientsweight,thenurseisawareofwhichoftheseguidelines?a.ThepatientisalwaysweighedweaNriUnRgSoInNlGyThiBs.CorOhMerundergarments.b.Thetypeofscaledoesnotmatter,aslongastheweightsaresimilarfromdaytoday.c.Thepatientmayleaveonhisorherjacketandshoesaslongasthesearedocumentednexttotheweight.d.Attemptsshouldbemadetoweighthepatientatapproximatelythesametimeofday,ifasequenceofweightsisnecessary.ANS:DAstandardizedbalancescaleisusedtomeasureweight.Thepatientshouldremovehisorhershoesandheavyouterclothing.Ifasequenceofrepeatedweightsisnecessary,thenthenurseshouldattempttoweighthepatientatapproximatelythesametimeofdayandwiththesametypesofclothingworneachtime.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare3.Duringanexaminationofachild,thenurseconsidersthatphysicalgrowthisthebestindexofachilds:a.Generalhealth.b.Geneticmakeup.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)112STUVIA.COMc.Nutritionalstatus.d.Activityandexercisepatterns.ANS:APhysicalgrowthisthebestindexofachildsgeneralhealth;recordingthechildsheightandweighthelpsdeterminenormalgrowthpatterns.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:HealthPromotionandMaintenance4.A1-month-oldinfanthasaheadmeasurementof34cmandhasachestcircumferenceof32cm.Basedontheinterpretationofthesefindings,thenursewould:a.Refertheinfanttoaphysicianforfurtherevaluation.b.Considerthesefindingsnormalfora1-month-oldinfant.c.Expectthechestcircumferencetobegreaterthantheheadcircumference.d.Asktheparenttoreturnin2weekstore-evaluatetheheadandchestcircumferences.NURSINGTB.COMANS:BThenewbornsheadmeasuresapproximately32to38cmandisapproximately2cmlargerthanthechestcircumference.Between6monthsand2years,bothmeasurementsareapproximatelythesame,andafterage2years,thechestcircumferenceisgreaterthantheheadcircumference.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance5.Thenurseisassessingan80-year-oldmalepatient.Whichassessmentfindingswouldbeconsiderednormal?a.Increaseinbodyweightfromhisyoungeryearsb.Additionaldepositsoffatonthethighsandlowerlegsc.Presenceofkyphosisandflexioninthekneesandhipsd.Changeinoverallbodyproportion,includingalongertrunkandshorterextremitiesANS:CChangesthatoccurintheagingpersonincludemoreprominentbonylandmarks,decreasedbodyweight(especiallyinmen),adecreaseinsubcutaneousfatfromthefaceandperiphery,andadditionalfatdepositedontheabdomenandhips.Posturalchangesofkyphosisandslightflexioninthekneesandhipsalsooccur.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)113STUVIA.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance6.Thenurseshouldmeasurerectaltemperaturesinwhichofthesepatients?a.School-agechildb.Olderadultc.Comatoseadultd.PatientreceivingoxygenbynasalcannulaANS:CRectaltemperaturesshouldbetakenwhentheotherroutesareimpractical,suchasforcomatoseorconfusedpersons,forthoseinshock,orforthosewhocannotclosethemouthbecauseofbreathingoroxygentubes,awiredmandible,orotherfacialdysfunctions.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare7.Thenurseispreparingtomeasurethelength,weight,chest,andheadcircumferenceofa6-month-oldinfant.Whichmeasurementtechniqueiscorrect?NURSINGTB.COMa.Measuringtheinfantslengthbyusingatapemeasureb.Weighingtheinfantbyplacinghimorheronanelectronicstandingscalec.Measuringthechestcircumferenceatthenipplelinewithatapemeasured.MeasuringtheheadcircumferencebywrappingthetapemeasureoverthenoseandcheekbonesANS:CTomeasurethechestcircumference,thetapeisencircledaroundthechestatthenippleline.Thelengthshouldbemeasuredonahorizontalmeasuringboard.Weightshouldbemeasuredonaplatform-typebalancescale.Headcircumferenceismeasuredwiththetapearoundthehead,alignedattheeyebrows,andattheprominentfrontalandoccipitalbones-thewidestspaniscorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare8.Thenurseknowsthatoneadvantageofthetympanicmembranethermometer(TMT)isthat:a.Rapidmeasurementisusefulforuncooperativeyoungerchildren.b.UsingtheTMTisthemostaccuratemethodformeasuringbodytemperatureinnewborninfants.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)114STUVIA.COMc.MeasuringtemperatureusingtheTMTisinexpensive.d.StudiesstronglysupporttheuseoftheTMTinchildrenundertheage6years.ANS:ATheTMTisusefulforyoungchildrenwhomaynotcooperatefororaltemperaturesandfearrectaltemperatures.However,theuseaTMTwithnewborninfantsandyoungchildrenisconflicting.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare9.Thenurseisexaminingapatientwhoiscomplainingoffeelingcold.Whichisamechanismofheatlossinthebody?a.Exerciseb.Radiationc.Metabolismd.FooddigestionANS:BNURSINGTB.COMThebodymaintainsasteadytemperaturethroughathermostatorfeedbackmechanism,whichisregulatedinthehypothalamusofthebrain.Thehypothalamusregulatesheatproductionfrommetabolism,exercise,fooddigestion,andexternalfactorswithheatlossthroughradiation,evaporationofsweat,convection,andconduction.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General10.Whenmeasuringapatientsbodytemperature,thenursekeepsinmindthatbodytemperatureisinfluencedby:a.Constipation.b.Patientsemotionalstate.c.Diurnalcycle.d.Nocturnalcycle.ANS:CNormaltemperatureisinfluencedbythediurnalcycle,exercise,andage.TheotherresponsesdonotinfluencePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)115STUVIA.COMbodytemperature.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General11.Whenevaluatingthetemperatureofolderadults,thenurseshouldrememberwhichaspectaboutanolderadultsbodytemperature?a.Thebodytemperatureoftheolderadultislowerthanthatofayoungeradult.b.Anolderadultsbodytemperatureisapproximatelythesameasthatofayoungchild.c.Bodytemperaturedependsonthetypeofthermometerused.d.Intheolderadult,thebodytemperaturevarieswidelybecauseoflesseffectiveheatcontrolmechanisms.ANS:AInolderadults,thebodytemperatureisusuallylowerthaninotheragegroups,withameantemperatureof36.2C.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:HealthPromotionandMaintenanceNURSINGTB.COM12.A60-year-oldmalepatienthasbeentreatedforpneumoniaforthepast6weeks.Heisseentodayintheclinicforanunexplainedweightlossof10poundsoverthelast6weeks.Thenurseknowsthat:a.Weightlossisprobablytheresultofunhealthyeatinghabits.b.Chronicdiseasessuchashypertensioncauseweightloss.c.Unexplainedweightlossoftenaccompaniesshort-termillnesses.d.Weightlossisprobablytheresultofamentalhealthdysfunction.ANS:CAnunexplainedweightlossmaybeasignofashort-termillnessorachronicillnesssuchasendocrinedisease,malignancy,depression,anorexianervosa,orbulimia.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:BasicCareandComfort13.Whenassessinga75-year-oldpatientwhohasasthma,thenursenotesthatheassumesatripodposition,leaningforwardwitharmsbracedonthechair.Onthebasisofthisobservation,thenurseshould:a.Assumethatthepatientiseagerandinterestedinparticipatingintheinterview.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)116STUVIA.COMb.Evaluatethepatientforabdominalpain,whichmaybeexacerbatedinthesittingposition.c.Assumethatthepatientishavingdifficultybreathingandassisthimtoasupineposition.d.Recognizethatatripodpositionisoftenusedwhenapatientishavingrespiratorydifficulties.ANS:DAssumingatripodpositionleaningforwardwitharmsbracedonchairarmsoccurswithchronicpulmonarydisease.Theotheractionsorassumptionsarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:BasicCareandComfort14.Whichoftheseactionsillustratesthecorrecttechniquethenurseshouldusewhenassessingoraltemperaturewithamercurythermometer?a.Wait30minutesifthepatienthasingestedhotoricedliquids.b.Leavethethermometerinplace3to4minutesifthepatientisafebrile.c.Placethethermometerinfrontofthetongue,andaskthepatienttoclosehisorherlips.d.Shakethemercury-in-glassthermoNmUeRteSrINdoGwTnB.tCoObMelow36.6Cbeforetakingthetemperature.ANS:BThethermometershouldbeleftinplace3to4minutesifthepersonisafebrileandupto8minutesifthepersonisfebrile.Thenurseshouldwait15minutesifthepersonhasjustingestedhotoricedliquidsand2minutesifheorshehasjustsmoked.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare15.ThenurseistakingtemperaturesinaclinicwithaTMT.WhichstatementistrueregardinguseoftheTMT?a.Atympanictemperatureismoretimeconsumingthanarectaltemperature.b.Thetympanicmethodismoreinvasiveanduncomfortablethantheoralmethod.c.Theriskofcross-contaminationisreduced,comparedwiththerectalroute.d.Thetympanicmembranemostaccuratelyreflectsthetemperatureintheophthalmicartery.ANS:CTheTMTisanoninvasive,nontraumaticdevicethatisextremelyquickandefficient.Thechanceofcross-PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)117STUVIA.COMcontaminationwiththeTMTisminimalbecausetheearcanalislinedwithskin,notmucousmembranes.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare16.Toassessarectaltemperatureaccuratelyinanadult,thenursewould:a.Usealubricatedblunttipthermometer.b.Insertthethermometer2to3inchesintotherectum.c.Leavethethermometerinplaceupto8minutesifthepatientisfebrile.d.Wait2to3minutesifthepatienthasrecentlysmokedacigarette.ANS:AAlubricatedrectalthermometer(withashort,blunttip)isinsertedonly2to3cm(1inch)intotheadultrectumandleftinplacefor2minutes.Cigarettesmokingdoesnotalterrectaltemperatures.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare17.Thenurseisperformingageneralsurveyofapatient.Whichfindingisconsiderednormal?NURSINGTB.COMa.Whenstanding,thepatientsbaseisnarrow.b.Thepatientappearsolderthanhisstatedage.c.Armspan(fingertiptofingertip)isgreaterthantheheight.d.Armspan(fingertiptofingertip)equalsthepatientsheight.ANS:DWhenperformingthegeneralsurvey,thepatientsarmspan(fingertiptofingertip)shouldequalthepatientsheight.AnarmspanthatisgreaterthanthepersonsheightmayindicateMarfansyndrome.Thebaseshouldbewidewhenthepatientisstanding,andanolderappearancethanthestatedagemayindicateahistoryofachronicillnessorchronicalcoholism.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrityPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)118STUVIA.COMChapter10:VitalSignsMULTIPLECHOICE1.Apatientsweeklybloodpressurereadingsfor2monthshaverangedbetween124/84mmHgand136/88mmHg,withanaveragereadingof126/86mmHg.Thenurseknowsthatthisbloodpressurefallswithinwhichbloodpressurecategory?a.Normalbloodpressureb.Prehypertensionc.Stage1hypertensiond.Stage2hypertensionANS:BAccordingtotheSeventhReportoftheJointNationalCommittee(JNC7)guidelines,prehypertensionbloodpressurereadingsaresystolicreadingsof120to139mmHgordiastolicreadingsof50to89mmHg.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare2.Whenassessinganolderadult,whichvitalNsiUgnRcShINanGgTeBs.oCcOcMurwithaging?a.Increaseinpulserateb.Widenedpulsepressurec.Increaseinbodytemperatured.DecreaseindiastolicbloodpressureANS:BWithaging,thenursekeepsinmindthatthesystolicbloodpressureincreases,leadingtowidenedpulsepressure.Withmanyolderpeople,boththesystolicanddiastolicpressuresincrease.Thepulserateandtemperaturedonotincrease.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance3.Whichtechniqueiscorrectwhenthenurseisassessingtheradialpulseofapatient?Thepulseiscountedfor:a.1minute,iftherhythmisirregular.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)119STUVIA.COMb.15secondsandthenmultipliedby4,iftherhythmisregular.c.2fullminutestodetectanyvariationinamplitude.d.10secondsandthenmultipliedby6,ifthepatienthasnohistoryofcardiacabnormalities.ANS:ARecentresearchsuggeststhatthe30-secondintervalmultipliedby2isthemostaccurateandefficienttechniquewhenheartratesarenormalorrapidandwhenrhythmsareregular.Iftherhythmisirregular,thenthepulseiscountedfor1fullminute.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare4.Whenassessingapatientspulse,thenurseshouldalsonoticewhichofthesecharacteristics?a.Forceb.Pallorc.Capillaryrefilltimed.TiminginthecardiaccycleNURSINGTB.COMANS:AThepulseisassessedforrate,rhythm,andforce.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare5.Whenassessingthepulseofa6-year-oldboy,thenursenoticesthathisheartratevarieswithhisrespiratorycycle,speedingupatthepeakofinspirationandslowingtonormalwithexpiration.Thenursesnextactionwouldbeto:a.Immediatelynotifythephysician.b.Considerthisfindingnormalinchildrenandyoungadults.c.Checkthechildsbloodpressure,andnoteanyvariationwithrespiration.d.Documentthatthischildhasbradycardia,andcontinuewiththeassessment.ANS:BSinusarrhythmiaiscommonlyfoundinchildrenandyoungadults.Duringtherespiratorycycle,theheartratevaries,speedingupatthepeakofinspirationandslowingtonormalwithexpiration.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)120STUVIA.COMDIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance6.Whenassessingtheforce,orstrength,ofapulse,thenurserecallsthatthepulse:a.Isusuallyrecordedona0-to2-pointscale.b.Demonstrateselasticityofthevesselwall.c.Isareflectionoftheheartsstrokevolume.d.Reflectsthebloodvolumeinthearteriesduringdiastole.ANS:CTheheartpumpsanamountofblood(thestrokevolume)intotheaorta.Theforceflaresthearterialwallsandgeneratesapressurewave,whichisfeltintheperipheryasthepulse.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General7.Thenurseisassessingthevitalsignsofa20-year-oldmalemarathonrunneranddocumentsthefollowingvitalsigns:temperature36C;pulse48beatsperminute;respirations14breathsperminute;bloodpressure104/68mmHg.Whichstatementistrueconcerningtheseresults?NURSINGTB.COMa.Thepatientisexperiencingtachycardia.b.Thesearenormalvitalsignsforahealthy,athleticadult.c.Thepatientspulserateisnotnormalhisphysicianshouldbenotified.d.Onthebasisofthesereadings,thepatientshouldreturntotheclinicin1week.ANS:BIntheadult,aheartratelessthan50beatsperminuteiscalledbradycardia,whichnormallyoccursinthewell-trainedathletewhoseheartmuscledevelopsalongwiththeskeletalmuscles.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance8.Thenurseisassessingthevitalsignsofa3-year-oldpatientwhoappearstohaveanirregularrespiratorypattern.Howshouldthenurseassessthischildsrespirations?a.Respirationsshouldbecountedfor1fullminute,noticingrateandrhythm.b.Childspulseandrespirationsshouldbesimultaneouslycheckedfor30seconds.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)121STUVIA.COMc.Childsrespirationsshouldbecheckedforaminimumof5minutestoidentifyanyvariationsinhisorherrespiratorypattern.d.Patientsrespirationsshouldbecountedfor15secondsandthenmultipliedby4toobtainthenumberofrespirationsperminute.ANS:ARespirationsarecountedfor1fullminuteifanabnormalityissuspected.Theotherresponsesarenotcorrectactions.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance9.Apatientsbloodpressureis118/82mmHg.Heasksthenurse,Whatdothenumbersmean?Thenursesbestreplyis:a.Thenumbersarewithinthenormalrangeandarenothingtoworryabout.b.Thebottomnumberisthediastolicpressureandreflectsthestrokevolumeoftheheart.c.Thetopnumberisthesystolicbloodpressureandreflectsthepressureofthebloodagainstthearterieswhentheheartcontracts.d.TheconceptofbloodpressureisdNifUficRuSlItNtoGTunBd.CerOstMand.Theprimarythingtobeconcernedaboutisthetopnumber,orthesystolicbloodpressure.ANS:CThesystolicpressureisthemaximumpressurefeltonthearteryduringleftventricularcontraction,orsystole.Thediastolicpressureistheelasticrecoil,orresting,pressurethatthebloodconstantlyexertsinbetweeneachcontraction.Thenurseshouldanswerthepatientsquestionandusetermshecanunderstand.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare10.Whilemeasuringapatientsbloodpressure,thenurserecallsthatcertainfactors,suchas,helpdeterminebloodpressure.a.Pulserateb.Pulsepressurec.Vascularoutputd.PeripheralvascularresistanceANS:DPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)122STUVIA.COMThelevelofbloodpressureisdeterminedbyfivefactors:cardiacoutput,peripheralvascularresistance,volumeofcirculatingblood,viscosity,andelasticityofthevesselwalls.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General11.Anurseishelpingatahealthfairatalocalmall.Whentakingbloodpressuresonavarietyofpeople,thenursekeepsinmindthat:a.Aftermenopause,bloodpressurereadingsinwomenareusuallylowerthanthosetakeninmen.b.ThebloodpressureofaBlackadultisusuallyhigherthanthatofaWhiteadultofthesameage.c.Bloodpressuremeasurementsinpeoplewhoareoverweightshouldbethesameasthoseofpeoplewhoareatanormalweight.d.Ateenagersbloodpressurereadingwillbelowerthanthatofanadult.ANS:BIntheUnitedStates,aBlackadultsbloodpressureisusuallyhigherthanthatofaWhiteadultofthesameage.TheincidenceofhypertensionistwiceashighinBlacksasitisinWhites.Aftermenopause,bloodpressureinwomenishigherthaninmen;bloodpressuremeasurementsinpeoplewhoareobeseareusuallyhigherthaninthosewhoarenotoverweight.Normally,agradualriseoccursthroughchildhoodandintotheadultyears.DIF:CognitiveLevel:Applying(Application)NURSINGTB.COMMSC:ClientNeeds:PhysiologicIntegrity12.Thenursenoticesacolleagueispreparingtocheckthebloodpressureofapatientwhoisobesebyusingastandard-sizedbloodpressurecuff.Thenurseshouldexpectthereadingto:a.Yieldafalselylowbloodpressure.b.Yieldafalselyhighbloodpressure.c.Bethesame,regardlessofcuffsize.d.Varyasaresultofthetechniqueofthepersonperformingtheassessment.ANS:BUsingacuffthatistoonarrowyieldsafalselyhighbloodpressurebecauseittakesextrapressuretocompresstheartery.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare13.Astudentislateforhisappointmentandhasrushedacrosscampustothehealthclinic.Thenurseshould:PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)123STUVIA.COMa.Allow5minutesforhimtorelaxandrestbeforecheckinghisvitalsigns.b.Checkthebloodpressureinbotharms,expectingadifferenceinthereadingsbecauseofhisrecentexercise.c.Immediatelymonitorhisvitalsignsonhisarrivalattheclinicandthen5minuteslater,recordinganydifferences.d.Checkhisbloodpressureinthesupineposition,whichwillprovideamoreaccuratereadingandwillallowhimtorelaxatthesametime.ANS:AAcomfortable,relaxedpersonyieldsavalidbloodpressure.Manypeopleareanxiousatthebeginningofanexamination;thenurseshouldallowatleasta5-minuterestperiodbeforemeasuringbloodpressure.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare14.Thenursewillperformapalpatedpressurebeforeauscultatingbloodpressure.Thereasonforthisisto:a.MoreclearlyheartheKorotkoffsounds.b.Detectthepresenceofanauscultatorygap.NURSINGTB.COMc.Avoidmissingafalselyelevatedbloodpressure.d.MorereadilyidentifyphaseIVoftheKorotkoffsounds.ANS:BInflationofthecuff20to30mmHgbeyondthepointatwhichapalpatedpulsedisappearswillavoidmissinganauscultatorygap,whichisaperiodwhentheKorotkoffsoundsdisappearduringauscultation.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare15.Thenurseistakinganinitialbloodpressurereadingona72-year-oldpatientwithdocumentedhypertension.Howshouldthenurseproceed?a.Cuffshouldbeplacedonthepatientsarmandinflated30mmHgabovethepatientspulserate.b.Cuffshouldbeinflatedto200mmHginanattempttoobtainthemostaccuratesystolicreading.c.Cuffshouldbeinflated30mmHgabovethepointatwhichthepalpatedpulsedisappears.d.Afterconfirmingthepatientspreviousbloodpressurereadings,thecuffshouldbeinflated30mmHgabovethehighestsystolicreadingrecorded.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)124STUVIA.COMANS:CAnauscultatorygapoccursinapproximately5%ofthepeople,mostofteninthosewithhypertension.Tocheckforthepresenceofanauscultatorygap,thecuffshouldbeinflated20to30mmHgbeyondthepointatwhichthepalpatedpulsedisappears.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare16.Thenursehascollectedthefollowinginformationonapatient:palpatedbloodpressure180mmHg;auscultatedbloodpressure170/100mmHg;apicalpulse60beatsperminute;radialpulse70beatsperminute.Whatisthepatientspulsepressure?a.10b.70c.80d.100ANS:BPulsepressureisthedifferencebetweensystoNlicUaRnSdINdGiaTstBo.lCicObMloodpressure(170100=70)andreflectsthestrokevolume.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity17.Whenauscultatingthebloodpressureofa25-year-oldpatient,thenursenoticesthephaseIKorotkoffsoundsbeginat200mmHg.At100mmHg,theKorotkoffsoundsmuffle.At92mmHg,theKorotkoffsoundsdisappear.Howshouldthenurserecordthispatientsbloodpressure?a.200/92b.200/100c.100/200/92d.ANS:A200/100/92Inadults,thelastaudiblesoundbestindicatesthediastolicpressure.Whenavarianceisgreaterthan10to12mmHgbetweenphasesIVandV,bothphasesshouldberecordedalongwiththesystolicreading(e.g.,142/98/80).DIF:CognitiveLevel:Analyzing(Analysis)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)125STUVIA.COMMSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare18.Apatientisseenintheclinicforcomplaintsoffaintingepisodesthatstartedlastweek.Howshouldthenurseproceedwiththeexamination?a.Bloodpressurereadingsaretakeninboththearmsandthethighs.b.Thepatientisassistedtoalyingposition,andhisbloodpressureistaken.c.Hisbloodpressureisrecordedinthelying,sitting,andstandingpositions.d.Hisbloodpressureisrecordedinthelyingandsittingpositions;thesenumbersarethenaveragedtoobtainameanbloodpressure.ANS:CIfthepersonisknowntohavehypertension,istakingantihypertensivemedications,orreportsahistoryoffaintingorsyncope,thenthebloodpressurereadingshouldbetakeninthreepositions:lying,sitting,andstanding.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare19.A70-year-oldmanhasabloodpressureof150/90mmHginalyingposition,130/80mmHginasittingposition,and100/60mmHginastandingposition.Howshouldthenurseevaluatethesefindings?NURSINGTB.COMa.Thesereadingsareanormalresponseandattributabletochangesinthepatientsposition.b.Thechangeinbloodpressurereadingsiscalledorthostatichypotension.c.Thebloodpressurereadinginthelyingpositioniswithinnormallimits.d.Thechangeinbloodpressurereadingsisconsideredwithinnormallimitsforthepatientsage.ANS:BOrthostatichypotensionisadropinsystolicpressureofmorethan20mmHg,whichoccurswithaquickchangetoastandingposition.Agingpeoplehavethegreatestriskofthisproblem.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance20.Thenurseishelpinganothernursetotakeabloodpressurereadingonapatientsthigh.Whichactioniscorrectregardingthighpressure?a.Eitherthepoplitealorfemoralvesselsshouldbeauscultatedtoobtainathighpressure.b.Thebestpositiontomeasurethighpressureisthesupinepositionwiththekneeslightlybent.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)126STUVIA.COMc.Ifthebloodpressureinthearmishighinanadolescent,thenitshouldbecomparedwiththethighpressure.d.Thethighpressureislowerthanthepressureinthearm,whichisattributabletothedistanceawayfromtheheartandthesizeofthepoplitealvessels.ANS:CWhenbloodpressuremeasuredatthearmisexcessivelyhigh,particularlyinadolescentsandyoungadults,itiscomparedwiththighpressuretocheckforcoarctationoftheaorta.Thepoplitealarteryisauscultatedforthereading.Generally,thighpressureishigherthanthatofthearm;however,ifcoarctationofthearteryispresentthenarmpressuresarehigherthanthighpressures.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare21.A4-month-oldchildisattheclinicforawell-babycheck-upandimmunizations.Whichoftheseactionsismostappropriatewhenthenurseisassessinganinfantsvitalsigns?a.Theinfantsradialpulseshouldbepalpated,andthenurseshouldnoticeanyfluctuationsresultingfromactivityorexercise.b.Thenurseshouldauscultateanapicalratefor1minuteandthenassessforanynormalirregularities,suchassinusarrhythmia.c.TheinfantsbloodpressureshouldNbeUaRsSsIeNssGeTdBb.yCOusMingastethoscopewithalargediaphragmpiecetohearthesoftmuffledKorotkoffsounds.d.Theinfantschestshouldbeobservedandtherespiratoryratecountedfor1minute;therespiratorypatternmayvarysignificantly.ANS:BThenursepalpatesorauscultatesanapicalratewithinfantsandtoddlers.Thepulseshouldbecountedfor1fullminutetoaccountfornormalirregularities,suchassinusarrhythmia.Childrenyoungerthan3yearsofagehavesuchsmallarmvessels;consequently,hearingKorotkoffsoundswithastethoscopeisdifficult.ThenurseshoulduseeitheranelectronicbloodpressuredevicethatusesoscillometryoraDopplerultrasounddevicetoamplifythesounds.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare22.Thenurseisconductingahealthfairforolderadults.Whichstatementistrueregardingvitalsignmeasurementsinagingadults?a.Thepulseismoredifficulttopalpatebecauseofthestiffnessofthebloodvessels.b.Anincreasedrespiratoryrateandashallowerinspiratoryphaseareexpectedfindings.c.Adecreasedpulsepressureoccursfromchangesinthesystolicanddiastolicbloodpressures.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)127STUVIA.COMd.Changesinthebodystemperatureregulatorymechanismleavetheolderpersonmorelikelytodevelopafever.ANS:BAgingcausesadecreaseinvitalcapacityanddecreasedinspiratoryreservevolume.Theexaminermaynoticeashallowerinspiratoryphaseandanincreasedrespiratoryrate.Anincreaseintherigidityofthearterialwallsmakesthepulseactuallyeasiertopalpate.Pulsepressureiswidenedinolderadults,andchangesinthebodytemperatureregulatorymechanismleavetheolderpersonlesslikelytohavefeverbutatagreaterriskforhypothermia.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance23.Inapatientwithacromegaly,thenursewillexpecttodiscoverwhichassessmentfindings?a.Heavy,flattenedfacialfeaturesb.Growthretardationandadelayedonsetofpubertyc.Overgrowthofboneintheface,head,hands,andfeetd.IncreasedheightandweightanddelayedsexualdevelopmentNURSINGTB.COMANS:CExcessivesecretionsofgrowthhormoneinadulthoodafternormalcompletionofbodygrowthcausesanovergrowthofthebonesintheface,head,hands,andfeetbutnochangeinheight.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare24.Thenurseisassessingchildreninapediatricclinic.Whichstatementistrueregardingthemeasurementofbloodpressureinchildren?a.Bloodpressureguidelinesforchildrenarebasedonage.b.PhaseIIKorotkoffsoundsarethebestindicatorofsystolicbloodpressureinchildren.c.UsingaDopplerdeviceisrecommendedforaccuratebloodpressuremeasurementsuntiladolescence.d.ThedisappearanceofphaseVKorotkoffsoundscanbeusedforthediastolicreadinginchildren.ANS:DThedisappearanceofphaseVKorotkoffsoundscanbeusedforthediastolicreadinginchildren,aswellasinadults.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)128STUVIA.COMDIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:HealthPromotionandMaintenance25.Whattypeofbloodpressuremeasurementerrorismostlikelytooccurifthenursedoesnotcheckforthepresenceofanauscultatorygap?a.Diastolicbloodpressuremaynotbeheard.b.Diastolicbloodpressuremaybefalselylow.c.Systolicbloodpressuremaybefalselylow.d.Systolicbloodpressuremaybefalselyhigh.ANS:CIfanauscultatorygapisundetected,thenafalselylowsystolicorfalselyhighdiastolicreadingmayresult,whichiscommoninpatientswithhypertension.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare26.Whenconsideringtheconceptsrelatedtobloodpressure,thenurseknowsthattheconceptofmeanarterialpressure(MAP)isbestdescribedbywhichstatement?NURSINGTB.COMa.MAPisthepressureofthearterialpulse.b.MAPreflectsthestrokevolumeoftheheart.c.MAPisthepressureforcingbloodintothetissues,averagedoverthecardiaccycle.d.MAPisanaverageofthesystolicanddiastolicbloodpressuresandreflectstissueperfusion.ANS:CMAPisthepressurethatforcesbloodintothetissues,averagedoverthecardiaccycle.Strokevolumeisreflectedbythebloodpressure.MAPisnotanarithmeticaverageofsystolicanddiastolicpressuresbecausediastolelastslonger;rather,itisavalueclosertodiastolicpressureplusonethirdofthepulsepressure.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare27.A75-year-oldmanwithahistoryofhypertensionwasrecentlychangedtoanewantihypertensivedrug.Hereportsfeelingdizzyattimes.Howshouldthenurseevaluatehisbloodpressure?a.Bloodpressureandpulseshouldberecordedinthesupine,sitting,andstandingpositions.b.ThepatientshouldbedirectedtowalkaroundtheroomandhisbloodpressureassessedafterthisPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)129STUVIA.COMactivity.c.Bloodpressureandpulseareassessedatthebeginningandattheendoftheexamination.d.Bloodpressureistakenontherightarmandthen5minuteslaterontheleftarm.ANS:AOrthostaticvitalsignsshouldbetakenwhenthepersonishypertensiveoristakingantihypertensivemedications,whenthepersonreportsfaintingorsyncope,orwhenvolumedepletionissuspected.Thebloodpressureandpulsereadingsarerecordedinthesupine,sitting,andstandingpositions.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare28.Whichofthesespecificmeasurementsisthebestindexofachildsgeneralhealth?a.Vitalsignsb.Heightandweightc.Headcircumferenced.ChestcircumferenceNURSINGTB.COMANS:BPhysicalgrowth,measuredbyheightandweight,isthebestindexofachildsgeneralhealth.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance29.Thenurseisassessingan8-year-oldchildwhosegrowthratemeasuresbelowthethirdpercentileforachildhisage.Heappearssignificantlyyoungerthanhisstatedageandischubbywithinfantilefacialfeatures.Whichconditiondoesthischildhave?a.Hypopituitarydwarfismb.Achondroplasticdwarfismc.Marfansyndromed.AcromegalyANS:AHypopituitarydwarfismiscausedbyadeficiencyingrowthhormoneinchildhoodandresultsinaretardationofgrowthbelowthethirdpercentile,delayedpuberty,andotherproblems.ThechildsappearancefitsthisPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)130STUVIA.COMdescription.Achondroplasticdwarfismisageneticdisorderresultingincharacteristicdeformities;Marfansyndromeisaninheritedconnectivetissuedisordercharacterizedbyatall,thinstatureandotherfeatures.Acromegalyistheresultofexcessivesecretionofgrowthhormoneinadulthood.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare30.Thenurseiscountinganinfantsrespirations.Whichtechniqueiscorrect?a.Watchingthechestriseandfallb.Watchingtheabdomenformovementc.Placingahandacrosstheinfantschestd.UsingastethoscopetolistentothebreathsoundsANS:BWatchingtheabdomenformovementisthecorrecttechniquebecausetheinfantsrespirationsarenormallymorediaphragmaticthanthoracic.Theotherresponsesdonotreflectcorrecttechniques.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenanceNURSINGTB.COM31.Whencheckingforproperbloodpressurecuffsize,whichguidelineiscorrect?a.Thestandardcuffsizeisappropriateforallsizes.b.Thelengthoftherubberbladdershouldequal80%ofthearmcircumference.c.Thewidthoftherubberbladdershouldequal80%ofthearmcircumference.d.Thewidthoftherubberbladdershouldequal40%ofthearmcircumference.ANS:DThewidthoftherubberbladdershouldequal40%ofthecircumferenceofthepersonsarm.Thelengthofthebladdershouldequal80%ofthiscircumference.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare32.Duringanexamination,thenursenoticesthatafemalepatienthasaroundmoonface,centraltrunkobesityandacervicalhump.Herskinisfragilewithbruises.Thenursedeterminesthatthepatienthaswhichcondition?a.MarfansyndromePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)131STUVIA.COMb.Gigantismc.Cushingsyndromed.AcromegalyANS:CCushingsyndromeischaracterizedbyweightgainandedemawithcentraltrunkandcervicalobesity(buffalohump)androundplethoricface(moonface).Excessivecatabolismcausesmusclewasting;weakness;thinarmsandlegs;reducedheight;andthin,fragileskinwithpurpleabdominalstriae,bruising,andacne.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare33.Thenurseispreparingtomeasurethevitalsignsofa6-month-oldinfant.Whichactionbythenurseiscorrect?a.Respirationsaremeasured;thenpulseandtemperature.b.Vitalsignsshouldbemeasuredmorefrequentlythaninanadult.c.Proceduresareexplainedtotheparent,andtheinfantisencouragedtohandletheequipment.NURSINGTB.COMd.Thenurseshouldfirstperformthephysicalexaminationtoallowtheinfanttobecomemorefamiliarwithherandthenmeasuretheinfantsvitalsigns.ANS:AWithaninfant,theorderofvitalsignmeasurementsisreversedtorespiration,pulse,andtemperature.Takingthetemperaturefirst,especiallyifitisrectal,maycausetheinfanttocry,whichwillincreasetherespiratoryandpulserate,thusmaskingthenormalrestingvalues.Thevitalsignsaremeasuredwiththesamepurposeandfrequencyaswouldbemeasuredinanadult.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCareMULTIPLERESPONSE1.Whilemeasuringapatientsbloodpressure,thenurseusesthepropertechniquetoobtainanaccuratereading.Whichofthesesituationswillresultinafalselyhighbloodpressurereading?Selectallthatapply.a.Thepersonsupportshisorherownarmduringthebloodpressurereading.b.Thebloodpressurecuffistoonarrowfortheextremity.c.Thearmisheldaboveleveloftheheart.d.Thecuffislooselywrappedaroundthearm.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)132STUVIA.COMe.Thepersonissittingwithhisorherlegscrossed.f.Thenursedoesnotinflatethecuffhighenough.ANS:A,B,D,ESeveralfactorscanresultinbloodpressurereadingsthataretoohighortoolow.Havingthepatientsarmheldabovetheleveloftheheartisonepartofthecorrecttechnique.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCareSHORTANSWER1.Whatisthepulsepressureforapatientwhosebloodpressureis158/96mmHgandwhosepulserateis72beatsperminute?ANS:62Thepulsepressureisthedifferencebetweenthesystolicanddiastolicandreflectsthestrokevolume.Thepulserateisnotnecessaryforpulsepressurecalculations.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareENnUvRirSoInNmGeTnBt:.CMOaMnagementofCarePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)133STUVIA.COMChapter11:PainAssessmentMULTIPLECHOICE1.Whenevaluatingapatientspain,thenurseknowsthatanexampleofacutepainwouldbe:a.Arthriticpain.b.Fibromyalgia.c.Kidneystones.d.Lowbackpain.ANS:CAcutepainisshort-termanddissipatesafteraninjuryheals,suchaswithkidneystones.Theotherconditionsareexamplesofchronicpainduringwhichthepaincontinuesfor6monthsorlongeranddoesnotstopwhentheinjuryheals.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:BasicCareandComfort2.Whichstatementindicatesthatthenurseunderstandsthepainexperiencedbyanolderadult?NURSINGTB.COMa.Olderadultsmustlearntotoleratepain.b.Painisanormalprocessofagingandistobeexpected.c.Painindicatesapathologicconditionoraninjuryandisnotanormalprocessofaging.d.Olderindividualsperceivepaintoalesserdegreethandoyoungerindividuals.ANS:CPainindicatesapathologicconditionoraninjuryandshouldneverbeconsideredsomethingthatanolderadultshouldexpectortolerate.Painisnotanormalprocessofaging,andnoevidencesuggeststhatpainperceptionisreducedwithaging.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:BasicCareandComfort3.A4-year-oldboyisbroughttotheemergencydepartmentbyhismother.Shesayshepointstohisstomachandsays,Ithurtssobad.Whichpainassessmenttoolwouldbethebestchoicewhenassessingthischildspain?a.DescriptorScaleb.NumericratingscalePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)134STUVIA.COMc.BriefPainInventoryd.FacesPainScaleRevised(FPS-R)ANS:DRatingscalescanbeintroducedattheageof4or5years.TheFPS-Risdesignedforusebychildrenandasksthechildtochooseafacethatshowshowmuchhurt(orpain)youhavenow.Youngchildrenshouldnotbeaskedtoratepainbyusingnumbers.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:BasicCareandComfort4.Apatientstatesthatthepainmedicationisnotworkingandrateshispostoperativepainata10ona1-to-10scale.Whichoftheseassessmentfindingsindicatesanacutepainresponsetopoorlycontrolledpain?a.Confusionb.Hyperventilationc.Increasedbloodpressureandpulsed.DepressionNURSINGTB.COMANS:CResponsestopoorlycontrolledacutepainincludetachycardia,elevatedbloodpressure,andhypoventilation.Confusionanddepressionareassociatedwithpoorlycontrolledchronicpain.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:BasicCareandComfort5.A60-year-oldwomanhasdevelopedreflexivesympatheticdystrophyafterarthroscopicrepairofhershoulder.Akeyfeatureofthisconditionisthatthe:a.Affectedextremitywilleventuallyregainitsfunction.b.Painisfeltatonesitebutoriginatesfromanotherlocation.c.Patientspainwillbeassociatedwithnausea,pallor,anddiaphoresis.d.Slightesttouch,suchasasleevebrushingagainstherarm,causessevereandintensepain.ANS:DAkeyfeatureofreflexivesympatheticdystrophyisthatatypicallyinnocuousstimuluscancreateasevere,intenselypainfulresponse.Theaffectedextremitybecomeslessfunctionalovertime.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)135STUVIA.COMDIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:BasicCareandComfort6.Thenurseisassessingapatientspain.Thenurseknowsthatthemostreliableindicatorofpainwouldbethe:a.Patientsvitalsigns.b.Physicalexamination.c.Resultsofacomputerizedaxialtomographicscan.d.Subjectivereport.ANS:DThesubjectivereportisthemostreliableindicatorofpain.Physicalexaminationfindingscanlendsupport,butthecliniciancannotexclusivelybasethediagnosisofpainonphysicalassessmentfindings.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare7.Apatienthashadarthriticpaininherhipsforseveralyearssinceahipfracture.Sheisabletomovearoundinherroomandhasnotofferedanycomplaintssofarthismorning.However,whenasked,shestatesthatherpainisbadthismorningandratesitatan8ona1-to-10scale.Whatdoesthenursesuspect?Thepatient:NURSINGTB.COMa.Isaddictedtoherpainmedicationsandcannotobtainpainrelief.b.Doesnotwanttotroublethenursingstaffwithhercomplaints.c.Isnotinpainbutratesithightoreceivepainmedication.d.Hasexperiencedchronicpainforyearsandhasadaptedtoit.ANS:DPersonswithchronicpaintypicallytrytogivelittleindicationthattheyareinpainand,overtime,adapttothepain.Asaresult,theyareatriskforunderdetection.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare8.Thenurseisreviewingtheprinciplesofpain.Whichtypeofpainisduetoanabnormalprocessingofthepainimpulsethroughtheperipheralorcentralnervoussystem?a.Visceralb.ReferredPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)136STUVIA.COMc.Cutaneousd.NeuropathicANS:DNeuropathicpainimpliesanabnormalprocessingofthepainmessage.Theothertypesofpainarenamedaccordingtotheirsources.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare9.Whenassessingthequalityofapatientspain,thenurseshouldaskwhichquestion?a.Whendidthepainstart?b.Isthepainastabbingpain?c.Isitasharppainordullpain?d.Whatdoesyourpainfeellike?ANS:DNURSINGTB.COMToassessthequalityofapersonspain,thepatientisaskedtodescribethepaininhisorherownwords.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare10.Whenassessingapatientspain,thenurseknowsthatanexampleofvisceralpainwouldbe:a.Hipfracture.b.Cholecystitis.c.Second-degreeburns.d.Painafteralegamputation.ANS:BVisceralpainoriginatesfromthelargerinteriororgans,suchasthegallbladder,liver,orkidneys.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare11.Thenurseisreviewingtheprinciplesofnociception.Duringwhichphaseofnociceptiondoestheconsciousawarenessofapainfulsensationoccur?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)137STUVIA.COMa.Perceptionb.Modulationc.Transductiond.TransmissionANS:APerceptionisthethirdphaseofnociceptionandindicatestheconsciousawarenessofapainfulsensation.Duringthisphase,thesensationisrecognizedbyhighercorticalstructuresandidentifiedaspain.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PhysiologicIntegrity:BasicCareandComfort12.Whenassessingtheintensityofapatientspain,whichquestionbythenurseisappropriate?a.Whatmakesyourpainbetterorworse?b.Howmuchpaindoyouhavenow?c.HowdoespainlimityouractivitieNs?URSINGTB.COMd.Whatdoesyourpainfeellike?ANS:BAskingthepatienthowmuchpaindoyouhave?isanassessmentoftheintensityofapatientspain;variousintensityscalescanbeused.Askingwhatmakesonespainbetterorworseassessesalleviatingoraggravatingfactors.Askingwhetherpainlimitsonesactivitiesassessesthedegreeofimpairmentandqualityoflife.Askingwhatdoesyourpainfeellikeassessesthequalityofpain.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:BasicCareandComfort13.Apatientiscomplainingofseverekneepainaftertwistingitduringabasketballgameandisrequestingpainmedication.Whichactionbythenurseisappropriate?a.Completingthephysicalexaminationfirstandthengivingthepainmedicationb.Tellingthepatientthatthepainmedicationmustwaituntilafterthex-rayimagesarecompletedc.Evaluatingthefullrangeofmotionofthekneeandthenmedicatingforpaind.AdministeringpainmedicationandthenproceedingwiththeassessmentPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)138STUVIA.COMANS:DAccordingtotheAmericanPainSociety(1992),Incasesinwhichthecauseofacutepainisuncertain,establishingadiagnosisisapriority,butsymptomatictreatmentofpainshouldbegivenwhiletheinvestigationisproceeding.Withoccasionalexceptions,(e.g.,theinitialexaminationofthepatientwithanacuteconditionoftheabdomen),itisrarelyjustifiedtodeferanalgesiauntiladiagnosisismade.Infact,acomfortablepatientisbetterabletocooperatewithdiagnosticprocedures.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:BasicCareandComfort14.Thenurseknowsthatwhichstatementistrueregardingthepainexperiencedbyinfants?a.Painininfantscanonlybeassessedbyphysiologicchanges,suchasanincreasedheartrate.b.TheFPS-Rcanbeusedtoassesspainininfants.c.Aprocedurethatinducespaininadultswillalsoinducepainintheinfant.d.Infantsfeelpainlessthandoadults.ANS:CIfaprocedureordiseaseprocesscausespaininanadult,thenitwillalsocausepaininaninfant.Physiologicchangescannotbeexclusivelyusedtoconfirmordenypainbecauseotherfactors,suchasmedications,fluidstatus,orstressmaycausephysiologicchangeNs.UTRhSeINFGPST-BR.CcOanMbeusedstartingatage4years.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:BasicCareandComfort15.Apatienthasbeenadmittedtothehospitalwithvertebralfracturesrelatedtoosteoporosis.Sheisinextremepain.Thistypeofpainwouldbeclassifiedas:a.Referred.b.Cutaneous.c.Visceral.d.Deepsomatic.ANS:DDeepsomaticpaincomesfromsourcessuchasthebloodvessels,joints,tendons,muscles,andbone.Referredpainisfeltatonesitebutoriginatesfromanotherlocation.Cutaneouspainisderivedfromtheskinsurfaceandsubcutaneoustissues.Visceralpainoriginatesfromthelarger,interiororgans.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:BasicCareandComfortPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)139STUVIA.COMMULTIPLERESPONSE1.Duringassessmentofapatientspain,thenurseisawarethatcertainnonverbalbehaviorsareassociatedwithchronicpain.Whichofthesebehaviorsareassociatedwithchronicpain?Selectallthatapply.a.Sleepingb.Moaningc.Diaphoresisd.Bracinge.Restlessnessf.RubbingANS:A,D,FBehaviorsthathavebeenassociatedwithchronicpainincludebracing,rubbing,diminishedactivity,sighing,andchangesinappetite.Inaddition,thosewithchronicpainmaysleepinanattemptatdistraction.Theotherbehaviorsareassociatedwithacutepain.DIF:CognitiveLevel:Applying(Application)NURSINGTB.COMMSC:ClientNeeds:PhysiologicIntegrity:BasicCareandComfort2.Duringanadmissionassessmentofapatientwithdementia,thenurseassessesforpainbecausethepatienthasrecentlyhadseveralfalls.Whichoftheseareappropriateforthenursetoassessinapatientwithdementia?Selectallthatapply.a.Askthepatient,Doyouhavepain?b.Assessthepatientsbreathingindependentofvocalization.c.Notewhetherthepatientiscallingout,groaning,orcrying.d.Havethepatientratepainona1-to-10scale.e.Observethepatientsbodylanguageforpacingandagitation.ANS:B,C,EPatientswithdementiamaysaynowhen,inreality,theyareveryuncomfortablebecausewordshavelosttheirmeaning.Patientswithdementiabecomelessabletoidentifyanddescribepainovertime,althoughpainisstillpresent.Peoplewithdementiacommunicatepainthroughtheirbehaviors.Agitation,pacing,andrepetitiveyellingmayindicatepainandnotaworseningofthedementia.(SeethePainAssessmentinAdvancedDementia[PAINAD]scale,whichmayalsobeusedtoassesspaininpersonswithdementia.)DIF:CognitiveLevel:Applying(Application)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)140STUVIA.COMNURSINGTB.COMMSC:ClientNeeds:PhysiologicIntegrity:BasicCareandComfortPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)141STUVIA.COMChapter12:NutritionAssessmentMULTIPLECHOICE1.Thenurserecognizeswhichofthesepersonsisatgreatestriskforundernutrition?a.5-month-oldinfantb.50-year-oldwomanc.20-year-oldcollegestudentd.30-year-oldhospitaladministratorANS:AVulnerablegroupsforundernutritionareinfants,children,pregnantwomen,recentimmigrants,personswithlowincomes,hospitalizedpeople,andagingadults.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:HealthPromotionandMaintenance2.Whenassessingapatientsnutritionalstatus,thenurserecallsthatthebestdefinitionofoptimalnutritionalstatusissufficientnutrientsthat:NURSINGTB.COMa.Areinexcessofdailybodyrequirements.b.Providefortheminimumbodyneeds.c.Providefordailybodyrequirementsbutdonotsupportincreasedmetabolicdemands.d.Providefordailybodyrequirementsandsupportincreasedmetabolicdemands.ANS:DOptimalnutritionalstatusisachievedwhensufficientnutrientsareconsumedtosupportday-to-daybodyneedsandanyincreasedmetabolicdemandsresultingfromgrowth,pregnancy,orillness.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:HealthPromotionandMaintenance3.Thenurseisprovidingnutritioninformationtothemotherofa1-year-oldchild.Whichofthesestatementsrepresentsaccurateinformationforthisagegroup?a.Maintainingadequatefatandcaloricintakeisimportantforachildinthisagegroup.b.Therecommendeddietaryallowancesforaninfantarethesameasforanadolescent.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)142STUVIA.COMc.Thebabysgrowthisminimalatthisage;therefore,caloricrequirementsaredecreased.d.Thebabyshouldbeplacedonskimmilktodecreasetheriskofcoronaryarterydiseasewhenheorshegrowsolder.ANS:ABecauseofrapidgrowth,especiallyofthebrain,bothinfantsandchildrenyoungerthan2yearsofageshouldnotdrinkskimorlow-fatmilkorbeplacedonlow-fatdiets.Fats(caloriesandessentialfattyacids)arerequiredforpropergrowthandcentralnervoussystemdevelopment.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance4.Apregnantwomanisinterestedinbreastfeedingherbabyandasksseveralquestionsaboutthetopic.Whichinformationisappropriateforthenursetosharewithher?a.Breastfeedingisbestwhenalsosupplementedwithbottlefeedings.b.Babieswhoarebreastfedoftenrequiresupplementalvitamins.c.Breastfeedingisrecommendedforinfantsforthefirst2yearsoflife.d.Breastmilkprovidesthenutrientsnecessaryforgrowth,aswellasnaturalimmunity.NURSINGTB.COMANS:DBreastfeedingisrecommendedforfull-terminfantsforthefirstyearoflifebecausebreastmilkisideallyformulatedtopromotenormalinfantgrowthanddevelopment,aswellasnaturalimmunity.Theotherstatementsarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance5.Amotherandher13-year-olddaughterexpresstheirconcernrelatedtothedaughtersrecentweightgainandherincreaseinappetite.Whichofthesestatementsrepresentsinformationthenurseshoulddiscusswiththem?a.Dietingandexercisingarenecessaryatthisage.b.Snacksshouldbehighinprotein,iron,andcalcium.c.Teenagerswhohaveaweightproblemshouldnotbeallowedtosnack.d.Alow-caloriedietisimportanttopreventtheaccumulationoffat.ANS:BAfteraperiodofslowgrowthinlatechildhood,adolescenceischaracterizedbyrapidphysicalgrowthandPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)143STUVIA.COMendocrineandhormonalchanges.Caloricandproteinrequirementsincreasetomeetthisdemand.Becauseofbonegrowthandincreasingmusclemass(and,ingirls,theonsetofmenarche),calciumandironrequirementsalsoincrease.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance6.Thenurseisassessinga30-year-oldunemployedimmigrantfromanunderdevelopedcountrywhohasbeenintheUnitedStatesfor1month.Whichoftheseproblemsrelatedtohisnutritionalstatusmightthenurseexpecttofind?a.Obesityb.Hypotensionc.Osteomalacia(softeningofthebones)d.CoronaryarterydiseaseANS:CGeneralundernutrition,hypertension,diarrhea,lactoseintolerance,osteomalacia,scurvy,anddentalcariesareamongthemorecommonnutrition-relatedproblemsofnewimmigrantsfromdevelopingcountries.DIF:CognitiveLevel:Applying(Application)NURSINGTB.COMMSC:ClientNeeds:HealthPromotionandMaintenance7.Forthefirsttime,thenurseisseeingapatientwhohasnohistoryofnutrition-relatedproblems.Theinitialnutritionalscreeningshouldincludewhichactivity?a.Caloriecountofnutrientsb.Anthropometricmeasuresc.Completephysicalexaminationd.MeasurementofweightandweighthistoryANS:DParametersusedfornutritionscreeningtypicallyincludeweightandweighthistory,conditionsassociatedwithincreasednutritionalrisk,dietinformation,androutinelaboratorydata.Theotherresponsesreflectamorein-depthassessmentratherthanascreening.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance8.Apatientisaskedtoindicateonaformhowmanytimesheeatsaspecificfood.Thismethoddescribeswhichofthesetoolsforobtainingdietaryinformation?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)144STUVIA.COMa.Fooddiaryb.Caloriecountc.24-hourrecalld.Food-frequencyquestionnaireANS:DWiththistool,informationiscollectedonhowmanytimesperday,week,ormonththeindividualeatsparticularfoods,whichprovidesanestimateofusualintake.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:HealthPromotionandMaintenance9.Thenurseisprovidingcarefora68-year-oldwomanwhoiscomplainingofconstipation.Whatconcernexistsregardinghernutritionalstatus?a.Absorptionofnutrientsmaybeimpaired.b.Constipationmayrepresentafoodallergy.NURSINGTB.COMc.Thepatientmayneedemergencysurgerytocorrecttheproblem.d.Gastrointestinalproblemswillincreasehercaloricdemand.ANS:AGastrointestinalsymptomssuchasvomiting,diarrhea,orconstipationmayinterferewithnutrientintakeorabsorption.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance10.Duringanutritionalassessment,whyisitimportantforthenursetoaskapatientwhatmedicationsheorsheistaking?a.Certaindrugscanaffectthemetabolismofnutrients.b.Thenurseneedstoassessthepatientforallergicreactions.c.Medicationsneedtobedocumentedintherecordforthephysiciansreview.d.Medicationscanaffectonesmemoryandabilitytoidentifyfoodeateninthelast24hours.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)145STUVIA.COMANS:AAnalgesics,antacids,anticonvulsants,antibiotics,diuretics,laxatives,antineoplasticdrugs,steroids,andoralcontraceptivesaredrugsthatcaninteractwithnutrients,impairingtheirdigestion,absorption,metabolism,oruse.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance11.Apatienttellsthenursethathisfoodsimplydoesnothaveanytasteanymore.Thenursesbestresponsewouldbe:a.Thatmustbereallyfrustrating.b.Whendidyoufirstnoticethischange?c.Myfooddoesntalwayshavealotoftasteeither.d.Sometimesthathappens,butyourtastewillcomeback.ANS:BWithchangesinappetite,taste,smell,orchewingorswallowing,theexaminershouldaskaboutthetypeofchangeandwhenthechangeoccurred.Theseproblemsinterferewithadequatenutrientintake.Theotherresponsesarenotcorrect.NURSINGTB.COMDIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance12.Thenurseisperforminganutritionalassessmentona15-year-oldgirlwhotellsthenursethatsheissofat.Assessmentrevealsthatsheis5feet4inchesandweighs110pounds.Thenursesappropriateresponsewouldbe:a.Howmuchdoyouthinkyoushouldweigh?b.Dontworryaboutit;yourenotthatoverweight.c.Thebestthingforyouwouldbetogoonadiet.d.IusedtoalwaysthinkIwasfatwhenIwasyourage.ANS:AAdolescentsincreasedbodyawarenessandself-consciousnessmaycauseeatingdisorderssuchasanorexianervosaorbulimia,conditionsinwhichtherealorperceivedbodyimagedoesnotfavorablycomparewithanidealimage.Thenurseshouldnotbelittletheadolescentsfeelings,provideunsolicitedadvice,oragreewithher.DIF:CognitiveLevel:Applying(Application)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)146STUVIA.COMMSC:ClientNeeds:HealthPromotionandMaintenance13.Thenurseisdiscussingappropriatefoodswiththemotherofa3-year-oldchild.Whichofthesefoodsarerecommended?a.Foodsthatthechildwilleat,nomatterwhattheyareb.Foodseasytoholdsuchashotdogs,nuts,andgrapesc.Anyfoods,aslongastherestofthefamilyisalsoeatingthemd.FingerfoodsandnutritioussnacksthatcannotcausechokingANS:DSmallportions,fingerfoods,simplemeals,andnutritioussnackshelpimprovethedietaryintakeofyoungchildren.Foodslikelytobeaspiratedshouldbeavoided(e.g.,hotdogs,nuts,grapes,roundcandies,popcorn).DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance14.Thenurseisreviewingthenutritionalassessmentofan82-year-oldpatient.Whichofthesefactorswillmostlikelyaffectthenutritionalstatusofanolderadult?a.Increaseintasteandsmellb.Livingaloneonafixedincomec.ChangeincardiovascularstatusNURSINGTB.COMd.IncreaseingastrointestinalmotilityandabsorptionANS:BSocioeconomicconditionsfrequentlyaffectthenutritionalstatusoftheagingadult;thesefactorsshouldbecloselyevaluated.Physicallimitations,income,andsocialisolationarefrequentproblemsthatinterferewiththeacquisitionofabalanceddiet.Adecreaseintasteandsmellanddecreasedgastrointestinalmotilityandabsorptionoccurwithaging.Cardiovascularstatusisnotafactorthataffectsanolderadultsnutritionalstatus.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance15.Whenconsideringanutritionalassessment,thenurseisawarethatthemostcommonanthropometricmeasurementsinclude:a.Heightandweight.b.Legcircumference.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)147STUVIA.COMc.Skinfoldthicknessofthebiceps.d.Hipandwaistmeasurements.ANS:AThemostcommonlyusedanthropometricmeasuresareheight,weight,tricepsskinfoldthickness,elbowbreadth,andarmandheadcircumferences.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:HealthPromotionandMaintenance16.Ifa29-year-oldwomanweighs156pounds,andthenursedeterminesheridealbodyweighttobe120pounds,thenhowwouldthenurseclassifythewomansweight?a.Obeseb.Mildlyoverweightc.Sufferingfrommalnutritiond.WithinappropriaterangeofidealweightANS:ANURSINGTB.COMObesity,asaresultofcaloricexcess,referstoweightmorethan20%aboveidealbodyweight.Forthispatient,20%ofheridealbodyweightwouldbe24pounds,andgreaterthan20%ofherbodyweightwouldbeover144pounds.Therefore,havingaweightof156poundswouldbeconsideredobese.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance17.Howshouldthenurseperformatricepsskinfoldassessment?a.Afterpinchingtheskinandfat,thecalipersareverticallyappliedtothefatfold.b.Theskinandfatonthefrontofthepatientsarmaregentlypinched,andthenthecalipersareapplied.c.Afterapplyingthecalipers,thenursewaits3secondsbeforetakingareading.Afterrepeatingtheprocedurethreetimes,anaverageisrecorded.d.Thepatientisinstructedtostandwithhisorherbacktotheexaminerandarmsfoldedacrossthechest.Theskinontheforearmispinched.ANS:CWhileholdingtheskinfold,theleverofthecalipersisreleased.Thenursewaits3secondsandthentakesaPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)148STUVIA.COMreading.Thisprocedureshouldberepeatedthreetimes,andanaverageofthethreeskinfoldmeasurementsisthenrecorded.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance18.Inteachingapatienthowtodeterminetotalbodyfatathome,thenurseincludesinstructionstoobtainmeasurementsof:a.Heightandweight.b.Framesizeandweight.c.Waistandhipcircumferences.d.Mid-upperarmcircumferenceandarmspan.ANS:ABodymassindex,calculatedbyusingheightandweightmeasurements,isapracticalmarkerofoptimalweightforheightandanindicatorofobesity.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenanceNURSINGTB.COM19.Thenurseisevaluatingpatientsforobesity-relateddiseasesbycalculatingthewaist-to-hipratios.Whichoneofthesepatientswouldbeatincreasedrisk?a.29-year-oldwomanwhosewaistmeasures33inchesandhipsmeasure36inchesb.32-year-oldmanwhosewaistmeasures34inchesandhipsmeasure36inchesc.38-year-oldmanwhosewaistmeasures35inchesandhipsmeasure38inchesd.46-year-oldwomanwhosewaistmeasures30inchesandhipsmeasure38inchesANS:AThewaist-to-hipratioassessesbodyfatdistributionasanindicatorofhealthrisk.Awaist-to-hipratioof1.0orgreaterinmenor0.8orgreaterinwomenisindicativeofandroid(upperbodyobesity)andincreasingriskforobesity-relateddiseaseandearlydeath.The29-year-oldwomanhasawaist-to-hipratioof0.92,whichisgreaterthan0.8.The32-year-oldmanhasawaist-to-hipratioof0.94;the38-year-oldmanhasawaist-to-hipratioof0.92;the46-year-oldwomanhasawaist-to-hipratioof0.78.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance20.A50-year-oldwomanwithelevatedtotalcholesterolandtriglyceridelevelsisvisitingtheclinictofindoutaboutherlaboratoryresults.WhatwouldbeimportantforthenursetoincludeinpatientteachinginrelationtoPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)149STUVIA.COMthesetests?a.Therisksofundernutritionshouldbeincluded.b.Offermethodstoreducethestressinherlife.c.Provideinformationregardingadietlowinsaturatedfat.d.Thisconditionishereditary;shecandonothingtochangethelevels.ANS:CThepatientwithelevatedcholesterolandtriglyceridelevelsshouldbetaughtabouteatingahealthydietthatlimitstheintakeoffoodshighinsaturatedfatsortransfats.Reducingdietaryfatsispartofthetreatmentforthiscondition.Theotherresponsesarenotpertinenttohercondition.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance21.Inperforminganassessmentona49-year-oldwomanwhohasimbalancednutritionasaresultofdysphagia,whichdatawouldthenurseexpecttofind?a.Increaseinhairgrowthb.Inadequatenutrientfoodintakec.Weight10%to20%overideald.Sore,inflamedbuccalcavityNURSINGTB.COMANS:BDysphagia,orimpairedswallowing,interfereswithadequatenutrientintake.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance22.A21-year-oldwomanhasbeenonalow-proteinliquiddietforthepast2months.Shehashadadequateintakeofcaloriesandappearswellnourished.Afterfurtherassessment,whatwouldthenurseexpecttofind?a.Poorskinturgorb.Decreasedserumalbuminc.Increasedlymphocytecountd.TricepsskinfoldlessthanstandardPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)150STUVIA.COMANS:BKwashiorkor(proteinmalnutrition)isduetodietsthatmaybehighincaloriesbutcontainlittleornoprotein(e.g.,low-proteinliquiddiets,faddiets,andlong-termuseofdextrose-containingintravenousfluids).Theserumalbuminwouldbelessthan3.5g/dL.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance23.Thenurseisperforminganutritionalassessmentonan80-year-oldpatient.Thenurseknowsthatphysiologicchangescandirectlyaffectthenutritionalstatusoftheolderadultandinclude:a.Slowedgastrointestinalmotility.b.Hyperstimulationofthesalivaryglands.c.Increasedsensitivitytospicyandaromaticfoods.d.Decreasedgastrointestinalabsorptioncausingesophagealreflux.ANS:ANormalphysiologicchangesinagingadultsthataffectnutritionalstatusincludeslowedgastrointestinalmotility,decreasedgastrointestinalabsorptionN,dUiRmSiInNisGhTedB.oClfOaMctoryandtastesensitivity,decreasedsalivaproduction,decreasedvisualacuity,andpoordentition.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:HealthPromotionandMaintenance24.Whichoftheseinterventionsismostappropriatewhenthenurseisplanningnutritionalinterventionsforahealthy,active74-year-oldwoman?a.Decreasingtheamountofcarbohydratestopreventleanmusclecatabolismb.Increasingtheamountofsoyandtofuinherdiettopromotebonegrowthandreverseosteoporosisc.Decreasingthenumberofcaloriessheiseatingbecauseofthedecreaseinenergyrequirementsfromthelossofleanbodymassd.IncreasingthenumberofcaloriessheiseatingbecauseoftheincreasedenergyneedsoftheolderadultANS:CImportantnutritionalfeaturesoftheolderyearsareadecreaseinenergyrequirementsasaresultoflossofleanbodymass,themostmetabolicallyactivetissue,andanincreaseinfatmass.DIF:CognitiveLevel:Applying(Application)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)151STUVIA.COMMSC:ClientNeeds:HealthPromotionandMaintenance25.A16-year-oldgirlisbeingseenattheclinicforgastrointestinalcomplaintsandweightloss.Thenursedeterminesthatmanyofhercomplaintsmayberelatedtoerraticeatingpatterns,eatingpredominantlyfastfoods,andhighcaffeineintake.Inthissituation,whichismostappropriatewhencollectingcurrentdietaryintakeinformation?a.Schedulingatimefordirectobservationoftheadolescentduringmealsb.Askingthepatientfora24-hourdietrecall,andassumingittobereflectiveofatypicaldayforherc.Havingthepatientcompleteafooddiaryfor3days,including2weekdaysand1weekenddayd.UsingthefoodfrequencyquestionnairetoidentifytheamountofintakeofspecificfoodsANS:CFooddiariesrequiretheindividualtowritedowneverythingconsumedforacertaintimeperiod.Becauseoftheerraticeatingpatternsofthisindividual,assessingdietaryintakeoverafewdayswouldproducemoreaccurateinformationregardingeatingpatterns.Directobservationisbestusedwithyoungchildrenorolderadults.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance26.ThenurseispreparingtomeasurefatandNleUanRbSoINdGyTmBa.sCsOaMndbonemineraldensity.Whichtoolisappropriate?a.Measuringtapeb.Skinfoldcalipersc.Bioelectricalimpedanceanalysis(BIA)d.Dual-energyx-rayabsorptiometry(DEXA)ANS:DDEXAmeasuresbothbonemineraldensityandfatandleanbodymass.BIAmeasuresfatandleanbodymassbutnotbonemineraldensity.Ameasuringtapemeasuresdistanceorlength,andskinfoldcalipersareusedtodetermineskinfoldthickness.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance27.Whichoftheseconditionsisduetoaninadequateintakeofbothproteinandcalories?a.ObesityPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)152STUVIA.COMb.Bulimiac.Marasmusd.KwashiorkorANS:CMarasmus,protein-caloriemalnutrition,isduetoaninadequateintakeofproteinandcaloriesorprolongedstarvation.Obesityisduetocaloricexcess;bulimiaisaneatingdisorder.Kwashiorkorisproteinmalnutrition.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation28.Duringanassessmentofapatientwhohasbeenhomelessforseveralyears,thenursenoticesthathistongueismagentaincolor,whichisanindicationofadeficiencyinwhatmineraland/orvitamin?a.Ironb.Riboflavinc.VitaminDandcalciumd.VitaminCNURSINGTB.COMANS:BMagentatongueisasignofriboflavindeficiency.Incontrast,apaletongueisprobablyattributabletoirondeficiency.VitaminDandcalciumdeficienciescauseosteomalaciainadults,andavitaminCdeficiencycausesscorbuticgums.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation29.A50-year-oldpatienthasbeenbroughttotheemergencydepartmentafterahousematefoundthatthepatientcouldnotgetoutofbedalone.Hehaslivedinagrouphomeforyearsbutforseveralmonthshasnotparticipatedintheactivitiesandhasstayedinhisroom.Thenurseassessesforsignsofundernutrition,andanx-raystudyrevealsthathehasosteomalacia,whichisadeficiencyof:a.Iron.b.Riboflavin.c.VitaminDandcalcium.d.VitaminC.ANS:CPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)153STUVIA.COMOsteomalaciaresultsfromadeficiencyofvitaminDandcalciuminadults.Irondeficiencywouldresultinanemia,riboflavindeficiencywouldresultinmagentatongue,andvitaminCdeficiencywouldresultinscurvyDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation30.Anolderadultpatientinanursinghomehasbeenreceivingtubefeedingsforseveralmonths.Duringanoralexamination,thenursenotesthatpatientsgumsareswollen,ulcerated,andbleedinginsomeareas.Thenursesuspectsthatthepatienthaswhatcondition?a.Ricketsb.VitaminAdeficiencyc.Linoleic-aciddeficiencyd.VitaminCdeficiencyANS:DVitaminCdeficiencycausesswollen,ulcerated,andbleedinggums,knownasscorbuticgums.RicketsisaconditionrelatedtovitaminDandcalciumdeficienciesininfantsandchildren.Linoleic-aciddeficiencycauseseczematousskin.VitaminAdeficiencycausesBitotspotsandvisualproblems.DIF:CognitiveLevel:Applying(Application)NURSINGTB.COMMSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation31.Thenurseisassessingthebodyweightasapercentageofidealbodyweightonanadolescentpatientwhowasadmittedforsuspectedanorexianervosa.Thepatientsusualweightwas125pounds,buttodaysheweighs98pounds.Thenursecalculatesthepatientsidealbodyweightandconcludesthatthepatientis:a.Experiencingmildmalnutrition.b.Experiencingmoderatemalnutrition.c.Experiencingseveremalnutrition.d.Stillwithinexpectedparameterswithhercurrentweight.ANS:BBydividinghercurrentweightbyherusualweightandthenmultiplyingby100,apercentageof78.4%isobtained,whichmeansthathercurrentweightis78.4%ofheridealbodyweight.Acurrentweightof80%to90%ofidealweightsuggestsmildmalnutrition;acurrentweightof70%to80%ofidealweightsuggestsmoderatemalnutrition;acurrentweightoflessthan70%ofidealweightsuggestsseveremalnutrition.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)154STUVIA.COMMULTIPLERESPONSE1.Thenurseisassessingapatientwhoisobeseforsignsofmetabolicsyndrome.Thisconditionisdiagnosedwhenthreeormorecertainriskfactorsarepresent.Whichoftheseassessmentfindingsareriskfactorsformetabolicsyndrome?Selectallthatapply.a.Fastingplasmaglucoselevellessthan100mg/dLb.Fastingplasmaglucoselevelgreaterthanorequalto110mg/dLc.Bloodpressurereadingof140/90mmHgd.Bloodpressurereadingof110/80mmHge.Triglyceridelevelof120mg/dLANS:B,CMetabolicsyndromeisdiagnosedwhenthreeormoreofthefollowingriskfactorsarepresent:(1)fastingplasmaglucoselevelgreaterthanorequalto100mg/dL;(2)bloodpressuregreaterthanorequalto130/85mmHg;(3)waistcircumferencegreaterthanorequalto40inchesformenand35inchesforwomen;(4)high-densitylipoproteincholesterollessthan40inmenandlessthan50inwomen;and(5)triglyceridelevelsgreaterthanorequalto150mg/dL(ATPIII,2001).DIF:CognitiveLevel:Applying(Application)NURSINGTB.COMMSC:ClientNeeds:HealthPromotionandMaintenanceSHORTANSWER1.Apatienthasbeenunabletoeatsolidfoodfor2weeksandisintheclinictodaycomplainingofweakness,tiredness,andhairloss.Thepatientstatesthatherusualweightis175pounds,buttodaysheweighs161pounds.Whatisherrecentweightchangepercentage?Tocalculaterecentweightchangepercentage,usethisformula:Usualweightcurrentweight100usualweightANS:8%175161=14pounds14175=0.080.08100=8%DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenancePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)155STUVIA.COMChapter13:Skin,Hair,andNailsMULTIPLECHOICE1.Thenurseeducatorispreparinganeducationmoduleforthenursingstaffontheepidermallayerofskin.Whichofthesestatementswouldbeincludedinthemodule?Theepidermisis:a.Highlyvascular.b.Thickandtough.c.Thinandnonstratified.d.Replacedevery4weeks.ANS:DTheepidermisisthinyettough,replacedevery4weeks,avascular,andstratifiedintoseveralzones.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:General2.Thenurseeducatorispreparinganeducationmoduleforthenursingstaffonthedermislayerofskin.Whichofthesestatementswouldbeincludedinthemodule?Thedermis:NURSINGTB.COMa.Containsmostlyfatcells.b.Consistsmostlyofkeratin.c.Isreplacedevery4weeks.d.Containssensoryreceptors.ANS:DThedermisconsistsmostlyofcollagen,hasresilientelastictissuethatallowstheskintostretch,andcontainsnerves,sensoryreceptors,bloodvessels,andlymphaticvessels.Itisnotreplacedevery4weeks.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:General3.Thenurseisexaminingapatientwhotellsthenurse,Isuresweatalot,especiallyonmyfaceandfeetbutitdoesnthaveanodor.Thenurseknowsthatthisconditioncouldberelatedto:a.Eccrineglands.b.Apocrineglands.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)156STUVIA.COMc.Disorderofthestratumcorneum.d.Disorderofthestratumgerminativum.ANS:ATheeccrineglandsarecoiledtubulesthatdirectlyopenontotheskinsurfaceandproduceadilutesalinesolutioncalledsweat.Apocrineglandsareprimarilylocatedintheaxillae,anogenitalarea,nipples,andnavalareaandmixwithbacterialfloratoproducethecharacteristicmuskybodyodor.Thepatientsstatementisnotrelatedtodisordersofthestratumcorneumorthestratumgerminativum.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation4.Anewborninfantisintheclinicforawell-babycheckup.Thenurseobservestheinfantforthepossibilityoffluidlossbecauseofwhichofthesefactors?a.Subcutaneousfatdepositsarehighinthenewborn.b.Sebaceousglandsareoverproductiveinthenewborn.c.Thenewbornsskinismorepermeablethanthatoftheadult.d.Theamountofvernixcaseosadramaticallyrisesinthenewborn.NURSINGTB.COMANS:CThenewbornsskinisthin,smooth,andelasticandisrelativelymorepermeablethanthatoftheadult;consequently,theinfantisatgreaterriskforfluidloss.Thesubcutaneouslayerintheinfantisinefficient,notthick,andthesebaceousglandsarepresentbutdecreaseinsizeandproduction.Vernixcaseosaisnotproducedafterbirth.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance5.Thenurseisbathingan80-year-oldmanandnoticesthathisskiniswrinkled,thin,lax,anddry.Thisfindingwouldberelatedtowhichfactorintheolderadult?a.Increasedvascularityoftheskinb.Increasednumbersofsweatandsebaceousglandsc.Anincreaseinelastinandadecreaseinsubcutaneousfatd.AnincreasedlossofelastinandadecreaseinsubcutaneousfatANS:DPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)157STUVIA.COMAnaccumulationoffactorsplacetheagingpersonatriskforskindiseaseandbreakdown:thethinningoftheskin,adecreaseinvascularityandnutrients,thelossofprotectivecushioningofthesubcutaneouslayer,alifetimeofenvironmentaltraumatoskin,thesocialchangesofaging,aincreasinglysedentarylifestyle,andthechanceofimmobility.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance6.Duringtheagingprocess,thehaircanlookgrayorwhiteandbegintofeelthinandfine.Thenurseknowsthatthisoccursbecauseofadecreaseinthenumberoffunctioning:a.Metrocytes.b.Fungacytes.c.Phagocytes.d.Melanocytes.ANS:DIntheaginghairmatrix,thenumberoffunctioningmelanocytesdecreases;asaresult,thehairlooksgrayorwhiteandfeelsthinandfine.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)NURSINGTB.COMMSC:ClientNeeds:HealthPromotionandMaintenance7.Duringanexamination,thenursefindsthatapatienthasexcessivedrynessoftheskin.Thebesttermtodescribethisconditionis:a.Xerosis.b.Pruritus.c.Alopecia.d.Seborrhea.ANS:AXerosisisthetermusedtodescribeskinthatisexcessivelydry.Pruritusreferstoitching,alopeciareferstohailoss,andseborrheareferstooilyskin.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:HealthPromotionandMaintenance8.A22-year-oldwomancomestotheclinicbecauseofseveresunburnandstates,Iwasoutinthesunforjustcoupleofminutes.Thenursebeginsamedicationreviewwithher,payingspecialattentiontowhichmedicationclass?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)158STUVIA.COMa.Nonsteroidalantiinflammatorydrugsforpainb.Tetracyclinesforacnec.Protonpumpinhibitorsforheartburnd.ThyroidreplacementhormoneforhypothyroidismANS:BDrugsthatmayincreasesunlightsensitivityandgiveaburnresponseincludesulfonamides,thiazidediuretics,oralhypoglycemicagents,andtetracycline.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance9.AwomanisleavingonatriptoHawaiiandhascomeinforacheckup.Duringtheexaminationthenurselearnsthatshehasdiabetesandtakesoralhypoglycemicagents.Thepatientneedstobeconcernedaboutwhichpossibleeffectofhermedications?a.Increasedpossibilityofbruisingb.SkinsensitivityasaresultofexposuretosaltwaterNURSINGTB.COMc.Lackofavailabilityofglucose-monitoringsuppliesd.ImportanceofsunscreenandavoidingdirectsunlightANS:DDrugsthatmayincreasesunlightsensitivityandgiveaburnresponseincludesulfonamides,thiazidediuretics,oralhypoglycemicagents,andtetracycline.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential10.A13-year-oldgirlisinterestedinobtaininginformationaboutthecauseofheracne.Thenurseshouldsharewithherthatacne:a.Iscontagious.b.Hasnoknowncause.c.Iscausedbyincreasedsebumproduction.d.Hasbeenfoundtoberelatedtopoorhygiene.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)159STUVIA.COMANS:CApproximately90%ofmalesand80%offemaleswilldevelopacne;causesareincreasedsebumproductionandepithelialcellsthatdonotdesquamatenormally.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance11.A75-year-oldwomanwhohasahistoryofdiabetesandperipheralvasculardiseasehasbeentryingtoremoveacornonthebottomofherfootwithapairofscissors.Thenursewillencouragehertostoptryingtoremovethecornwithscissorsbecause:a.Thewomancouldbeatincreasedriskforinfectionandlesionsbecauseofherchronicdisease.b.Withherdiabetes,shehasincreasedcirculationtoherfoot,anditcouldcauseseverebleeding.c.Sheis75yearsoldandisunabletosee;consequently,sheplacesherselfatgreaterriskforself-injurywiththescissors.d.Withherperipheralvasculardisease,herrangeofmotionislimitedandshemaynotbeabletoreachthecornsafely.ANS:AApersonalhistoryofdiabetesandperipheralvasculardiseaseincreasesapersonsriskforskinlesionsinthefeetorankles.ThepatientneedstoseekaprofNeUssRioSnINalGfTorBa.CssOisMtancewithcornremoval.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential12.Thenursekeepsinmindthatathoroughskinassessmentisextremelyimportantbecausetheskinholdsinformationaboutapersons:a.Supportsystems.b.Circulatorystatus.c.Socioeconomicstatus.d.Psychologicalwellness.ANS:BTheskinholdsinformationaboutthebodyscirculation,nutritionalstatus,andsignsofsystemicdiseases,aswellastopicaldataontheintegumentarysystemitself.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCarePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)160STUVIA.COM13.Apatientcomesinforaphysicalexaminationandcomplainsoffreezingtodeathwhilewaitingforherexamination.Thenursenotesthatherskinispaleandcoolandattributesthisfindingto:a.Venouspooling.b.Peripheralvasodilation.c.Peripheralvasoconstriction.d.Decreasedarterialperfusion.ANS:CAchillyorair-conditionedenvironmentcausesvasoconstriction,whichresultsinfalsepallorandcoolness.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:BasicCareandComfort14.Apatientcomestotheclinicandtellsthenursethathehasbeenconfinedtohisreclinerchairforapproximately3dayswithhisfeetdownandheasksthenursetoevaluatehisfeet.Duringtheassessment,thenursemightexpecttofind:a.Pallorb.Coolnessc.Distendedveinsd.ProlongedcapillaryfillingtimeNURSINGTB.COMANS:CKeepingthefeetinadependentpositioncausesvenouspooling,resultinginredness,warmth,anddistendedveins.Prolongedelevationwouldcausepallorandcoolness.Immobilizationorprolongedinactivitywouldcauseprolongedcapillaryfillingtime.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation15.Apatientisespeciallyworriedaboutanareaofskinonherfeetthathasturnedwhite.Thehealthcareproviderhastoldherthatherconditionisvitiligo.Thenurseexplainstoherthatvitiligois:a.Causedbyanexcessofmelaninpigmentb.Causedbyanexcessofapocrineglandsinherfeetc.CausedbythecompleteabsenceofmelaninpigmentPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)161STUVIA.COMd.RelatedtoimpetigoandcanbetreatedwithanointmentANS:CVitiligoisthecompleteabsenceofmelaninpigmentinpatchyareasofwhiteorlightskinontheface,neck,hands,feet,bodyfolds,andaroundorificesotherwise,thedepigmentedskinisnormal.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation16.Apatienttellsthenursethathehasnoticedthatoneofhismoleshasstartedtoburnandbleed.Whenassessinghisskin,thenursepaysspecialattentiontothedangersignsforpigmentedlesionsandisconcernedwithwhichadditionalfinding?a.Colorvariationb.Borderregularityc.Symmetryoflesionsd.Diameteroflessthan6mmANS:AAbnormalcharacteristicsofpigmentedlesionsNaUrReSsuINmGmTaBri.zCeOdMinthemnemonicABCD:asymmetryofpigmentedlesion,borderirregularity,colorvariation,anddiametergreaterthan6mm.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance17.Apatientcomestotheclinicandstatesthathehasnoticedthathisskinisredderthannormal.Thenurseunderstandsthatthisconditionisduetohyperemiaandknowsthatitcanbecausedby:a.Decreasedamountsofbilirubininthebloodb.Excessbloodintheunderlyingbloodvesselsc.Decreasedperfusiontothesurroundingtissuesd.ExcessbloodinthedilatedsuperficialcapillariesANS:DErythemaisanintenserednessoftheskincausedbyexcessblood(hyperemia)inthedilatedsuperficialcapillaries.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)162STUVIA.COM18.Duringaskinassessment,thenursenoticesthataMexican-Americanpatienthasskinthatisyellowish-brown;however,theskinonthehardandsoftpalateispinkandthepatientssclerasarenotyellow.Fromthisfinding,thenursecouldprobablyruleout:a.Pallorb.Jaundicec.Cyanosisd.IrondeficiencyANS:BJaundiceisexhibitedbyayellowcolor,whichindicatesrisinglevelsofbilirubinintheblood.Jaundiceisfirstnoticedinthejunctionofthehardandsoftpalateinthemouthandinthescleras.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation19.Ablackpatientisintheintensivecareunitbecauseofimpendingshockafteranaccident.Thenurseexpectstofindwhatcharacteristicsinthispatientsskin?a.Ruddyblue.b.Generalizedpallor.c.Ashen,gray,ordull.d.Patchyareasofpallor.NURSINGTB.COMANS:CPallorattributabletoshock,withdecreasedperfusionandvasoconstriction,inblack-skinnedpeoplewillcausetheskintoappearashen,gray,ordull.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation20.Anolderadultwomanisbroughttotheemergencydepartmentafterbeingfoundlyingonthekitchenfloorfor2days;sheisextremelydehydrated.Whatwouldthenurseexpecttoseeduringtheexamination?a.Smoothmucousmembranesandlipsb.Drymucousmembranesandcrackedlipsc.PalemucousmembranesPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)163STUVIA.COMd.WhitepatchesonthemucousmembranesANS:BWithdehydration,mucousmembranesappeardryandthelipslookparchedandcracked.Theotherresponsesarenotfoundindehydration.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation21.A42-year-oldwomancomplainsthatshehasnoticedseveralsmall,slightlyraised,brightreddotsonherchest.Onexamination,thenurseexpectsthatthespotsareprobably:a.Anasarca.b.Scleroderma.c.Senileangiomas.d.Latentmyeloma.ANS:CCherry(senile)angiomasaresmall,smooth,slightlyraisedbrightreddotsthatcommonlyappearonthetrunkofadultsover30yearsold.NURSINGTB.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation22.A65-year-oldmanwithemphysemaandbronchitishascometotheclinicforafollow-upappointment.Onassessment,thenursemightexpecttoseewhichfinding?a.Anasarcab.Sclerodermac.Pedalerythemad.ClubbingofthenailsANS:DClubbingofthenailsoccurswithcongenitalcyanoticheartdiseaseandneoplasticandpulmonarydiseases.Theotherresponsesareassessmentfindingsnotassociatedwithpulmonarydiseases.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation23.AnewborninfanthasDownsyndrome.Duringtheskinassessment,thenursenoticesatransientmottlingPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)164STUVIA.COMinthetrunkandextremitiesinresponsetothecooltemperatureintheexaminationroom.Theinfantsmotheralsonoticesthemottlingandaskswhatitis.Thenurseknowsthatthismottlingiscalled:a.Cafaulait.b.Carotenemia.c.Acrocyanosis.d.Cutismarmorata.ANS:DPersistentorpronouncedcutismarmorataoccurswithinfantsbornwithDownsyndromeorthosebornprematurelyandisatransientmottlinginthetrunkandextremitiesinresponsetocoolroomtemperatures.Acafaulaitspotisalargeroundorovalpatchoflight-brownpigmentation.Carotenemiaproducesayellow-orangecolorinlight-skinnedpersons.Acrocyanosisisabluishcoloraroundthelips,handsandfingernails,andfeetandtoenails.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation24.A35-year-oldpregnantwomancomestotheclinicforamonthlyappointment.Duringtheassessment,thenursenoticesthatshehasabrownpatchofhyperpigmentationonherface.Thenursecontinuestheskinassessmentawarethatanotherfindingmaybe:NURSINGTB.COMa.Keratoses.b.Xerosis.c.Chloasma.d.Acrochordons.ANS:CInpregnancy,skinchangescanincludestriae,lineanigra(abrownish-blacklinedownthemidline),chloasma(brownpatchesofhyperpigmentation),andvascularspiders.Keratosesareraised,thickenedareasofpigmentationthatlookcrusted,scaly,andwarty.Xerosisisdryskin.Acrochordons,orskintags,occurmoreoftenintheagingadult.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation25.Amanhascomeintotheclinicforaskinassessmentbecauseheisworriedhemighthaveskincancer.Duringtheskinassessmentthenursenoticesseveralareasofpigmentationthatlookgreasy,dark,andstuckonhisskin.Whichisthebestprediction?a.Senilelentigines,whichdonotbecomecancerousPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)165STUVIA.COMb.Actinickeratoses,whichareprecursorstobasalcellcarcinomac.Acrochordons,whichareprecursorstosquamouscellcarcinomad.Seborrheickeratoses,whichdonotbecomecancerousANS:DSeborrheickeratosesappearlikedark,greasy,stuck-onlesionsthatprimarilydeveloponthetrunk.Theselesionsdonotbecomecancerous.Senilelentiginesarecommonlycalledliverspotsandarenotprecancerous.Actinic(senileorsolar)keratosesarelesionsthatarered-tanscalyplaquesthatincreaseovertheyearstobecomeraisedandroughened.Theymayhaveasilvery-whitescaleadherenttotheplaque.Theyoccuronsun-exposedsurfacesandaredirectlyrelatedtosunexposure.Theyarepremalignantandmaydevelopintosquamouscellcarcinoma.Acrochordonsareskintagsandarenotprecancerous.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation26.A70-year-oldwomanwholovestogardenhassmall,flat,brownmaculesoverherarmsandhands.Sheasks,Whatcausestheseliverspots?Thenursetellsher,Theyare:a.Signsofdecreasedhematocritrelatedtoanemia.b.Duetothedestructionofmelanininyourskinfromexposuretothesun.NURSINGTB.COMc.Clustersofmelanocytesthatappearafterextensivesunexposure.d.Areasofhyperpigmentationrelatedtodecreasedperfusionandvasoconstriction.ANS:CLiverspots,orsenilelentigines,areclustersofmelanocytesthatappearontheforearmsanddorsaofthehandsafterextensivesunexposure.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation27.Thenursenoticesthatapatienthasasolid,elevated,circumscribedlesionthatislessthan1cmindiameter.Whendocumentingthisfinding,thenursereportsthisasa:a.Bulla.b.Wheal.c.Nodule.d.Papule.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)166STUVIA.COMANS:DApapuleissomethingonecanfeel,issolid,elevated,circumscribed,lessthan1cmindiameter,andisduetosuperficialthickeningintheepidermis.Abullaislargerthan1cm,superficial,andthinwalled.Awhealissuperficial,raised,transient,erythematous,andirregularinshapeattributabletoedema.Anoduleissolid,elevated,hardorsoft,andlargerthan1cm.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation28.Thenursejustnotedfromthemedicalrecordthatthepatienthasalesionthatisconfluentinnature.Onexamination,thenurseexpectstofind:a.Lesionsthatruntogether.b.Annularlesionsthathavegrowntogether.c.Lesionsarrangedinalinealonganerveroute.d.Lesionsthataregroupedorclusteredtogether.ANS:AConfluentlesions(aswithurticaria[hives])runtogether.Groupedlesionsareclusteredtogether.Annularlesionsarecircularinnature.ZosteriformlesioNnUsRaSreINaGrrTanBg.CedOaMlonganerveroute.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation29.Apatienthashadaterribleitchforseveralmonthsthathehasbeencontinuouslyscratching.Onexamination,thenursemightexpecttofind:a.Akeloid.b.Afissure.c.Keratosis.d.Lichenification.ANS:DLichenificationresultsfromprolonged,intensescratchingthateventuallythickenstheskinandproducestightlypackedsetsofpapules.Akeloidisahypertrophicscar.Afissureisalinearcrackwithabruptedges,whichextendsintothedermis;itcanbedryormoist.Keratosesarelesionsthatareraised,thickenedareasofpigmentationthatappearcrusted,scaly,andwarty.DIF:CognitiveLevel:Understanding(Comprehension)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)167STUVIA.COMMSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation30.Aphysicianhasdiagnosedapatientwithpurpura.Afterleavingtheroom,anursingstudentasksthenursewhatthephysiciansawthatledtothatdiagnosis.Thenurseshouldsay,Thephysicianisreferringtothe:a.Bluedilationofbloodvesselsinastar-shapedlinearpatternonthelegs.b.Fieryred,star-shapedmarkingonthecheekthathasasolidcircularcenter.c.Confluentandextensivepatchofpetechiaeandecchymosesonthefeet.d.Tinyareasofhemorrhagethatarelessthan2mm,round,discrete,anddarkredincolor.ANS:CPurpuraisaconfluentandextensivepatchofpetechiaeandecchymosesandaflatmacularhemorrhageobservedingeneralizeddisorderssuchasthrombocytopeniaandscurvy.Thebluedilationofbloodvesselsinastar-shapedlinearpatternonthelegsdescribesavenouslake.Thefieryred,star-shapedmarkingonthecheekthathasasolidcircularcenterdescribesaspiderorstarangioma.Thetinyareasofhemorrhagethatarelessthan2mm,round,discrete,anddarkredincolordescribespetechiae.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation31.Amotherhasnoticedthatherson,whohasbeentoanewbabysitter,hassomeblistersandscabsonhisfaceandbuttocks.Onexamination,thenurseNnoUtiRcSeIsNmGoTisBt.,CthOiMn-roofedvesicleswithathinerythematousbaseandsuspects:a.Eczema.b.Impetigo.c.Herpeszoster.d.Diaperdermatitis.ANS:BImpetigoismoist,thin-roofedvesicleswithathinerythematousbaseandisacontagiousbacterialinfectionoftheskinandmostcommonininfantsandchildren.Eczemaischaracterizedbyerythematouspapulesandvesicleswithweeping,oozing,andcrusts.Herpeszoster(i.e.,chickenpoxorvaricella)ischaracterizedbysmall,tightvesiclesthatareshinywithanerythematousbase.Diaperdermatitisischaracterizedbyred,moistmaculopapularpatcheswithpoorlydefinedborders.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation32.Thenursenoticesthataschool-agedchildhasbluish-white,red-basedspotsinhermouththatareelevatedapproximately1to3mm.Whatothersignswouldthenurseexpecttofindinthispatient?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)168STUVIA.COMa.Pink,papularrashonthefaceandneckb.Pruriticvesiclesoverhertrunkandneckc.Hyperpigmentationonthechest,abdomen,andbackofthearmsd.Red-purple,maculopapular,blotchyrashbehindtheearsandonthefaceANS:DWithmeasles(rubeola),theexaminerassessesared-purple,blotchyrashonthethirdorfourthdayofillnessthatappearsfirstbehindtheears,spreadsovertheface,andthenovertheneck,trunk,arms,andlegs.Therashappearscopperyanddoesnotblanch.Thebluish-white,red-basedspotsinthemouthareknownasKoplikspots.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation33.Thenurseisassessingtheskinofapatientwhohasacquiredimmunodeficiencysyndrome(AIDS)andnoticesmultiplepatchlikelesionsonthetempleandbeardareathatarefaintpinkincolor.Thenurserecognizestheselesionsas:a.Measles(rubeola).b.Kaposissarcoma.c.Angiomas.d.Herpeszoster.NURSINGTB.COMANS:BKaposissarcomaisavasculartumorthat,intheearlystages,appearsasmultiple,patchlike,faintpinklesionsoverthepatientstempleandbeardareas.Measlesischaracterizedbyared-purplemaculopapularblotchyrashthatappearsonthethirdorfourthdayofillness.Therashisfirstobservedbehindtheears,spreadsovertheface,andthenspreadsovertheneck,trunk,arms,andlegs.Cherry(senile)angiomasaresmall(1to5mm),smooth,slightlyraisedbrightreddotsthatcommonlyappearonthetrunkinalladultsover30yearsold.Herpeszostercausesvesiclesupto1cminsizethatareelevatedwithacavitycontainingclearfluid.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation34.A45-year-oldfarmercomesinforaskinevaluationandcomplainsofhairlossonhishead.Hishairseemstobebreakingoffinpatches,andhenoticessomescalingonhishead.Thenursebeginstheexaminationsuspecting:a.Tineacapitis.b.Folliculitis.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)169STUVIA.COMc.Toxicalopecia.d.Seborrheicdermatitis.ANS:ATineacapitisisroundedpatchyhairlossonthescalp,leavingbroken-offhairs,pustules,andscalesontheskin,andiscausedbyafungalinfection.LesionsarefluorescentunderaWoodlightandareusuallyobservedinchildrenandfarmers;tineacapitisishighlycontagious.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation35.Amotherbringsherchildintotheclinicforanexaminationofthescalpandhair.Shestatesthatthechildhasdevelopedirregularlyshapedpatcheswithbroken-off,stublikehairinsomeplaces;sheisworriedthatthisconditioncouldbesomeformofprematurebaldness.Thenursetellsherthatitis:a.Folliculitisthatcanbetreatedwithanantibiotic.b.Traumaticalopeciathatcanbetreatedwithantifungalmedications.c.Tineacapitisthatishighlycontagiousandneedsimmediateattention.d.Trichotillomania;herchildprobabNlyUhRaSsIaNhGaTbBit.CoOfaMbsentmindedlytwirlingherhair.ANS:DTrichotillomania,self-inducedhairloss,isusuallyduetohabit.Itformsirregularlyshapedpatcheswithbroken-off,stublikehairsofvaryinglengths.Apersonisnevercompletelybald.Itoccursasachildabsentmindedlyrubsortwirlstheareawhilefallingasleep,reading,orwatchingtelevision.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation36.Thenursehasdiscovereddecreasedskinturgorinapatientandknowsthatthisfindingisexpectedinwhichcondition?a.Severeobesityb.Childhoodgrowthspurtsc.Severedehydrationd.ConnectivetissuedisorderssuchassclerodermaANS:CPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)170STUVIA.COMDecreasedskinturgorisassociatedwithseveredehydrationorextremeweightloss.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation37.Whileperforminganassessmentofa65-year-oldmanwithahistoryofhypertensionandcoronaryarterydisease,thenursenoticesthepresenceofbilateralpittingedemainthelowerlegs.Theskinispuffyandtightbutnormalincolor.Noincreasedrednessortendernessisobservedoverhislowerlegs,andtheperipheralpulsesareequalandstrong.Inthissituation,thenursesuspectsthatthelikelycauseoftheedemaiswhichcondition?a.Heartfailureb.Venousthrombosisc.Localinflammationd.BlockageoflymphaticdrainageANS:ABilateraledemaoredemathatisgeneralizedovertheentirebodyiscausedbyacentralproblemsuchasheartfailureorkidneyfailure.Unilateraledemausuallyhasalocalorperipheralcause.DIF:CognitiveLevel:Analyzing(Analysis)NURSINGTB.COMMSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation38.A40-year-oldwomanreportsachangeinmolesize,accompaniedbycolorchanges,itching,burning,andbleedingoverthepastmonth.Shehasadarkcomplexionandhasnofamilyhistoryofskincancer,butshehashadmanyblisteringsunburnsinthepast.Thenursewould:a.Tellthepatienttowatchthelesionandreportbackin2months.b.Referthepatientbecauseofthesuggestionofmelanomaonthebasisofhersymptoms.c.Askadditionalquestionsregardingenvironmentalirritantsthatmayhavecausedthiscondition.d.Tellthepatientthatthesesignssuggestacompoundnevus,whichisverycommoninyoungtomiddle-agedadults.ANS:BTheABCDdangersignsofmelanomaareasymmetry,borderirregularity,colorvariation,anddiameter.Inaddition,individualsmayreportachangeinsize,thedevelopmentofitching,burning,andbleeding,oranew-pigmentedlesion.Anyoneofthesesignsraisesthesuggestionofmelanomaandwarrantsimmediatereferral.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)171STUVIA.COM39.Thenurseisassessingforclubbingofthefingernailsandexpectstofind:a.Nailbasesthatarefirmandslightlytender.b.Curvednailswithaconvexprofileandridgesacrossthenails.c.Nailbasesthatfeelspongywithanangleofthenailbaseof150degrees.d.Nailbaseswithanangleof180degreesorgreaterandnailbasesthatfeelspongy.ANS:DThenormalnailisfirmatitsbaseandhasanangleof160degrees.Inclubbing,theanglestraightensto180degreesorgreaterandthenailbasefeelsspongy.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation40.Thenurseisassessingapatientwhohasliverdiseaseforjaundice.Whichoftheseassessmentfindingsisindicativeoftruejaundice?a.Yellowpatchesintheoutersclerab.YellowcolorofthesclerathatexteNnUdRsSuIpNtGoTthBe.CirOisMc.Skinthatappearsyellowwhenexaminedunderlowlightd.YellowdepositsonthepalmsandsolesofthefeetwherejaundicefirstappearsANS:BTheyellowscleraofjaundiceextendsuptotheedgeoftheiris.Callusesonthepalmsandsolesofthefeetoftenappearyellowbutarenotclassifiedasjaundice.Scleraljaundiceshouldnotbeconfusedwiththenormalyellowsubconjunctivalfattydepositsthatarecommonintheouterscleraofdark-skinnedpersons.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation41.Thenurseisassessingforinflammationinadark-skinnedperson.Whichtechniqueisthebest?a.Assessingtheskinforcyanosisandswellingb.Assessingtheoralmucosaforgeneralizederythemac.Palpatingtheskinforedemaandincreasedwarmthd.PalpatingfortendernessandlocalareasofecchymosisPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)172STUVIA.COMANS:CBecauseinflammationcannotbeseenindark-skinnedpersons,palpatingtheskinforincreasedwarmth,fortautortightlypulledsurfacesthatmaybeindicativeofedema,andforahardeningofdeeptissuesorbloodvesselsisoftennecessary.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation42.Afewdaysafterasummerhikingtrip,a25-year-oldmancomestotheclinicwitharash.Onexamination,thenursenotesthattherashisred,macular,withabullseyepatternacrosshismidriffandbehindhisknees.Thenursesuspects:a.Rubeola.b.Lymedisease.c.Allergytomosquitobites.d.RockyMountainspottedfever.ANS:BLymediseaseoccursinpeoplewhospendtimNeUoRutSdIoNoGrsTiBn.CMOaMythroughSeptember.Thefirstdiseasestateexhibitsthedistinctivebullseyeandaredmacularorpapularrashthatradiatesfromthesiteofthetickbitewithsomecentralclearing.Therashspreads5cmorlarger,andisusuallyintheaxilla,midriff,inguinal,orbehindtheknee,withregionallymphadenopathy.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation43.A52-year-oldwomanhasapapuleonhernosethathasrounded,pearlybordersandacentralredulcer.Shesaidshefirstnoticeditseveralmonthsagoandthatithasslowlygrownlarger.Thenursesuspectswhichcondition?a.Acneb.Basalcellcarcinomac.Melanomad.SquamouscellcarcinomaANS:BBasalcellcarcinomausuallystartsasaskin-coloredpapulethatdevelopsrounded,pearlyborderswithacentralredulcer.Itisthemostcommonformofskincancerandgrowsslowly.Thisdescriptiondoesnotfitacnelesions.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)173STUVIA.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation44.Afatherbringsinhis2-month-oldinfanttotheclinicbecausetheinfanthashaddiarrheaforthelast24hours.Hesayshisbabyhasnotbeenabletokeepanyformuladownandthatthediarrheahasbeenatleastevery2hours.Thenursesuspectsdehydration.Thenurseshouldtestskinmobilityandturgorovertheinfants:a.Sternum.b.Forehead.c.Forearms.d.Abdomen.ANS:DMobilityandturgoraretestedovertheabdomeninaninfant.Poorturgor,ortenting,indicatesdehydrationormalnutrition.Theothersitesarenotappropriateforcheckingskinturgorinaninfant.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation45.Asemiconsciouswomanisbroughttotheemergencydepartmentaftershewasfoundonthefloorinherkitchen.Herface,nailbeds,lips,andoralmucNoUsaRaSrIeNaGbTrBig.ChOtcMherry-redcolor.Thenursesuspectsthatthiscoloringisdueto:a.Polycythemia.b.Carbonmonoxidepoisoning.c.Carotenemia.d.Uremia.ANS:BAbrightcherry-redcoloringintheface,uppertorso,nailbeds,lips,andoralmucosaappearsincasesofcarbonmonoxidepoisoning.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation46.Apatienthasbeenadmittedforseverepsoriasis.Thenurseexpectstoseewhatfindinginthepatientsfingernails?a.SplinterhemorrhagesPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)174STUVIA.COMb.Paronychiac.Pittingd.BeaulinesANS:CSharplydefinedpittingandcrumblingofthenails,eachwithdistaldetachmentcharacterizepittingnailsandareassociatedwithpsoriasis.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationMULTIPLERESPONSE1.Thenurseispreparingforacertificationcourseinskincareandneedstobefamiliarwiththevariouslesionsthatmaybeidentifiedonassessmentoftheskin.Whichofthefollowingdefinitionsarecorrect?Selectallthatapply.a.Petechiae:Tinypunctatehemorrhages,1to3mm,roundanddiscrete,darkred,purple,orbrownincolorb.Bulla:Elevated,circumscribedlesionfilledwithturbidfluid(pus)NURSINGTB.COMc.Papule:Hypertrophicscard.Vesicle:Knownasafrictionblistere.Nodule:Solid,elevated,andhardorsoftgrowththatislargerthan1cmANS:A,D,EApustuleisanelevated,circumscribedlesionfilledwithturbidfluid(pus).Ahypertrophicscarisakeloid.Abullaislargerthan1cmandcontainsclearfluid.Apapuleissolidandelevatedbutmeasureslessthan1cm.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation2.Apatienthasbeenadmittedtoahospitalafterthestaffinthenursinghomenoticedapressureulcerinhissacralarea.ThenurseexaminesthepressureulceranddeterminesthatitisastageIIulcer.WhichofthesefindingsarecharacteristicofastageIIpressureulcer?Selectallthatapply.a.Intactskinappearsredbutisnotbroken.b.Partialthicknessskinerosionisobservedwithalossofepidermisordermis.c.Ulcerextendsintothesubcutaneoustissue.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)175STUVIA.COMd.Localizedrednessinlightskinwillblanchwithfingertippressure.e.Openblisterareashaveared-pinkwoundbed.f.Patchesofescharcoverpartsofthewound.ANS:B,EStageIpressureulcershaveintactskinthatappearsredbutisnotbroken,andlocalizedrednessinintactskinwillblanchewithfingertippressure.StageIIpressureulcershavepartialthicknessskinerosionwithalossofepidermisoralsothedermis;openblistershaveared-pinkwoundbed.StageIIIpressureulcersarefullthickness,extendingintothesubcutaneoustissue;subcutaneousfatmaybeseenbutnotmuscle,bone,ortendon.StageIVpressureulcersinvolveallskinlayersandextendintosupportingtissue,exposingmuscle,bone,andtendon.Slough(stringymatterattachedtothewoundbed)oreschar(blackorbrownnecrotictissue)maybepresent.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationNURSINGTB.COMPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)176STUVIA.COMChapter14:Head,Face,Neck,andRegionalLymphaticsMULTIPLECHOICE1.Aphysiciantellsthenursethatapatientsvertebraprominensistenderandasksthenursetoreevaluatetheareain1hour.Theareaofthebodythenursewillassessis:a.Justabovethediaphragm.b.Justlateraltothekneecap.c.AttheleveloftheC7vertebra.d.AttheleveloftheT11vertebra.ANS:CTheC7vertebrahasalongspinousprocess,calledthevertebraprominens,whichispalpablewhentheheadisflexed.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation2.Amotherbringsher2-month-olddaughterinforanexaminationandsays,Mydaughterrolledoveragainstthewall,andnowIhavenoticedthatshehastNhUisRsSpIoNtGthTaBti.sCOsoMftonthetopofherhead.Issomethingterriblywrong?Thenursesbestresponsewouldbe:a.Perhapsthatcouldbearesultofyourdietaryintakeduringpregnancy.b.Yourbabymayhavecraniosynostosis,adiseaseofthesuturesofthebrain.c.Thatsoftspotmaybeanindicationofcretinismorcongenitalhypothyroidism.d.Thatsoftspotisnormal,andactuallyallowsforgrowthofthebrainduringthefirstyearofyourbabyslife.ANS:DMembrane-coveredsoftspotsallowforgrowthofthebrainduringthefirstyearoflife.Theygraduallyossify;thetriangular-shapedposteriorfontanelisclosedby1to2months,andthediamond-shapedanteriorfontanelclosesbetween9monthsand2years.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance3.Thenursenoticesthatapatientspalpebralfissuresarenotsymmetric.Onexamination,thenursemayfindthatdamagehasoccurredtowhichcranialnerve(CN)?a.IIIPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)177STUVIA.COMb.Vc.VIId.VIIIANS:CFacialmusclesaremediatedbyCNVII;asymmetryofpalpebralfissuresmaybeattributabletodamagetoCNVII(Bellpalsy).DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation4.Apatientisunabletodifferentiatebetweensharpanddullstimulationtobothsidesofherface.Thenursesuspects:a.Bellpalsy.b.Damagetothetrigeminalnerve.c.Frostbitewithresultantparesthesiatothecheeks.NURSINGTB.COMd.Scleroderma.ANS:BFacialsensationsofpainortoucharemediatedbyCNV,whichisthetrigeminalnerve.BellpalsyisassociatedwithCNVIIdamage.Frostbiteandsclerodermaarenotassociatedwiththisproblem.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation5.Whenexaminingthefaceofapatient,thenurseisawarethatthetwopairsofsalivaryglandsthatareaccessibletoexaminationaretheandglands.a.Occipital;submentalb.Parotid;jugulodigastricc.Parotid;submandibulard.Submandibular;occipitalANS:CTwopairsofsalivaryglandsaccessibletoexaminationonthefacearetheparotidglands,whichareinthePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)178STUVIA.COMcheeksoverthemandible,anteriortoandbelowtheear;andthesubmandibularglands,whicharebeneaththemandibleattheangleofthejaw.Theparotidglandsarenormallynonpalpable.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare6.Apatientcomestothecliniccomplainingofneckandshoulderpainandisunabletoturnherhead.ThenursesuspectsdamagetoCNandproceedswiththeexaminationby.a.XI;palpatingtheanteriorandposteriortrianglesb.XI;askingthepatienttoshrughershouldersagainstresistancec.XII;percussingthesternomastoidandsubmandibularneckmusclesd.XII;assessingforapositiveRombergsignANS:BThemajorneckmusclesarethesternomastoidandthetrapezius.TheyareinnervatedbyCNXI,thespinalaccessory.Theinnervatedmusclesassistwithheadrotationandheadflexion,movementoftheshoulders,andextensionandturningofthehead.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareENnUvRirSoInNmGeTnBt:.CMOaMnagementofCare7.WhenexaminingapatientsCNfunction,thenurseremembersthatthemusclesintheneckthatareinnervatedbyCNXIarethe:a.Sternomastoidandtrapezius.b.Spinalaccessoryandomohyoid.c.Trapeziusandsternomandibular.d.Sternomandibularandspinalaccessory.ANS:AThemajorneckmusclesarethesternomastoidandthetrapezius.TheyareinnervatedbyCNXI,thespinalaccessory.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General8.Apatientslaboratorydatarevealanelevatedthyroxine(T4)level.Thenursewouldproceedwithanexaminationofthegland.a.ThyroidPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)179STUVIA.COMb.Parotidc.Adrenald.ParathyroidANS:AThethyroidglandisahighlyvascularendocrineglandthatsecretesT4andtriiodothyronine(T3).TheotherglandsdonotsecreteT4.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare9.ApatientsaysthatshehasrecentlynoticedalumpinthefrontofherneckbelowherAdamsapplethatseemstobegettingbigger.Duringtheassessment,thefindingthatleadsthenursetosuspectthatthismaynotbeacancerousthyroidnoduleisthatthelump(nodule):a.Istender.b.Ismobileandnothard.c.DisappearswhenthepatientsmileNs.URSINGTB.COMd.Ishardandfixedtothesurroundingstructures.ANS:BPainless,rapidlygrowingnodulesmaybecancerous,especiallytheappearanceofasinglenoduleinayoungperson.However,cancerousnodulestendtobehardandfixedtosurroundingstructures,notmobile.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation10.Thenursenoticesthatapatientssubmentallymphnodesareenlarged.Inanefforttoidentifythecauseofthenodeenlargement,thenursewouldassessthepatients:a.Infraclaviculararea.b.Supraclaviculararea.c.Areadistaltotheenlargednode.d.Areaproximaltotheenlargednode.ANS:DPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)180STUVIA.COMWhennodesareabnormal,thenurseshouldchecktheareaintowhichtheydrainforthesourceoftheproblem.Theareaproximal(upstream)tothelocationoftheabnormalnodeshouldbeexplored.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare11.Thenurseisawarethatthefourareasinthebodywherelymphnodesareaccessiblearethe:a.Head,breasts,groin,andabdomen.b.Arms,breasts,inguinalarea,andlegs.c.Headandneck,arms,breasts,andaxillae.d.Headandneck,arms,inguinalarea,andaxillae.ANS:DNodesarelocatedthroughoutthebody,buttheyareaccessibletoexaminationonlyinfourareas:headandneck,arms,inguinalregion,andaxillae.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare12.AmotherbringshernewborninforanassNesUsRmSeInNtGanTdB.aCskOsM,Istheresomethingwrongwithmybaby?Hisheadseemssobig.Whichstatementistrueregardingtherelativeproportionsoftheheadandtrunkofthenewborn?a.Atbirth,theheadisonefifththetotallength.b.Headcircumferenceshouldbegreaterthanchestcircumferenceatbirth.c.Theheadsizereaches90%ofitsfinalsizewhenthechildis3yearsold.d.Whentheanteriorfontanelclosesat2months,theheadwillbemoreproportionedtothebody.ANS:BThenurserecognizesthatduringthefetalperiod,headgrowthpredominates.Headsizeisgreaterthanchestcircumferenceatbirth,andtheheadsizegrowsduringchildhood,reaching90%ofitsfinalsizewhenthechildisage6years.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance13.Apatient,an85-year-oldwoman,iscomplainingaboutthefactthatthebonesinherfacehavebecomemorenoticeable.Whatexplanationshouldthenursegiveher?a.Dietslowinproteinandhighincarbohydratesmaycauseenhancedfacialbones.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)181STUVIA.COMb.Bonescanbecomemorenoticeableifthepersondoesnotuseadermatologicallyapprovedmoisturizer.c.Morenoticeablefacialbonesareprobablyduetoacombinationoffactorsrelatedtoaging,suchasdecreasedelasticity,subcutaneousfat,andmoistureinherskin.d.Facialskinbecomesmoreelasticwithage.Thisincreasedelasticitycausestheskintobemoretaught,drawingattentiontothefacialbones.ANS:CThefacialbonesandorbitsappearmoreprominentintheagingadult,andthefacialskinsags,whichisattributabletodecreasedelasticity,decreasedsubcutaneousfat,anddecreasedmoistureintheskin.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance14.Apatientreportsexcruciatingheadachepainononesideofhishead,especiallyaroundhiseye,forehead,andcheekthathaslastedapproximatelyto2hours,occurringonceortwiceeachday.Thenurseshouldsuspect:a.Hypertension.b.Clusterheadaches.NURSINGTB.COMc.Tensionheadaches.d.Migraineheadaches.ANS:BClusterheadachesproducepainaroundtheeye,temple,forehead,andcheekandareunilateralandalwaysonthesamesideofthehead.Theyareexcruciatingandoccuronceortwiceperdayandlastto2hourseach.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation15.Apatientcomplainsthatwhilestudyingforanexaminationhebegantonoticeasevereheadacheinthefrontotemporalareaofhisheadthatisthrobbingandissomewhatrelievedwhenheliesdown.Hetellsthenursethathismotheralsohadtheseheadaches.Thenursesuspectsthathemaybesufferingfrom:a.Hypertension.b.Clusterheadaches.c.Tensionheadaches.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)182STUVIA.COMd.Migraineheadaches.ANS:DMigraineheadachestendtobesupraorbital,retroorbital,orfrontotemporalwithathrobbingquality.Theyaresevereinqualityandarerelievedbylyingdown.Migrainesareassociatedwithafamilyhistoryofmigraineheadaches.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation16.A19-year-oldcollegestudentisbroughttotheemergencydepartmentwithasevereheadachehedescribesas,LikenothingIveeverhadbefore.Histemperatureis40C,andhehasastiffneck.Thenurselooksforothersignsandsymptomsofwhichproblem?a.Headinjuryb.Clusterheadachec.Migraineheadached.MeningealinflammationANS:DNURSINGTB.COMTheacuteonsetofneckstiffnessandpainalongwithheadacheandfeveroccurswithmeningealinflammation.Asevereheadacheinanadultorchildwhohasneverhaditbeforeisaredflag.Headinjuryandclusterormigraineheadachesarenotassociatedwithafeverorstiffneck.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation17.Duringawell-babycheckup,thenursenoticesthata1-week-oldinfantsfacelookssmallcomparedwithhiscranium,whichseemsenlarged.Onfurtherexamination,thenursealsonoticesdilatedscalpveinsanddowncastorsettingsuneyes.Thenursesuspectswhichcondition?a.Craniotabesb.Microcephalyc.Hydrocephalusd.CaputsuccedaneumANS:CHydrocephalusoccurswiththeobstructionofdrainageofcerebrospinalfluidthatresultsinexcessiveaccumulation,increasingintracranialpressure,andanenlargementofthehead.Thefacelookssmall,comparedwiththeenlargedcranium,anddilatedscalpveinsanddowncastorsettingsuneyesarenoted.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)183STUVIA.COMCraniotabesisasofteningoftheskullsouterlayer.Microcephalyisanabnormallysmallhead.Acaputsuccedaneumisedematousswellingandecchymosisofthepresentingpartoftheheadcausedbybirthtrauma.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance18.Thenurseneedstopalpatethetemporomandibularjointforcrepitation.Thisjointislocatedjustbelowthetemporalarteryandanteriortothe:a.Hyoidbone.b.Vagusnerve.c.Tragus.d.Mandible.ANS:CThetemporomandibularjointisjustbelowthetemporalarteryandanteriortothetragus.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:General19.ApatienthascomeinforanexaminationaNnUdRsStaINteGs,TIBh.aCvOeMthisspotinfrontofmyearlobeonmycheekthatseemstobegettingbiggerandistender.Whatdoyouthinkitis?Thenursenotesswellingbelowtheangleofthejawandsuspectsthatitcouldbeaninflammationofhis:a.Thyroidgland.b.Parotidgland.c.Occipitallymphnode.d.Submentallymphnode.ANS:BSwellingoftheparotidglandisevidentbelowtheangleofthejawandismostvisiblewhentheheadisextended.Painfulinflammationoccurswithmumps,andswellingalsooccurswithabscessesortumors.Swellingoccursanteriortothelowerearlobe.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation20.Amalepatientwithahistoryofacquiredimmunodeficiencysyndrome(AIDS)hascomeinforanexaminationandhestates,IthinkthatIhavethemumps.Thenursewouldbeginbyexaminingthe:a.Thyroidgland.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)184STUVIA.COMb.Parotidgland.c.Cervicallymphnodes.d.Mouthandskinforlesions.ANS:BTheparotidglandmaybecomeswollenwiththeonsetofmumps,andparotidenlargementhasbeenfoundwithhumanimmunodeficiencyvirus(HIV).DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation21.Thenursesuspectsthatapatienthashyperthyroidism,andthelaboratorydataindicatethatthepatientsT4andT3hormonelevelsareelevated.Whichofthesefindingswouldthenursemostlikelyfindonexamination?a.Tachycardiab.Constipationc.Rapiddyspnead.AtrophiednodularthyroidglandNURSINGTB.COMANS:AT4andT3arethyroidhormonesthatstimulatetherateofcellularmetabolism,resultingintachycardia.Withanenlargedthyroidglandasinhyperthyroidism,thenursemightexpecttofinddiffuseenlargement(goiter)oranodularlumpbutnotanatrophiedgland.Dyspneaandconstipationarenotfindingsassociatedwithhyperthyroidism.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation22.AvisitorfromPolandwhodoesnotspeakEnglishseemstobesomewhatapprehensiveaboutthenurseexamininghisneck.Hewouldprobablybemorecomfortablewiththenurseexamininghisthyroidglandfrom:a.Behindwiththenurseshandsplacedfirmlyaroundhisneck.b.Thesidewiththenurseseyesavertedtowardtheceilingandthumbsonhisneck.c.Thefrontwiththenursesthumbsplacedoneithersideofhistracheaandhisheadtiltedforward.d.Thefrontwiththenursesthumbsplacedoneithersideofhistracheaandhisheadtiltedbackward.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)185STUVIA.COMANS:CExaminingthispatientsthyroidglandfromthebackmaybeunsettlingforhim.Itwouldbebesttoexaminehisthyroidglandusingtheanteriorapproach,askinghimtotiphisheadforwardandtotherightandthentotheleft.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare23.Apatientsthyroidglandisenlarged,andthenurseispreparingtoauscultatethethyroidglandforthepresenceofabruit.Abruitisasoundthatisheardbestwiththeofthestethoscope.a.Lowgurgling;diaphragmb.Loud,whooshing,blowing;bellc.Soft,whooshing,pulsatile;belld.High-pitchedtinkling;diaphragmANS:CIfthethyroidglandisenlarged,thenthenurseshouldauscultateitforthepresenceofabruit,whichisasoft,pulsatile,whooshing,blowingsoundheardbestwiththebellofthestethoscope.DIF:CognitiveLevel:Understanding(ComprNehUeRnSsiIoNnG)TB.COMMSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare24.Thenursenoticesthataninfanthasalarge,softlumponthesideofhisheadandthathismotherisveryconcerned.Shetellsthenursethatshenoticedthelumpapproximately8hoursafterherbabysbirthandthatitseemstobegettingbigger.Onepossibleexplanationforthisis:a.Hydrocephalus.b.Craniosynostosis.c.Cephalhematoma.d.Caputsuccedaneum.ANS:CAcephalhematomaisasubperiostealhemorrhagethatistheresultofbirthtrauma.Itissoft,fluctuant,andwelldefinedoveronecranialbone.Itappearsseveralhoursafterbirthandgraduallyincreasesinsize.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation25.AmotherbringsinhernewborninfantforanassessmentandtellsthenursethatshehasnoticedthatPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)186STUVIA.COMwheneverhernewbornsheadisturnedtotherightside,shestraightensoutthearmandlegonthesamesideandflexestheoppositearmandleg.Afterobservingthisonexamination,thenursetellsherthatthisreflexis:a.Abnormalandiscalledtheatonicneckreflex.b.Normalandshoulddisappearbythefirstyearoflife.c.Normalandiscalledthetonicneckreflex,whichshoulddisappearbetween3and4monthsofage.d.Abnormal.Thebabyshouldbeflexingthearmandlegontherightsideofhisbodywhentheheadisturnedtotheright.ANS:CBy2weeks,theinfantshowsthetonicneckreflexwhensupineandtheheadisturnedtooneside(extensionofsamearmandleg,flexionofoppositearmandleg).Thetonicneckreflexdisappearsbetween3and4monthsofage.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance26.Duringanadmissionassessment,thenursenoticesthatamalepatienthasanenlargedandratherthickskull.Thenursesuspectsacromegalyandwouldfurtherassessfor:a.Exophthalmos.NURSINGTB.COMb.Bowedlongbones.c.Coarsefacialfeatures.d.Acorn-shapedcranium.ANS:CAcromegalyisexcessivesecretionofgrowthhormonethatcreatesanenlargedskullandthickenedcranialbones.Patientswillhaveelongatedheads,massivefaces,prominentnosesandlowerjaws,heavyeyebrowridges,andcoarsefacialfeatures.Exophthalmosisassociatedwithhyperthyroidism.Bowedlongbonesandanacorn-shapedcraniumresultfromPagetdisease.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation27.WhenexaminingchildrenaffectedwithDownsyndrome(trisomy21),thenurselooksforthepossiblepresenceof:a.Eardysplasia.b.Long,thinneck.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)187STUVIA.COMc.Protrudingthintongue.d.Narrowandraisednasalbridge.ANS:AWiththechromosomalaberrationtrisomy21,alsoknownasDownsyndrome,headandfacecharacteristicsmayincludeupslantingeyeswithinnerepicanthalfolds,aflatnasalbridge,asmallbroadflatnose,aprotrudingthicktongue,eardysplasia,ashortbroadneckwithwebbing,andsmallhandswithasinglepalmarcrease.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation28.Apatientvisitstheclinicbecausehehasrecentlynoticedthattheleftsideofhismouthisparalyzed.Hestatesthathecannotraisehiseyebroworwhistle.Thenursesuspectsthathehas:a.Cushingsyndrome.b.Parkinsondisease.c.Bellpalsy.d.ExperiencedacerebrovascularaccNidUeRntS(INCGVTAB).oCrOsMtroke.ANS:DWithanuppermotorneuronlesion,aswithaCVA,thepatientwillhaveparalysisoflowerfacialmuscles,buttheupperhalfofthefacewillnotbeaffectedowingtotheintactnervefromtheunaffectedhemisphere.Thepersonisstillabletowrinkletheforeheadandclosetheeyes.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation29.Awomancomestotheclinicandstates,Ivebeensickforsolong!Myeyeshavegottensopuffy,andmyeyebrowsandhairhavebecomecoarseanddry.Thenursewillassessforothersignsandsymptomsof:a.Cachexia.b.Parkinsonsyndrome.c.Myxedema.d.Scleroderma.ANS:CMyxedema(hypothyroidism)isadeficiencyofthyroidhormonethat,whensevere,causesanonpittingedemaPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)188STUVIA.COMormyxedema.Thepatientwillhaveapuffyedematousface,especiallyaroundtheeyes(periorbitaledema);coarsefacialfeatures;dryskin;anddry,coarsehairandeyebrows.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation30.Duringanexaminationofafemalepatient,thenursenoteslymphadenopathyandsuspectsanacuteinfection.Acutelyinfectedlymphnodeswouldbe:a.Clumped.b.Unilateral.c.Firmbutfreelymovable.d.Firmandnontender.ANS:CAcutelyinfectedlymphnodesarebilateral,enlarged,warm,tender,andfirmbutfreelymovable.Unilaterallyenlargednodesthatarefirmandnontendermayindicatecancer.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationNURSINGTB.COM31.Thephysicianreportsthatapatientwithanecktumorhasatrachealshift.Thenurseisawarethatthismeansthatthepatientstracheais:a.Pulledtotheaffectedside.b.Pushedtotheunaffectedside.c.Pulleddownward.d.Pulleddownwardinarhythmicpattern.ANS:BThetracheaispushedtotheunaffectedsidewithanaorticaneurysm,atumor,unilateralthyroidlobeenlargement,orapneumothorax.Thetracheaispulledtotheaffectedsidewithlargeatelectasis,pleuraladhesions,orfibrosis.Trachealtugisarhythmicdownwardpullthatissynchronouswithsystoleandoccurswithaorticarchaneurysm.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation32.Duringanassessmentofaninfant,thenursenotesthatthefontanelsaredepressedandsunken.Thenursesuspectswhichcondition?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)189STUVIA.COMa.Ricketsb.Dehydrationc.Mentalretardationd.IncreasedintracranialpressureANS:BDepressedandsunkenfontanelsoccurwithdehydrationormalnutrition.Mentalretardationandricketshavenoeffectonthefontanels.Increasedintracranialpressurewouldcausetenseorbulgingandpossiblypulsatingfontanels.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation33.Thenurseisperforminganassessmentona7-year-oldchildwhohassymptomsofchronicwateryeyes,sneezing,andclearnasaldrainage.Thenursenoticesthepresenceofatransverselineacrossthebridgeofthenose,darkblueshadowsbelowtheeyes,andadoublecreaseonthelowereyelids.Thesefindingsarecharacteristicof:a.Allergies.b.Sinusinfection.c.Nasalcongestion.d.Upperrespiratoryinfection.NURSINGTB.COMANS:AChronicallergiesoftendevelopchronicfacialcharacteristicsandincludeblueshadowsbelowtheeyes,adoubleorsinglecreaseonthelowereyelids,open-mouthbreathing,andatransverselineonthenose.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation34.Whileperformingawell-childassessmentona5yearold,thenursenotesthepresenceofpalpable,bilateral,cervical,andinguinallymphnodes.Theyareapproximately0.5cminsize,round,mobile,andnontender.Thenursesuspectsthatthischild:a.Haschronicallergies.b.Mayhaveaninfection.c.Isexhibitinganormalfindingforawellchildofthisage.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)190STUVIA.COMd.Shouldbereferredforadditionalevaluation.ANS:CPalpablelymphnodesarenormalinchildrenuntilpubertywhenthelymphoidtissuebeginstoatrophy.Lymphnodesmaybeupto1cminsizeinthecervicalandinguinalareasbutarediscrete,movable,andnontender.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance35.Thenursehasjustcompletedalymphnodeassessmentona60-year-oldhealthyfemalepatient.Thenurseknowsthatmostlymphnodesinhealthyadultsarenormally:a.Shotty.b.Nonpalpable.c.Large,firm,andfixedtothetissue.d.Rubbery,discrete,andmobile.ANS:BMostlymphnodesarenonpalpableinadults.Thepalpabilityoflymphnodesdecreaseswithage.Normalnodesfeelmovable,discrete,soft,andnontenNdeUr.RSINGTB.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation36.Duringanexaminationofapatientinherthirdtrimesterofpregnancy,thenursenoticesthatthepatientsthyroidglandisslightlyenlarged.Noenlargementhadbeenpreviouslynoticed.Thenursesuspectsthatthepatient:a.Hasaniodinedeficiency.b.Isexhibitingearlysignsofgoiter.c.Isexhibitinganormalenlargementofthethyroidglandduringpregnancy.d.Needsfurthertestingforpossiblethyroidcancer.ANS:CThethyroidglandenlargesslightlyduringpregnancybecauseofhyperplasiaofthetissueandincreasedvascularity.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCarePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)191STUVIA.COM37.Duringanexamination,thenurseknowsthatthebestwaytopalpatethelymphnodesintheneckisdescribedbywhichstatement?a.Usinggentlepressure,palpatewithbothhandstocomparethetwosides.b.Usingstrongpressure,palpatewithbothhandstocomparethetwosides.c.Gentlypincheachnodebetweenonesthumbandforefinger,andthenmovedowntheneckmuscle.d.Usingtheindexandmiddlefingers,gentlypalpatebyapplyingpressureinarotatingpattern.ANS:AUsinggentlepressureisrecommendedbecausestrongpressurecanpushthenodesintotheneckmuscles.Palpatingwithbothhandstocomparethetwosidessymmetricallyisusuallymostefficient.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare38.Duringawell-babycheckup,amotherisconcernedbecauseher2-month-oldinfantcannotholdherheadupwhensheispulledtoasittingposition.Whichresponsebythenurseisappropriate?a.Headcontrolisusuallyachievedby4monthsofage.NURSINGTB.COMb.Youshouldntbetryingtopullyourbabyuplikethatuntilsheisolder.c.Headcontrolshouldbeachievedbythistime.d.Thisinabilityindicatespossiblenervedamagetotheneckmuscles.ANS:AHeadcontrolisachievedby4monthswhenthebabycanholdtheheaderectandsteadywhenpulledtoaverticalposition.Theotherresponsesarenotappropriate.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance39.Duringanexaminationofa3-year-oldchild,thenursenoticesabruitoverthelefttemporalarea.Thenurseshould:a.Continuetheexaminationbecauseabruitisanormalfindingforthisage.b.Checkforthebruitagainin1hour.c.Notifytheparentsthatabruithasbeendetectedintheirchild.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)192STUVIA.COMd.Stoptheexamination,andnotifythephysician.ANS:ABruitsarecommonintheskullinchildrenunder4or5yearsofageandinchildrenwithanemia.Theyaresystolicorcontinuousandareheardoverthetemporalarea.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance40.Duringanexamination,thenursefindsthatapatientslefttemporalarteryistortuousandfeelshardenedandtender,comparedwiththerighttemporalartery.Thenursesuspectswhichcondition?a.Crepitationb.Mastoiditisc.Temporalarteritisd.BellpalsyANS:CWithtemporalarteritis,thearteryappearsmoretortuousandfeelshardenedandtender.TheseassessmentfindingsarenotconsistentwiththeotherrespoNnUsResS.INGTB.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationMULTIPLERESPONSE1.Thenurseisassessinga1-month-oldinfantathiswell-babycheckup.Whichassessmentfindingsareappropriateforthisage?Selectallthatapply.a.Headcircumferenceequaltochestcircumferenceb.Headcircumferencegreaterthanchestcircumferencec.Headcircumferencelessthanchestcircumferenced.Fontanelsfirmandslightlyconcavee.Absenttonicneckreflexf.NonpalpablecervicallymphnodesANS:B,D,FPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)193STUVIA.COMNURSINGTB.COMAninfantsheadcircumferenceislargerthanthechestcircumference.Atage2years,bothmeasurementsarethesame.Duringchildhood,thechestcircumferencegrowstoexceedtheheadcircumferenceby5to7cm.Thefontanelsshouldfeelfirmandslightlyconcaveintheinfant,andtheyshouldclosebyage9months.Thetonicneckreflexispresentuntilbetween3and4monthsofage,andcervicallymphnodesarenormallynonpalpableinaninfant.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenancePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)194STUVIA.COMChapter15:EyesMULTIPLECHOICE1.Whenexaminingtheeye,thenursenoticesthatthepatientseyelidmarginsapproximatecompletely.Thenurserecognizesthatthisassessmentfinding:a.Isexpected.b.Mayindicateaproblemwithextraocularmuscles.c.Mayresultinproblemswithtearing.d.Indicatesincreasedintraocularpressure.ANS:AThepalpebralfissureistheellipticalopenspacebetweentheeyelids,and,whenclosed,thelidmarginsapproximatecompletely,whichisanormalfinding.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation2.Duringocularexaminations,thenursekeepsinmindthatmovementoftheextraocularmusclesis:NURSINGTB.COMa.Decreasedintheolderadult.b.Impairedinapatientwithcataracts.c.Stimulatedbycranialnerves(CNs)IandII.d.StimulatedbyCNsIII,IV,andVI.ANS:DMovementoftheextraocularmusclesisstimulatedbythreeCNs:III,IV,andVI.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation3.Thenurseisperforminganexternaleyeexamination.Whichstatementregardingtheouterlayeroftheeyeistrue?a.Theouterlayeroftheeyeisverysensitivetotouch.b.Theouterlayeroftheeyeisdarklypigmentedtopreventlightfromreflectinginternally.c.Thetrigeminalnerve(CNV)andthetrochlearnerve(CNIV)arestimulatedwhentheouterPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)195STUVIA.COMsurfaceoftheeyeisstimulated.d.Thevisualreceptivelayeroftheeyeinwhichlightwavesarechangedintonerveimpulsesislocatedintheouterlayeroftheeye.ANS:AThecorneaandthescleramakeuptheouterlayeroftheeye.Thecorneaisverysensitivetotouch.Themiddlelayer,thechoroid,hasdarkpigmentationtopreventlightfromreflectinginternally.Thetrigeminalnerve(CNV)andthefacialnerve(CNVII)arestimulatedwhentheoutersurfaceoftheeyeisstimulated.Theretina,intheinnerlayeroftheeye,iswherelightwavesarechangedintonerveimpulses.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation4.Whenexaminingapatientseyes,thenurserecallsthatstimulationofthesympatheticbranchoftheautonomicnervoussystem:a.Causespupillaryconstriction.b.Adjuststheeyefornearvision.c.Elevatestheeyelidanddilatesthepupil.d.CausescontractionoftheciliarybNodUyR.SINGTB.COMANS:CStimulationofthesympatheticbranchoftheautonomicnervoussystemdilatesthepupilandelevatestheeyelid.Parasympatheticnervoussystemstimulationcausesthepupiltoconstrict.Themusclefibersoftheiriscontractthepupilinbrightlighttoaccommodatefornearvision.Theciliarybodycontrolsthethicknessofthelens.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation5.Thenurseisreviewingcausesofincreasedintraocularpressure.Whichofthesefactorsdeterminesintraocularpressure?a.Thicknessorbulgingofthelensb.Posteriorchamberasitaccommodatesincreasedfluidc.Contractionoftheciliarybodyinresponsetotheaqueouswithintheeyed.AmountofaqueousproducedandresistancetoitsoutflowattheangleoftheanteriorchamberANS:DPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)196STUVIA.COMIntraocularpressureisdeterminedbyabalancebetweentheamountofaqueousproducedandtheresistancetoitsoutflowattheangleoftheanteriorchamber.Theotherresponsesareincorrect.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation6.Thenurseisconductingavisualexamination.Whichofthesestatementsregardingvisualpathwaysandvisualfieldsistrue?a.Therightsideofthebraininterpretsthevisionfortherighteye.b.Theimageformedontheretinaisupsidedownandreversedfromitsactualappearanceintheoutsideworld.c.Lightraysarerefractedthroughthetransparentmediaoftheeyebeforestrikingthepupil.d.Lightimpulsesareconductedthroughtheopticnervetothetemporallobesofthebrain.ANS:BTheimageformedontheretinaisupsidedownandreversedfromitsactualappearanceintheoutsideworld.Thelightraysarerefractedthroughthetransparentmediaoftheeyebeforestrikingtheretina,andthenerveimpulsesareconductedthroughtheopticnervetracttothevisualcortexoftheoccipitallobeofthebrain.Theleftsideofthebraininterpretsvisionfortherighteye.DIF:CognitiveLevel:Remembering(KnowleNdUgeR)SINGTB.COMMSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation7.Thenurseistestingapatientsvisualaccommodation,whichreferstowhichaction?a.Pupillaryconstrictionwhenlookingatanearobjectb.Pupillarydilationwhenlookingatafarobjectc.Changesinperipheralvisioninresponsetolightd.InvoluntaryblinkinginthepresenceofbrightlightANS:AThemusclefibersoftheiriscontractthepupilinbrightlightandaccommodatefornearvision,whichalsoresultsinpupilconstriction.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation8.Apatienthasanormalpupillarylightreflex.Thenurserecognizesthatthisreflexindicatesthat:a.Theeyesconvergetofocusonthelight.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)197STUVIA.COMb.Lightisreflectedatthesamespotinbotheyes.c.Theeyefocusestheimageinthecenterofthepupil.d.Constrictionofbothpupilsoccursinresponsetobrightlight.ANS:DThepupillarylightreflexisthenormalconstrictionofthepupilswhenbrightlightshinesontheretina.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation9.Amotheraskswhenhernewborninfantseyesightwillbedeveloped.Thenurseshouldreply:a.Visionisnottotallydevelopeduntil2yearsofage.b.Infantsdeveloptheabilitytofocusonanobjectatapproximately8monthsofage.c.Byapproximately3monthsofage,infantsdevelopmorecoordinatedeyemovementsandcanfixateonanobject.NURSINGTB.COMd.Mostinfantshaveuncoordinatedeyemovementsforthefirstyearoflife.ANS:CEyemovementsmaybepoorlycoordinatedatbirth,butby3to4monthsofage,theinfantshouldestablishbinocularityandshouldbeabletofixatesimultaneouslyonasingleimagewithbotheyes.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance10.Thenurseisreviewinginage-relatedchangesintheeyeforaclass.Whichofthesephysiologicchangesisresponsibleforpresbyopia?a.Degenerationofthecorneab.Lossoflenselasticityc.Decreasedadaptationtodarknessd.DecreaseddistancevisionabilitiesANS:BPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)198STUVIA.COMThelensloseselasticityanddecreasesitsabilitytochangeshapetoaccommodatefornearvision.Thisconditioniscalledpresbyopia.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance11.Whichoftheseassessmentfindingswouldthenurseexpecttoseewhenexaminingtheeyesofablackpatient?a.Increasednightvisionb.Darkretinalbackgroundc.Increasedphotosensitivityd.NarrowedpalpebralfissuresANS:BAnethnicallybasedvariabilityinthecoloroftheirisandinretinalpigmentationexists,withdarkerirideshavingdarkerretinasbehindthem.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCareNURSINGTB.COM12.A52-year-oldpatientdescribesthepresenceofoccasionalfloatersorspotsmovinginfrontofhiseyes.Thenurseshould:a.Examinetheretinatodeterminethenumberoffloaters.b.Presumethepatienthasglaucomaandreferhimforfurthertesting.c.Considerthesetobeabnormalfindings,andreferhimtoanophthalmologist.d.Knowthatfloatersareusuallyinsignificantandarecausedbycondensedvitreousfibers.ANS:DFloatersareacommonsensationwithmyopiaoraftermiddleageandareattributabletocondensedvitreousfibers.Floatersorspotsarenotusuallysignificant,buttheacuteonsetoffloatersmayoccurwithretinaldetachment.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance13.Thenurseispreparingtoassessthevisualacuityofa16-year-oldpatient.Howshouldthenurseproceed?a.Performtheconfrontationtest.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)199STUVIA.COMb.AskthepatienttoreadtheprintonahandheldJaegercard.c.UsetheSnellenchartpositioned20feetawayfromthepatient.d.Determinethepatientsabilitytoreadnewsprintatadistanceof12to14inches.ANS:CTheSnellenalphabetchartisthemostcommonlyusedandmostaccuratemeasureofvisualacuity.Theconfrontationtestisagrossmeasureofperipheralvision.TheJaegercardornewspapertestsareusedtotestnearvision.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare14.Apatientsvisionisrecordedas20/30whentheSnelleneyechartisused.Thenurseinterpretstheseresultstoindicatethat:a.At30feetthepatientcanreadtheentirechart.b.Thepatientcanreadat20feetwhatapersonwithnormalvisioncanreadat30feet.c.Thepatientcanreadthechartfrom20feetinthelefteyeand30feetintherighteye.NURSINGTB.COMd.Thepatientcanreadfrom30feetwhatapersonwithnormalvisioncanreadfrom20feet.ANS:BThetopnumberindicatesthedistancethepersonisstandingfromthechart;thedenominatorgivesthedistanceatwhichanormaleyecansee.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation15.ApatientisunabletoreadeventhelargestlettersontheSnellenchart.Thenurseshouldtakewhichactionnext?a.Referthepatienttoanophthalmologistoroptometristforfurtherevaluation.b.Assesswhetherthepatientcancountthenursesfingerswhentheyareplacedinfrontofhisorhereyes.c.AskthepatienttoputonhisorherreadingglassesandattempttoreadtheSnellenchartagain.d.Shortenthedistancebetweenthepatientandthechartuntilthelettersareseen,andrecordthatdistance.ANS:DPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)200STUVIA.COMIfthepersonisunabletoseeeventhelargestletterswhenstanding20feetfromthechart,thenthenurseshouldshortenthedistancetothechartuntilthelettersareseen,andrecordthatdistance(e.g.,10/200).Ifvisualacuityisevenlower,thenthenurseshouldassesswhetherthepersoncancountfingerswhentheyarespreadinfrontoftheeyesorcandistinguishlightperceptionfromapenlight.Ifvisionispoorerthan20/30,thenareferraltoanophthalmologistoroptometristisnecessary,butthenursemustfirstassessthevisualacuity.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation16.Apatientsvisionisrecordedas20/80ineacheye.Thenurseinterpretsthisfindingtomeanthatthepatient:a.Haspoorvision.b.Hasacutevision.c.Hasnormalvision.d.Ispresbyopic.ANS:ANormalvisualacuityis20/20ineacheye;thelargerthedenominator,thepoorerthevision.DIF:CognitiveLevel:Applying(Application)NURSINGTB.COMMSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation17.Whenperformingthecorneallightreflexassessment,thenursenotesthatthelightisreflectedat2oclockineacheye.Thenurseshould:a.Considerthisanormalfinding.b.Refertheindividualforfurtherevaluation.c.Documentthisfindingasanasymmetriclightreflex.d.Performtheconfrontationtesttovalidatethefindings.ANS:AReflectionofthelightonthecorneasshouldbeinexactlythesamespotoneacheye,orsymmetric.Ifasymmetryisnoted,thenthenurseshouldadministerthecovertest.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare18.Thenurseisperformingthediagnosticpositionstest.Normalfindingswouldbewhichoftheseresults?a.ConvergenceoftheeyesPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)201STUVIA.COMb.Parallelmovementofbotheyesc.Nystagmusinextremesuperiorgazed.SlightamountoflidlagwhenmovingtheeyesfromasuperiortoaninferiorpositionANS:BAnormalresponseforthediagnosticpositionstestisparalleltrackingoftheobjectwithbotheyes.EyemovementthatisnotparallelindicatesaweaknessofanextraocularmuscleordysfunctionoftheCNthatinnervatesit.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare19.Duringanassessmentofthescleraofablackpatient,thenursewouldconsiderwhichoftheseanexpectedfinding?a.Yellowfattydepositsoverthecorneab.Pallorneartheoutercanthusofthelowerlidc.YellowcolorofthesclerathatexteNnUdRsSuIpNtGoTthBe.CirOisMd.PresenceofsmallbrownmaculesonthescleraANS:DNormallyindark-skinnedpeople,smallbrownmaculesmaybeobservedinthesclera.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare20.A60-year-oldmanisattheclinicforaneyeexamination.Thenursesuspectsthathehasptosisofoneeye.Howshouldthenursecheckforthis?a.Performtheconfrontationtest.b.Assesstheindividualsnearvision.c.Observethedistancebetweenthepalpebralfissures.d.Performthecorneallighttest,andlookforsymmetryofthelightreflex.ANS:CPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)202STUVIA.COMPtosisisadroopingoftheuppereyelidthatwouldbeapparentbyobservingthedistancebetweentheupperandlowereyelids.Theconfrontationtestmeasuresperipheralvision.Measuringnearvisionorthecorneallighttestdoesnotcheckforptosis.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance21.Duringanexaminationoftheeye,thenursewouldexpectwhatnormalfindingwhenassessingthelacrimalapparatus?a.Presenceoftearsalongtheinnercanthusb.Blockednasolacrimalductinanewborninfantc.Slightswellingovertheupperlidandalongthebonyorbitiftheindividualhasacoldd.AbsenceofdrainagefromthepunctawhenpressingagainsttheinnerorbitalrimANS:DNoswelling,redness,ordrainagefromthepunctashouldbeobservedwhenitispressed.Regurgitationoffluidfromthepuncta,whenpressed,indicatesductblockage.Thelacrimalglandsarenotfunctionalatbirth.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareENnUvRirSoInNmGeTnBt:.CMOaMnagementofCare22.Whenassessingthepupillarylightreflex,thenurseshouldusewhichtechnique?a.Shineapenlightfromdirectlyinfrontofthepatient,andinspectforpupillaryconstriction.b.Askthepatienttofollowthepenlightineightdirections,andobserveforbilateralpupilconstriction.c.Shinealightacrossthepupilfromtheside,andobservefordirectandconsensualpupillaryconstriction.d.Askthepatienttofocusonadistantobject.Thenaskthepatienttofollowthepenlighttoapproximately7cmfromthenose.ANS:CTotestthepupillarylightreflex,thenurseshouldadvancealightinfromthesideandnotethedirectandconsensualpupillaryconstriction.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare23.Thenurseisassessingapatientseyesfortheaccommodationresponseandwouldexpecttoseewhichnormalfinding?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)203STUVIA.COMa.Dilationofthepupilsb.Consensuallightreflexc.Conjugatemovementoftheeyesd.ConvergenceoftheaxesoftheeyesANS:DTheaccommodationreactionincludespupillaryconstrictionandconvergenceoftheaxesoftheeyes.Theotheresponsesarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare24.Inusingtheophthalmoscopetoassessapatientseyes,thenursenoticesaredglowinthepatientspupils.Onthebasisofthisfinding,thenursewould:a.Suspectthatanopacityispresentinthelensorcornea.b.Checkthelightsourceoftheophthalmoscopetoverifythatitisfunctioning.NURSINGTB.COMc.Considertheredglowanormalreflectionoftheophthalmoscopelightofftheinnerretina.d.Continuewiththeophthalmoscopicexamination,andreferthepatientforfurtherevaluation.ANS:CTheredglowfillingthepersonspupilistheredreflexandisanormalfindingcausedbythereflectionoftheophthalmoscopelightofftheinnerretina.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare25.Thenurseisexaminingapatientsretinawithanophthalmoscope.Whichfindingisconsiderednormal?a.Opticdiscthatisayellow-orangecolorb.Opticdiscmarginsthatareblurredaroundtheedgesc.Presenceofpigmentedcrescentsinthemaculararead.PresenceofthemaculalocatedonthenasalsideoftheretinaANS:APHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)204STUVIA.COMTheopticdiscislocatedonthenasalsideoftheretina.Itscolorisacreamyyellow-orangetoapink,andtheedgesaredistinctandsharplydemarcated,notblurred.Apigmentedcrescentisblackandisduetotheaccumulationofpigmentinthechoroid.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare26.A2-week-oldinfantcanfixateonanobjectbutcannotfollowalightorbrighttoy.Thenursewould:a.Considerthisanormalfinding.b.Assessthepupillarylightreflexforpossibleblindness.c.Continuewiththeexamination,andassessvisualfields.d.Expectthata2-week-oldinfantshouldbeabletofixateandfollowanobject.ANS:ABy2to4weeksaninfantcanfixateonanobject.Bytheageof1month,theinfantshouldfixateandfollowabrightlightortoy.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenanceNURSINGTB.COM27.Thenurseisassessingcolorvisionofamalechild.Whichstatementiscorrect?Thenurseshould:a.Checkcolorvisionannuallyuntiltheageof18years.b.Askthechildtoidentifythecolorofhisorherclothing.c.Testforcolorvisiononcebetweentheagesof4and8years.d.Begincolorvisionscreeningatthechilds2-yearcheckup.ANS:CTestboysonlyonceforcolorvisionbetweentheagesof4and8years.Colorvisionisnottestedingirlsbecauseitisrareingirls.TestingisperformedwiththeIshiharatest,whichisaseriesofpolychromaticcards.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance28.Thenurseisperforminganeye-screeningclinicatadaycarecenter.Whenexamininga2-year-oldchild,thenursesuspectsthatthechildhasalazyeyeandshould:a.Examinetheexternalstructuresoftheeye.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)205STUVIA.COMb.AssessvisualacuitywiththeSnelleneyechart.c.Assessthechildsvisualfieldswiththeconfrontationtest.d.Testforstrabismusbyperformingthecorneallightreflextest.ANS:DTestingforstrabismusisdonebyperformingthecorneallightreflextestandthecovertest.TheSnelleneyechartandconfrontationtestarenotusedtotestforstrabismus.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance29.Thenurseisperforminganeyeassessmentonan80-year-oldpatient.Whichofthesefindingsisconsideredabnormal?a.Decreaseintearproductionb.Unequalpupillaryconstrictioninresponsetolightc.Presenceofarcussenilisobservedaroundthecornead.LossoftheouterhairontheeyebrNowUsRaStItNriGbuTtBab.CleOtMoadecreaseinhairfolliclesANS:BPupilsaresmallintheolderadult,andthepupillarylightreflexmaybeslowed,butpupillaryconstrictionshouldbesymmetric.Theassessmentfindingsintheotherresponsesareconsiderednormalinolderpersons.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance30.Thenursenoticesthepresenceofperiorbitaledemawhenperforminganeyeassessmentona70-year-oldpatient.Thenurseshould:a.Checkforthepresenceofexophthalmos.b.Suspectthatthepatienthashyperthyroidism.c.Askthepatientifheorshehasahistoryofheartfailure.d.Assessforblepharitis,whichisoftenassociatedwithperiorbitaledema.ANS:CPeriorbitaledemaoccurswithlocalinfections,crying,andsystemicconditionssuchasheartfailure,renalfailure,allergy,andhypothyroidism.Periorbitaledemaisnotassociatedwithblepharitis.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)206STUVIA.COMDIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation31.Whenalightisdirectedacrosstheirisofapatientseyefromthetemporalside,thenurseisassessingfor:a.Drainagefromdacryocystitis.b.Presenceofconjunctivitisovertheiris.c.Presenceofshadows,whichmayindicateglaucoma.d.Scatteredlightreflex,whichmaybeindicativeofcataracts.ANS:CThepresenceofshadowsintheanteriorchambermaybeasignofacuteangle-closureglaucoma.Thenormalirisisflatandcreatesnoshadows.Thismethodisnotcorrectfortheassessmentofdacryocystitis,conjunctivitis,orcataracts.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare32.Inapatientwhohasanisocoria,thenursewouldexpecttoobserve:a.Dilatedpupils.b.Excessivetearing.c.Pupilsofunequalsize.d.Unevencurvatureofthelens.NURSINGTB.COMANS:CUnequalpupilsizeistermedanisocoria.Itnormallyexistsin5%ofthepopulationbutmayalsobeindicativeofcentralnervoussystemdisease.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation33.Apatientcomestotheemergencydepartmentafteraboxingmatch,andhislefteyeisswollenalmostshut.Hehasbruisesonhisfaceandneck.Hesaysheisworriedbecausehecantseewellfromhislefteye.Thephysiciansuspectsretinaldamage.Thenurserecognizesthatsignsofretinaldetachmentinclude:a.Lossofcentralvision.b.Shadowordiminishedvisioninonequadrantoronehalfofthevisualfield.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)207STUVIA.COMc.Lossofperipheralvision.d.Suddenlossofpupillaryconstrictionandaccommodation.ANS:BWithretinaldetachment,thepersonhasshadowsordiminishedvisioninonequadrantoronehalfofthevisualfield.Theotherresponsesarenotsignsofretinaldetachment.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation34.Apatientcomesintothecliniccomplainingofpaininherrighteye.Onexamination,thenurseseesapustuleatthelidmarginthatispainfultotouch,red,andswollen.Thenurserecognizesthatthisisa:a.Chalazion.b.Hordeolum(stye).c.Dacryocystitis.d.Blepharitis.ANS:BNURSINGTB.COMAhordeolum,orstye,isapainful,red,andswollenpustuleatthelidmargin.Achalazionisanoduleprotrudingonthelid,towardtheinside,andisnontender,firm,withdiscreteswelling.Dacryocystitisisaninflammationofthelacrimalsac.Blepharitisisinflammationoftheeyelids.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation35.A68-year-oldwomanisintheeyeclinicforacheckup.Shetellsthenursethatshehasbeenhavingtroublereadingthepaper,sewing,andevenseeingthefacesofhergrandchildren.Onexamination,thenursenotesthatshehassomelossofcentralvisionbutherperipheralvisionisnormal.Thesefindingssuggestthatshemayhave:a.Maculardegeneration.b.Visionthatisnormalforsomeoneherage.c.Thebeginningstagesofcataractformation.d.Increasedintraocularpressureorglaucoma.ANS:AMaculardegenerationisthemostcommoncauseofblindness.Itischaracterizedbythelossofcentralvision.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)208STUVIA.COMCataractswouldshowlensopacity.Chronicopen-angleglaucoma,themostcommontypeofglaucoma,involvesagraduallossofperipheralvision.Thesefindingsarenotconsistentwithvisionthatisconsiderednormalatanyage.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation36.Apatientcomesintotheemergencydepartmentafteranaccidentatwork.Amachineblewdustintohiseyes,andhewasnotwearingsafetyglasses.Thenurseexamineshiscorneasbyshiningalightfromthesideacrossthecornea.Whatfindingswouldsuggestthathehassufferedacornealabrasion?a.Smoothandclearcorneasb.Opacityofthelensbehindthecorneac.Bleedingfromtheareasacrossthecornead.ShatteredlooktothelightraysreflectingoffthecorneaANS:DAcornealabrasioncausesirregularridgesinreflectedlight,whichproduceashatteredappearancetolightrays.Noopacitiesshouldbeobservedinthecornea.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Applying(Application)NURSINGTB.COMMSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation37.Anophthalmicexaminationrevealspapilledema.Thenurseisawarethatthisfindingindicates:a.Retinaldetachment.b.Diabeticretinopathy.c.Acute-angleglaucoma.d.Increasedintracranialpressure.ANS:DPapilledema,orchokeddisk,isaserioussignofincreasedintracranialpressure,whichiscausedbyaspace-occupyingmasssuchasabraintumororhematoma.Thispressurecausesvenousstasisintheglobe,showingredness,congestion,andelevationoftheopticdisc,blurredmargins,hemorrhages,andabsentvenouspulsations.Papilledemaisnotassociatedwiththeconditionsintheotherresponses.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation38.Duringaphysicaleducationclass,astudentishitintheeyewiththeendofabaseballbat.Whenexaminedintheemergencydepartment,thenursenoticesthepresenceofbloodintheanteriorchamberoftheeye.ThisPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)209STUVIA.COMfindingindicatesthepresenceof:a.Hypopyon.b.Hyphema.c.Cornealabrasion.d.Pterygium.ANS:BHyphemaisthetermforbloodintheanteriorchamberandisaseriousresultofblunttrauma(afistorabaseball)orspontaneoushemorrhageandmayindicatescleralruptureormajorintraoculartrauma.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation39.Duringanassessment,thenursenoticesthatanolderadultpatienthastearsrollingdownhisfacefromhislefteye.Closerexaminationshowsthatthelowerlidislooseandrollingoutward.Thepatientcomplainsofhiseyefeelingdryanditchy.Whichactionbythenurseiscorrect?a.AssessingtheeyeforapossibleforeignbodyNURSINGTB.COMb.Documentingthefindingasptosisc.Assessingforothersignsofectropiond.Contactingtheprescriber;thesearesignsofbasalcellcarcinomaANS:CTheconditiondescribedisknownasectropion,anditoccursinolderadultsandisattributabletoatrophyoftheelasticandfibroustissues.Thelowerliddoesnotapproximatetotheeyeball,and,asaresult,thepunctacannoeffectivelysiphontears;excessivetearingresults.Ptosisisadroopingoftheuppereyelid.Thesesignsdonotsuggestthepresenceofaforeignbodyintheeyeorbasalcellcarcinoma.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationMULTIPLERESPONSE1.Duringanexamination,apatientstatesthatshewasdiagnosedwithopen-angleglaucoma2yearsago.Thenurseassessesforcharacteristicsofopen-angleglaucoma.Whichofthesearecharacteristicsofopen-angleglaucoma?Selectallthatapply.a.Patientmayexperiencesensitivitytolight,nausea,andhalosaroundlights.b.Patientexperiencestunnelvisioninthelatestages.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)210STUVIA.COMc.Immediatetreatmentisneeded.d.Visionlossbeginswithperipheralvision.e.Open-angleglaucomacausessuddenattacksofincreasedpressurethatcauseblurredvision.f.Virtuallynosymptomsareexhibited.ANS:B,D,FOpen-angleglaucomaisthemostcommontypeofglaucoma;virtuallynosymptomsareexhibited.Visionlossbeginswiththeperipheralvision,whichoftengoesunnoticedbecauseindividualslearntocompensateintuitivelybyturningtheirheads.Theothercharacteristicsarethoseofclosed-angleglaucoma.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationNURSINGTB.COMPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)211STUVIA.COMChapter16:EarsMULTIPLECHOICE1.Thenurseneedstopulltheportionoftheearthatconsistsofmovablecartilageandskindownandbackwhenadministeringeardrops.Thisportionoftheeariscalledthe:a.Auricle.b.Concha.c.Outermeatus.d.Mastoidprocess.ANS:ATheexternaleariscalledtheauricleorpinnaandconsistsofmovablecartilageandskin.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation2.Thenurseisexaminingapatientsearsandnoticescerumenintheexternalcanal.Whichofthesestatementsaboutcerumeniscorrect?NURSINGTB.COMa.Stickyhoney-coloredcerumenisasignofinfection.b.Thepresenceofcerumenisindicativeofpoorhygiene.c.Thepurposeofcerumenistoprotectandlubricatetheear.d.Cerumenisnecessaryfortransmittingsoundthroughtheauditorycanal.ANS:CTheearislinedwithglandsthatsecretecerumen,whichisayellowwaxymaterialthatlubricatesandprotectstheear.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation3.Whenexaminingtheearwithanotoscope,thenursenotesthatthetympanicmembraneshouldappear:a.Lightpinkwithaslightbulge.b.Pearlygrayandslightlyconcave.c.Pulledinatthebaseoftheconeoflight.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)212STUVIA.COMd.Whitishwithasmallfleckoflightinthesuperiorportion.ANS:BThetympanicmembraneisatranslucentmembranewithapearlygraycolorandaprominentconeoflightintheanteroinferiorquadrant,whichisthereflectionoftheotoscopelight.Thetympanicmembraneisovalandslightlyconcave,pulledinatitscenterbythemalleus,whichisoneofthemiddleearossicles.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation4.Thenurseisreviewingthestructuresoftheear.Whichofthesestatementsconcerningtheeustachiantubeistrue?a.Theeustachiantubeisresponsiblefortheproductionofcerumen.b.Itremainsopenexceptwhenswallowingoryawning.c.Theeustachiantubeallowspassageofairbetweenthemiddleandouterear.d.Ithelpsequalizeairpressureonbothsidesofthetympanicmembrane.ANS:DNURSINGTB.COMTheeustachiantubeallowsanequalizationofairpressureoneachsideofthetympanicmembranesothatthemembranedoesnotruptureduring,forexample,altitudechangesinanairplane.Thetubeisnormallyclosed,butitopenswithswallowingoryawning.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation5.Apatientwithamiddleearinfectionasksthenurse,Whatdoesthemiddleeardo?Thenurserespondsbytellingthepatientthatthemiddleearfunctionsto:a.Maintainbalance.b.Interpretsoundsastheyentertheear.c.Conductvibrationsofsoundstotheinnerear.d.Increaseamplitudeofsoundfortheinnereartofunction.ANS:CAmongitsotherfunctions,themiddleearconductssoundvibrationsfromtheoutereartothecentralhearingapparatusintheinnerear.Theotherresponsesarenotfunctionsofthemiddleear.DIF:CognitiveLevel:Understanding(Comprehension)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)213STUVIA.COMMSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation6.Thenurseisreviewingthefunctionofthecranialnerves(CNs).WhichCNisresponsibleforconductingnerveimpulsestothebrainfromtheorganofCorti?a.Ib.IIIc.VIIId.XIANS:CThenerveimpulsesareconductedbytheauditoryportionofCNVIIItothebrain.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation7.Thenurseisassessingapatientwhomayhavehearingloss.Whichofthesestatementsistrueconcerningairconduction?a.Airconductionisthenormalpathwayforhearing.NURSINGTB.COMb.Vibrationsofthebonesintheskullcauseairconduction.c.Amplitudeofsounddeterminesthepitchthatisheard.d.Lossofairconductioniscalledaconductivehearingloss.ANS:AThenormalpathwayofhearingisairconduction,whichstartswhensoundwavesproducevibrationsonthetympanicmembrane.Conductivehearinglossresultsfromamechanicaldysfunctionoftheexternalormiddleear.Theotherstatementsarenottrueconcerningairconduction.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation8.Apatienthasbeenshowntohaveasensorineuralhearingloss.Duringtheassessment,itwouldbeimportantforthenurseto:a.Speakloudlysothepatientcanhearthequestions.b.Assessformiddleearinfectionasapossiblecause.c.Askthepatientwhatmedicationsheiscurrentlytaking.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)214STUVIA.COMd.Lookforthesourceoftheobstructionintheexternalear.ANS:CAsimpleincreaseinamplitudemaynotenablethepersontounderstandspokenwords.Sensorineuralhearinglossmaybecausedbypresbycusis,whichisagradualnervedegenerationthatoccurswithagingandbyototoxicdrugs,whichaffectthehaircellsinthecochlea.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare9.Duringaninterview,thepatientstateshehasthesensationthateverythingaroundhimisspinning.Thenurserecognizesthattheportionoftheearresponsibleforthissensationisthe:a.Cochlea.b.CNVIII.c.OrganofCorti.d.Labyrinth.ANS:DNURSINGTB.COMIfthelabyrintheverbecomesinflamed,thenitfeedsthewronginformationtothebrain,creatingastaggeringgaitandastrong,spinning,whirlingsensationcalledvertigo.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare10.Apatientinherfirsttrimesterofpregnancyisdiagnosedwithrubella.Whichofthesestatementsiscorrectregardingthesignificanceofthisinrelationtotheinfantshearing?a.Rubellamayaffectthemothershearingbutnottheinfants.b.RubellacandamagetheinfantsorganofCorti,whichwillimpairhearing.c.Rubellaisonlydangeroustotheinfantinthesecondtrimesterofpregnancy.d.RubellacanimpairthedevelopmentofCNVIIIandthusaffecthearing.ANS:BIfmaternalrubellainfectionoccursduringthefirsttrimester,thenitcandamagetheorganofCortiandimpairhearing.DIF:CognitiveLevel:Understanding(Comprehension)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)215STUVIA.COMMSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation11.Themotherofa2-year-oldisconcernedbecausehersonhashadthreeearinfectionsinthepastyear.Whatwouldbeanappropriateresponsebythenurse?a.Itisunusualforasmallchildtohavefrequentearinfectionsunlesssomethingelseiswrong.b.Weneedtochecktheimmunesystemofyoursontodeterminewhyheishavingsomanyearinfections.c.Earinfectionsarenotuncommonininfantsandtoddlersbecausetheytendtohavemorecerumenintheexternalear.d.Yoursonseustachiantubeisshorterandwiderthanyoursbecauseofhisage,whichallowsforinfectionstodevelopmoreeasily.ANS:DTheinfantseustachiantubeisrelativelyshorterandwiderthantheadultseustachiantube,anditspositionismorehorizontal;consequently,pathogensfromthenasopharynxcanmoreeasilymigratethroughtothemiddleear.Theotherresponsesarenotappropriate.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance12.A31-year-oldpatienttellsthenursethathNeUhaRsSnINotGicTeBd.CaOprMogressivelossinhishearing.Hesaysthatitdoesseemtohelpwhenpeoplespeaklouderorifheturnsupthevolumeofatelevisionorradio.Themostlikelycauseofhishearinglossis:a.Otosclerosis.b.Presbycusis.c.Traumatothebones.d.Frequentearinfections.ANS:AOtosclerosisisacommoncauseofconductivehearinglossinyoungadultsbetweentheagesof20and40years.Presbycusisisatypeofhearinglossthatoccurswithaging.Traumaandfrequentearinfectionsarenotalikelycauseofhishearingloss.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation13.A70-year-oldpatienttellsthenursethathehasnoticedthatheishavingtroublehearing,especiallyinlargegroups.Hesaysthathecantalwaystellwherethesoundiscomingfromandthewordsoftensoundmixedup.Whatmightthenursesuspectasthecauseforthischange?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)216STUVIA.COMa.Atrophyoftheapocrineglandsb.Ciliabecomingcoarseandstiffc.Nervedegenerationintheinnereard.ScarringofthetympanicmembraneANS:CPresbycusisisatypeofhearinglossthatoccursin60%ofthoseolderthan65yearsofage,eveninthoselivinginaquietenvironment.Thissensorineurallossisgradualandcausedbynervedegenerationintheinnerear.Wordssoundgarbled,andtheabilitytolocalizesoundisalsoimpaired.Thiscommunicationdysfunctionisaccentuatedwhenbackgroundnoiseispresent.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance14.Duringanassessmentofa20-year-oldAsianpatient,thenursenoticesthathehasdry,flakycerumeninhiscanal.Whatisthesignificanceofthisfinding?Thisfinding:a.Isprobablytheresultoflesionsfromeczemainhisear.b.Representspoorhygiene.NURSINGTB.COMc.Isanormalfinding,andnofurtherfollow-upisnecessary.d.Couldbeindicativeofchangeincilia;thenurseshouldassessforhearingloss.ANS:CAsiansandNativeAmericansaremorelikelytohavedrycerumen,whereasBlacksandWhitesusuallyhavewetcerumen.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare15.Thenurseistakingthehistoryofapatientwhomayhaveaperforatedeardrum.Whatwouldbeanimportantquestioninthissituation?a.Doyouevernoticeringingorcracklinginyourears?b.Whenwasthelasttimeyouhadyourhearingchecked?c.Haveyoueverbeentoldthatyouhaveanytypeofhearingloss?d.Isthereanyrelationshipbetweentheearpainandthedischargeyoumentioned?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)217STUVIA.COMANS:DTypicallywithperforation,earpainoccursfirst,stoppingwithapoppingsensation,andthendrainageoccurs.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare16.A31-year-oldpatienttellsthenursethathehasnoticedpaininhisleftearwhenpeoplespeakloudlytohim.Thenurseknowsthatthisfinding:a.Isnormalforpeopleofhisage.b.Isacharacteristicofrecruitment.c.Mayindicateamiddleearinfection.d.Indicatesthatthepatienthasacerumenimpaction.ANS:BRecruitmentissignificanthearinglossoccurringwhenspeechisatlowintensity,butsoundactuallybecomespainfulwhenthespeakerrepeatsataloudervolume.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareENnUvRirSoInNmGeTnBt:.CMOaMnagementofCare17.Whilediscussingthehistoryofa6-month-oldinfant,themothertellsthenursethatshetookasignificantamountofaspirinwhileshewaspregnant.Whatquestionwouldthenursewanttoincludeinthehistory?a.Doesyourbabyseemtostartlewithloudnoises?b.Hasyourbabyhadanysurgeriesonherears?c.Haveyounoticedanydrainagefromherears?d.Howmanyearinfectionshasyourbabyhadsincebirth?ANS:AChildrenatriskforahearingdeficitincludethoseexposedinuterotoavarietyofconditions,suchasmaternalrubellaortomaternalototoxicdrugs.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance18.Thenurseisperforminganotoscopicexaminationonanadult.Whichoftheseactionsiscorrect?a.TiltingthepersonsheadforwardduringtheexaminationPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)218STUVIA.COMb.Oncethespeculumisintheear,releasingthetractionc.Pullingthepinnaupandbackbeforeinsertingthespeculumd.UsingthesmallestspeculumtodecreasetheamountofdiscomfortANS:CThepinnaispulledupandbackonanadultorolderchild,whichhelpsstraightentheS-shapeofthecanal.Tractionshouldnotbereleasedontheearuntiltheexaminationiscompletedandtheotoscopeisremoved.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare19.Thenurseisassessinga16-year-oldpatientwhohassufferedheadinjuriesfromarecentmotorvehicleaccident.Whichofthesestatementsindicatesthemostimportantreasonforassessingforanydrainagefromtheearcanal?a.Ifthedrumhasruptured,thenpurulentdrainagewillresult.b.Bloodyorclearwaterydrainagecanindicateabasalskullfracture.c.Theauditorycanalmanybeoccludedfromincreasedcerumen.NURSINGTB.COMd.Foreignbodiesfromtheaccidentmaycauseocclusionofthecanal.ANS:BFrankbloodorclearwaterydrainage(cerebrospinalleak)afteratraumasuggestsabasalskullfractureandwarrantsimmediatereferral.Purulentdrainageindicatesotitisexternaorotitismedia.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation20.Inperformingavoicetesttoassesshearing,whichoftheseactionswouldthenurseperform?a.Shieldthelipssothatthesoundismuffled.b.Whisperasetofrandomnumbersandletters,andthenaskthepatienttorepeatthem.c.Askthepatienttoplacehisfingerinhiseartooccludeoutsidenoise.d.Standapproximately4feetawaytoensurethatthepatientcanreallyhearatthisdistance.ANS:BWiththehead30to60cm(1to2feet)fromthepatientsear,theexaminerexhalesandslowlywhispersasetofrandomnumbersandletters,suchas5,B,6.Normally,thepatientisaskedtorepeateachnumberandletterPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)219STUVIA.COMcorrectlyafterhearingtheexaminersaythem.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare21.Inperforminganexaminationofa3-year-oldchildwithasuspectedearinfection,thenursewould:a.Omittheotoscopicexaminationifthechildhasafever.b.Pulltheearupandbackbeforeinsertingthespeculum.c.Askthemothertoleavetheroomwhileexaminingthechild.d.Performtheotoscopicexaminationattheendoftheassessment.ANS:DInadditiontoitsplaceinthecompleteexamination,eardrumassessmentismandatoryforanyinfantorchildrequiringcareforanillnessorfever.Fortheinfantoryoungchild,thetimingoftheotoscopicexaminationisbesttowardtheendofthecompleteexamination.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare22.ThenurseispreparingtoperformanotoscNoUpiRcSeIxNaGmTinBa.CtioOnMofanewborninfant.Whichstatementistrueregardingthisexamination?a.Immobilityofthedrumisanormalfinding.b.Aninjectedmembranewouldindicateaninfection.c.Thenormalmembranemayappearthickandopaque.d.Theappearanceofthemembraneisidenticaltothatofanadult.ANS:CDuringthefirstfewdaysafterthebirth,thetympanicmembraneofanewbornoftenappearsthickenedandopaque.Itmaylookinjectedandhaveamildrednessfromincreasedvascularity.Theotherstatementsarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance23.Thenurseassessesthehearingofa7-month-oldbyclappinghands.Whatistheexpectedresponse?Theinfant:a.Turnshisorherheadtolocalizethesound.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)220STUVIA.COMb.Showsnoobviousresponsetothenoise.c.Showsastartleandacousticblinkreflex.d.Stopsanymovement,andappearstolistenforthesound.ANS:AWithaloudsuddennoise,thenurseshouldnoticetheinfantturninghisorherheadtolocalizethesoundandtorespondtohisorherownname.Astartlereflexandacousticblinkreflexisexpectedinnewborns;atage3to4months,theinfantstopsanymovementandappearstolisten.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance24.Thenurseisperforminganearexaminationofan80-year-oldpatient.Whichofthesefindingswouldbeconsiderednormal?a.High-tonefrequencylossb.Increasedelasticityofthepinnac.Thin,translucentmembraned.Shiny,pinktympanicmembraneNURSINGTB.COMANS:AAhigh-tonefrequencyhearinglossisapparentforthoseaffectedwithpresbycusis,thehearinglossthatoccurswithaging.Thepinnaloseselasticity,causingearlobestobependulous.Theeardrummaybewhiterincolorandmoreopaqueanddullerintheolderpersonthanintheyoungeradult.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance25.Anassessmentofa23-year-oldpatientrevealsthefollowing:anauriclethatistenderandreddish-blueincolorwithsmallvesicles.Thenursewouldneedtoknowadditionalinformationthatincludeswhichofthese?a.Anychangeintheabilitytohearb.Anyrecentdrainagefromtheearc.Recenthistoryoftraumatotheeard.AnyprolongedexposuretoextremecoldANS:DPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)221STUVIA.COMFrostbitecausesreddish-bluediscolorationandswellingoftheauricleafterexposuretoextremecold.Vesiclesorbullaemaydevelop,andthepersonfeelspainandtenderness.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation26.Whileperformingtheotoscopicexaminationofa3-year-oldboywhohasbeenpullingonhisleftear,thenursefindsthathislefttympanicmembraneisbrightredandthatthelightreflexisnotvisible.Thenurseinterpretsthesefindingstoindicatea(n):a.Fungalinfection.b.Acuteotitismedia.c.Perforationoftheeardrum.d.Cholesteatoma.ANS:BAbsentordistortedlightreflexandabrightredcoloroftheeardrumareindicativeofacuteotitismedia.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationNURSINGTB.COM27.Themotherofa2-year-oldtoddlerisconcernedabouttheupcomingplacementoftympanostomytubesinhersonsears.Thenursewouldincludewhichofthesestatementsintheteachingplan?a.Thetubesareplacedintheinnerear.b.Thetubesareusedinchildrenwithsensorineuralloss.c.Thetubesarepermanentlyinsertedduringasurgicalprocedure.d.Thepurposeofthetubesistodecreasethepressureandallowfordrainage.ANS:DPolyethylenetubesaresurgicallyinsertedintotheeardrumtorelievemiddleearpressureandtopromotedrainageofchronicorrecurrentmiddleearinfections.Tubesspontaneouslyextrudein6monthsto1year.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation28.Inanindividualwithotitisexterna,whichofthesesignswouldthenurseexpecttofindonassessment?a.RhinorrheaPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)222STUVIA.COMb.Periorbitaledemac.Painoverthemaxillarysinusesd.EnlargedsuperficialcervicalnodesANS:DThelymphaticdrainageoftheexternalearflowstotheparotid,mastoid,andsuperficialcervicalnodes.Thesignsaresevereswellingofthecanal,inflammation,andtenderness.Rhinorrhea,periorbitaledema,andpainoverthemaxillarysinusesdonotoccurwithotitisexterna.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation29.Whenperforminganotoscopicexaminationofa5-year-oldchildwithahistoryofchronicearinfections,thenurseseesthathisrighttympanicmembraneisamber-yellowincolorandthatairbubblesarevisiblebehindthetympanicmembrane.Thechildreportsoccasionalhearinglossandapoppingsoundwithswallowing.Thepreliminaryanalysisbasedonthisinformationisthatthechild:a.Mostlikelyhasserousotitismedia.b.Hasanacutepurulentotitismedia.c.HasevidenceofaresolvingcholesNteUaRtoSmINa.GTB.COMd.Isexperiencingtheearlystagesofperforation.ANS:AAnamber-yellowcolortothetympanicmembranesuggestsserumorpusinthemiddleear.Airorfluidorbubblesbehindthetympanicmembraneareoftenvisible.Thepatientmayhavefeelingsoffullness,transienthearingloss,andapoppingsoundwithswallowing.Thesefindingsmostlikelysuggestthatthechildhasserousotitismedia.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation30.Thenurseisperforminganassessmentona65-year-oldman.Hereportsacrustynodulebehindthepinna.Itintermittentlybleedsandhasnothealedoverthepast6months.Onphysicalassessment,thenursefindsanulceratedcrustednodulewithaninduratedbase.Thepreliminaryanalysisinthissituationisthatthis:a.Ismostlikelyabenignsebaceouscyst.b.Ismostlikelyakeloid.c.Couldbeapotentialcarcinoma,andthepatientshouldbereferredforabiopsy.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)223STUVIA.COMd.Isatophus,whichiscommonintheolderadultandisasignofgout.ANS:CAnulceratedcrustednodulewithaninduratedbasethatfailstohealischaracteristicofacarcinoma.Theselesionsfailtohealandintermittentlybleed.Individualswithsuchsymptomsshouldbereferredforabiopsy.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation31.Thenursesuspectsthatapatienthasotitismedia.Earlysignsofotitismediaincludewhichofthesefindingsofthetympanicmembrane?a.Redandbulgingb.Hypomobilityc.Retractionwithlandmarksclearlyvisibled.Flat,slightlypulledinatthecenter,andmoveswithinsufflationANS:BAnearlysignofotitismediaishypomobilityoNfUthReSItyNmGpTaBn.iCcOmMembrane.Aspressureincreases,thetympanicmembranebeginstobulge.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare32.Thenurseisperformingamiddleearassessmentona15-year-oldpatientwhohashadahistoryofchronicearinfections.Whenexaminingtherighttympanicmembrane,thenurseseesthepresenceofdensewhitepatches.Thetympanicmembraneisotherwiseunremarkable.Itispearly,withthelightreflexat5oclockandlandmarksvisible.Thenurseshould:a.Referthepatientforthepossibilityofafungalinfection.b.Knowthatthesearescarscausedfromfrequentearinfections.c.Considerthatthesefindingsmayrepresentthepresenceofbloodinthemiddleear.d.Beconcernedabouttheabilitytohearbecauseofthisabnormalityonthetympanicmembrane.ANS:BDensewhitepatchesonthetympanicmembranearesequelaeofrepeatedearinfections.Theydonotnecessarilyaffecthearing.DIF:CognitiveLevel:Analyzing(Analysis)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)224STUVIA.COMMSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare33.Thenurseispreparingtodoanotoscopicexaminationona2-year-oldchild.Whichoneofthesereflectsthecorrectprocedure?a.Pullingthepinnadownb.Pullingthepinnaupandbackc.Slightlytiltingthechildsheadtowardtheexaminerd.InstructingthechildtotouchhischintohischestANS:AForanotoscopicexaminationonaninfantoronachildunder3yearsofage,thepinnaispulleddown.Theotherresponsesarenotpartofthecorrectprocedure.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance34.Thenurseisconductingachildsafetyclassfornewmothers.Whichfactorplacesyoungchildrenatriskforearinfections?a.Familyhistoryb.Airconditioningc.Excessivecerumend.PassivecigarettesmokeNURSINGTB.COMANS:DExposuretopassiveandgestationalsmokeisariskfactorforearinfectionsininfantsandchildren.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential35.Duringanotoscopicexamination,thenursenoticesanareaofblackandwhitedotsonthetympanicmembraneandtheearcanalwall.Whatdoesthisfindingsuggest?a.Malignancyb.Viralinfectionc.BloodinthemiddleearPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)225STUVIA.COMd.YeastorfungalinfectionANS:DAcolonyofblackorwhitedotsonthedrumorcanalwallsuggestsayeastorfungalinfection(otomycosis).DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:BasicCareandComfort36.A17-year-oldstudentisaswimmeronherhighschoolsswimteam.Shehashadthreeboutsofotitisexternathisseasonandwantstoknowwhattodotopreventit.Thenurseinstructsherto:a.Useacotton-tippedswabtodrytheearcanalsthoroughlyaftereachswim.b.Userubbingalcoholor2%aceticacideardropsaftereveryswim.c.Irrigatetheearswithwarmwaterandabulbsyringeaftereachswim.d.Rinsetheearswithawarmedsolutionofmineraloilandhydrogenperoxide.ANS:BWithotitisexterna(swimmersear),swimmingcausestheexternalcanaltobecomewaterloggedandswell;skinfoldsaresetupforinfection.Otitisexternacanbepreventedbyusingrubbingalcoholor2%aceticacideardropsaftereveryswim.NURSINGTB.COMDIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance37.Duringanexamination,thepatientstatesheishearingabuzzingsoundandsaysthatitisdrivingmecrazy!Thenurserecognizesthatthissymptomindicates:a.Vertigo.b.Pruritus.c.Tinnitus.d.Cholesteatoma.ANS:CTinnitusisasoundthatcomesfromwithinaperson;itcanbearinging,crackling,orbuzzingsound.Itaccompaniessomehearingoreardisorders.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:BasicCareandComfort38.Duringanexamination,thenursenoticesthatthepatientstumblesalittlewhilewalking,and,whenshesitsPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)226STUVIA.COMdown,sheholdsontothesidesofthechair.Thepatientstates,Itfeelsliketheroomisspinning!Thenursenoticesthatthepatientisexperiencing:a.Objectivevertigo.b.Subjectivevertigo.c.Tinnitus.d.Dizziness.ANS:AWithobjectivevertigo,thepatientfeelsliketheroomspins;withsubjectivevertigo,thepersonfeelslikeheorsheisspinning.Tinnitusisasoundthatcomesfromwithinaperson;itcanbearinging,crackling,orbuzzingsound.Itaccompaniessomehearingoreardisorders.Dizzinessisnotthesameastruevertigo;thepersonwhoisdizzymayfeelunsteadyandlightheaded.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation39.Apatienthasbeenadmittedafteranaccidentatwork.Duringtheassessment,thepatientishavingtroublehearingandstates,Idontknowwhatthematteris.Allofasudden,Icanthearyououtofmyleftear!Whatshouldthenursedonext?NURSINGTB.COMa.Makenoteofthisfindingforthereporttothenextshift.b.Preparetoremovecerumenfromthepatientsear.c.Notifythepatientshealthcareprovider.d.Irrigatetheearwithrubbingalcohol.ANS:CAnysuddenlossofhearinginoneorbothearsthatisnotassociatedwithanupperrespiratoryinfectionneedstobereportedatoncetothepatientshealthcareprovider.Hearinglossassociatedwithtraumaisoftensudden.Irrigatingtheearorremovingcerumenisnotappropriateatthistime.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:BasicCareandComfortMULTIPLERESPONSE1.Thenurseistestingthehearingofa78-year-oldmanandisremindedofthechangesinhearingthatoccurwithagingthatincludewhichofthefollowing?Selectallthatapply.a.Hearinglossrelatedtoagingbeginsinthemid40s.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)227STUVIA.COMb.Progressionofhearinglossisslow.c.Theagingpersonhaslow-frequencytoneloss.d.Theagingpersonmayfindithardertohearconsonantsthanvowels.e.Soundsmaybegarbledanddifficulttolocalize.f.Hearinglossreflectsnervedegenerationofthemiddleear.ANS:B,D,EPresbycusisisatypeofhearinglossthatoccurswithagingandisfoundin60%ofthoseolderthan65years.Itisagradualsensorineurallosscausedbynervedegenerationintheinnerearorauditorynerve,anditslowlyprogressesaftertheageof50years.Thepersonfirstnoticesahigh-frequencytoneloss;itishardertohearconsonants(high-pitchedcomponentsofspeech)thanvowels,whichmakeswordssoundgarbled.Theabilitytolocalizesoundisalsoimpaired.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenanceNURSINGTB.COMPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)228STUVIA.COMChapter17:Nose,Mouth,andThroatMULTIPLECHOICE1.Theprimarypurposeoftheciliatedmucousmembraneinthenoseisto:a.Warmtheinhaledair.b.Filteroutdustandbacteria.c.Filtercoarseparticlesfrominhaledair.d.Facilitatethemovementofairthroughthenares.ANS:BThenasalhairsfilterthecoarsestmatterfrominhaledair,whereasthemucousblanketfiltersoutdustandbacteria.Therichbloodsupplyofthenasalmucosawarmstheinhaledair.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General2.Theprojectionsinthenasalcavitythatincreasethesurfaceareaarecalledthe:a.Meatus.b.Septum.c.Turbinates.d.Kiesselbachplexus.NURSINGTB.COMANS:CThelateralwallsofeachnasalcavitycontainthreeparallelbonyprojections:thesuperior,middle,andinferiorturbinates.Theseincreasethesurfacearea,makingmorebloodvesselsandmucousmembraneavailabletowarm,humidify,andfiltertheinhaledair.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General3.Thenurseisreviewingthedevelopmentofthenewborninfant.Regardingthesinuses,whichstatementistrueinrelationtoanewborninfant?a.Sphenoidsinusesarefullsizeatbirth.b.Maxillarysinusesreachfullsizeafterpuberty.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)229STUVIA.COMc.Frontalsinusesarefairlywelldevelopedatbirth.d.Maxillaryandethmoidsinusesaretheonlysinusespresentatbirth.ANS:DOnlythemaxillaryandethmoidsinusesarepresentatbirth.Thesphenoidsinusesareminuteatbirthanddevelopafterpuberty.Thefrontalsinusesareabsentatbirth,arefairlywelldevelopedatage7to8years,andreachfullsizeafterpuberty.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General4.Thetissuethatconnectsthetonguetothefloorofthemouthisthe:a.Uvula.b.Palate.c.Papillae.d.Frenulum.ANS:DNURSINGTB.COMThefrenulumisamidlinefoldoftissuethatconnectsthetonguetothefloorofthemouth.Theuvulaisthefreeprojectionhangingdownfromthemiddleofthesoftpalate.Thepalateisthearchingroofofthemouth.Papillaearetherough,bumpyelevationsonthetonguesdorsalsurface.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General5.Thesalivaryglandthatisthelargestandlocatedinthecheekinfrontoftheearisthegland.a.Parotidb.Stensensc.Sublinguald.SubmandibularANS:AThemouthcontainsthreepairsofsalivaryglands.Thelargest,theparotidgland,lieswithinthecheeksinfrontoftheearextendingfromthezygomaticarchdowntotheangleofthejaw.TheStensensduct(notgland)drainstheparotidglandontothebuccalmucosaoppositethesecondmolar.Thesublingualglandislocatedwithinthefloorofthemouthunderthetongue.ThesubmandibularglandliesbeneaththemandibleattheanglePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)230STUVIA.COMofthejaw.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General6.Inassessingthetonsilsofa30yearold,thenursenoticesthattheyareinvoluted,granularinappearance,andappeartohavedeepcrypts.Whatiscorrectresponsetothesefindings?a.Referthepatienttoathroatspecialist.b.Noresponseisneeded;thisappearanceisnormalforthetonsils.c.Continuewiththeassessment,lookingforanyotherabnormalfindings.d.Obtainathroatcultureonthepatientforpossiblestreptococcal(strep)infection.ANS:BThetonsilsarethesamecolorasthesurroundingmucousmembrane,althoughtheylookmoregranularandtheirsurfaceshowsdeepcrypts.Tonsillartissueenlargesduringchildhooduntilpubertyandtheninvolutes.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare7.ThenurseisobtainingahealthhistoryonaN3U-mRoSnINthG-oTlBd.iCnOfaMnt.Duringtheinterview,themotherstates,Ithinksheisgettingherfirsttoothbecauseshehasstarteddroolingalot.Thenursesbestresponsewouldbe:a.Youreright,droolingisusuallyasignofthefirsttooth.b.Itwouldbeunusualfora3montholdtobegettingherfirsttooth.c.Thiscouldbethesignofaproblemwiththesalivaryglands.d.Sheisjuststartingtosalivateandhasntlearnedtoswallowthesaliva.ANS:DIntheinfant,salivationstartsat3months.Thebabywilldroolforafewmonthsbeforelearningtoswallowthesaliva.Thisdroolingdoesnotheraldtheeruptionofthefirsttooth,althoughmanyparentsthinkitdoes.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance8.Thenurseisassessingan80-year-oldpatient.Whichofthesefindingswouldbeexpectedforthispatient?a.Hypertrophyofthegumsb.IncreasedproductionofsalivaPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)231STUVIA.COMc.Decreasedabilitytoidentifyodorsd.FinerandlessprominentnasalhairANS:CThesenseofsmellmaybereducedbecauseofadecreaseinthenumberofolfactorynervefibers.Nasalhairsgrowcoarserandstifferwithaging.Thegumsmayrecedewithaging,nothypertrophy,andsalivaproductiondecreases.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance9.Thenurseisperforminganoralassessmentona40-year-oldBlackpatientandnoticesthepresenceofa1cm,nontender,grayish-whitelesionontheleftbuccalmucosa.Whichoneofthesestatementsistrue?Thislesionis:a.Leukoedemaandiscommonindark-pigmentedpersons.b.Theresultofhyperpigmentationandisnormal.c.Toruspalatinusandwouldnormallybefoundonlyinsmokers.d.IndicativeofcancerandshouldbeNimURmSeIdNiaGteTlBy.CteOstMed.ANS:ALeukoedema,agrayish-whitebenignlesionoccurringonthebuccalmucosa,ismostoftenobservedinBlacks.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation10.Whileobtainingahealthhistory,apatienttellsthenursethathehasfrequentnosebleedsandasksthebestwaytogetthemtostop.Whatwouldbethenursesbestresponse?a.Whilesittingup,placeacoldcompressoveryournose.b.Situpwithyourheadtiltedforwardandpinchyournose.c.Justallowthebleedingtostoponitsown,butdontblowyournose.d.Lieonyourbackwithyourheadtiltedbackandpinchyournose.ANS:BWithanosebleed,thepersonshouldsitupwiththeheadtiltedforwardandpinchthenosebetweenthethumbandforefingerfor5to15minutes.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)232STUVIA.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation11.A92-year-oldpatienthashadastroke.Therightsideofhisfaceisdrooping.Thenursemightalsosuspectwhichoftheseassessmentfindings?a.Epistaxisb.Rhinorrheac.Dysphagiad.XerostomiaANS:CDysphagiaisdifficultywithswallowingandmayoccurwithavarietyofdisorders,includingstrokeandotherneurologicdiseases.Rhinorrheaisarunnynose,epistaxisisabloodynose,andxerostomiaisadrymouth.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation12.Whileobtainingahealthhistoryfromthemotherofa1-year-oldchild,thenursenoticesthatthebabyhashadabottleinhismouththeentiretime.Themotherstates,Itmakesagreatpacifier.Thebestresponsebythenursewouldbe:NURSINGTB.COMa.Youreright.Bottlesmakeverygoodpacifiers.b.Usingabottleasapacifierisbetterfortheteeththanthumb-sucking.c.Itsokaytouseabottleaslongasitcontainsmilkandnotjuice.d.Prolongeduseofabottlecanincreasetheriskfortoothdecayandearinfections.ANS:DProlongedbottleuseduringthedayorwhengoingtosleepplacestheinfantatriskfortoothdecayandmiddleearinfections.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance13.A72-year-oldpatienthasahistoryofhypertensionandchroniclungdisease.Animportantquestionforthenursetoincludeinthehealthhistorywouldbe:a.Doyouuseafluoridesupplement?b.Haveyouhadtonsillitisinthelastyear?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)233STUVIA.COMc.Atwhatagedidyougetyourfirsttooth?d.Haveyounoticedanydrynessinyourmouth?ANS:DXerostomia(drymouth)isasideeffectofmanydrugstakenbyolderpeople,includingantidepressants,anticholinergics,antispasmodics,antihypertensives,antipsychotics,andbronchodilators.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation14.Thenurseisusinganotoscopetoassessthenasalcavity.Whichofthesetechniquesiscorrect?a.Insertingthespeculumatleast3cmintothevestibuleb.Avoidingtouchingthenasalseptumwiththespeculumc.Gentlydisplacingthenosetothesidethatisbeingexaminedd.KeepingthespeculumtipmedialtoavoidtouchingthefloorofthenaresANS:BNURSINGTB.COMThecorrecttechniqueforusinganotoscopeistoinserttheapparatusintothenasalvestibule,avoidingpressureonthesensitivenasalseptum.Thetipofthenoseshouldbeliftedupbeforeinsertingthespeculum.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare15.Thenurseisperforminganassessmentona21-year-oldpatientandnoticesthathisnasalmucosaappearspale,gray,andswollen.Whatwouldbethemostappropriatequestiontoaskthepatient?a.Areyouawareofhavinganyallergies?b.Doyouhaveanelevatedtemperature?c.Haveyouhadanysymptomsofacold?d.Haveyoubeenhavingfrequentnosebleeds?ANS:AWithchronicallergies,themucosalooksswollen,boggy,pale,andgray.Elevatedbodytemperature,colds,andnosebleedsdonotcausethesemucosalchanges.DIF:CognitiveLevel:Applying(Application)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)234STUVIA.COMMSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare16.Thenurseispalpatingthesinusareas.Ifthefindingsarenormal,thenthepatientshouldreportwhichsensation?a.Nosensationb.Firmpressurec.Painduringpalpationd.PainsensationbehindeyesANS:BThepersonshouldfeelfirmpressurebutnopain.Sinusareasaretendertopalpationinpersonswithchronicallergiesoranacuteinfection(sinusitis).DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare17.Duringanoralassessmentofa30-year-oldBlackpatient,thenursenoticesbluishlipsandadarklinealongthegingivalmargin.Whatactionwouldthenurseperforminresponsetothisfinding?a.CheckthepatientshemoglobinforNaUnRemSIiNa.GTB.COMb.Assessforothersignsofinsufficientoxygensupply.c.Proceedwiththeassessment,knowingthatthisappearanceisanormalfinding.d.Askifhehasbeenexposedtoanexcessiveamountofcarbonmonoxide.ANS:CSomeBlacksmayhavebluishlipsandadarklineonthegingivalmargin;thisappearanceisanormalfinding.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare18.Duringanassessmentofa20-year-oldpatientwitha3-dayhistoryofnauseaandvomiting,thenursenoticesdrymucosaanddeepverticalfissuresinthetongue.Thesefindingsarereflectiveof:a.Dehydration.b.Irritationbygastricjuices.c.Anormaloralassessment.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)235STUVIA.COMd.Sideeffectsfromnauseamedication.ANS:ADrymouthoccurswithdehydrationorfever.Thetonguehasdeepverticalfissures.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation19.A32-year-oldwomanisattheclinicforlittlewhitebumpsinmymouth.Duringtheassessment,thenursenotesthatshehasa0.5cmwhite,nontenderpapuleunderhertongueandoneonthemucosaofherrightcheekWhatwouldthenursetellthepatient?a.Thesespotsindicateaninfectionsuchasstrepthroat.b.Thesebumpscouldbeindicativeofaseriouslesion,soIwillreferyoutoaspecialist.c.Thisconditioniscalledleukoplakiaandcanbecausedbychronicirritationsuchaswithsmoking.d.ThesebumpsareFordycegranules,whicharesebaceouscystsandarenotaseriouscondition.ANS:DFordycegranulesaresmall,isolatedwhiteoryellowpapulesonthemucosaofthecheek,tongue,andlips.TheselittlesebaceouscystsarepainlessandaNreUnRoStIsNigGnTifBic.CanOtM.Chalky,whiteraisedpatcheswouldindicateleukoplakia.Instrepthroat,theexaminerwouldseetonsilsthatarebrightred,swollen,andmayhaveexudatesorwhitespots.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation20.A10yearoldisattheclinicforasorethroatthathaslasted6days.Whichofthesefindingswouldbeconsistentwithanacuteinfection?a.Tonsils1+/1-4+andpink;thesamecolorastheoralmucosab.Tonsils2+/1-4+withsmallplugsofwhitedebrisc.Tonsils3+/1-4+withlargewhitespotsd.Tonsils3+/1-4+withpalecoloringANS:CWithanacuteinfection,tonsilsarebrightredandswollenandmayhaveexudateorlargewhitespots.Tonsilsareenlargedto2+,3+,or4+withanacuteinfection.DIF:CognitiveLevel:Understanding(Comprehension)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)236STUVIA.COMMSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation21.Immediatelyafterbirth,thenurseisunabletosuctionthenaresofanewborn.Anattemptismadetopassacatheterthroughbothnasalcavitieswithnosuccess.Whatshouldthenursedonext?a.Attempttosuctionagainwithabulbsyringe.b.Waitafewminutes,andtryagainoncetheinfantstopscrying.c.Recognizethatthissituationrequiresimmediateintervention.d.Contactthephysiciantoscheduleanappointmentfortheinfantathisorhernexthospitalvisit.ANS:CDeterminingthepatencyofthenaresintheimmediatenewbornperiodisessentialbecausemostnewbornsareobligatenosebreathers.Naresblockedwithamnioticfluidaregentlysuctionedwithabulbsyringe.Ifobstructionissuspected,thenasmalllumen(5to10Fr)catheterispasseddowneachnaristoconfirmpatency.Theinabilitytopassacatheterthroughthenasalcavityindicateschoanalatresia,whichrequiresimmediateintervention.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation22.Thenursenoticesthatthemotherofa2-year-oldboybringshimintotheclinicquitefrequentlyforvariousinjuriesandsuspectstheremaybesomechildNaUbuRsSeINinGvoTlBv.eCdO.DMuringaninspectionofhismouth,thenurseshouldlookfor:a.Swollen,redtonsils.b.Ulcerationsonthehardpalate.c.Bruisingonthebuccalmucosaorgums.d.Smallyellowpapulesalongthehardpalate.ANS:CThenurseshouldnoticeanybruisingorlacerationonthebuccalmucosaorgumsofaninfantoryoungchild.Traumamayindicatechildabusefromaforcedfeedingofabottleorspoon.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential23.Thenurseisassessinga3yearoldfordrainagefromthenose.Onassessment,apurulentdrainagethathasaveryfoulodorisnotedfromtheleftnarisandnodrainageisobservedfromtherightnaris.Thechildisafebrilewithnoothersymptoms.Whatshouldthenursedonext?a.Refertothephysicianforanantibioticorder.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)237STUVIA.COMb.Havethemotherbringthechildbackin1week.c.Performanotoscopicexaminationoftheleftnares.d.Tellthemotherthatthisdrainageisnormalforachildofthisage.ANS:CChildrenarepronetoputanobjectupthenose,producingunilateralpurulentdrainagewithafoulodor.Becausesomeriskforaspirationexists,removalshouldbeprompt.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation24.Duringanassessmentofa26yearoldattheclinicforaspotonmylipIthinkiscancer,thenursenoticesagroupofclearvesicleswithanerythematousbasearoundthemlocatedatthelip-skinborder.ThepatientmentionsthatshejustreturnedfromHawaii.Whatwouldbethemostappropriateresponsebythenurse?a.Tellthepatientsheneedstoseeaskinspecialist.b.Discussthebenefitsofhavingabiopsyperformedonanyunusuallesion.c.TellthepatientthatthesevesiclesareindicativeofherpessimplexIorcoldsoresandthattheywillhealin4to10days.NURSINGTB.COMd.Tellthepatientthatthesevesiclesaremostlikelytheresultofariboflavindeficiencyanddiscussnutrition.ANS:CColdsoresaregroupsofclearvesicleswithasurroundingerythematousbase.Theseevolveintopustulesorcrustsandhealin4to10days.Themostlikelysiteisthelip-skinjunction.Infectionoftenrecursinthesamesite.Recurrentherpesinfectionsmaybeprecipitatedbysunlight,fever,colds,orallergy.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation25.Whileperforminganassessmentofthemouth,thenursenoticesthatthepatienthasa1-cmulcerationthatiscrustedwithanelevatedborderandlocatedontheouterthirdofthelowerlip.Whatotherinformationwouldbemostimportantforthenursetoassess?a.Nutritionalstatusb.Whenthepatientfirstnoticedthelesionc.Whetherthepatienthashadarecentcoldd.WhetherthepatienthashadanyrecentexposuretosickanimalsPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)238STUVIA.COMANS:BWithcarcinoma,theinitiallesionisroundandindurated,butthenitbecomescrustedandulceratedwithanelevatedborder.Mostcancersoccurbetweentheouterandmiddlethirdsofthelip.Anylesionthatisstillunhealedafter2weeksshouldbereferred.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential26.Apregnantwomanstatesthatsheisconcernedabouthergumsbecauseshehasnoticedtheyareswollenandhavestartedbleeding.Whatwouldbeanappropriateresponsebythenurse?a.YourconditionisprobablyduetoavitaminCdeficiency.b.Imnotsurewhatcausesswollenandbleedinggums,butletmeknowifitsnotbetterinafewweeks.c.Youneedtomakeanappointmentwithyourdentistassoonaspossibletohavethischecked.d.Swollenandbleedinggumscanbecausedbythechangeinhormonalbalanceinyoursystemduringpregnancy.ANS:DNURSINGTB.COMGummarginsareredandswollenandeasilybleedwithgingivitis.Achanginghormonalbalancemaycausethisconditiontooccurinpregnancyandpuberty.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation27.A40-year-oldpatientwhohasjustfinishedchemotherapyforbreastcancertellsthenursethatsheisconcernedabouthermouth.Duringtheassessmentthenursefindsareasofbuccalmucosathatarerawandredwithsomebleeding,aswellasotherareasthathaveawhite,cheesycoating.Thenurserecognizesthatthisabnormalityis:a.Aphthousulcers.b.Candidiasis.c.Leukoplakia.d.Koplikspots.ANS:BCandidiasisisawhite,cheesy,curdlikepatchonthebuccalmucosaandtongue.Itscrapesoff,leavingaraw,redsurfacethateasilybleeds.Italsooccursaftertheuseofantibioticsorcorticosteroidsandinpersonswhoareimmunosuppressed.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)239STUVIA.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation28.Thenurseisassessingapatientinthehospitalwhohasreceivednumerousantibioticsandnoticesthathistongueappearstobeblackandhairy.Inresponsetohisconcern,whatwouldthenursesay?a.Wewillneedtogetabiopsytodeterminethecause.b.Thisisanovergrowthofhairandwillgoawayinafewdays.c.Black,hairytongueisafungalinfectioncausedbyalltheantibioticsyouhavereceived.d.Thisisprobablycausedbythesamebacteriayouhadinyourlungs.ANS:CAblack,hairytongueisnotreallyhairbuttheelongationoffiliformpapillaeandpainlessovergrowthofmycelialthreadsoffungusinfectiononthetongue.Itoccursaftertheuseofantibiotics,whichinhibitnormalbacteriaandallowaproliferationoffungus.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation29.Thenurseisassessingapatientwithahistoryofintravenousdrugabuse.Inassessinghismouth,thenursenoticesadarkredconfluentmaculeontheharNdUpRalSaItNe.GTThBis.CcOoMuldbeanearlysignof:a.Acquiredimmunodeficiencysyndrome(AIDS).b.Measles.c.Leukemia.d.Carcinoma.ANS:AOralKaposissarcomaisabruiselike,darkredorviolet,confluentmaculethatusuallyoccursonthehardpalate.Itmayappearonthesoftpalateorgingivalmargin.OrallesionsmaybeamongtheearliestlesionstodevelopwithAIDS.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation30.Amotherbringsher4-month-oldinfanttotheclinicwithconcernsregardingasmallpadinthemiddleoftheupperlipthathasbeentheresince1monthofage.Theinfanthasnohealthproblems.Onphysicalexamination,thenursenoticesa0.5-cm,fleshy,elevatedareainthemiddleoftheupperlip.Noevidenceofinflammationordrainageisobserved.Whatwouldthenursetellthismother?a.Thisareaofirritationiscausedfromteethingandisnothingtoworryabout.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)240STUVIA.COMb.Thisfindingisabnormalandshouldbeevaluatedbyanotherhealthcareprovider.c.Thisareaofirritationistheresultofchronicdroolingandshouldresolvewithinthenextmonthortwo.d.Thiselevatedareaisasuckingtuberclecausedfromthefrictionofbreastfeedingorbottle-feedingandisnormal.ANS:DAnormalfindingininfantsisthesuckingtubercle,asmallpadinthemiddleoftheupperlipfromthefrictionofbreastfeedingorbottle-feeding.Thisconditionisnotcausedbyirritation,teething,orexcessivedrooling,andevaluationbyanotherhealthcareproviderisnotwarranted.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance31.Amotherisconcernedbecauseher18-month-oldtoddlerhas12teeth.Sheiswonderingifthisisnormalforachildofthisage.Thenursesbestresponsewouldbe:a.Howmanyteethdidyouhaveatthisage?b.All20deciduousteethareexpectedtoeruptbyage4years.NURSINGTB.COMc.Thisisanormalnumberofteethforan18monthold.d.Normally,byage2years,16deciduousteethareexpected.ANS:CTheguidelinesforthenumberofteethforchildrenyoungerthan2yearsoldareasfollows:thechildsageinmonthsminusthenumber6shouldbeequaltotheexpectednumberofdeciduousteeth.Normally,all20teethareinby2yearsold.Inthisinstance,thechildis18monthsold,minus6,equals12deciduousteethexpected.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance32.Whenexaminingthemouthofanolderpatient,thenurserecognizeswhichfindingisduetotheagingprocess?a.Teethappearingshorterb.Tonguethatlookssmootherinappearancec.Buccalmucosathatisbeefyredinappearanced.Small,painlesslumponthedorsumofthetonguePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)241STUVIA.COMANS:BIntheagingadult,thetonguelookssmootherbecauseofpapillaryatrophy.Theteethareslightlyyellowedandappearlongerbecauseoftherecessionofgingivalmargins.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:HealthPromotionandMaintenance33.Whenexaminingthenaresofa45-year-oldpatientwhohascomplaintsofrhinorrhea,itchingofthenoseandeyes,andsneezing,thenursenoticesthefollowing:paleturbinates,swellingoftheturbinates,andclearrhinorrhea.Whichoftheseconditionsismostlikelythecause?a.Nasalpolypsb.Acutesinusitisc.Allergicrhinitisd.AcuterhinitisANS:CRhinorrhea,itchingofthenoseandeyes,andsneezingarepresentwithallergicrhinitis.Onphysicalexamination,serousedemaisnoted,andthetuNrUbiRnSatIeNsGuTsBua.CllOyMappearpalewithasmooth,glisteningsurface.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation34.Whenassessingthetongueofanadult,thenurseknowsthatanabnormalfindingwouldbe:a.Smoothglossydorsalsurface.b.Thinwhitecoatingoverthetongue.c.Raisedpapillaeonthedorsalsurface.d.Visiblevenouspatternsontheventralsurface.ANS:AThedorsalsurfaceofthetongueisnormallyroughenedfrompapillae.Athinwhitecoatingmaybepresent.Theventralsurfacemayshowveins.Smooth,glossyareasmayindicateatrophicglossitis.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation35.Thenurseisperforminganassessment.Whichofthesefindingswouldcausethegreatestconcern?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)242STUVIA.COMa.Painfulvesicleinsidethecheekfor2daysb.Presenceofmoist,nontenderStensensductsc.Stippledgingivalmarginsthatsnuglyadheretotheteethd.UlcerationonthesideofthetonguewithrollededgesANS:DUlcerationonthesideorbaseofthetongueorunderthetongueraisesthesuspicionofcancerandmustbeinvestigated.Theriskofearlymetastasisispresentbecauseofrichlymphaticdrainage.Thevesiclemaybeanaphthousulcer,whichispainfulbutnotdangerous.Theotherresponsesarenormalfindings.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare36.Apatienthasbeendiagnosedwithstrepthroat.Thenurseisawarethatwithouttreatment,whichcomplicationmayoccur?a.Rubellab.LeukoplakiaNURSINGTB.COMc.Rheumaticfeverd.ScarletfeverANS:CUntreatedstrepthroatmayleadtorheumaticfever.Whenperformingahealthhistory,thepatientshouldbeaskedwhetherhisorhersorethroathasbeendocumentedasstreptococcal.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential37.Duringacheckup,a22-year-oldwomantellsthenursethatsheusesanover-the-counternasalspraybecauseofherallergies.Shealsostatesthatitdoesnotworkaswellasitusedtowhenshefirststartedusingit.Thebestresponsebythenursewouldbe:a.Youshouldneveruseover-the-counternasalspraysbecauseoftheriskofaddiction.b.Youshouldtryswitchingtoanotherbrandofmedicationtopreventthisproblem.c.Continuingtousethissprayisimportanttokeepyourallergiesundercontrol.d.Usingthesenasalmedicationsirritatestheliningofthenoseandmaycausereboundswelling.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)243STUVIA.COMANS:DThemisuseofover-the-counternasalmedicationsirritatesthemucosa,causingreboundswelling,whichisacommonproblem.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential38.Duringanoralexaminationofa4-year-oldNative-Americanchild,thenursenoticesthatheruvulaispartiallysplit.Whichofthesestatementsisaccurate?a.ThisconditionisacleftpalateandiscommoninNativeAmericans.b.AbifiduvulamayoccurinsomeNative-Americangroups.c.Thisconditionisduetoaninjuryandshouldbereportedtotheauthorities.d.Abifiduvulaispalatinus,whichfrequentlyoccursinNativeAmericans.ANS:BBifiduvula,aconditioninwhichtheuvulaisspliteithercompletelyorpartially,occursinsomeNative-Americangroups.DIF:CognitiveLevel:Applying(Application)NURSINGTB.COMMSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation39.Apatientcomesintothecliniccomplainingoffacialpain,fever,andmalaise.Onexamination,thenursenotesswollenturbinatesandpurulentdischargefromthenose.Thepatientalsocomplainsofadull,throbbingpaininhischeeksandteethontherightsideandpainwhenthenursepalpatestheareas.Thenurserecognizesthatthispatienthas:a.Posteriorepistaxis.b.Frontalsinusitis.c.Maxillarysinusitis.d.Nasalpolyps.ANS:CSignsofmaxillarysinusitisincludefacialpainafterupperrespiratoryinfection,redswollennasalmucosa,swollenturbinates,andpurulentdischarge.Thepersonalsohasfever,chills,andmalaise.Withmaxillarysinusitis,dullthrobbingpainoccursinthecheeksandteethonthesameside,andpainwithpalpationispresent.Withfrontalsinusitis,painisabovethesupraorbitalridge.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)244STUVIA.COM40.Awomanwhoisinthesecondtrimesterofpregnancymentionsthatshehashadmorenosebleedsthaneversinceshebecamepregnant.Thenurserecognizesthatthisisaresultof:a.Aproblemwiththepatientscoagulationsystem.b.Increasedvascularityintheupperrespiratorytractasaresultofthepregnancy.c.Increasedsusceptibilitytocoldsandnasalirritation.d.Inappropriateuseofnasalsprays.ANS:BNasalstuffinessandepistaxismayoccurduringpregnancyasaresultofincreasedvascularityintheupperrespiratorytract.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenanceMULTIPLERESPONSE1.Thenurseisteachingahealthclasstohigh-schoolboys.Whendiscussingthetopicofusingsmokelesstobacco(SLT),whichofthesestatementsareaccurate?Selectallthatapply.a.OnepinchofSLTinthemouthforN3U0RmSIiNnuGtTesBd.CeOlivMerstheequivalentofonecigarette.b.UsingSLThasbeenassociatedwithagreaterriskoforalcancerthansmoking.c.Painisanearlysignoforalcancer.d.Painisrarelyanearlysignoforalcancer.e.ToothdecayisanotherriskofSLTbecauseoftheuseofsugarasasweetener.f.SLTisconsideredahealthyalternativetosmoking.ANS:B,D,EOnepinchofSLTinthemouthfor30minutesdeliverstheequivalentofthreecigarettes.Painisrarelyanearlysignoforalcancer.ManybrandsofSLTaresweetenedwithsugars,whichpromotestoothdecay.SLTisnotconsideredahealthyalternativetosmoking,andtheuseofSLThasbeenassociatedwithagreaterriskoforalcancerthansmoking.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance2.Duringanassessment,apatientmentionsthatIjustcantsmelllikeIusedto.Icanbarelysmelltherosesinmygarden.Whyisthat?Forwhichpossiblecausesofchangesinthesenseofsmellwillthenurseassess?Selectallthatapply.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)245STUVIA.COMa.Chronicalcoholuseb.Cigarettesmokingc.Frequentepisodesofstrepthroatd.Chronicallergiese.Agingf.HerpessimplexvirusIANS:B,D,ESenThesenseofsmelldiminisheswithcigarettesmoking,chronicallergies,andaging.Chronicalcoholuse,ahistoryofstrepthroat,andherpessimplexvirusIarenotassociatedwithchangesinthesenseofsmell.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationNURSINGTB.COMPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)246STUVIA.COMChapter18:Breasts,Axillae,andRegionalLymphaticsMULTIPLECHOICE1.Whichofthefollowingstatementsistrueregardingtheinternalstructuresofthebreast?Thebreastismadeupof:a.Primarilymusclewithverylittlefibroustissue.b.Fibrous,glandular,andadiposetissues.c.Primarilymilkducts,knownaslactiferousducts.d.Glandulartissue,whichsupportsthebreastbyattachingtothechestwall.ANS:BThebreastismadeupofglandular,fibrous(includingthesuspensoryligaments),andadiposetissues.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General2.Inperformingabreastexamination,thenurseknowsthatexaminingtheupperouterquadrantofthebreastisespeciallyimportant.Thereasonforthisisthattheupperouterquadrantis:NURSINGTB.COMa.Thelargestquadrantofthebreast.b.Thelocationofmostbreasttumors.c.Wheremostofthesuspensoryligamentsattach.d.Morepronetoinjuryandcalcificationsthanotherlocationsinthebreast.ANS:BTheupperouterquadrantisthesiteofmostbreasttumors.Intheupperouterquadrant,thenurseshouldnoticetheaxillarytailofSpence,thecone-shapedbreasttissuethatprojectsupintotheaxilla,closetothepectoralgroupofaxillarylymphnodes.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare3.Inperforminganassessmentofawomansaxillarylymphsystem,thenurseshouldassesswhichofthesenodes?a.Central,axillary,lateral,andsternalb.Pectoral,lateral,anterior,andsternalPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)247STUVIA.COMc.Central,lateral,pectoral,andsubscapulard.Lateral,pectoral,axillary,andsuprascapularANS:CThebreasthasextensivelymphaticdrainage.Fourgroupsofaxillarynodesarepresent:(1)central,(2)pectoral(anterior),(3)subscapular(posterior),and(4)lateral.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare4.Ifapatientreportsarecentbreastinfection,thenthenurseshouldexpecttofindnodeenlargement.a.Nonspecificb.Ipsilateralaxillaryc.Contralateralaxillaryd.InguinalandcervicalNURSINGTB.COMANS:BThebreasthasextensivelymphaticdrainage.Mostofthelymph,morethan75%,drainsintotheipsilateral,orsameside,axillarynodes.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation5.A9-year-oldgirlisintheclinicforasportphysicalexamination.Aftersomeinitialshynessshefinallyasks,AmInormal?Idontseemtoneedabrayet,butIhavesomefriendswhodo.WhatifInevergetbreasts?Thenursesbestresponsewouldbe:a.Dontworry,youstillhaveplentyoftimetodevelop.b.Iknowjusthowyoufeel,Iwasalatebloomermyself.Justbepatient,andtheywillgrow.c.Youwillprobablygetyourperiodsbeforeyounoticeanysignificantgrowthinyourbreasts.d.Iunderstandthatitishardtofeeldifferentfromyourfriends.Breastsusuallydevelopbetween8and10yearsofage.ANS:DAdolescentbreastdevelopmentusuallybeginsbetween8and10yearsofage.Thenurseshouldnotbelittlethegirlsfeelingsbyusingstatementslikedontworryorbysharingpersonalexperiences.ThebeginningofbreastPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)248STUVIA.COMdevelopmentprecedesmenarchebyapproximately2years.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance6.Apatientcontactstheofficeandtellsthenursethatsheisworriedabouther10-year-olddaughterhavingbreastcancer.Shedescribesaunilateralenlargementoftherightbreastwithassociatedtenderness.Sheisworriedbecausetheleftbreastisnotenlarged.Whatwouldbethenursesbestresponse?Tellthemotherthat:a.Breastdevelopmentisusuallyfairlysymmetricandthatthedaughtershouldbeexaminedrightaway.b.Sheshouldbringinherdaughterrightawaybecausebreastcancerisfairlycommoninpreadolescentgirls.c.Althoughanexaminationofherdaughterwouldruleoutaproblem,herbreastdevelopmentismostlikelynormal.d.Itisunusualforbreaststhatarefirstdevelopingtofeeltenderbecausetheyhaventdevelopedmuchfibroustissue.ANS:COccasionally,onebreastmaygrowfasterthantheother,producingatemporaryasymmetry,whichmaycausesomedistress;reassuranceisnecessary.Tendernessisalsocommon.NURSINGTB.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation7.A14-year-oldgirlisanxiousaboutnothavingreachedmenarche.Whentakingthehealthhistory,thenurseshouldascertainwhichofthefollowing?Theagethat:a.Thegirlbegantodevelopbreasts.b.Hermotherdevelopedbreasts.c.Shebegantodeveloppubichair.d.Shebegantodevelopaxillaryhair.ANS:AFulldevelopmentfromstage2tostage5takesanaverageof3years,althoughtherangeis1to6years.Pubichairdevelopsduringthistime,andaxillaryhairappears2yearsaftertheonsetofpubichair.Thebeginningofbreastdevelopmentprecedesmenarchebyapproximately2years.Menarcheoccursinbreastdevelopmentstage3or4,usuallyjustafterthepeakoftheadolescentgrowthspurt,whichoccursaroundage12years.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenancePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)249STUVIA.COM8.Awomanisinthefamilyplanningclinicseekingbirthcontrolinformation.Shestatesthatherbreastschangeallmonthlongandthatsheisworriedthatthisisunusual.Whatisthenursesbestresponse?Thenurseshouldtellherthat:a.Continualchangesinherbreastsareunusual.Thebreastsofnonpregnantwomenusuallystayprettymuchthesameallmonthlong.b.Breastchangesinresponsetostressareverycommonandthatsheshouldassessherlifeforstressfulevents.c.Becauseofthechanginghormonesduringthemonthlymenstrualcycle,cyclicbreastchangesarecommon.d.Breastchangesnormallyoccuronlyduringpregnancyandthatapregnancytestisneededatthistime.ANS:CBreastsofthenonpregnantwomanchangewiththeebbandflowofhormonesduringthemonthlymenstrualcycle.Duringthe3to4daysbeforemenstruation,thebreastsfeelfull,tight,heavy,andoccasionallysore.Thebreastvolumeissmallestondays4to7ofthemenstrualcycle.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance9.AwomanhasjustlearnedthatsheispregnaNnUt.RWSIhNaGtaTrBe.sCoOmMethingsthenurseshouldteachheraboutherbreasts?a.Shecanexpectherareolaetobecomelargeranddarkerincolor.b.Breastsmaybeginsecretingmilkafterthefourthmonthofpregnancy.c.Sheshouldinspectherbreastsforvisibleveinsandimmediatelyreportthese.d.Duringpregnancy,breastchangesarefairlyuncommon;mostofthechangesoccurafterthebirth.ANS:ATheareolaebecomelargerandgrowadarkerbrownaspregnancyprogresses,andthetuberclesbecomemoreprominent.(Thebrowncolorfadesafterlactation,buttheareolaeneverreturntotheiroriginalcolor).Avenouspatternisanexpectedfindingandprominentovertheskinsurfaceanddoesnotneedtobereported.Afterthefourthmonthofpregnancy,colostrum,athick,yellowfluid(precursortomilk),maybeexpressedfromthebreasts.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation10.Thenurseisteachingapregnantwomanaboutbreastmilk.Whichstatementbythenurseiscorrect?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)250STUVIA.COMa.Yourbreastmilkisimmediatelypresentafterthedeliveryofyourbaby.b.Breastmilkisrichinproteinandsugars(lactose)buthasverylittlefat.c.Thecolostrum,whichispresentrightafterbirth,doesnotcontainthesamenutrientsasbreastmilk.d.Youmaynoticeathick,yellowfluidexpressedfromyourbreastsasearlyasthefourthmonthofpregnancy.ANS:DAfterthefourthmonth,colostrummaybeexpressed.Thisthickyellowfluidistheprecursorofmilk,anditcontainsthesameamountofproteinandlactosebutpracticallynofat.Thebreastsproducecolostrumforthefirstfewdaysafterdelivery.Itisrichwithantibodiesthatprotectthenewbornagainstinfection;therefore,breastfeedingisimportant.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation11.A65-year-oldpatientremarksthatshejustcannotbelievethatherbreastssagsomuch.Shestatesitmustbefromalackofexercise.Whatexplanationshouldthenurseofferher?Aftermenopause:a.Onlywomenwithlargebreastsexperiencesagging.b.SaggingisusuallyduetodecreaseNdUmRuSsIcNleGmTBas.CsOwMithinthebreast.c.Adietthatishighinproteinwillhelpmaintainmusclemass,whichkeepsthebreastsfromsagging.d.Theglandularandfattissueatrophies,causingbreastsizeandelasticitytodiminish,resultinginbreaststhatsag.ANS:DAftermenopause,theglandulartissueatrophiesandisreplacedwithconnectivetissue.Thefatenvelopealsoatrophies,beginninginthemiddleyearsandbecomingsignificantintheeighthandninthdecadesoflife.Thesechangesdecreasebreastsizeandelasticity;consequently,thebreastsdroopandsag,lookingflattenedandflabby.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance12.Inexamininga70-year-oldmalepatient,thenursenoticesthathehasbilateralgynecomastia.Whichofthefollowingdescribesthenursesbestcourseofaction?a.Recommendthathemakeanappointmentwithhisphysicianforamammogram.b.Ignoreit.Benignbreastenlargementinmenisnotunusual.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)251STUVIA.COMc.Explainthatthisconditionmaybetheresultofhormonalchanges,andrecommendthatheseehisphysician.d.Explainthatgynecomastiainmenisusuallyassociatedwithprostateenlargementandrecommendthathebethoroughlyscreened.ANS:CGynecomastiamayreappearintheagingmanandmaybeattributabletoatestosteronedeficiency.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare13.Duringanexaminationofa7-year-oldgirl,thenursenoticesthatthegirlisshowingbreastbudding.Whatshouldthenursedonext?a.Asktheyounggirlifherperiodshavestarted.b.Assessthegirlsweightandbodymassindex(BMI).c.Askthegirlsmotheratwhatageshestartedtodevelopbreasts.d.Nothing;breastbuddingisanormalfinding.NURSINGTB.COMANS:BResearchhasshownthatgirlswithoverweightorobeseBMIlevelshaveahigheroccurrenceofearlyonsetofbreastbudding(beforeage8yearsforblackgirlsandage10yearsforwhitegirls)andearlymenarche.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance14.Thenurseisreviewingstatisticsregardingbreastcancer.Whichwoman,aged40yearsintheUnitedStateshasthehighestriskfordevelopingbreastcancer?a.Blackb.Whitec.Asiand.AmericanIndianANS:ATheincidenceofbreastcancervarieswithindifferentculturalgroups.Whitewomenhaveahigherincidenceofbreastcancerthanblackwomenstartingatage45years;butblackwomenhaveahigherincidencebeforeage45years.Asian,Hispanic,andAmericanIndianwomenhavealowerriskfordevelopmentofbreastcancerPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)252STUVIA.COM(AmericanCancerSociety,2009-2010).DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential15.Thenurseispreparingforaclassinearlydetectionofbreastcancer.WhichstatementistruewithregardtobreastcancerinblackwomenintheUnitedStates?a.Breastcancerisnotathreattoblackwomen.b.Blackwomenhavealowerincidenceofregionalordistantbreastcancerthanwhitewomen.c.Blackwomenaremorelikelytodieofbreastcanceratanyage.d.Breastcancerincidenceinblackwomenishigherthanthatofwhitewomenafterage45.ANS:CBlackwomenhaveahigherincidenceofbreastcancerbeforeage45yearsthanwhitewomenandaremorelikelytodieoftheirdisease.Inaddition,blackwomenaresignificantlymorelikelytobediagnosedwithregionalordistantbreastcancerthanarewhitewomen.Theseracialdifferencesinmortalityratesmayberelatedtoaninsufficientuseofscreeningmeasuresandalackofaccesstohealthcare.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:ReNduUcRtiSoInNoGfTRBi.sCkOPMotential16.Duringabreasthealthinterview,apatientstatesthatshehasnoticedpaininherleftbreast.Thenursesmostappropriateresponsetothiswouldbe:a.Dontworryaboutthepain;breastcancerisnotpainful.b.Iwouldlikesomemoreinformationaboutthepaininyourleftbreast.c.Oh,Ihadpainlikethataftermysonwasborn;itturnedouttobeablockedmilkduct.d.Breastpainisalmostalwaystheresultofbenignbreastdisease.ANS:BBreastpainoccurswithtrauma,inflammation,infection,orbenignbreastdisease.Thenursewillneedtogathermoreinformationaboutthepatientspainratherthanmakestatementsthatignorethepatientsconcerns.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare17.Duringahealthhistoryinterview,afemalepatientstatesthatshehasnoticedafewdropsofcleardischargefromherrightnipple.Whatshouldthenursedonext?a.Immediatelycontactthephysiciantoreportthedischarge.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)253STUVIA.COMb.Askherifsheispossiblypregnant.c.Askthepatientsomeadditionalquestionsaboutthemedicationssheistaking.d.Immediatelyobtainasampleforcultureandsensitivitytesting.ANS:CTheuseofsomemedications,suchasoralcontraceptives,phenothiazines,diuretics,digitalis,steroids,methyldopa,andcalciumchannelblockers,maycauseclearnippledischarge.Bloodyorblood-tingeddischargefromthenipple,notclear,issignificant,especiallyifalumpisalsopresent.Inthepregnantfemale,colostrumwouldbeathick,yellowishliquid,anditwouldbenormallyexpressedafterthefourthmonthofpregnancy.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare18.Duringaphysicalexamination,a45-year-oldwomanstatesthatshehashadacrusty,itchyrashonherbreastforapproximately2weeks.Intryingtofindthecauseoftherash,whichquestionwouldbeimportantforthenursetoask?a.Istherashraisedandred?b.Doesitappeartobecyclic?NURSINGTB.COMc.Wheredidtherashfirstappearonthenipple,theareola,orthesurroundingskin?d.Whatwasshedoingwhenshefirstnoticedtherash,anddoheractionsmakeitworse?ANS:CThelocationwheretherashfirstappearedisimportantforthenursetodetermine.Pagetdiseasestartswithasmallcrustonthenippleapexandthenspreadstotheareola.Eczemaorotherdermatitisrarelystartsatthenippleunlessitisaresultofbreastfeeding.Itusuallystartsontheareolaorsurroundingskinandthenspreadstothenipple.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation19.Apatientisnewlydiagnosedwithbenignbreastdisease.Thenurserecognizeswhichstatementaboutbenignbreastdiseasetobetrue?Thepresenceofbenignbreastdisease:a.Makesithardtoexaminethebreasts.b.Frequentlyturnsintocancerinawomanslateryears.c.Iseasilyreducedwithhormonereplacementtherapy.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)254STUVIA.COMd.Isusuallydiagnosedbeforeawomanreacheschildbearingage.ANS:AThepresenceofbenignbreastdisease(formerlyfibrocysticbreastdisease)makesithardtoexaminethebreasts;thegenerallumpinessofthebreastconcealsanewlump.Theotherstatementsarenottrue.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare20.Duringanannualphysicalexamination,a43-year-oldpatientstatesthatshedoesnotperformmonthlybreastself-examinations(BSEs).ShetellsthenursethatshebelievesthatmammogramsdoamuchbetterjobthanIevercouldtofindalump.Thenurseshouldexplaintoherthat:a.BSEsmaydetectlumpsthatappearbetweenmammograms.b.BSEsareunnecessaryuntiltheageof50years.c.SheiscorrectmammographyisagoodreplacementforBSE.d.ShedoesnotneedtoperformBSEsaslongasaphysicianchecksherbreastsannually.ANS:ANURSINGTB.COMThemonthlypracticeofBSE,alongwithclinicalbreastexaminationandmammograms,arecomplementaryscreeningmeasures.Mammographycanrevealcancerstoosmalltobedetectedbythewomanorbythemostexperiencedexaminer.However,intervallumpsmaybecomepalpablebetweenmammograms.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential21.Duringaninterview,apatientrevealsthatsheispregnant.Shestatesthatsheisnotsurewhethershewillbreastfeedherbabyandasksforsomeinformationaboutthis.Whichofthesestatementsbythenurseisaccurate?a.Breastfedbabiestendtobemorecolicky.b.Breastfeedingprovidestheperfectfoodandantibodiesforyourbaby.c.Breastfedbabieseatmoreoftenthaninfantsonformula.d.Breastfeedingissecondnature,andeverywomancandoit.ANS:BExclusivelybreastfeedingfor6monthsprovidestheperfectfoodandantibodiesforthebaby,decreasestheriskofearinfections,promotesbonding,andprovidesrelaxation.DIF:CognitiveLevel:Applying(Application)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)255STUVIA.COMMSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential22.Thenurseisreviewingriskfactorsforbreastcancer.Whichofthesewomenhaveriskfactorsthatplacethematahigherriskforbreastcancer?a.37yearoldwhoisslightlyoverweightb.42yearoldwhohashadovariancancerc.45yearoldwhohasneverbeenpregnantd.65yearoldwhosemotherhadbreastcancerANS:DRiskfactorsforbreastcancerincludehavingafirst-degreerelativewithbreastcancer(mother,sister,ordaughter)andbeingolderthan50yearsofage.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential23.Duringanexaminationofawoman,thenursenoticesthatherleftbreastisslightlylargerthanherrightbreast.Whichofthesestatementsistrueaboutthisfinding?a.BreastsshouldalwaysbesymmetrNicU.RSINGTB.COMb.Asymmetryofbreastsizeandshapeisprobablyduetobreastfeedingandisnothingtoworryabout.c.Asymmetryisnotunusual,butthenurseshouldverifythatthischangeisnotnew.d.Asymmetryofbreastsizeandshapeisveryunusualandmeansshemayhaveaninflammationorgrowth.ANS:CThenurseshouldnoticesymmetryofsizeandshape.Itiscommontohaveaslightasymmetryinsize;oftentheleftbreastisslightlylargerthantheright.Asuddenincreaseinthesizeofonebreastsignifiesinflammationornewgrowth.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation24.ThenurseisassistingwithaBSEclinic.Whichofthesewomenreflectabnormalfindingsduringtheinspectionphaseofbreastexamination?a.Womanwhosenipplesareindifferentplanes(deviated).b.Womanwhoseleftbreastisslightlylargerthanherright.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)256STUVIA.COMc.Nonpregnantwomanwhoseskinismarkedwithlinearstriae.d.Pregnantwomanwhosebreastshaveafinebluenetworkofveinsvisibleundertheskin.ANS:AThenipplesshouldbesymmetricallyplacedonthesameplaneonthetwobreasts.Withdeviationinpointing,anunderlyingcancermaycausefibrosisinthemammaryducts,whichpullsthenippleangletowardit.Theotherexamplesarenormalfindings.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation25.Duringthephysicalexamination,thenursenoticesthatafemalepatienthasaninvertedleftnipple.Whichstatementregardingthisismostaccurate?a.Normalnippleinversionisusuallybilateral.b.Unilateralinversionofanippleisalwaysaserioussign.c.Whethertheinversionisarecentchangeshouldbedetermined.d.Nippleinversionisnotsignificantunlessaccompaniedbyanunderlyingpalpablemass.NURSINGTB.COMANS:CThenurseshoulddistinguishbetweenarecentlyretractednipplefromonethathasbeeninvertedformanyyearsorsincepuberty.Normalnippleinversionmaybeunilateralorbilateralandusuallycanbepulledout;thatis,ifitisnotfixed.Recentnippleretractionsignifiesacquireddisease.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation26.Thenurseisperformingabreastexamination.Whichofthesestatementsbestdescribesthecorrectproceduretousewhenscreeningfornippleandskinretractionduringabreastexamination?Havethewoman:a.Bendoverandtouchhertoes.b.Liedownonherleftsideandnoticeanyretraction.c.Shiftfromasupinepositiontoastandingposition,andnoteanylagorretraction.d.Slowlyliftherarmsaboveherhead,andnoteanyretractionorlaginmovement.ANS:DThewomanshouldbedirectedtochangepositionwhilecheckingthebreastsforsignsofskinretraction.Initially,sheshouldbeaskedtoliftherarmsslowlyoverherhead.BothbreastsshouldmoveupPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)257STUVIA.COMsymmetrically.Retractionsignsareduetofibrosisinthebreasttissue,usuallycausedbygrowingneoplasms.Thenurseshouldnoticewhethermovementofonebreastislagging.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare27.Thenurseispalpatingafemalepatientsbreastsduringanexamination.Whichofthesepositionsismostlikelytomakesignificantlumpsmoredistinctduringbreastpalpation?a.Supinewiththearmsraisedoverherheadb.Sittingwiththearmsrelaxedathersidesc.Supinewiththearmsrelaxedathersidesd.SittingwiththearmsflexedandfingertipstouchinghershouldersANS:AThenurseshouldhelpthewomantoasupineposition,tuckasmallpadunderthesidetobepalpated,andhelpthewomanraiseherarmoverherhead.Thesemaneuverswillflattenthebreasttissueandmediallydisplaceit.Anysignificantlumpswillthenfeelmoredistinct.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareENnUvRirSoInNmGeTnBt:.CMOaMnagementofCare28.Whichoftheseclinicalsituationswouldthenurseconsidertobeoutsidenormallimits?a.Apatienthashadonepregnancyandstatesthatshebelievesshemaybeenteringmenopause.Herbreastexaminationrevealsbreaststhataresoftandslightlysagging.b.Apatienthasneverbeenpregnant.Herbreastexaminationrevealslargependulousbreaststhathaveafirm,transverseridgealongthelowerquadrantinbothbreasts.c.Apatienthasneverbeenpregnantandreportsthatsheshouldbeginherperiodtomorrow.Herbreastexaminationrevealsbreasttissuethatisnodularandsomewhatengorged.Shestatesthattheexaminationwasslightlypainful.d.Apatienthashadtwopregnancies,andshebreastfedbothofherchildren.Heryoungestchildisnow10yearsold.Herbreastexaminationrevealsbreasttissuethatissomewhatsoft,andshehasasmallamountofthickyellowdischargefrombothnipples.ANS:DIfanydischargeappears,thenurseshouldnoteitscolorandconsistency.Exceptinpregnancyandlactation,anydischargeisabnormal.Innulliparouswomen,normalbreasttissuefeelsfirm,smooth,andelastic;afterpregnancy,thetissuefeelssoftandloose.Premenstrualengorgementisnormal,andconsistsofaslightenlargement,tendernesstopalpation,andageneralizednodularity.Afirm,transverseridgeofcompressedtissueinthelowerquadrants,knownastheinframammaryridge,isespeciallynoticeableinlargebreasts.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)258STUVIA.COMDIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare29.Apatientstatesduringtheinterviewthatshenoticedanewlumpintheshowerafewdaysago.Itwasonherleftbreastnearheraxilla.Thenurseshouldplanto:a.Palpatethelumpfirst.b.Palpatetheunaffectedbreastfirst.c.Avoidpalpatingthelumpbecauseitcouldbeacyst,whichmightrupture.d.Palpatethebreastwiththelumpfirstbutplantopalpatetheaxillalast.ANS:BIfthewomanmentionsabreastlumpshehasdiscoveredherself,thenthenurseshouldexaminetheunaffectedbreastfirsttolearnabaselineofnormalconsistencyforthisindividual.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare30.Thenursehaspalpatedalumpinafemalepatientsrightbreast.Thenursedocumentsthisasasmall,round,firm,distinct,lumplocatedat2oclock,2cmfromthenipple.Itisnontenderandfixed.Noassociatedretractionoftheskinornipple,noerythema,aNnUdRnSoIaNxGilTlaBr.yClOyMmphadenopathyareobserved.Whatinformationismissingfromthedocumentation?a.Shapeofthelumpb.Consistencyofthelumpc.Sizeofthelumpd.WhetherthelumpissolitaryormultipleANS:CIfthenursefeelsalumpormass,thenheorsheshouldnotethesecharacteristics:(1)location,(2)sizejudgeincentimetersinthreedimensions:widthlengththickness,(3)shape,(4)consistency,(5)motility,(6)distinctness,(7)nipple,(8)theskinoverthelump,(9)tenderness,and(10)lymphadenopathy.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare31.ThenurseisconductingaclassonBSE.WhichofthesestatementsindicatestheproperBSEtechnique?a.ThebesttimetoperformBSEisinthemiddleofthemenstrualcycle.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)259STUVIA.COMb.ThewomanneedstoperformBSEonlybimonthlyunlessshehasfibrocysticbreasttissue.c.ThebesttimetoperformaBSEis4to7daysafterthefirstdayofthemenstrualperiod.d.Ifshesuspectsthatsheispregnant,thenthewomanshouldnotperformaBSEuntilherbabyisborn.ANS:CThenurseshouldhelpeachwomanestablisharegularscheduleofself-care.ThebesttimetoconductaBSEisrightafterthemenstrualperiod,orthefourththroughseventhdayofthemenstrualcycle,whenthebreastsarethesmallestandleastcongested.Thepregnantormenopausalwomanwhoisnothavingmenstrualperiodsshouldbeadvisedtoselectafamiliardatetoexamineherbreastseachmonthforexample,herbirthdateorthedaytherentisdue.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential32.ThenurseispreparingtoteachawomanaboutBSE.Whichstatementbythenurseiscorrect?a.BSEismoreimportantthaneverforyoubecauseyouhaveneverhadanychildren.b.BSEissoimportantbecauseoneoutofninewomenwilldevelopbreastcancerinherlifetime.c.BSEonamonthlybasiswillhelpyNoUuRbSeIcNoGmTeBf.aCmOiMliarwithyourownbreastsandfeeltheirnormalvariations.d.BSEwillsaveyourlifebecauseyouarelikelytofindacancerouslumpbetweenmammograms.ANS:CThenurseshouldstressthataregularmonthlyBSEwillfamiliarizethewomanwithherownbreastsandtheirnormalvariations.BSEisapositivestepthatwillreassureherofherhealthystate.Whileteaching,thenurseshouldfocusonthepositiveaspectsofBSEandavoidcitingfrighteningmortalitystatisticsaboutbreastcancer,whichmaygenerateexcessivefearanddenialthatcanobstructawomansself-careactions.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential33.A55-year-oldpostmenopausalwomanisbeingseenintheclinicforherannualexamination.Sheisconcernedaboutchangesinherbreaststhatshehasnoticedoverthepast5years.Shestatesthatherbreastshavedecreasedinsizeandthattheelasticityhaschangedsothatherbreastsseemflatandflabby.Thenursesbestreplywouldbe:a.Thischangeoccursmostoftenbecauseoflong-termuseofbrasthatdonotprovideenoughsupporttothebreasttissues.b.Thisisanormalchangethatoccursaswomengetolderandisduetotheincreasedlevelsofprogesteroneduringtheagingprocess.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)260STUVIA.COMc.Decreasesinhormonesaftermenopausecausesatrophyoftheglandulartissueinthebreastandisanormalprocessofaging.d.Posturalchangesinthespinemakeitappearthatyourbreastshavechangedinshape.Exercisestostrengthenthemusclesoftheupperbackandchestwallwillhelppreventthechangesinelasticityandsize.ANS:CThehormonalchangesofmenopausecausethebreastglandulartissuetoatrophy,makingthebreastsmorependulous,flattened,andsagging.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance34.A43-year-oldwomanisattheclinicforaroutineexamination.Shereportsthatshehashadabreastlumpinherrightbreastforyears.Recently,ithasbeguntochangeinconsistencyandisbecomingharder.Shereportsthat5yearsagoherphysicianevaluatedthelumpanddeterminedthatitwasnothingtoworryabout.Theexaminationvalidatesthepresenceofamassintherightupperouterquadrantat1oclock,approximately5cmfromthenipple.Itisfirm,mobile,andnontender,withbordersthatarenotwelldefined.Thenursereplies:a.Becauseofthechangeinconsistencyofthelump,itshouldbefurtherevaluatedbyaphysician.b.Thechangescouldberelatedtoyourmenstrualcycles.Keeptrackofthechangesinthemasseachmonth.NURSINGTB.COMc.Thelumpisprobablynothingtoworryaboutbecauseithasbeenpresentforyearsandwasdeterminedtobenoncancerous5yearsago.d.Becauseyouareexperiencingnopainandthesizehasnotchanged,youshouldcontinuetomonitorthelumpandreturntotheclinicin3months.ANS:AAlumpthathasbeenpresentforyearsandisnotexhibitingchangesmaynotbeseriousbutshouldstillbeexplored.Anyrecentchangeoranewlumpshouldbeevaluated.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare35.DuringadiscussionaboutBSEswitha30-year-oldwoman,whichofthesestatementsbythenurseismostappropriate?a.Thebesttimetoexamineyourbreastsisduringovulation.b.Examineyourbreastseverymonthonthesamedayofthemonth.c.Examineyourbreastsshortlyafteryourmenstrualperiodeachmonth.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)261STUVIA.COMd.Thebesttimetoexamineyourbreastsisimmediatelybeforemenstruation.ANS:CThebesttimetoconductaBSEisshortlyafterthemenstrualperiodwhenthebreastsarethesmallestandleastcongested.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare36.ThenurseisdiscussingBSEswithapostmenopausalwoman.ThebesttimeforpostmenopausalwomentoperformBSEsis:a.Onthesamedayeverymonth.b.Daily,duringtheshowerorbath.c.Oneweekafterhermenstrualperiod.d.Everyyearwithherannualgynecologicexamination.ANS:APostmenopausalwomenarenolongerexperiencingregularmenstrualcyclesbutneedtocontinuetoperformBSEsonamonthlybasis.ChoosingthesameNdaUyRoSfINthGeTmBo.CntOhMisahelpfulremindertoperformtheexamination.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare37.Whileinspectingapatientsbreasts,thenursefindsthattheleftbreastisslightlylargerthantherightwiththebilateralpresenceofMontgomeryglands.Thenurseshould:a.PalpateovertheMontgomeryglands,checkingfordrainage.b.Considerthesefindingsasnormal,andproceedwiththeexamination.c.Askextensivehealthhistoryquestionsregardingthewomansbreastasymmetry.d.Continuewiththeexamination,andthenreferthepatientforfurtherevaluationoftheMontgomeryglands.ANS:BNormalfindingsofthebreastincludeonebreast(mostoftentheleft)slightlylargerthantheotherandthepresenceofMontgomeryglandsacrosstheareola.DIF:CognitiveLevel:Analyzing(Analysis)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)262STUVIA.COMMSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare38.Duringanexamination,thenursenotesasupernumerarynipplejustunderthepatientsleftbreast.Thepatienttellsthenursethatshealwaysthoughtitwasamole.Whichstatementaboutthisfindingiscorrect?a.Thisvariationisnormalandnotasignificantfinding.b.Thisfindingissignificantandneedsfurtherinvestigation.c.Asupernumerarynipplealsocontainsglandulartissueandmayleakmilkduringpregnancyandlactation.d.Thepatientiscorrectasupernumerarynippleisactuallyamolethathappenstobelocatedunderthebreast.ANS:AAsupernumerarynipplelookslikeamole,butcloseexaminationrevealsatinynippleandareola;itisnotasignificantfinding.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare39.Whileexamininga75-year-oldwoman,thenursenoticesthattheskinoverherrightbreastisthickenedandthehairfolliclesareexaggerated.Thisconditionisknownas:NURSINGTB.COMa.Dimpling.b.Retraction.c.Peaudorange.d.Benignbreastdisease.ANS:CThisconditionisknownaspeaudorange.Lymphaticobstructionproducesedema,whichthickenstheskinandexaggeratesthehairfollicles.Theskinhasapig-skinororange-peelappearance,andthisconditionsuggestscancer.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation40.Whenabreastfeedingmotherisdiagnosedwithabreastabscess,whichoftheseinstructionsfromthenurseiscorrect?Themotherneedsto:a.Continuetonurseonbothsidestoencouragemilkflow.b.Immediatelydiscontinuenursingtoallowforhealing.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)263STUVIA.COMc.Temporarilydiscontinuenursingontheaffectedbreast,andmanuallyexpressmilkanddiscardit.d.Temporarilydiscontinuenursingonaffectedbreast,butmanuallyexpressmilkandgiveittothebaby.ANS:CWithabreastabscess,thepatientmusttemporarilydiscontinuenursingontheaffectedbreast,manuallyexpressthemilk,andthendiscardit.Nursingcancontinueontheunaffectedside.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation41.Anewmothercallstheclinictoreportthatpartofherleftbreastisred,swollen,tender,veryhot,andhard.Shehasafeverof38.3C.Shealsohashadsymptomsofinfluenza,suchaschills,sweating,andfeelingtired.Thenursenoticesthatshehasbeenbreastfeedingfor1month.Fromherdescription,whatconditiondoesthenursesuspect?a.Mastitisb.Pagetdiseasec.Pluggedmilkductd.MammaryductectasiaNURSINGTB.COMANS:AThesymptomsdescribemastitis,whichstemsfromaninfectionorstasiscausedbyapluggedduct.Apluggedductdoesnothaveinfectionpresent.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation42.Duringabreastexaminationonafemalepatient,thenursenoticesthatthenippleisflat,broad,andfixed.Thepatientstatesitstarteddoingthatafewmonthsago.Thisfindingsuggests:a.Dimpling.b.Retractednipple.c.Nippleinversion.d.Deviationinnipplepointing.ANS:BPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)264STUVIA.COMTheretractednipplelooksflatterandbroader,similartoanunderlyingcrater.Arecentretractionsuggestscancer,whichcausesfibrosisofthewholeductsystemandpullsinthenipple.Italsomayoccurwithbenignlesionssuchasectasiaoftheducts.Thenurseshouldnotconfuseretractionwiththenormallong-standingtypeofnippleinversion,whichhasnobroadeningandisnotfixed.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation43.A54-year-oldmancomestotheclinicwithahorribleproblem.Hetellsthenursethathehasjustdiscoveredalumponhisbreastandisfearfulofcancer.Thenurseknowswhichstatementaboutbreastcancerinmenistrue?a.Breastmassesinmenaredifficulttodetectbecauseofminimalbreasttissue.b.Breastcancerinmenrarelyspreadstothelymphnodes.c.Onepercentofallbreastcancersoccursinmen.d.Mostbreastmassesinmenarediagnosedasgynecomastia.ANS:COnepercentofallbreastcancersoccursinmen.Theearlyspreadingtoaxillarylymphnodesisattributabletominimalbreasttissue.DIF:CognitiveLevel:Applying(Application)NURSINGTB.COMMSC:ClientNeeds:HealthPromotionandMaintenanceMULTIPLERESPONSE1.Thenurseisassessingthebreastsofa68-year-oldwomananddiscoversamassintheupperouterquadrantoftheleftbreast.Whenassessingthismass,thenurseisawarethatcharacteristicsofacancerousmassincludewhichofthefollowing?Selectallthatapply.a.Nontendermassb.Dull,heavypainonpalpationc.Rubberytextureandmobiled.Hard,dense,andimmobilee.Regularborderf.Irregular,poorlydelineatedborderANS:A,D,FCancerousbreastmassesaresolitary,unilateral,andnontender.Theyaresolid,hard,dense,andfixedtoPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)265STUVIA.COMunderlyingtissuesorskinascancerbecomesinvasive.Theirbordersareirregularandpoorlydelineated.Theyareoftenpainless,althoughthepersonmayexperiencepain.Theyaremostcommonintheupperouterquadrant.Adull,heavypainonpalpationandamasswitharubberytextureandaregularborderarecharacteristicsofbenignbreastdisease.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation2.Thenurseisexamininga62-year-oldmanandnotesthathehasbilateralgynecomastia.Thenurseshouldexplorehishealthhistoryforwhichrelatedconditions?Selectallthatapply.a.Malnutritionb.Hyperthyroidismc.Type2diabetesmellitusd.Liverdiseasee.HistoryofalcoholabuseANS:B,D,EGynecomastiaoccurswithCushingsyndrome,livercirrhosis,adrenaldisease,hyperthyroidism,andnumerousdrugs,suchasalcoholandmarijuanause,estrNogUeRnStIrNeaGtmTBen.CtOfoMrprostatecancer,antibiotics(metronidazole,isoniazid),digoxin,angiotensin-convertingenzyme(ACE)inhibitors,diazepam,andtricyclicantidepressants.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)266STUVIA.COMChapter19:ThoraxandLungsMULTIPLECHOICE1.Whichofthesestatementsistrueregardingthevertebraprominens?Thevertebraprominensis:a.ThespinousprocessofC7.b.Usuallynonpalpableinmostindividuals.c.Oppositetheinteriorborderofthescapula.d.Locatednexttothemanubriumofthesternum.ANS:AThespinousprocessofC7isthevertebraprominensandisthemostprominentbonyspurprotrudingatthebaseoftheneck.Countingribsandintercostalspacesontheposteriorthoraxisdifficultbecauseofthemusclesandsofttissue.Thevertebraprominensiseasiertoidentifyandisusedasastartingpointincountingthoracicprocessesandidentifyinglandmarksontheposteriorchest.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General2.WhenperformingarespiratoryassessmentNonUaRSpIaNtiGenTtB,t.hCeOnMursenoticesacostalangleofapproximately90degrees.Thischaracteristicis:a.Observedinpatientswithkyphosis.b.Indicativeofpectusexcavatum.c.Anormalfindinginahealthyadult.d.Anexpectedfindinginapatientwithabarrelchest.ANS:CTherightandleftcostalmarginsformananglewheretheymeetatthexiphoidprocess.Usually,thisangleis90degreesorless.Theangleincreaseswhentheribcageischronicallyoverinflated,asinemphysema.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare3.Whenassessingapatientslungs,thenurserecallsthattheleftlung:a.Consistsoftwolobes.b.Isdividedbythehorizontalfissure.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)267STUVIA.COMc.Primarilyconsistsofanupperlobeontheposteriorchest.d.Isshorterthantherightlungbecauseoftheunderlyingstomach.ANS:ATheleftlunghastwolobes,andtherightlunghasthreelobes.Therightlungisshorterthantheleftlungbecauseoftheunderlyingliver.Theleftlungisnarrowerthantherightlungbecausetheheartbulgestotheleft.Theposteriorchestisalmostalllowerlobes.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General4.Whichstatementabouttheapicesofthelungsistrue?Theapicesofthelungs:a.Areatthelevelofthesecondribanteriorly.b.Extend3to4cmabovetheinnerthirdoftheclavicles.c.Arelocatedatthesixthribanteriorlyandtheeighthriblaterally.d.Restonthediaphragmatthefifthintercostalspaceinthemidclavicularline(MCL).ANS:BNURSINGTB.COMTheapexofthelungontheanteriorchestis3to4cmabovetheinnerthirdoftheclavicles.Ontheposteriorchest,theapicesareatthelevelofC7.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General5.Duringanexaminationoftheanteriorthorax,thenurseisawarethatthetracheabifurcatesanteriorlyatthe:a.Costalangle.b.Sternalangle.c.Xiphoidprocess.d.Suprasternalnotch.ANS:BThesternalanglemarksthesiteoftrachealbifurcationintotherightandleftmainbronchi;itcorrespondswiththeupperbordersoftheatriaoftheheart,anditliesabovethefourththoracicvertebraontheback.DIF:CognitiveLevel:Remembering(Knowledge)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)268STUVIA.COMMSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare6.Duringanassessment,thenurseknowsthatexpectedassessmentfindingsinthenormaladultlungincludethepresenceof:a.Adventitioussoundsandlimitedchestexpansion.b.Increasedtactilefremitusanddullpercussiontones.c.Muffledvoicesoundsandsymmetrictactilefremitus.d.Absentvoicesoundsandhyperresonantpercussiontones.ANS:CNormallungfindingsincludesymmetricchestexpansion,resonantpercussiontones,vesicularbreathsoundsovertheperipherallungfields,muffledvoicesounds,andnoadventitioussounds.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare7.Theprimarymusclesofrespirationincludethe:a.Diaphragmandintercostals.b.Sternomastoidsandscaleni.c.Trapeziiandrectusabdominis.NURSINGTB.COMd.Externalobliquesandpectoralismajor.ANS:AThemajormuscleofrespirationisthediaphragm.Theintercostalmusclesliftthesternumandelevatetheribsduringinspiration,increasingtheanteroposteriordiameter.Expirationisprimarilypassive.Forcedinspirationinvolvestheuseofothermuscles,suchastheaccessoryneckmusclessternomastoid,scaleni,andtrapeziimuscles.Forcedexpirationinvolvestheabdominalmuscles.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General8.A65-year-oldpatientwithahistoryofheartfailurecomestotheclinicwithcomplaintsofbeingawakenedfromsleepwithshortnessofbreath.Whichactionbythenurseismostappropriate?a.Obtainingadetailedhealthhistoryofthepatientsallergiesandahistoryofasthmab.TellingthepatienttosleeponhisorherrightsidetofacilitateeaseofrespirationsPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)269STUVIA.COMc.Assessingforothersignsandsymptomsofparoxysmalnocturnaldyspnead.AssuringthepatientthatparoxysmalnocturnaldyspneaisnormalandwillprobablyresolvewithinthenextweekANS:CThepatientisexperiencingparoxysmalnocturnaldyspneabeingawakenedfromsleepwithshortnessofbreathandtheneedtobeuprighttoachievecomfort.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare9.Whenassessingtactilefremitus,thenurserecallsthatitisnormaltofeeltactilefremitusmostintenselyoverwhichlocation?a.Betweenthescapulaeb.Thirdintercostalspace,MCLc.Fifthintercostalspace,midaxillaryline(MAL)d.Overthelowerlobes,posteriorsideNURSINGTB.COMANS:ANormally,fremitusismostprominentbetweenthescapulaeandaroundthesternum.Thesesitesarewherethemajorbronchiareclosesttothechestwall.Fremitusnormallydecreasesasoneprogressesdownthechestbecausemoretissueimpedessoundtransmission.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare10.Thenurseisreviewingthetechniqueofpalpatingfortactilefremituswithanewgraduate.Whichstatementbythegraduatenursereflectsacorrectunderstandingoftactilefremitus?Tactilefremitus:a.Iscausedbymoistureinthealveoli.b.Indicatesthatairispresentinthesubcutaneoustissues.c.Iscausedbysoundsgeneratedfromthelarynx.d.Reflectsthebloodflowthroughthepulmonaryarteries.ANS:CFremitusisapalpablevibration.Soundsgeneratedfromthelarynxaretransmittedthroughpatentbronchiandthelungparenchymatothechestwallwheretheyarefeltasvibrations.CrepitusisthetermforairinthePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)270STUVIA.COMsubcutaneoustissues.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare11.Duringpercussion,thenurseknowsthatadullpercussionnoteelicitedoveralunglobemostlikelyresultsfrom:a.Shallowbreathing.b.Normallungtissue.c.Decreasedadiposetissue.d.Increaseddensityoflungtissue.ANS:DAdullpercussionnoteindicatesanabnormaldensityinthelungs,aswithpneumonia,pleuraleffusion,atelectasis,oratumor.Resonanceistheexpectedfindinginnormallungtissue.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:General12.ThenurseisobservingtheauscultationtecNhUniRqSuIeNoGfTaBno.CthOeMrnurse.Thecorrectmethodtousewhenprogressingfromoneauscultatorysiteonthethoraxtoanotheriscomparison.a.Side-to-sideb.Top-to-bottomc.Posterior-to-anteriord.Interspace-by-interspaceANS:ASide-to-sidecomparisonismostimportantwhenauscultatingthechest.Thenurseshouldlistentoatleastonefullrespirationineachlocation.Theothertechniquesarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare13.Whenauscultatingthelungsofanadultpatient,thenursenotesthatlow-pitched,softbreathsoundsareheardovertheposteriorlowerlobes,withinspirationbeinglongerthanexpiration.Thenurseinterpretsthatthesesoundsare:a.Normallyauscultatedoverthetrachea.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)271STUVIA.COMb.Bronchialbreathsoundsandnormalinthatlocation.c.Vesicularbreathsoundsandnormalinthatlocation.d.Bronchovesicularbreathsoundsandnormalinthatlocation.ANS:CVesicularbreathsoundsarelow-pitched,softsoundswithinspirationbeinglongerthanexpiration.Thesebreathsoundsareexpectedovertheperipherallungfieldswhereairflowsthroughsmallerbronchiolesandalveoli.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare14.Thenurseisauscultatingthechestinanadult.Whichtechniqueiscorrect?a.Instructingthepatienttotakedeep,rapidbreathsb.Instructingthepatienttobreatheinandoutthroughhisorhernosec.Firmlyholdingthediaphragmofthestethoscopeagainstthechestd.LightlyholdingthebellofthestetNhoUsRcoSpINeGagTaBin.CstOtMhechesttoavoidfrictionANS:CFirmlyholdingthediaphragmofthestethoscopeagainstthechestisthecorrectwaytoauscultatebreathsounds.Thepatientshouldbeinstructedtobreathethroughhisorhermouth,alittledeeperthanusual,butnottohyperventilate.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare15.Thenurseispercussingoverthelungsofapatientwithpneumonia.Thenurseknowsthatpercussionoveranareaofatelectasisinthelungswillreveal:a.Dullness.b.Tympany.c.Resonance.d.Hyperresonance.ANS:AAdullpercussionnotesignalsanabnormaldensityinthelungs,aswithpneumonia,pleuraleffusion,PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)272STUVIA.COMatelectasis,oratumor.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation16.Duringauscultationofthelungs,thenurseexpectsdecreasedbreathsoundstobeheardinwhichsituation?a.Whenthebronchialtreeisobstructedb.Whenadventitioussoundsarepresentc.Inconjunctionwithwhisperedpectoriloquyd.Inconditionsofconsolidation,suchaspneumoniaANS:ADecreasedorabsentbreathsoundsoccurwhenthebronchialtreeisobstructed,asinemphysema,andwhensoundtransmissionisobstructed,asinpleurisy,pneumothorax,orpleuraleffusion.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation17.Thenurseknowsthatanormalfindingwhenassessingtherespiratorysystemofanolderadultis:NURSINGTB.COMa.Increasedthoracicexpansion.b.Decreasedmobilityofthethorax.c.Decreasedanteroposteriordiameter.d.Bronchovesicularbreathsoundsthroughoutthelungs.ANS:BThecostalcartilagesbecomecalcifiedwithaging,resultinginalessmobilethorax.Chestexpansionmaybesomewhatdecreased,andthechestcagecommonlyshowsanincreasedanteroposteriordiameter.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance18.Amotherbringsher3-month-oldinfanttotheclinicforevaluationofacold.Shetellsthenursethathehashadarunnynoseforaweek.Whenperformingthephysicalassessment,thenursenotesthatthechildhasnasalflaringandsternalandintercostalretractions.Thenursesnextactionshouldbeto:a.Assurethemotherthatthesesignsarenormalsymptomsofacold.b.Recognizethattheseareserioussigns,andcontactthephysician.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)273STUVIA.COMc.Askthemotheriftheinfanthashadtroublewithfeedings.d.Performacompletecardiacassessmentbecausethesesignsareprobablyindicativeofearlyheartfailure.ANS:BTheinfantisanobligatorynosebreatheruntiltheageof3months.Normally,noflaringofthenostrilsandnosternalorintercostalretractionoccurs.Significantretractionsofthesternumandintercostalmusclesandnasalflaringindicateincreasedinspiratoryeffort,asinpneumonia,acuteairwayobstruction,asthma,andatelectasis;therefore,immediatereferraltothephysicianiswarranted.Thesesignsdonotindicateheartfailure,andanassessmentoftheinfantsfeedingisnotapriorityatthistime.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation19.Whenassessingtherespiratorysystemofa4-year-oldchild,whichofthesefindingswouldthenurseexpect?a.Crepituspalpatedatthecostochondraljunctionsb.Nodiaphragmaticexcursionasaresultofachildsdecreasedinspiratoryvolumec.PresenceofbronchovesicularbreaNthUsRoSuInNdGsTinBt.hCeOpMeripherallungfieldsd.Irregularrespiratorypatternandarespiratoryrateof40breathsperminuteatrestANS:CBronchovesicularbreathsoundsintheperipherallungfieldsoftheinfantandyoungchilduptoage5or6yearsarenormalfindings.Theirthinchestwallswithunderdevelopedmusculaturedonotdampenthesound,asdothethickerchestwallsofadults;therefore,breathsoundsareloudandharsh.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare20.Wheninspectingtheanteriorchestofanadult,thenurseshouldincludewhichassessment?a.Diaphragmaticexcursionb.Symmetricchestexpansionc.Presenceofbreathsoundsd.ShapeandconfigurationofthechestwallANS:DPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)274STUVIA.COMInspectionoftheanteriorchestincludesshapeandconfigurationofthechestwall;assessmentofthepatientslevelofconsciousnessandthepatientsskincolorandcondition;qualityofrespirations;presenceorabsenceofretractionandbulgingoftheintercostalspaces;anduseofaccessorymuscles.Symmetricchestexpansionisassessedbypalpation.Diaphragmaticexcursionisassessedbypercussionoftheposteriorchest.Breathsoundsareassessedbyauscultation.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare21.Thenurseknowsthatauscultationoffinecrackleswouldmostlikelybenoticedin:a.Ahealthy5-year-oldchild.b.Apregnantwoman.c.Theimmediatenewbornperiod.d.Associationwithapneumothorax.ANS:CFinecracklesarecommonlyheardintheimmediatenewbornperiodasaresultoftheopeningoftheairwaysandaclearingoffluid.Persistentfinecrackleswouldbenoticedwithpneumonia,bronchiolitis,oratelectasis.DIF:CognitiveLevel:Applying(Application)NURSINGTB.COMMSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare22.Duringanassessmentofanadult,thenursehasnotedunequalchestexpansionandrecognizesthatthisoccursinwhichsituation?a.Inanobesepatientb.Whenpartofthelungisobstructedorcollapsedc.Whenbulgingoftheintercostalspacesispresentd.WhenaccessorymusclesareusedtoaugmentrespiratoryeffortANS:BUnequalchestexpansionoccurswhenpartofthelungisobstructedorcollapsed,aswithpneumonia,orwhenguardingtoavoidpostoperativeincisionalpain.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation23.Duringauscultationofthelungsofanadultpatient,thenursenoticesthepresenceofbronchophony.Thenurseshouldassessforsignsofwhichcondition?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)275STUVIA.COMa.Airwayobstructionb.Emphysemac.Pulmonaryconsolidationd.AsthmaANS:CPathologicconditionsthatincreaselungdensity,suchaspulmonaryconsolidation,willenhancethetransmissionofvoicesounds,suchasbronchophony.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation24.Thenurseisreviewingthecharacteristicsofbreathsounds.Whichstatementaboutbronchovesicularbreathsoundsistrue?Bronchovesicularbreathsoundsare:a.Musicalinquality.b.Usuallycausedbyapathologicdisease.c.Expectednearthemajorairways.NURSINGTB.COMd.Similartobronchialsoundsexceptshorterinduration.ANS:CBronchovesicularbreathsoundsareheardovermajorbronchiwherefeweralveoliarelocatedposteriorlybetweenthescapulae,especiallyontheright;andanteriorly,aroundtheuppersternuminthefirstandsecondintercostalspaces.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare25.Thenurseislisteningtothebreathsoundsofapatientwithsevereasthma.Airpassingthroughnarrowedbronchioleswouldproducewhichoftheseadventitioussounds?a.Wheezesb.Bronchialsoundsc.Bronchophonyd.WhisperedpectoriloquyPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)276STUVIA.COMANS:AWheezesarecausedbyairsqueezedorcompressedthroughpassagewaysnarrowedalmosttoclosurebycollapsing,swelling,secretions,ortumors,suchaswithacuteasthmaorchronicemphysema.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation26.Apatienthasalonghistoryofchronicobstructivepulmonarydisease(COPD).Duringtheassessment,thenursewillmostlikelyobservewhichofthese?a.Unequalchestexpansionb.Increasedtactilefremitusc.Atrophiedneckandtrapeziusmusclesd.Anteroposterior-to-transversediameterratioof1:1ANS:DAnanteroposterior-to-transversediameterratioof1:1orbarrelchestisobservedinindividualswithCOPDbecauseofhyperinflationofthelungs.Theribsaremorehorizontal,andthechestappearsasifheldincontinuousinspiration.Neckmusclesarehypertrophiedfromaidinginforcedrespiration.Chestexpansionmaybedecreasedbutsymmetric.Decreasedtactilefremitusoccursfromdecreasedtransmissionofvibrations.NURSINGTB.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation27.Ateenagepatientcomestotheemergencydepartmentwithcomplaintsofaninabilitytobreatheandasharppainintheleftsideofhischest.Theassessmentfindingsincludecyanosis,tachypnea,trachealdeviationtotheright,decreasedtactilefremitusontheleft,hyperresonanceontheleft,anddecreasedbreathsoundsontheleft.Thenurseinterpretsthattheseassessmentfindingsareconsistentwith:a.Bronchitis.b.Pneumothorax.c.Acutepneumonia.d.Asthmaticattack.ANS:BWithapneumothorax,freeairinthepleuralspacecausespartialorcompletelungcollapse.Ifthepneumothoraxislarge,thentachypneaandcyanosisareevident.Unequalchestexpansion,decreasedorabsenttactilefremitus,trachealdeviationtotheunaffectedside,decreasedchestexpansion,hyperresonantpercussiontones,anddecreasedorabsentbreathsoundsarefoundwiththepresenceofpneumothorax.DIF:CognitiveLevel:Analyzing(Analysis)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)277STUVIA.COMMSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation28.Anadultpatientwithahistoryofallergiescomestothecliniccomplainingofwheezinganddifficultyinbreathingwhenworkinginhisyard.Theassessmentfindingsincludetachypnea,theuseofaccessoryneckmuscles,prolongedexpiration,intercostalretractions,decreasedbreathsounds,andexpiratorywheezes.Thenurseinterpretsthattheseassessmentfindingsareconsistentwith:a.Asthma.b.Atelectasis.c.Lobarpneumonia.d.Heartfailure.ANS:AAsthmaisallergichypersensitivitytocertaininhaledparticlesthatproducesinflammationandareactionofbronchospasm,whichincreasesairwayresistance,especiallyduringexpiration.Anincreasedrespiratoryrate,theuseofaccessorymuscles,aretractionoftheintercostalmuscles,prolongedexpiration,decreasedbreathsounds,andexpiratorywheezingareallcharacteristicsofasthma.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation29.ThenurseisassessingthelungsofanoldeNrUadRuSlIt.NWGThBic.hCOofMthesechangesarenormalintherespiratorysystemoftheolderadult?a.Severedyspneaisexperiencedonexertion,resultingfromchangesinthelungs.b.Respiratorymusclestrengthincreasestocompensateforadecreasedvitalcapacity.c.Decreaseinsmallairwayclosureoccurs,leadingtoproblemswithatelectasis.d.Lungsarelesselasticanddistensible,whichdecreasestheirabilitytocollapseandrecoil.ANS:DIntheagingadult,thelungsarelesselasticanddistensible,whichdecreasestheirabilitytocollapseandrecoil.Vitalcapacityisdecreased,andalossofintra-alveolarseptaoccurs,causinglesssurfaceareaforgasexchange.Thelungbasesbecomelessventilated,andtheolderpersonisatriskfordyspneawithexertionbeyondhisorherusualworkload.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance30.Awomaninher26thweekofpregnancystatesthatsheisnotreallyshortofbreathbutfeelsthatsheisawareofherbreathingandtheneedtobreathe.Whatisthenursesbestreply?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)278STUVIA.COMa.Thediaphragmbecomesfixedduringpregnancy,makingitdifficulttotakeinadeepbreath.b.Theincreaseinestrogenlevelsduringpregnancyoftencausesadecreaseinthediameteroftheribcageandmakesitdifficulttobreathe.c.Whatyouareexperiencingisnormal.Somewomenmayinterpretthisasshortnessofbreath,butitisanormalfindingandnothingiswrong.d.Thisincreasedawarenessoftheneedtobreatheisnormalasthefetusgrowsbecauseoftheincreasedoxygendemandonthemothersbody,whichresultsinanincreasedrespiratoryrate.ANS:CDuringpregnancy,thewomanmaydevelopanincreasedawarenessoftheneedtobreathe.Somewomenmayinterpretthisasdyspnea,althoughstructurallynothingiswrong.Increasesinestrogenrelaxthechestcageligaments,causinganincreaseinthetransversediameter.Althoughthegrowingfetusincreasestheoxygendemandonthemothersbody,thisincreaseddemandiseasilymetbytheincreasingtidalvolume(deeperbreathing).Littlechangeoccursintherespiratoryrate.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance31.A35-year-oldrecentimmigrantisbeingseenintheclinicforcomplaintsofacoughthatisassociatedwithrust-coloredsputum,low-gradeafternoonfevers,andnightsweatsforthepast2months.Thenursespreliminaryanalysis,basedonthishistory,isthatthispatientmaybesufferingfrom:NURSINGTB.COMa.Bronchitis.b.Pneumonia.c.Tuberculosis.d.Pulmonaryedema.ANS:CSputumisnotdiagnosticalone,butsomeconditionshavecharacteristicsputumproduction.Tuberculosisoftenproducesrust-coloredsputuminadditiontoothersymptomsofnightsweatsandlow-gradeafternoonfevers.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation32.A70-year-oldpatientisbeingseenintheclinicforsevereexacerbationofhisheartfailure.Whichofthesefindingsisthenursemostlikelytoobserveinthispatient?a.Shortnessofbreath,orthopnea,paroxysmalnocturnaldyspnea,andankleedemab.Raspingcough,thickmucoidsputum,wheezing,andbronchitisPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)279STUVIA.COMc.Productivecough,dyspnea,weightloss,anorexia,andtuberculosisd.Fever,drynonproductivecough,anddiminishedbreathsoundsANS:AApersonwithheartfailureoftenexhibitsincreasedrespiratoryrate,shortnessofbreathonexertion,orthopnea,paroxysmalnocturnaldyspnea,nocturia,ankleedema,andpallorinlight-skinnedindividuals.Apatientwithraspingcough,thickmucoidsputum,andwheezingmayhavebronchitis.Productivecough,dyspnea,weightloss,anddyspneaindicatetuberculosis;fever,drynonproductivecough,anddiminishedbreathsoundsmayindicatePneumocystisjiroveci(P.carinii)pneumonia.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation33.Apatientcomestothecliniccomplainingofacoughthatisworseatnightbutnotasbadduringtheday.Thenurserecognizesthatthiscoughmayindicate:a.Pneumonia.b.Postnasaldriporsinusitis.c.Exposuretoirritantsatwork.d.ChronicbronchialirritationfromsNmUoRkiSnIgN.GTB.COMANS:BAcoughthatprimarilyoccursatnightmayindicatepostnasaldriporsinusitis.Exposuretoirritantsatworkcausesanafternoonoreveningcough.Smokersexperienceearlymorningcoughing.Coughingassociatedwithacuteillnessessuchaspneumoniaiscontinuousthroughouttheday.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation34.Duringamorningassessment,thenursenoticesthatthepatientssputumisfrothyandpink.Whichconditioncouldthisfindingindicate?a.Croupb.Tuberculosisc.Viralinfectiond.PulmonaryedemaANS:DPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)280STUVIA.COMSputum,alone,isnotdiagnostic,butsomeconditionshavecharacteristicsputumproduction.Pink,frothysputumindicatespulmonaryedemaoritmaybeasideeffectofsympathomimeticmedications.Croupisassociatedwithabarkingcough,notsputumproduction.Tuberculosismayproducerust-coloredsputum.Viralinfectionsmayproducewhiteorclearmucoidsputum.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation35.Duringauscultationofbreathsounds,thenurseshouldcorrectlyusethestethoscopeinwhichofthefollowingways?a.Listeningtoatleastonefullrespirationineachlocationb.Listeningasthepatientinhalesandthengoingtothenextsiteduringexhalationc.Instructingthepatienttobreatheinandoutrapidlywhilelisteningtothebreathsoundsd.Ifthepatientismodest,listeningtosoundsoverhisorherclothingorhospitalgownANS:ADuringauscultationofbreathsoundswithastethoscope,listeningtoonefullrespirationineachlocationisimportant.Duringtheexamination,thenurseshouldmonitorthebreathingandoffertimesforthepersontobreathenormallytopreventpossibledizziness.DIF:CognitiveLevel:Applying(Application)NURSINGTB.COMMSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare36.Apatienthasbeenadmittedtotheemergencydepartmentwithapossiblemedicaldiagnosisofpulmonaryembolism.Thenurseexpectstoseewhichassessmentfindingsrelatedtothiscondition?a.Absentordecreasedbreathsoundsb.Productivecoughwiththin,frothysputumc.Chestpainthatisworseondeepinspirationanddyspnead.DiffuseinfiltrateswithareasofdullnessuponpercussionANS:CFindingsforpulmonaryembolismincludechestpainthatisworseondeepinspiration,dyspnea,apprehension,anxiety,restlessness,partialarterialpressureofoxygen(PaO2)lessthan80mmHg,diaphoresis,hypotension,crackles,andwheezes.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation37.Duringpalpationoftheanteriorchestwall,thenursenoticesacoarse,cracklingsensationovertheskinPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)281STUVIA.COMsurface.Onthebasisofthesefindings,thenursesuspects:a.Tactilefremitus.b.Crepitus.c.Frictionrub.d.Adventitioussounds.ANS:BCrepitusisacoarse,cracklingsensationpalpableovertheskinsurface.Itoccursinsubcutaneousemphysemawhenairescapesfromthelungandentersthesubcutaneoustissue,suchasafteropenthoracicinjuryorsurgery.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation38.Thenurseisauscultatingthelungsofapatientwhohadbeensleepingandnoticesshort,popping,cracklingsoundsthatstopafterafewbreaths.Thenurserecognizesthatthesebreathsoundsare:a.Atelectaticcracklesthatdonothaveapathologiccause.NURSINGTB.COMb.Finecracklesandmaybeasignofpneumonia.c.Vesicularbreathsounds.d.Finewheezes.ANS:AOnetypeofadventitioussound,atelectaticcrackles,doesnothaveapathologiccause.Theyareshort,popping,cracklingsoundsthatsoundsimilartofinecracklesbutdonotlastbeyondafewbreaths.Whensectionsofalveoliarenotfullyaerated(asinpeoplewhoareasleeporinolderadults),theydeflateslightlyandaccumulatesecretions.Cracklesareheardwhenthesesectionsareexpandedbyafewdeepbreaths.Atelectaticcracklesareheardonlyintheperiphery,usuallyindependentportionsofthelungs,anddisappearafterthefirstfewbreathsorafteracough.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare39.Apatienthasbeenadmittedtotheemergencydepartmentforasuspecteddrugoverdose.Hisrespirationsareshallow,withanirregularpattern,witharateof12respirationsperminute.Thenurseinterpretsthisrespirationpatternaswhichofthefollowing?a.Bradypneab.Cheyne-StokesrespirationsPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)282STUVIA.COMc.Hypoventilationd.ChronicobstructivebreathingANS:CHypoventilationischaracterizedbyanirregular,shallowpattern,andcanbecausedbyanoverdoseofnarcoticsoranesthetics.Bradypneaisslowbreathing,witharatelessthan10respirationsperminute.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare40.Apatientwithpleuritishasbeenadmittedtothehospitalandcomplainsofpainwithbreathing.Whatotherkeyassessmentfindingwouldthenurseexpecttofinduponauscultation?a.Stridorb.Frictionrubc.Cracklesd.WheezingANS:BNURSINGTB.COMApatientwithpleuritiswillexhibitapleuralfrictionrubuponauscultation.Thissoundismadewhenthepleuraebecomeinflamedandrubtogetherduringrespiration.Thesoundissuperficial,coarse,andlow-pitched,asiftwopiecesofleatherarebeingrubbedtogether.Stridorisassociatedwithcroup,acuteepiglottitisinchildren,andforeignbodyinhalation.Cracklesareassociatedwithpneumonia,heartfailure,chronicbronchitis,andotherdiseases.Wheezesareassociatedwithdiffuseairwayobstructioncausedbyacuteasthmaorchronicemphysema.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCareMULTIPLERESPONSE1.Thenurseisassessingvoicesoundsduringarespiratoryassessment.Whichofthesefindingsindicatesanormalassessment?Selectallthatapply.a.Voicesoundsarefaint,muffled,andalmostinaudiblewhenthepatientwhispersone,two,threeinaverysoftvoice.b.Asthepatientrepeatedlysaysninety-nine,theexaminerclearlyhearsthewordsninety-nine.c.Whenthepatientspeaksinanormalvoice,theexaminercanhearasoundbutcannotexactlydistinguishwhatisbeingsaid.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)283STUVIA.COMNURSINGTB.COMd.Asthepatientsaysalongee-ee-eesound,theexamineralsohearsalongee-ee-eesound.e.Asthepatientsaysalongee-ee-eesound,theexaminerhearsalongaaaaaasound.ANS:A,C,DAsapatientrepeatedlysaysninety-nine,normallytheexaminerhearsvoicesoundsbutcannotdistinguishwhatisbeingsaid.Ifaclearninety-nineisauscultated,thenitcouldindicateincreasedlungdensity,whichenhancesthetransmissionofvoicesounds,whichisameasureofbronchophony.Whenapatientsaysalongee-ee-eesound,normallytheexamineralsohearsalongee-ee-eesoundthroughauscultation,whichisameasureofegophony.Iftheexaminerhearsalongaaaaaasoundinstead,thissoundcouldindicateareasofconsolidationorcompression.Withwhisperedpectoriloquy,aswhenapatientwhispersaphrasesuchasone-two-three,thenormalresponsewhenauscultatingvoicesoundsistohearsoundsthatarefaint,muffled,andalmostinaudible.Iftheexaminerclearlyhearsthewhisperedvoice,asifthepatientisspeakingthroughthestethoscope,thenconsolidationofthelungfieldsmayexist.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCarePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)284STUVIA.COMChapter20:HeartandNeckVesselsMULTIPLECHOICE1.Thesacthatsurroundsandprotectstheheartiscalledthe:a.Pericardium.b.Myocardium.c.Endocardium.d.Pleuralspace.ANS:AThepericardiumisatough,fibrousdouble-walledsacthatsurroundsandprotectstheheart.Ithastwolayersthatcontainafewmillilitersofserouspericardialfluid.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General2.Thedirectionofbloodflowthroughtheheartisbestdescribedbywhichofthese?a.VenacavarightatriumrightventriNclUeRluSnINgsGpTuBl.mCoOnMaryarteryleftatriumleftventricleb.Rightatriumrightventriclepulmonaryarterylungspulmonaryveinleftatriumleftventriclec.Aortarightatriumrightventriclelungspulmonaryveinleftatriumleftventriclevenacavad.RightatriumrightventriclepulmonaryveinlungspulmonaryarteryleftatriumleftventricleANS:BReturningbloodfromthebodyemptiesintotherightatriumandflowsintotherightventricleandthengoestothelungsthroughthepulmonaryartery.Thelungsoxygenatetheblood,anditisthenreturnedtotheleftatriumthroughthepulmonaryvein.Thebloodgoesfromtheretotheleftventricleandthenouttothebodythroughtheaorta.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General3.Thenurseisreviewingtheanatomyandphysiologicfunctioningoftheheart.Whichstatementbestdescribeswhatismeantbyatrialkick?a.Theatriacontractduringsystoleandattempttopushagainstclosedvalves.b.Contractionoftheatriaatthebeginningofdiastolecanbefeltasapalpitation.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)285STUVIA.COMc.Atrialkickisthepressureexertedagainsttheatriaastheventriclescontractduringsystole.d.Theatriacontracttowardtheendofdiastoleandpushtheremainingbloodintotheventricles.ANS:DTowardtheendofdiastole,theatriacontractandpushthelastamountofblood(approximately25%ofstrokevolume)intotheventricles.Thisactivefillingphaseiscalledpresystole,oratrialsystole,orsometimestheatrialkick.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General4.Whenlisteningtoheartsounds,thenurseknowsthevalveclosuresthatcanbeheardbestatthebaseoftheheartare:a.Mitralandtricuspid.b.Tricuspidandaortic.c.Aorticandpulmonic.d.Mitralandpulmonic.NURSINGTB.COMANS:CThesecondheartsound(S2)occurswiththeclosureofthesemilunar(aorticandpulmonic)valvesandsignalstheendofsystole.Althoughitisheardoveralltheprecordium,theS2isloudestatthebaseoftheheart.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:General5.Whichofthesestatementsdescribestheclosureofthevalvesinanormalcardiaccycle?a.Theaorticvalveclosesslightlybeforethetricuspidvalve.b.Thepulmonicvalveclosesslightlybeforetheaorticvalve.c.Thetricuspidvalveclosesslightlylaterthanthemitralvalve.d.Boththetricuspidandpulmonicvalvescloseatthesametime.ANS:CEventsoccurjustslightlylaterintherightsideoftheheartbecauseoftherouteofmyocardialdepolarization.Asaresult,twodistinctcomponentstoeachoftheheartsoundsexist,andsometimestheycanbeheardseparately.Inthefirstheartsound,themitralcomponent(M1)closesjustbeforethetricuspidcomponent(T1).PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)286STUVIA.COMDIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:General6.Thecomponentoftheconductionsystemreferredtoasthepacemakeroftheheartisthe:a.Atrioventricular(AV)node.b.Sinoatrial(SA)node.c.BundleofHis.d.Bundlebranches.ANS:BSpecializedcellsintheSAnodenearthesuperiorvenacavainitiateanelectricalimpulse.BecausetheSAnodehasanintrinsicrhythm,itiscalledthepacemakeroftheheart.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General7.Theelectricalstimulusofthecardiaccyclefollowswhichsequence?a.AVnodeSAnodebundleofHisb.BundleofHisAVnodeSAnodeNURSINGTB.COMc.SAnodeAVnodebundleofHisbundlebranchesd.AVnodeSAnodebundleofHisbundlebranchesANS:DSpecializedcellsintheSAnodenearthesuperiorvenacavainitiateanelectricalimpulse.Thecurrentflowsinanorderlysequence,firstacrosstheatriatotheAVnodelowintheatrialseptum.Thereitisdelayedslightly,allowingtheatriathetimetocontractbeforetheventriclesarestimulated.ThentheimpulsetravelstothebundleofHis,therightandleftbundlebranches,andthenthroughtheventricles.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:General8.Thefindingsfromanassessmentofa70-year-oldpatientwithswellinginhisanklesincludejugularvenouspulsations5cmabovethesternalanglewhentheheadofhisbediselevated45degrees.Thenurseknowsthatthisfindingindicates:a.Decreasedfluidvolume.b.Increasedcardiacoutput.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)287STUVIA.COMc.Narrowingofjugularveins.d.Elevatedpressurerelatedtoheartfailure.ANS:DBecausenocardiacvalveexiststoseparatethesuperiorvenacavafromtherightatrium,thejugularveinsgiveinformationabouttheactivityontherightsideoftheheart.Theyreflectfillingpressuresandvolumechanges.Normaljugularvenouspulsationis2cmorlessabovethesternalangle.Elevatedpressureismorethan3cmabovethesternalangleat45degreesandoccurswithheartfailure.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation9.Whenassessinganewborninfantwhois5minutesold,thenurseknowswhichofthesestatementstobetrue?a.Theleftventricleislargerandweighsmorethantherightventricle.b.Thecirculationofanewbornisidenticaltothatofanadult.c.Bloodcanflowintotheleftsideoftheheartthroughanopeningintheatrialseptum.NURSINGTB.COMd.Theforamenovaleclosesjustminutesbeforebirth,andtheductusarteriosusclosesimmediatelyafter.ANS:CFirst,approximatelytwothirdsofthebloodisshuntedthroughanopeningintheatrialseptum,theforamenovale,intotheleftsideoftheheart,whereitispumpedoutthroughtheaorta.Theforamenovalecloseswithinthefirsthourafterbirthbecausethepressureintherightsideoftheheartisnowlowerthanintheleftside.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance10.A25-year-oldwomaninherfifthmonthofpregnancyhasabloodpressureof100/70mmHg.Inreviewingherpreviousexamination,thenursenotesthatherbloodpressureinhersecondmonthwas124/80mmHg.Inevaluatingthischange,whatdoesthenurseknowtobetrue?a.Thisdeclineinbloodpressureistheresultofperipheralvasodilatationandisanexpectedchange.b.Becauseofincreasedcardiacoutput,thebloodpressureshouldbehigheratthistime.c.Thischangeinbloodpressureisnotanexpectedfindingbecauseitmeansadecreaseincardiacoutput.d.Thisdeclineinbloodpressuremeansadecreaseincirculatingbloodvolume,whichisdangerousforthefetus.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)288STUVIA.COMANS:ADespitetheincreasedcardiacoutput,arterialbloodpressuredecreasesinpregnancybecauseofperipheralvasodilatation.Thebloodpressuredropstoitslowestpointduringthesecondtrimesterandthenrisesafterthat.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation11.Inassessinga70-year-oldman,thenursefindsthefollowing:bloodpressure140/100mmHg;heartrate104beatsperminuteandslightlyirregular;andthesplitS2heartsound.Whichofthesefindingscanbeexplainedbyexpectedhemodynamicchangesrelatedtoage?a.Increaseinrestingheartrateb.Increaseinsystolicbloodpressurec.Decreaseindiastolicbloodpressured.IncreaseindiastolicbloodpressureANS:BWithaging,anincreaseinsystolicbloodpressNuUreRoScINcuGrsT.BN.CoOsiMgnificantchangeindiastolicpressureandnochangeintherestingheartrateoccurwithaging.Cardiacoutputatrestisdoesnotchangedwithaging.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance12.A45-year-oldmanisintheclinicforaroutinephysicalexamination.Duringtherecordingofhishealthhistory,thepatientstatesthathehasbeenhavingdifficultysleeping.Illbesleepinggreat,andthenIwakeupandfeellikeIcantgetmybreath.Thenursesbestresponsetothiswouldbe:a.Whenwasyourlastelectrocardiogram?b.Itsprobablybecauseitsbeensohotatnight.c.Doyouhaveanyhistoryofproblemswithyourheart?d.Haveyouhadarecentsinusinfectionorupperrespiratoryinfection?ANS:CParoxysmalnocturnaldyspnea(shortnessofbreathgenerallyoccurringatnight)occurswithheartfailure.Lyingdownincreasesthevolumeofintrathoracicblood,andtheweakenedheartcannotaccommodatetheincreasedload.Classically,thepersonawakensafter2hoursofsleep,arises,andflingsopenawindowwiththeperceptionofneedingfreshair.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)289STUVIA.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation13.Inassessingapatientsmajorriskfactorsforheartdisease,whichwouldthenursewanttoincludewhentakingahistory?a.Familyhistory,hypertension,stress,andageb.Personalitytype,highcholesterol,diabetes,andsmokingc.Smoking,hypertension,obesity,diabetes,andhighcholesterold.Alcoholconsumption,obesity,diabetes,stress,andhighcholesterolANS:CToassessformajorriskfactorsofcoronaryarterydisease,thenurseshouldcollectdataregardingelevatedserumcholesterol,elevatedbloodpressure,bloodglucoselevelsabove100mg/dLorknowndiabetesmellitus,obesity,anylengthofhormonereplacementtherapyforpostmenopausalwomen,cigarettesmoking,andlowactivitylevel.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential14.Themotherofa3-month-oldinfantstatesNthUaRthSeINrGbaTbBy.ChaOsMnotbeengainingweight.Withfurtherquestioning,thenursefindsthattheinfantfallsasleepafternursingandwakesupafterashorttime,hungryagain.Whatotherinformationwouldthenursewanttohave?a.Infantssleepingpositionb.Siblinghistoryofeatingdisordersc.Amountofbackgroundnoisewheneatingd.PresenceofdyspneaordiaphoresiswhensuckingANS:DToscreenforheartdiseaseinaninfant,thefocusshouldbeonfeeding.Fatigueduringfeedingshouldbenoted.Aninfantwithheartfailuretakesfewerounceseachfeeding,becomesdyspneicwithsucking,maybediaphoretic,andthenfallsintoexhaustedsleepandawakensafterashorttimehungryagain.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation15.Inassessingthecarotidarteriesofanolderpatientwithcardiovasculardisease,thenursewould:a.Palpatethearteryintheupperonethirdoftheneck.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)290STUVIA.COMb.Listenwiththebellofthestethoscopetoassessforbruits.c.Simultaneouslypalpatebotharteriestocompareamplitude.d.Instructthepatienttotakeslowdeepbreathsduringauscultation.ANS:BIfcardiovasculardiseaseissuspected,thenthenurseshouldauscultateeachcarotidarteryforthepresenceofabruit.Thenurseshouldavoidcompressingtheartery,whichcouldcreateanartificialbruitandcompromisecirculationifthecarotidarteryisalreadynarrowedbyatherosclerosis.Excessivepressureonthecarotidsinusareahighintheneckshouldbeavoided,andexcessivevagalstimulationcouldslowdowntheheartrate,especiallyinolderadults.Palpatingonlyonecarotidarteryatatimewillavoidcompromisingarterialbloodtothebrain.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare16.Duringanassessmentofa68-year-oldmanwitharecentonsetofright-sidedweakness,thenursehearsablowing,swishingsoundwiththebellofthestethoscopeovertheleftcarotidartery.Thisfindingwouldindicate:a.Valvulardisorder.b.Bloodflowturbulence.c.Fluidvolumeoverload.d.Ventricularhypertrophy.NURSINGTB.COMANS:BAbruitisablowing,swishingsoundindicatingbloodflowturbulence;normally,noneispresent.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare17.Duringaninspectionoftheprecordiumofanadultpatient,thenursenoticesthechestmovinginaforcefulmanneralongthesternalborder.Thisfindingmostlikelysuggestsa(n):a.Normalheart.b.Systolicmurmur.c.Enlargementoftheleftventricle.d.Enlargementoftherightventricle.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)291STUVIA.COMANS:DNormally,theexaminermayormaynotseeanapicalimpulse;whenvisible,itoccupiesthefourthorfifthintercostalspaceatorinsidethemidclavicularline.Aheaveorliftisasustainedforcefulthrustingoftheventricleduringsystole.Itoccurswithventricularhypertrophyasaresultofincreasedworkload.Arightventricularheaveisseenatthesternalborder;aleftventricularheaveisseenattheapex.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare18.Duringanassessmentofahealthyadult,wherewouldthenurseexpecttopalpatetheapicalimpulse?a.Thirdleftintercostalspaceatthemidclavicularlineb.Fourthleftintercostalspaceatthesternalborderc.Fourthleftintercostalspaceattheanterioraxillarylined.FifthleftintercostalspaceatthemidclavicularlineANS:DTheapicalimpulseshouldoccupyonlyoneintercostalspace,thefourthorfifth,anditshouldbeatormedialtothemidclavicularline.DIF:CognitiveLevel:Remembering(KnowleNdUgeR)SINGTB.COMMSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare19.Thenurseisexaminingapatientwhohaspossiblecardiacenlargement.Whichstatementaboutpercussionoftheheartistrue?a.Percussionisausefultoolforoutliningtheheartsborders.b.Percussioniseasierinpatientswhoareobese.c.Studiesshowthatpercussedcardiacbordersdonotcorrelatewellwiththetruecardiacborder.d.Onlyexperthealthcareprovidersshouldattemptpercussionoftheheart.ANS:CNumerouscomparisonstudieshaveshownthatthepercussedcardiacbordercorrelatesonlymoderatelywiththetruecardiacborder.Percussionisoflimitedusefulnesswiththefemalebreasttissue,inapersonwhoisobese,orinapersonwithamuscularchestwall.Chestx-rayimagesorechocardiographicexaminationsaresignificantlymoreaccurateindetectingheartenlargement.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCarePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)292STUVIA.COM20.Thenurseispreparingtoauscultateforheartsounds.Whichtechniqueiscorrect?a.Listeningtothesoundsattheaortic,tricuspid,pulmonic,andmitralareasb.ListeningbyinchingthestethoscopeinaroughZpattern,fromthebaseoftheheartacrossanddown,thenovertotheapexc.Listeningtothesoundsonlyatthesitewheretheapicalpulseisfelttobethestrongestd.ListeningforallpossiblesoundsatatimeateachspecifiedareaANS:BAuscultationofbreathsoundsshouldnotbelimitedtoonlyfourlocations.Soundsproducedbythevalvesmaybeheardallovertheprecordium.ThestethoscopeshouldbeinchedinaroughZpatternfromthebaseoftheheartacrossanddown,thenovertotheapex;or,startingattheapex,itshouldbeslowlyworkedup.Listeningselectivelytoonesoundatatimeisbest.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare21.Whilecountingtheapicalpulseona16-year-oldpatient,thenursenoticesanirregularrhythm.Hisratespeedsuponinspirationandslowsonexpiration.Whatwouldbethenursesresponse?a.TalkwiththepatientabouthisintaNkUeRoSfIcNafGfTeiBn.eC.OMb.Performanelectrocardiogramaftertheexamination.c.Nofurtherresponseisneededbecausesinusarrhythmiacanoccurnormally.d.Referthepatienttoacardiologistforfurthertesting.ANS:CTherhythmshouldberegular,althoughsinusarrhythmiaoccursnormallyinyoungadultsandchildren.Withsinusarrhythmia,therhythmvarieswiththepersonsbreathing,increasingatthepeakofinspirationandslowingwithexpiration.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance22.Whenlisteningtoheartsounds,thenurseknowsthattheS1:a.IslouderthantheS2atthebaseoftheheart.b.Indicatesthebeginningofdiastole.c.Coincideswiththecarotidarterypulse.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)293STUVIA.COMd.Iscausedbytheclosureofthesemilunarvalves.ANS:CTheS1coincideswiththecarotidarterypulse,isthestartofsystole,andislouderthantheS2attheapexoftheheart;theS2islouderthantheS1atthebase.Thenurseshouldgentlyfeelthecarotidarterypulsewhileauscultatingattheapex;thesoundheardaseachpulseisfeltistheS1.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:General23.Duringthecardiacauscultation,thenursehearsasoundimmediatelyoccurringaftertheS2atthesecondleftintercostalspace.Tofurtherassessthissound,whatshouldthenursedo?a.Havethepatientturntotheleftsidewhilethenurselistenswiththebellofthestethoscope.b.Askthepatienttoholdhisorherbreathwhilethenurselistensagain.c.NofurtherassessmentisneededbecausethenurseknowsthissoundisanS3.d.Watchthepatientsrespirationswhilelisteningfortheeffectonthesound.ANS:DNURSINGTB.COMAsplitS2isanormalphenomenonthatoccurstowardtheendofinspirationinsomepeople.AsplitS2isheardonlyinthepulmonicvalvearea,thesecondleftinterspace.WhenthesplitS2isfirstheard,thenurseshouldnobetemptedtoaskthepersontoholdhisorherbreathsothatthenursecanconcentrateonthesounds.Breathholdingwillonlyequalizeejectiontimesintherightandleftsidesoftheheartandcausethesplittogoaway.Rather,thenurseshouldconcentrateonthesplitwhilewatchingthepersonschestriseupanddownwithbreathing.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare24.Whichofthesefindingswouldthenurseexpecttonoticeduringacardiacassessmentona4-year-oldchild?a.S3whensittingupb.Persistenttachycardiaabove150beatsperminutec.Murmuratthesecondleftintercostalspacewhensupined.PalpableapicalimpulseinthefifthleftintercostalspacelateraltomidclavicularlineANS:CPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)294STUVIA.COMSomemurmursarecommoninhealthychildrenoradolescentsandaretermedinnocentorfunctional.Theinnocentmurmurisheardatthesecondorthirdleftintercostalspaceanddisappearswithsitting,andtheyoungpersonhasnoassociatedsignsofcardiacdysfunction.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance25.Whileauscultatingheartsoundsona7-year-oldchildforaroutinephysicalexamination,thenursehearsanS3,asoftmurmurattheleftmidsternalborder,andavenoushumwhenthechildisstanding.Whatwouldbeacorrectinterpretationofthesefindings?a.S3isindicativeofheartdiseaseinchildren.b.Thesefindingscanallbenormalinachild.c.Thesefindingsareindicativeofcongenitalproblems.d.Thevenoushummostlikelyindicatesananeurysm.ANS:BAphysiologicS3iscommoninchildren.Avenoushum,causedbyturbulenceofbloodflowinthejugularvenoussystem,iscommoninhealthychildrenandhasnopathologicsignificance.Heartmurmursthatareinnocent(orfunctional)inoriginareverycommonthroughchildhood.NURSINGTB.COMDIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance26.Duringtheprecordialassessmentonanpatientwhois8monthspregnant,thenursepalpatestheapicalimpulseatthefourthleftintercostalspacelateraltothemidclavicularline.Thisfindingwouldindicate:a.Rightventricularhypertrophy.b.Increasedvolumeandsizeoftheheartasaresultofpregnancy.c.Displacementoftheheartfromelevationofthediaphragm.d.Increasedbloodflowthroughtheinternalmammaryartery.ANS:CPalpationoftheapicalimpulseishigherandmorelateral,comparedwiththenormalposition,becausetheenlarginguteruselevatesthediaphragmanddisplacestheheartupandtotheleftandrotatesitonitslongaxis.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance27.InassessingforanS4heartsoundwithastethoscope,thenursewouldlistenwiththe:PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)295STUVIA.COMa.Bellofthestethoscopeatthebasewiththepatientleaningforward.b.Bellofthestethoscopeattheapexwiththepatientintheleftlateralposition.c.Diaphragmofthestethoscopeintheaorticareawiththepatientsitting.d.Diaphragmofthestethoscopeinthepulmonicareawiththepatientsupine.ANS:BTheS4isaventricularfillingsoundthatoccurswhentheatriacontractlateindiastoleandisheardimmediatelybeforetheS1.TheS4isaverysoftsoundwithaverylowpitch.Thenurseneedsagoodbellandmustlistenforthissound.AnS4isheardbestattheapex,withthepersonintheleftlateralposition.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare28.A70-year-oldpatientwithahistoryofhypertensionhasabloodpressureof180/100mmHgandaheartrateof90beatsperminute.ThenursehearsanextraheartsoundattheapeximmediatelybeforetheS1.Thesoundisheardonlywiththebellofthestethoscopewhilethepatientisintheleftlateralposition.Withthesefindingsandthepatientshistory,thenurseknowsthatthisextraheartsoundismostlikelya(n):a.SplitS1.NURSINGTB.COMb.Atrialgallop.c.Diastolicmurmur.d.Summationsound.ANS:BApathologicS4istermedanatrialgalloporanS4gallop.Itoccurswithdecreasedcomplianceoftheventricleandwithsystolicoverload(afterload),includingoutflowobstructiontotheventricle(aorticstenosis)andsystemichypertension.Aleft-sidedS4occurswiththeseconditionsandisheardbestattheapexwiththepatientintheleftlateralposition.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance29.Thenurseisperformingacardiacassessmentona65-year-oldpatient3daysafterhermyocardialinfarction(MI).Heartsoundsarenormalwhensheissupine,butwhensheissittingandleaningforward,thenursehearsahigh-pitched,scratchysoundwiththediaphragmofthestethoscopeattheapex.Itdisappearsoninspiration.Thenursesuspects:a.Increasedcardiacoutput.b.AnotherMI.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)296STUVIA.COMc.Inflammationoftheprecordium.d.Ventricularhypertrophyresultingfrommuscledamage.ANS:CInflammationoftheprecordiumgivesrisetoafrictionrub.Thesoundishighpitchedandscratchy,similartosandpaperbeingrubbed.Africtionrubisbestheardwiththediaphragmofthestethoscope,withthepersonsittingupandleaningforward,andwiththebreathheldinexpiration.Africtionrubcanbeheardanyplaceontheprecordium.Usually,however,thesoundisbestheardattheapexandleftlowersternalborder,whichareplaceswherethepericardiumcomesinclosecontactwiththechestwall.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation30.Themotherofa10-month-oldinfanttellsthenursethatshehasnoticedthathersonbecomesbluewhenheiscryingandthatthefrequencyofthisisincreasing.Heisalsonotcrawlingyet.Duringtheexaminationthenursepalpatesathrillattheleftlowersternalborderandauscultatesaloudsystolicmurmurinthesamearea.Whatwouldbethemostlikelycauseofthesefindings?a.TetralogyofFallotb.Atrialseptaldefectc.Patentductusarteriosusd.VentricularseptaldefectNURSINGTB.COMANS:AThecauseofthesefindingsistetralogyofFallot.Itssubjectivefindingsinclude:(1)severecyanosis,notinthefirstmonthsoflifebutdevelopingastheinfantgrows,andrightventricleoutflow(i.e.,pulmonic)stenosisthatgetsworse;(2)cyanosiswithcryingandexertionatfirstandthenatrest;and(3)sloweddevelopment.Itsobjectivefindingsinclude:(1)thrillpalpableattheleftlowersternalborder;(2)theS1isnormal,theS2hasaloudA2,andtheP2isdiminishedorabsent;and(3)themurmurissystolic,loud,andcrescendo-decrescendo.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance31.A30-year-oldwomanwithahistoryofmitralvalveproblemsstatesthatshehasbeenverytired.Shehasstartedwakingupatnightandfeelslikeherheartispounding.Duringtheassessment,thenursepalpatesathrillandliftatthefifthleftintercostalspacemidclavicularline.Inthesamearea,thenursealsoauscultatesablowing,swishingsoundrightaftertheS1.Thesefindingswouldbemostconsistentwith:a.Heartfailure.b.Aorticstenosis.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)297STUVIA.COMc.Pulmonaryedema.d.Mitralregurgitation.ANS:DThesefindingsareconsistentwithmitralregurgitation.Itssubjectivefindingsincludefatigue,palpitation,andorthopnea,anditsobjectivefindingsare:(1)athrillinsystoleattheapex;(2)aliftattheapex;(3)theapicalimpulsedisplaceddownandtotheleft;(4)theS1isdiminished,theS2isaccentuated,andtheS3attheapexisoftenpresent;and(5)apansystolicmurmurthatisoftenloud,blowing,bestheardattheapex,andradiatingwelltotheleftaxilla.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation32.Duringacardiacassessmentona38-year-oldpatientinthehospitalforchestpain,thenursefindsthefollowing:jugularveinpulsations4cmabovethesternalanglewhenthepatientiselevatedat45degrees,bloodpressure98/60mmHg,heartrate130beatsperminute,ankleedema,difficultybreathingwhensupine,andanS3onauscultation.Whichoftheseconditionsbestexplainsthecauseofthesefindings?a.Fluidoverloadb.Atrialseptaldefectc.MId.HeartfailureNURSINGTB.COMANS:DHeartfailurecausesdecreasedcardiacoutputwhentheheartfailsasapumpandthecirculationbecomesbackedupandcongested.Signsandsymptomsincludedyspnea,orthopnea,paroxysmalnocturnaldyspnea,decreasedbloodpressure,dependentandpittingedema;anxiety;confusion;jugularveindistention;andfatigue.TheS3isassociatedwithheartfailureandisalwaysabnormalafter35yearsofage.TheS3maybetheearliestsignofheartfailure.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation33.ThenurseknowsthatnormalsplittingoftheS2isassociatedwith:a.Expiration.b.Inspiration.c.Exercisestate.d.Lowrestingheartrate.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)298STUVIA.COMANS:BNormalorphysiologicsplittingoftheS2isassociatedwithinspirationbecauseoftheincreasedbloodreturntotherightsideoftheheart,delayingclosureofthepulmonicvalve.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare34.Duringacardiovascularassessment,thenurseknowsthatathrillis:a.Vibrationthatispalpable.b.Palpatedintherightepigastricarea.c.Associatedwithventricularhypertrophy.d.Murmurauscultatedatthethirdintercostalspace.ANS:AAthrillisapalpablevibrationthatsignifiesturbulentbloodflowandaccompaniesloudmurmurs.Theabsenceofathrilldoesnotruleoutthepresenceofamurmur.DIF:CognitiveLevel:Remembering(Knowledge)NURSINGTB.COMMSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare35.Duringacardiovascularassessment,thenurseknowsthatanS4heartsoundis:a.Heardattheonsetofatrialdiastole.b.Usuallyanormalfindingintheolderadult.c.Heardattheendofventriculardiastole.d.Heardbestoverthesecondleftintercostalspacewiththeindividualsittingupright.ANS:CAnS4heartsoundisheardattheendofdiastolewhentheatriacontract(atrialsystole)andwhentheventriclesareresistanttofilling.TheS4occursjustbeforetheS1.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare36.Duringanassessment,thenursenotesthatthepatientsapicalimpulseislaterallydisplacedandispalpableoverawidearea.Thisfindingindicates:PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)299STUVIA.COMa.Systemichypertension.b.Pulmonichypertension.c.Pressureoverload,asinaorticstenosis.d.Volumeoverload,asinheartfailure.ANS:DWithvolumeoverload,asinheartfailureandcardiomyopathy,cardiacenlargementlaterallydisplacestheapicalimpulseandispalpableoverawiderareawhenleftventricularhypertrophyanddilationarepresent.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare37.Whenthenurseisauscultatingthecarotidarteryforbruits,whichofthesestatementsreflectsthecorrecttechnique?a.Whilelisteningwiththebellofthestethoscope,thepatientisaskedtotakeadeepbreathandholdit.b.Whileauscultatingonesidewiththebellofthestethoscope,thecarotidarteryispalpatedontheothersidetocheckpulsations.NURSINGTB.COMc.Whilelightlyapplyingthebellofthestethoscopeoverthecarotidarteryandlistening,thepatientisaskedtotakeabreath,exhale,andbrieflyholdit.d.Whilefirmlyplacingthebellofthestethoscopeoverthecarotidarteryandlistening,thepatientisaskedtotakeabreath,exhale,andbrieflyholdit.ANS:CThecorrecttechniqueforauscultatingthecarotidarteryforbruitsinvolvesthenurselightlyapplyingthebellofthestethoscopeoverthecarotidarteryatthreelevels.Whilelistening,thenurseasksthepatienttakeabreath,exhale,andbrieflyholdit.Holdingthebreathoninhalationwillalsotensethelevatorscapulaemuscles,whichmakesithardtohearthecarotidarteries.Examiningonlyonecarotidarteryatatimewillavoidcompromisingarterialbloodflowtothebrain.Pressureoverthecarotidsinus,whichmayleadtodecreasedheartrate,decreasedbloodpressure,andcerebralischemiawithsyncope,shouldbeavoided.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare38.Thenurseispreparingforaclassonriskfactorsforhypertensionandreviewsrecentstatistics.Whichracialgrouphasthehighestprevalenceofhypertensionintheworld?a.Blacksb.WhitesPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)300STUVIA.COMc.AmericanIndiansd.HispanicsANS:AAccordingtotheAmericanHeartAssociation,theprevalenceofhypertensionishigheramongBlacksthaninotherracialgroups.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential39.Thenurseisassessingapatientwithpossiblecardiomyopathyandassessesthehepatojugularreflux.Ifheartfailureispresent,thenthenurseshouldrecognizewhichfindingwhilepushingontherightupperquadrantofthepatientsabdomen,justbelowtheribcage?a.Thejugularveinswillriseforafewsecondsandthenrecedebacktothepreviousleveliftheheartisproperlyworking.b.Thejugularveinswillremainelevatedaslongaspressureontheabdomenismaintained.c.Animpulsewillbevisibleatthefourthorfifthintercostalspaceatorinsidethemidclavicularline.d.ThejugularveinswillnotbedetecNteUdRdSuIrNinGgTtBh.iCsOmManeuver.ANS:BWhenperforminghepatojugularreflux,thejugularveinswillriseforafewsecondsandthenrecedebacktothepreviousleveliftheheartisabletopumptheadditionalvolumecreatedbythepushing.However,withheartfailure,thejugularveinsremainelevatedaslongaspressureontheabdomenismaintained.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare40.Thenurseisassessingtheapicalpulseofa3-month-oldinfantandfindsthattheheartrateis135beatsperminute.Thenurseinterpretsthisresultas:a.Normalforthisage.b.Lowerthanexpected.c.Higherthanexpected,probablyasaresultofcrying.d.Higherthanexpected,reflectingpersistenttachycardia.ANS:APHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)301STUVIA.COMTheheartratemayrangefrom100to180beatsperminuteimmediatelyafterbirthandthenstabilizetoanaverageof120to140beatsperminute.Infantsnormallyhavewidefluctuationswithactivity,from170beatsperminuteormorewithcryingorbeingactiveto70to90beatsperminutewithsleeping.Persistenttachycardiaisgreaterthan200beatsperminuteinnewbornsorgreaterthan150beatsperminuteininfants.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCareMULTIPLERESPONSE1.Thenurseispresentingaclassonriskfactorsforcardiovasculardisease.WhichoftheseareconsideredmodifiableriskfactorsforMI?Selectallthatapply.a.Ethnicityb.Abnormallipidsc.Smokingd.Gendere.Hypertensionf.Diabetesg.FamilyhistoryNURSINGTB.COMANS:B,C,E,FNinemodifiableriskfactorsforMI,asidentifiedbyarecentstudy,includeabnormallipids,smoking,hypertension,diabetes,abdominalobesity,psychosocialfactors,consumptionoffruitsandvegetables,alcoholuse,andregularphysicalactivity.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenanceSHORTANSWER1.Thenurseisassessingapatientspulsesandnoticesadifferencebetweenthepatientsapicalpulseandradialpulse.Theapicalpulsewas118beatsperminute,andtheradialpulsewas105beatsperminute.Whatisthepulsedeficit?ANS:13Thenurseshouldcountaserialmeasurement(oneaftertheother)oftheapicalpulseandthentheradialpulse.Normally,everybeatheardattheapexshouldperfusetotheperipheryandbepalpable.Thetwocountsshouldbeidentical.Iftheyaredifferent,thenthenurseshouldsubtracttheradialratefromtheapicalpulseandrecordtheremainderasthepulsedeficit.DIF:CognitiveLevel:Analyzing(Analysis)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)302STUVIA.COMNURSINGTB.COMMSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCarePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)303STUVIA.COMChapter21:PeripheralVascularSystemandLymphaticSystemMULTIPLECHOICE1.Whichstatementistrueregardingthearterialsystem?a.Arteriesarelarge-diametervessels.b.Thearterialsystemisahigh-pressuresystem.c.Thewallsofarteriesarethinnerthanthoseoftheveins.d.Arteriescangreatlyexpandtoaccommodatealargebloodvolumeincrease.ANS:BThepumpingheartmakesthearterialsystemahigh-pressuresystem.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General2.Thenurseisreviewingthebloodsupplytothearm.Themajorarterysupplyingthearmistheartery.a.Ulnarb.Radialc.Brachiald.DeeppalmarNURSINGTB.COMANS:CThemajorarterysupplyingthearmisthebrachialartery.Thebrachialarterybifurcatesintotheulnarandradialarteriesimmediatelybelowtheelbow.Inthehand,theulnarandradialarteriesformtwoarchesknownasthesuperficialanddeeppalmararches.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General3.Thenurseispreparingtoassessthedorsalispedisartery.Whereisthecorrectlocationforpalpation?a.Behindthekneeb.Overthelateralmalleolusc.InthegroovebehindthemedialmalleolusPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)304STUVIA.COMd.LateraltotheextensortendonofthegreattoeANS:DThedorsalispedisarteryislocatedonthedorsumofthefoot.Thenurseshouldpalpatejustlateraltoandparallelwiththeextensortendonofthebigtoe.Thepoplitealarteryispalpatedbehindtheknee.TheposteriortibialpulseispalpatedinthegroovebetweenthemalleolusandtheAchillestendon.Nopulseispalpatedatthelateralmalleolus.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:General4.A65-year-oldpatientisexperiencingpaininhisleftcalfwhenheexercisesthatdisappearsafterrestingforafewminutes.Thenurserecognizesthatthisdescriptionismostconsistentwiththeleftleg.a.Venousobstructionofb.Claudicationduetovenousabnormalitiesinc.Ischemiacausedbyapartialblockageofanarterysupplyingd.IschemiacausedbythecompleteblockageofanarterysupplyingANS:CNURSINGTB.COMIschemiaisadeficientsupplyofoxygenatedarterialbloodtoatissue.Apartialblockagecreatesaninsufficiensupply,andtheischemiamaybeapparentonlyduringexercisewhenoxygenneedsincrease.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation5.Thenurseisreviewingvenousbloodflowpatterns.Whichofthesestatementsbestdescribesthemechanism(s)bywhichvenousbloodreturnstotheheart?a.Intraluminalvalvesensureunidirectionalflowtowardtheheart.b.Contractingskeletalmusclesmilkblooddistallytowardtheveins.c.High-pressuresystemofthehearthelpsfacilitatevenousreturn.d.Increasedthoracicpressureanddecreasedabdominalpressurefacilitatevenousreturntotheheart.ANS:ABloodmovesthroughtheveinsby(1)contractingskeletalmusclesthatproximallymilktheblood;(2)pressuregradientscausedbybreathing,duringwhichinspirationmakesthethoracicpressuredecreaseandtheabdominalpressureincrease;and(3)theintraluminalvalves,whichensureunidirectionalflowtowardtheheart.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)305STUVIA.COMDIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:General6.Whichvein(s)is(are)responsibleformostofthevenousreturninthearm?a.Deepb.Ulnarc.Subclaviand.SuperficialANS:DThesuperficialveinsofthearmsareinthesubcutaneoustissueandareresponsibleformostofthevenousreturn.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General7.A70-year-oldpatientisscheduledforopen-heartsurgery.Thesurgeonplanstousethegreatsaphenousveinforthecoronarybypassgrafts.Thepatientasks,Whathappenstomycirculationwhenthisveinisremoved?Thenurseshouldreply:NURSINGTB.COMa.Venousinsufficiencyisacommonproblemafterthistypeofsurgery.b.Oh,youhavelotsofveinsyouwontevennoticethatithasbeenremoved.c.Youwillprobablyexperiencedecreasedcirculationaftertheveinisremoved.d.Thisveincanberemovedwithoutharmingyourcirculationbecausethedeeperveinsinyourlegareingoodcondition.ANS:DAslongasthefemoralandpoplitealveinsremainintact,thesuperficialveinscanbeexcisedwithoutharmingcirculation.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation8.Thenurseisreviewingtheriskfactorsforvenousdisease.Whichofthesesituationsbestdescribesapersonathighestriskforthedevelopmentofvenousdisease?a.Womaninhersecondmonthofpregnancyb.Personwhohasbeenonbedrestfor4daysPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)306STUVIA.COMc.Personwitha30-year,1packperdaysmokinghabitd.OlderadulttakinganticoagulantmedicationANS:BPeoplewhoundergoprolongedstanding,sitting,orbedrestareatriskforvenousdisease.Hypercoagulable(notanticoagulated)statesandvein-walltraumaalsoplacethepersonatriskforvenousdisease.Obesityandthelatemonthsofpregnancyarealsoriskfactors.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential9.Thenurseisteachingareviewclassonthelymphaticsystem.Aparticipantshowscorrectunderstandingofthematerialwithwhichstatement?a.Lymphflowispropelledbythecontractionoftheheart.b.Theflowoflymphisslow,comparedwiththatoftheblood.c.Oneofthefunctionsofthelymphistoabsorblipidsfromthebiliarytract.d.Lymphvesselshavenovalves;theNreUfRorSeI,NlyGmTBph.CfOluMidflowsfreelyfromthetissuespacesintothebloodstream.ANS:BTheflowoflymphisslow,comparedwithflowoftheblood.Lymphflowisnotpropelledbytheheartbutratherbycontractingskeletalmuscles,pressurechangessecondarytobreathing,andcontractionofthevesselwalls.Lymphdoesnotabsorblipidsfromthebiliarytract.Thevesselsdohavevalves;therefore,flowisonewayfromthetissuespacestothebloodstream.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation10.Whenperforminganassessmentofapatient,thenursenoticesthepresenceofanenlargedrightepitrochlearlymphnode.Whatshouldthenursedonext?a.Assessthepatientsabdomen,andnoticeanytenderness.b.Carefullyassessthecervicallymphnodes,andcheckforanyenlargement.c.Askadditionalhealthhistoryquestionsregardinganyrecentearinfectionsorsorethroats.d.Examinethepatientslowerarmandhand,andcheckforthepresenceofinfectionorlesions.ANS:DPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)307STUVIA.COMTheepitrochlearnodesarelocatedintheantecubitalfossaanddrainthehandandlowerarm.Theotheractionsarenotcorrectforthisassessmentfinding.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare11.A35-year-oldmanisseenintheclinicforaninfectioninhisleftfoot.Whichofthesefindingsshouldthenurseexpecttoseeduringanassessmentofthispatient?a.Hardandfixedcervicalnodesb.Enlargedandtenderinguinalnodesc.Bilateralenlargementofthepoplitealnodesd.PelletlikenodesinthesupraclavicularregionANS:BTheinguinalnodesinthegroindrainmostofthelymphofthelowerextremities.Withlocalinflammation,thenodesinthatareabecomeswollenandtender.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationNURSINGTB.COM12.Thenurseisexaminingthelymphaticsystemofahealthy3-year-oldchild.Whichfindingshouldthenurseexpect?a.Excessiveswellingofthelymphnodesb.Presenceofpalpablelymphnodesc.Nopalpablenodesbecauseoftheimmatureimmunesystemofachildd.FewernumbersandasmallersizeoflymphnodescomparedwiththoseofanadultANS:BLymphnodesarerelativelylargeinchildren,andthesuperficialonesareoftenpalpableevenwhenthechildishealthy.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance13.Duringanassessmentofanolderadult,thenurseshouldexpecttonoticewhichfindingasanormalphysiologicchangeassociatedwiththeagingprocess?a.HormonalchangescausingvasodilationandaresultingdropinbloodpressurePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)308STUVIA.COMb.Progressiveatrophyoftheintramuscularcalfveins,causingvenousinsufficiencyc.Peripheralbloodvesselsgrowingmorerigidwithage,producingariseinsystolicbloodpressured.Narrowingoftheinferiorvenacava,causinglowbloodflowandincreasesinvenouspressureresultinginvaricositiesANS:CPeripheralbloodvesselsgrowmorerigidwithage,resultinginariseinsystolicbloodpressure.Agingproducesprogressiveenlargementoftheintramuscularcalfveins,notatrophy.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance14.A67-year-oldpatientstatesthatherecentlybegantohavepaininhisleftcalfwhenclimbingthe10stairstohisapartment.Thispainisrelievedbysittingforapproximately2minutes;thenheisabletoresumehisactivities.Thenurseinterpretsthatthispatientismostlikelyexperiencing:a.Claudication.b.Soremuscles.c.Musclecramps.d.Venousinsufficiency.NURSINGTB.COMANS:AIntermittentclaudicationfeelslikeacrampandisusuallyrelievedbyrestwithin2minutes.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation15.Apatientcomplainsoflegpainthatwakeshimatnight.Hestatesthathehasbeenhavingproblemswithhislegs.Hehaspaininhislegswhentheyareelevatedthatdisappearswhenhedanglesthem.Herecentlynoticedasoreontheinneraspectoftherightankle.Onthebasisofthishealthhistoryinformation,thenurseinterpretsthatthepatientismostlikelyexperiencing:a.Painrelatedtolymphaticabnormalities.b.Problemsrelatedtoarterialinsufficiency.c.Problemsrelatedtovenousinsufficiency.d.Painrelatedtomusculoskeletalabnormalities.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)309STUVIA.COMANS:BNightlegpainiscommoninagingadultsandmayindicatetheischemicrestpainofperipheralvasculardisease.Alterationsinarterialcirculationcausepainthatbecomesworsewithlegelevationandiseasedwhentheextremityisdangled.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation16.Duringanassessment,thenurseusestheprofilesigntodetect:a.Pittingedema.b.Earlyclubbing.c.Symmetryofthefingers.d.Insufficientcapillaryrefill.ANS:BThenurseshouldusetheprofilesign(viewingthefingerfromtheside)todetectearlyclubbing.DIF:CognitiveLevel:Understanding(Comprehension)NURSINGTB.COMMSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation17.Thenurseisperforminganassessmentonanadult.Theadultsvitalsignsarenormal,andcapillaryrefilltimeis5seconds.Whatshouldthenursedonext?a.Askthepatientaboutahistoryoffrostbite.b.Suspectthatthepatienthasvenousinsufficiency.c.Considerthisadelayedcapillaryrefilltime,andinvestigatefurther.d.Considerthisanormalcapillaryrefilltimethatrequiresnofurtherassessment.ANS:CNormalcapillaryrefilltimeislessthan1to2seconds.Thefollowingconditionscanskewthefindings:acoolroom,decreasedbodytemperature,cigarettesmoking,peripheraledema,andanemia.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance18.Whenassessingapatient,thenursenotesthattheleftfemoralpulseasdiminished,1+/4+.Whatshouldthenursedonext?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)310STUVIA.COMa.Documentthefinding.b.Auscultatethesiteforabruit.c.Checkforcalfpain.d.Checkcapillaryrefillinthetoes.ANS:BIfapulseisweakordiminishedatthefemoralsite,thenthenurseshouldauscultateforabruit.Thepresenceoabruit,orturbulentbloodflow,indicatespartialocclusion.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare19.Whenperformingaperipheralvascularassessmentonapatient,thenurseisunabletopalpatetheulnarpulses.Thepatientsskiniswarmandcapillaryrefilltimeisnormal.Next,thenurseshould:a.Checkforthepresenceofclaudication.b.Refertheindividualforfurtherevaluation.c.Considerthisfindingasnormal,anNdUpRrSoIcNeeGdTwBi.CthOtMheperipheralvascularevaluation.d.Askthepatientifheorshehasexperiencedanyunusualcrampingortinglinginthearm.ANS:CPalpatingtheulnarpulsesisnotusuallynecessary.Theulnarpulsesarenotoftenpalpableinthenormalperson.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare20.Thenurseisassessingthepulsesofapatientwhohasbeenadmittedforuntreatedhyperthyroidism.Thenurseshouldexpecttofinda(n)pulse.a.Normalb.Absentc.Boundingd.Weak,threadyANS:CPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)311STUVIA.COMAfull,boundingpulseoccurswithhyperkineticstates(e.g.,exercise,anxiety,fever),anemia,andhyperthyroidism.Anabsentpulseoccurswithocclusion.Weak,threadypulsesoccurwithshockandperipheraarterydisease.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation21.ThenurseispreparingtoperformamodifiedAllentest.Whichisanappropriatereasonforthistest?a.Tomeasuretherateoflymphaticdrainageb.Toevaluatetheadequacyofcapillarypatencybeforevenousblooddrawsc.Toevaluatetheadequacyofcollateralcirculationbeforecannulatingtheradialarteryd.ToevaluatethevenousrefillratethatoccursaftertheulnarandradialarteriesaretemporarilyoccludedANS:CAmodifiedAllentestisusedtoevaluatetheadequacyofcollateralcirculationbeforetheradialarteryiscannulated.TheotherresponsesarenotreasonsforamodifiedAllentest.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhNysUioRlSoIgNicGATBda.CpOtaMtion22.Apatienthasbeendiagnosedwithvenousstasis.Whichofthesefindingswouldthenursemostlikelyobserve?a.Unilateralcoolfootb.Thin,shiny,atrophicskinc.Pallorofthetoesandcyanosisofthenailbedsd.BrownishdiscolorationtotheskinofthelowerlegANS:DAbrowndiscolorationoccurswithchronicvenousstasisasaresultofhemosiderindeposits(aby-productofredbloodcelldegradation).Pallor,cyanosis,atrophicskin,andunilateralcoolnessareallsignsassociatedwitharterialproblems.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation23.Thenurseisattemptingtoassessthefemoralpulseinapatientwhoisobese.Whichoftheseactionswouldbemostappropriate?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)312STUVIA.COMa.Thepatientisaskedtoassumeaproneposition.b.Thepatientisaskedtobendhisorherkneestothesideinafroglikeposition.c.Thenursefirmlypressesagainstthebonewiththepatientinasemi-Fowlerposition.d.Thenurselistenswithastethoscopeforpulsations;palpatingthepulseinanobesepersonisextremelydifficult.ANS:BTohelpexposethefemoralarea,particularlyinobesepeople,thenurseshouldaskthepersontobendhisorherkneestothesideinafroglikeposition.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare24.Whenauscultatingoverapatientsfemoralarteries,thenursenoticesthepresenceofabruitontheleftside.Thenurseknowsthatbruits:a.Areoftenassociatedwithvenousdisease.b.Occurinthepresenceoflymphadenopathy.NURSINGTB.COMc.Inthefemoralarteriesarecausedbyhypermetabolicstates.d.Occurwithturbulentbloodflow,indicatingpartialocclusion.ANS:DAbruitoccurswithturbulentbloodflowandindicatespartialocclusionoftheartery.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare25.Howshouldthenursedocumentmild,slightpittingedematheanklesofapregnantpatient?a.1+/0-4+b.3+/0-4+c.4+/0-4+d.BrawnyedemaANS:APHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)313STUVIA.COMIfpittingedemaispresent,thenthenurseshouldgradeitonascaleof1+(mild)to4+(severe).Brawnyedemaappearsasnonpittingedemaandfeelshardtothetouch.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare26.Apatienthashard,nonpittingedemaoftheleftlowerlegandankle.Therightleghasnoedema.Basedonthesefindings,thenurserecallsthat:a.Nonpitting,hardedemaoccurswithlymphaticobstruction.b.Alterationsinarterialfunctionwillcauseedema.c.Phlebitisofasuperficialveinwillcausebilateraledema.d.Long-standingarterialobstructionwillcausepittingedema.ANS:AUnilateraledemaoccurswithocclusionofadeepveinandwithunilaterallymphaticobstruction.Withthesefactors,theedemaisnonpittingandfeelshardtothetouch(brawnyedema).DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationNURSINGTB.COM27.Whenassessingapatientspulse,thenursenotesthattheamplitudeisweakerduringinspirationandstrongerduringexpiration.Whenthenursemeasuresthebloodpressure,thereadingdecreases20mmHgduringinspirationandincreaseswithexpiration.Thispatientisexperiencingpulsus:a.Alternans.b.Bisferiens.c.Bigeminus.d.Paradoxus.ANS:DInpulsusparadoxus,beatshaveweakeramplitudewithinspirationandstrongeramplitudewithexpirationandisbestdeterminedduringbloodpressuremeasurement;readingdecreases(>10mmHg)duringinspirationandincreaseswithexpiration.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare28.Duringanassessment,thenursehaselevatedapatientslegs12inchesoffthetableandhashadhimwaghisfeettodrainoffvenousblood.Afterhelpinghimsitupanddanglehislegsoverthesideofthetable,thenurseshouldexpectthatanormalfindingatthispointwouldbe:PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)314STUVIA.COMa.Significantelevationalpallor.b.Venousfillingwithin15seconds.c.Nochangeinthecolorationoftheskin.d.Colorreturningtothefeetwithin20secondsofassumingasittingposition.ANS:BInthistest,itnormallytakes10secondsorlessforthecolortoreturntothefeetand15secondsfortheveinsofthefeettofill.Significantelevationalpallor,aswellasdelayedvenousfilling,occurswitharterialinsufficiency.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare29.Duringavisittotheclinic,awomaninherseventhmonthofpregnancycomplainsthatherlegsfeelheavyinthecalfandthatsheoftenhasfootcrampsatnight.Thenursenoticesthatthepatienthasdilated,tortuousveinsapparentinherlowerlegs.Whichconditionisreflectedbythesefindings?a.Deep-veinthrombophlebitisb.Varicoseveinsc.Lymphedemad.RaynaudphenomenonNURSINGTB.COMANS:BSuperficialvaricoseveinsarecausedbyincompetentdistantvalvesintheveins,whichresultsintherefluxofblood,producingdilated,tortuousveins.Varicoseveinsaremorecommoninwomen,andpregnancycanalsobeacause.Symptomsincludeaching,heavinessinthecalf,easyfatigability,andnightlegorfootcramps.Dilated,tortuousveinsareobservedonassessment.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation30.Duringanassessment,thenursenoticesthatapatientsleftarmisswollenfromtheshoulderdowntothefingers,withnonpittingbrawnyedema.Therightarmisnormal.Thepatienthadaleft-sidedmastectomy1yearago.Thenursesuspectswhichproblem?a.Venousstasisb.Lymphedemac.ArteriosclerosisPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)315STUVIA.COMd.Deep-veinthrombosisANS:BLymphedemaafterbreastcancercausesunilateralswellingandnonpittingbrawnyedema,withoverlyingskinindurated.Itiscausedbytheremovaloflymphnodeswithbreastsurgeryordamagetolymphnodesandchannelswithradiationtherapyforbreastcancer,andlymphedemacanimpededrainageoflymph.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare31.Thenurseispreparingtoassesstheankle-brachialindex(ABI)ofapatient.WhichstatementabouttheABIistrue?a.NormalABIindicesarefrom0.5to1.0.b.Normalanklepressureisslightlylowerthanthebrachialpressure.c.TheABIisareliablemeasurementofperipheralvasculardiseaseinindividualswithdiabetes.d.AnABIof0.9to0.7indicatesthepresenceofperipheralvasculardiseaseandmildclaudication.ANS:DNURSINGTB.COMUseoftheDopplerstethoscopeisanoninvasivewaytodeterminetheextentofperipheralvasculardisease.Thenormalanklepressureisslightlygreaterthanorequaltothebrachialpressure.AnABIof0.9to0.7indicatesthepresenceofperipheralvasculardiseaseandmildclaudication.TheABIislessreliableinpatientswithdiabetesmellitusbecauseofclaudication,whichmakesthearteriesnoncompressibleandmaygiveafalsehigh-anklepressure.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare32.Thenurseisperformingawell-childcheckupona5-year-oldboy.Hehasnocurrentconditionthatwouldleadthenursetosuspectanillness.Hishealthhistoryisunremarkable,andhereceivedimmunizations1weekago.Whichofthesefindingsshouldbeconsiderednormalinthispatient?a.Enlarged,warm,andtendernodesb.Lymphadenopathyofthecervicalnodesc.Palpablefirm,small,shotty,mobile,andnontenderlymphnodesd.Firm,rubbery,andlargenodes,somewhatfixedtotheunderlyingtissueANS:CPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)316STUVIA.COMPalpablelymphnodesareoftennormalinchildrenandinfants.Theyaresmall,firm,shotty,mobile,andnontender.Vaccinationscanproducelymphadenopathy.Enlarged,warm,andtendernodesindicateacurrentinfection.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance33.WhenusingaDopplerultrasonicstethoscope,thenurserecognizesvenousflowwhenwhichsoundisheard?a.Lowhummingsoundb.Regularlub,dubpatternc.Swishing,whooshingsoundd.Steady,even,flowingsoundANS:CWhenusingtheDopplerultrasonicstethoscope,thepulsesiteisfoundwhenonehearsaswishing,whooshingsound.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareENnUvRirSoInNmGeTnBt:.CMOaMnagementofCare34.Thenurseisdescribingaweak,threadypulseonthedocumentationflowsheet.Whichstatementiscorrect?a.Iseasilypalpable;poundsunderthefingertips.b.Hasgreaterthannormalforce,thensuddenlycollapses.c.Ishardtopalpate,mayfadeinandout,andiseasilyobliteratedbypressure.d.Rhythmisregular,butforcevarieswithalternatingbeatsoflargeandsmallamplitude.ANS:CAweak,threadypulseishardtopalpate,mayfadeinandout,andiseasilyobliteratedbypressure.Itisassociatedwithdecreasedcardiacoutputandperipheralarterialdisease.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare35.Duringanassessment,apatienttellsthenursethatherfingersoftenchangecolorwhenshegoesoutincoldweather.Shedescribestheseepisodesasherfingersfirstturningwhite,thenblue,thenredwithaburning,throbbingpain.Thenursesuspectsthatsheisexperiencing:PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)317STUVIA.COMa.Lymphedema.b.Raynauddisease.c.Deep-veinthrombosis.d.Chronicarterialinsufficiency.ANS:BTheconditionwithepisodesofabrupt,progressivetricolorchangesofthefingersinresponsetocold,vibration,orstressisknownasRaynauddisease.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation36.Duringaroutineofficevisit,apatienttakesoffhisshoesandshowsthenursethisawfulsorethatwontheal.Oninspection,thenursenotesa3-cmroundulcerontheleftgreattoe,withapaleischemicbase,well-definededges,andnodrainage.Thenurseshouldassessforothersignsandsymptomsof:a.Varicosities.b.Venousstasisulcer.NURSINGTB.COMc.Arterialischemiculcer.d.Deep-veinthrombophlebitis.ANS:CArterialischemiculcersoccuratthetoes,metatarsalheads,heels,andlateralankleandarecharacterizedbyapaleischemicbase,well-definededges,andnobleeding.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation37.Thenurseisreviewinganassessmentofapatientsperipheralpulsesandnoticesthatthedocumentationstatesthattheradialpulsesare2+.Thenurserecognizesthatthisreadingindicateswhattypeofpulse?a.Boundingb.Normalc.Weakd.AbsentPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)318STUVIA.COMANS:BWhendocumentingtheforce,oramplitude,ofpulses,3+indicatesanincreased,full,orboundingpulse,2+indicatesanormalpulse,1+indicatesaweakpulse,and0indicatesanabsentpulse.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCareMULTIPLERESPONSE1.Apatientisrecoveringfromseveralhoursoforthopedicsurgery.Duringanassessmentofthepatientslowerlegs,thenursewillmonitorforsignsofacutevenoussymptoms.Signsofacutevenoussymptomsincludewhichofthefollowing?Selectallthatapply.a.Intense,sharppain,withthedeepmuscletendertothetouchb.Aching,tiredpain,withafeelingoffullnessc.Painthatisworseattheendofthedayd.Suddenonsete.Warm,red,andswollencalff.PainthatisrelievedwithelevationNoUfRthSeINleGgTB.COMANS:A,D,ESignsandsymptomsofacutevenousproblemsincludepaininthecalfthathasasuddenonsetandthatisintenseandsharpwithtendernessinthedeepmusclewhentouched.Thecalfiswarm,red,andswollen.Theotheroptionsaresymptomsofchronicvenousproblems.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential2.Apatienthasbeenadmittedwithchronicarterialsymptoms.Duringtheassessment,thenurseshouldexpectwhichfindings?Selectallthatapply.a.Patienthasahistoryofdiabetesandcigarettesmoking.b.Skinofthepatientispaleandcool.c.Hisankleshavetwosmall,weepingulcers.d.Patientworkslonghourssittingatacomputerdesk.e.Hestatesthatthepaingetsworsewhenwalking.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)319STUVIA.COMNURSINGTB.COMf.Patientstatesthatthepainisworseattheendoftheday.ANS:A,B,EPatientswithchronicarterialsymptomsoftenhaveahistoryofsmokinganddiabetes(amongotherriskfactors).Thepainhasagradualonsetwithexertionandisrelievedwithrestordangling.Theskinappearscoolandpale.Theotherresponsesreflectchronicvenousproblems.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotentialPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)320STUVIA.COMChapter22:AbdomenMULTIPLECHOICE1.Thenurseispercussingtheseventhrightintercostalspaceatthemidclavicularlineovertheliver.Whichsoundshouldthenurseexpecttohear?a.Dullnessb.Tympanyc.Resonanced.HyperresonanceANS:ATheliverislocatedintherightupperquadrantandwouldelicitadullpercussionnote.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare2.Whichstructureislocatedintheleftlowerquadrantoftheabdomen?a.Liverb.Duodenumc.Gallbladderd.SigmoidcolonNURSINGTB.COMANS:DThesigmoidcolonislocatedintheleftlowerquadrantoftheabdomen.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General3.Apatientishavingdifficultyswallowingmedicationsandfood.Thenursewoulddocumentthatthispatienthas:a.Aphasia.b.Dysphasia.c.Dysphagia.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)321STUVIA.COMd.Anorexia.ANS:CDysphagiaisaconditionthatoccurswithdisordersofthethroatoresophagusandresultsindifficultyswallowing.Aphasiaanddysphasiaarespeechdisorders.Anorexiaisalossofappetite.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare4.Thenursesuspectsthatapatienthasadistendedbladder.Howshouldthenurseassessforthiscondition?a.Percussandpalpateinthelumbarregion.b.Inspectandpalpateintheepigastricregion.c.Auscultateandpercussintheinguinalregion.d.Percussandpalpatethemidlineareaabovethesuprapubicbone.ANS:DDullpercussionsoundswouldbeelicitedoveradistendedbladder,andthehypogastricareawouldseemfirmtopalpation.NURSINGTB.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare5.Thenurseisawarethatonechangethatmayoccurinthegastrointestinalsystemofanagingadultis:a.Increasedsalivation.b.Increasedliversize.c.Increasedesophagealemptying.d.Decreasedgastricacidsecretion.ANS:DGastricacidsecretiondecreaseswithaging.Asoneages,salivationdecreases,esophagealemptyingisdelayed,andliversizedecreases.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance6.A22-year-oldmancomestotheclinicforanexaminationafterfallingoffhismotorcycleandlandingonhisleftsideonthehandlebars.Thenursesuspectsthathemayhaveinjuredhisspleen.WhichofthesestatementsPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)322STUVIA.COMistrueregardingassessmentofthespleeninthissituation?a.Thespleencanbeenlargedasaresultoftrauma.b.Thespleenisnormallyfeltonroutinepalpation.c.Ifanenlargedspleenisnoted,thenthenurseshouldthoroughlypalpatetodetermineitssize.d.Anenlargedspleenshouldnotbepalpatedbecauseitcaneasilyrupture.ANS:DIfanenlargedspleenisfelt,thenthenurseshouldreferthepersonandshouldnotcontinuetopalpateit.Anenlargedspleenisfriableandcaneasilyrupturewithoverpalpation.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation7.Apatientsabdomenisbulgingandstretchedinappearance.Thenurseshoulddescribethisfindingas:a.Obese.b.Herniated.c.Scaphoid.d.Protuberant.NURSINGTB.COMANS:DAprotuberantabdomenisrounded,bulging,andstretched.Ascaphoidabdomencavesinward.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation8.Thenurseisdescribingascaphoidabdomen.Tothehorizontalplane,ascaphoidcontouroftheabdomendepictsaprofile.a.Flatb.Convexc.Bulgingd.ConcavePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)323STUVIA.COMANS:DContourdescribestheprofileoftheabdomenfromtheribmargintothepubicbone;ascaphoidcontourisonethatisconcavefromahorizontalplane.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation9.Whileexaminingapatient,thenurseobservesabdominalpulsationsbetweenthexiphoidprocessandumbilicus.Thenursewouldsuspectthattheseare:a.Pulsationsoftherenalarteries.b.Pulsationsoftheinferiorvenacava.c.Normalabdominalaorticpulsations.d.Increasedperistalsisfromabowelobstruction.ANS:CNormally,thepulsationsfromtheaortaareobservedbeneaththeskinintheepigastricarea,particularlyinthinpersonswhohavegoodmusclewallrelaxation.DIF:CognitiveLevel:Applying(Application)NURSINGTB.COMMSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare10.Apatienthashypoactivebowelsounds.Thenurseknowsthatapotentialcauseofhypoactivebowelsoundsis:a.Diarrhea.b.Peritonitis.c.Laxativeuse.d.Gastroenteritis.ANS:BDiminishedorabsentbowelsoundssignaldecreasedmotilityfrominflammationasexhibitedwithperitonitis,withparalyticileusafterabdominalsurgery,orwithlatebowelobstruction.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation11.Thenurseiswatchinganewgraduatenurseperformauscultationofapatientsabdomen.Whichstatementbythenewgraduateshowsacorrectunderstandingofthereasonauscultationprecedespercussionandpalpationoftheabdomen?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)324STUVIA.COMa.Weneedtodeterminetheareasoftendernessbeforeusingpercussionandpalpation.b.Auscultationpreventsdistortionofbowelsoundsthatmightoccurafterpercussionandpalpation.c.Auscultationallowsthepatientmoretimetorelaxandthereforebemorecomfortablewiththephysicalexamination.d.Auscultationpreventsdistortionofvascularsounds,suchasbruitsandhums,thatmightoccurafterpercussionandpalpation.ANS:BAuscultationisperformedfirst(afterinspection)becausepercussionandpalpationcanincreaseperistalsis,whichwouldgiveafalseinterpretationofbowelsounds.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare12.Thenurseislisteningtobowelsounds.Whichofthesestatementsistrueofbowelsounds?Bowelsounds:a.Areusuallyloud,high-pitched,rushing,andtinklingsounds.b.Areusuallyhigh-pitched,gurgling,andirregularsounds.NURSINGTB.COMc.Soundliketwopiecesofleatherbeingrubbedtogether.d.Originatefromthemovementofairandfluidthroughthelargeintestine.ANS:BBowelsoundsarehigh-pitched,gurgling,andcascadingsoundsthatirregularlyoccurfrom5to30timesperminute.Theyoriginatefromthemovementofairandfluidthroughthesmallintestine.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare13.Thephysiciancommentsthatapatienthasabdominalborborygmi.Thenurseknowsthatthistermrefersto:a.Loudcontinualhum.b.Peritonealfrictionrub.c.Hypoactivebowelsounds.d.Hyperactivebowelsounds.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)325STUVIA.COMANS:DBorborygmiisthetermusedforhyperperistalsiswhenthepersonactuallyfeelshisorherstomachgrowling.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare14.Duringanabdominalassessment,thenursewouldconsiderwhichofthesefindingsasnormal?a.Presenceofabruitinthefemoralareab.Tympanicpercussionnoteintheumbilicalregionc.Palpablespleenbetweentheninthandeleventhribsintheleftmidaxillarylined.DullpercussionnoteintheleftupperquadrantatthemidclavicularlineANS:BTympanyshouldpredominateinallfourquadrantsoftheabdomenbecauseairintheintestinesrisestothesurfacewhenthepersonissupine.Vascularbruitsarenotusuallypresent.Normally,thespleenisnotpalpable.Dullnesswouldnotbefoundintheareaoflungresonance(leftupperquadrantatthemidclavicularline).DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareENnUvRirSoInNmGeTnBt:.CMOaMnagementofCare15.Thenurseisassessingtheabdomenofapregnantwomanwhoiscomplainingofhavingacidindigestionallthetime.Thenurseknowsthatesophagealrefluxduringpregnancycancause:a.Diarrhea.b.Pyrosis.c.Dysphagia.d.Constipation.ANS:BPyrosis,orheartburn,iscausedbyesophagealrefluxduringpregnancy.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation16.Thenurseisperformingpercussionduringanabdominalassessment.Percussionnotesheardduringtheabdominalassessmentmayinclude:a.Flatness,resonance,anddullness.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)326STUVIA.COMb.Resonance,dullness,andtympany.c.Tympany,hyperresonance,anddullness.d.Resonance,hyperresonance,andflatness.ANS:CPercussionnotesnormallyheardduringtheabdominalassessmentmayincludetympany,whichshouldpredominatebecauseairintheintestinesrisestothesurfacewhenthepersonissupine;hyperresonance,whichmaybepresentwithgaseousdistention;anddullness,whichmaybefoundoveradistendedbladder,adiposetissue,fluid,oramass.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare17.Anolderpatienthasbeendiagnosedwithperniciousanemia.Thenurseknowsthatthisconditioncouldberelatedto:a.Increasedgastricacidsecretion.b.Decreasedgastricacidsecretion.c.DelayedgastrointestinalemptyingNtiUmReS.INGTB.COMd.Increasedgastrointestinalemptyingtime.ANS:BGastricacidsecretiondecreaseswithagingandmaycauseperniciousanemia(becauseitinterfereswithvitaminB12absorption),iron-deficiencyanemia,andmalabsorptionofcalcium.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation18.Apatientiscomplainingofasharppainalongthecostovertebralangles.Thenurseisawarethatthissymptomismostoftenindicativeof:a.Ovaryinfection.b.Liverenlargement.c.Kidneyinflammation.d.Spleenenlargement.ANS:CPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)327STUVIA.COMSharppainalongthecostovertebralanglesoccurswithinflammationofthekidneyorparanephricarea.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation19.Anursenoticesthatapatienthasascites,whichindicatesthepresenceof:a.Fluid.b.Feces.c.Flatus.d.Fibroidtumors.ANS:AAscitesisfreefluidintheperitonealcavityandoccurswithheartfailure,portalhypertension,cirrhosis,hepatitis,pancreatitis,andcancer.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation20.ThenurseknowsthatduringanabdominaNlaUsRseSsIsNmGeTnBt,.dCeOeMppalpationisusedtodetermine:a.Bowelmotility.b.Enlargedorgans.c.Superficialtenderness.d.Overallimpressionofskinsurfaceandsuperficialmusculature.ANS:BWithdeeppalpation,thenurseshouldnoticethelocation,size,consistency,andmobilityofanypalpableorgansandthepresenceofanyabnormalenlargement,tenderness,ormasses.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare21.Thenursenoticesthatapatienthashadablack,tarrystoolandrecallsthatapossiblecausewouldbe:a.Gallbladderdisease.b.Overuseoflaxatives.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)328STUVIA.COMc.Gastrointestinalbleeding.d.Localizedbleedingaroundtheanus.ANS:CBlackstoolsmaybetarryasaresultofoccultblood(melena)fromgastrointestinalbleeding.Redbloodinstoolsoccurswithlocalizedbleedingaroundtheanus.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation22.Duringanabdominalassessment,thenurseelicitstendernessonlightpalpationintherightlowerquadrant.Thenurseinterpretsthatthisfindingcouldindicateadisorderofwhichofthesestructures?a.Spleenb.Sigmoidc.Appendixd.GallbladderNURSINGTB.COMANS:CTheappendixislocatedintherightlowerquadrant.Whentheiliopsoasmuscleisinflamed,whichoccurswithaninflamedorperforatedappendix,painisfeltintherightlowerquadrant.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation23.Thenurseisassessingtheabdomenofanolderadult.Whichstatementregardingtheolderadultandabdominalassessmentistrue?a.Abdominaltoneisincreased.b.Abdominalmusculatureisthinner.c.Abdominalrigiditywithanacuteabdominalconditionismorecommon.d.Theolderadultwithanacuteabdominalconditioncomplainsmoreaboutpainthantheyoungerperson.ANS:BIntheolderadult,theabdominalmusculatureisthinnerandhaslesstonethanthatoftheyoungeradult,andabdominalrigiditywithanacuteabdominalconditionislesscommonintheagingperson.TheolderadultwithPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)329STUVIA.COManacuteabdominalconditionoftencomplainslessaboutpainthantheyoungerperson.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance24.Duringanassessmentofanewborninfant,thenurserecallsthatpyloricstenosiswouldbeexhibitedby:a.Projectilevomiting.b.Hypoactivebowelactivity.c.Palpableolive-sizedmassintherightlowerquadrant.d.Pronouncedperistalticwavescrossingfromrighttoleft.ANS:ASignificantperistalsis,togetherwithprojectilevomiting,inthenewbornsuggestspyloricstenosis.Afterfeeding,pronouncedperistalticwavescrossfromlefttoright,leadingtoprojectilevomiting.Onecanalsopalpateanolive-sizedmassintherightupperquadrant.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance25.ThenurseisreviewingtheassessmentofaNnUaRoSrtIiNcGanTeBu.rCyOsmM.Whichofthesestatementsistrueregardinganaorticaneurysm?a.Abruitisabsent.b.Femoralpulsesareincreased.c.Apulsatingmassisusuallypresent.d.Mostarelocatedbelowtheumbilicus.ANS:CMostaorticaneurysmsarepalpableduringroutineexaminationandfeellikeapulsatingmass.Abruitwillbeaudible,andfemoralpulsesarepresentbutdecreased.Suchaneurysmsarelocatedintheupperabdomenjusttotheleftofmidline.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation26.Duringanabdominalassessment,thenurseisunabletohearbowelsoundsinapatientsabdomen.Beforereportingthisfindingassilentbowelsounds,thenurseshouldlistenforatleast:a.1minute.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)330STUVIA.COMb.5minutes.c.10minutes.d.2minutesineachquadrant.ANS:BAbsentbowelsoundsarerare.Thenursemustlistenfor5minutesbeforedecidingthatbowelsoundsarecompletelyabsent.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare27.Apatientissuspectedofhavinginflammationofthegallbladder,orcholecystitis.Thenurseshouldconductwhichofthesetechniquestoassessforthiscondition?a.Obturatortestb.TestforMurphysignc.Assessforreboundtendernessd.IliopsoasmuscletestNURSINGTB.COMANS:BNormally,palpatingthelivercausesnopain.Inapersonwithinflammationofthegallbladder,orcholecystitis,painoccursasthedescendingliverpushestheinflamedgallbladderontotheexamininghandduringinspiration(Murphytest).Thepersonfeelssharppainandabruptlystopsmidwayduringinspiration.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation28.Justbeforegoinghome,anewmotherasksthenurseabouttheinfantsumbilicalcord.Whichofthesestatementsiscorrect?a.Itshouldfalloffin10to14days.b.Itwillsoftenbeforeitfallsoff.c.Itcontainstwoveinsandoneartery.d.Skinwillcovertheareawithin1week.ANS:APHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)331STUVIA.COMAtbirth,theumbilicalcordiswhiteandcontainstwoumbilicalarteriesandoneveininsidetheWhartonjelly.Theumbilicalstumpdrieswithinaweek,hardens,andfallsoffin10to14days.Skinwillcovertheareain3to4weeks.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance29.Whichofthesepercussionfindingswouldthenurseexpecttofindinapatientwithalargeamountofascites?a.Dullnessacrosstheabdomenb.Flatnessintherightupperquadrantc.Hyperresonanceintheleftupperquadrantd.TympanyintherightandleftlowerquadrantsANS:AAlargeamountofasciticfluidproducesadullsoundtopercussion.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationNURSINGTB.COM30.A40-year-oldmanstatesthathisphysiciantoldhimthathehasahernia.Heasksthenursetoexplainwhataherniais.Whichresponsebythenurseisappropriate?a.Noneedtoworry.Mostmenyouragedevelophernias.b.Aherniaisaloopofbowelprotrudingthroughaweakspotintheabdominalmuscles.c.Aherniaistheresultofprenatalgrowthabnormalitiesthatarejustnowcausingproblems.d.Illhavetohaveyourphysicianexplainthistoyou.ANS:BThenurseshouldexplainthataherniaisaprotrusionoftheabdominalviscerathroughanabnormalopeninginthemusclewall.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation31.A45-year-oldmanisintheclinicforaphysicalexamination.Duringtheabdominalassessment,thenursepercussestheabdomenandnoticesanareaofdullnessabovetherightcostalmarginofapproximately11cm.Thenurseshould:a.Documentthepresenceofhepatomegaly.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)332STUVIA.COMb.Askadditionalhealthhistoryquestionsregardinghisalcoholintake.c.Describethisdullnessasindicativeofanenlargedliver,andreferhimtoaphysician.d.Considerthisfindingasnormal,andproceedwiththeexamination.ANS:DAliverspanof10.5cmisthemeanformalesand7cmforfemales.Menandtallerindividualsareattheupperendofthisrange.Womenandshorterindividualsareatthelowerendofthisrange.Aliverspanof11cmiswithinnormallimitsforthisindividual.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare32.Whenpalpatingtheabdomenofa20-year-oldpatient,thenursenoticesthepresenceoftendernessintheleftupperquadrantwithdeeppalpation.Whichofthesestructuresismostlikelytobeinvolved?a.Spleenb.Sigmoidcolonc.Appendixd.GallbladderNURSINGTB.COMANS:AThespleenislocatedintheleftupperquadrantoftheabdomen.Thegallbladderisintherightupperquadrant,thesigmoidcolonisintheleftlowerquadrant,andtheappendixisintherightlowerquadrant.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation33.Thenurseisreviewingstatisticsforlactoseintolerance.IntheUnitedStates,theincidenceoflactoseintoleranceishigherinadultsofwhichethnicgroup?a.Blacksb.Hispanicsc.Whitesd.AsiansANS:APHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)333STUVIA.COMArecentstudyfoundestimatesoflactose-intoleranceprevalenceasfollows:19.5%forBlacks,10%forHispanics,and7.72%forWhites.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance34.Thenurseisassessingapatientforpossiblepepticulcerdisease.Whichconditionorhistoryoftencausesthisproblem?a.Hypertensionb.Streptococcalinfectionsc.Recurrentconstipationwithfrequentlaxativeused.FrequentuseofnonsteroidalantiinflammatorydrugsANS:DPepticulcerdiseaseoccurswiththefrequentuseofnonsteroidalantiinflammatorydrugs,alcoholuse,smokingandHelicobacterpyloriinfection.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotentialNURSINGTB.COM35.Duringreporting,thestudentnursehearsthatapatienthashepatomegalyandrecognizesthatthistermrefersto:a.Enlargedliver.b.Enlargedspleen.c.Distendedbowel.d.Excessivediarrhea.ANS:AThetermhepatomegalyreferstoanenlargedliver.Thetermsplenomegalyreferstoanenlargedspleen.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation36.Duringanassessment,thenursenoticesthatapatientsumbilicusisenlargedandeverted.Itispositionedmidlinewithnochangeinskincolor.Thenurserecognizesthatthepatientmayhavewhichcondition?a.Intra-abdominalbleedingPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)334STUVIA.COMb.Constipationc.Umbilicalherniad.AbdominaltumorANS:CTheumbilicusisnormallymidlineandinvertedwithnosignsofdiscoloration.Withanumbilicalhernia,themassisenlargedandeverted.Theotherresponsesareincorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation37.Duringanabdominalassessment,thenursetestsforafluidwave.Apositivefluidwavetestoccurswith:a.Splenomegaly.b.Distendedbladder.c.Constipation.d.Ascites.NURSINGTB.COMANS:DIfascites(fluidintheabdomen)ispresent,thentheexaminerwillfeelafluidwavewhenassessingtheabdomen.Afluidwaveisnotpresentwithsplenomegaly,adistendedbladder,orconstipation.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation38.Thenurseispreparingtoexamineapatientwhohasbeencomplainingofrightlowerquadrantpain.Whichtechniqueiscorrectduringtheassessment?Thenurseshould:a.Examinethetenderareafirst.b.Examinethetenderarealast.c.Avoidpalpatingthetenderarea.d.Palpatethetenderareafirst,andthenauscultateforbowelsounds.ANS:BPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)335STUVIA.COMThenurseshouldsavetheexaminationofanyidentifiedtenderareasuntillast.Thismethodavoidspainandtheresultingmusclerigiditythatwouldobscuredeeppalpationlaterintheexamination.Auscultationisperformedbeforepercussionandpalpationbecausepercussionandpalpationcanincreaseperistalsis,whichwouldgiveafalseinterpretationofbowelsounds.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare39.Duringahealthhistory,thepatienttellsthenurse,Ihavepainallthetimeinmystomach.Itsworse2hoursafterIeat,butitgetsbetterifIeatagain!Basedonthesesymptoms,thenursesuspectsthatthepatienthaswhichcondition?a.Appendicitisb.Gastriculcerc.Duodenalulcerd.CholecystitisANS:CPainassociatedwithduodenalulcersoccurs2to3hoursafterameal;itmayrelievedbymorefood.Chronicpainassociatedwithgastriculcersusuallyoccursonanemptystomach.Severe,acutepainwouldoccurwithappendicitisandcholecystitis.NURSINGTB.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCareMULTIPLERESPONSE1.Thenursesuspectsthatapatienthasappendicitis.Whichoftheseproceduresareappropriateforusewhenassessingforappendicitisoraperforatedappendix?Selectallthatapply.a.TestfortheMurphysignb.TestfortheBlumbergsignc.Testforshiftingdullnessd.Performtheiliopsoasmuscleteste.TestforfluidwaveANS:B,DTestingfortheBlumbergsign(reboundtenderness)andperformingtheiliopsoasmuscletestshouldbeusedwhenassessingforappendicitis.TheMurphysignisusedwhenassessingforaninflamedgallbladderorcholecystitis.Testingforafluidwaveandshiftingdullnessisperformedwhenassessingforascites.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)336STUVIA.COMNURSINGTB.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)337STUVIA.COMChapter23:MusculoskeletalSystemMULTIPLECHOICE1.Apatientisbeingassessedforrange-of-jointmovement.Thenurseaskshimtomovehisarmintowardthecenterofhisbody.Thismovementiscalled:a.Flexion.b.Abduction.c.Adduction.d.Extension.ANS:CMovingalimbtowardthemidlineofthebodyiscalledadduction;movingalimbawayfromthemidlineofthebodyiscalledabduction.Flexionisbendingalimbatajoint;andextensionisstraighteningalimbatajoint.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation2.ApatienttellsthenursethatsheishavingaNhUarRdStIiNmGeTbBri.CngOiMngherhandtohermouthwhensheeatsortriestobrushherteeth.Thenurseknowsthatforhertomoveherhandtohermouth,shemustperformwhichmovement?a.Flexionb.Abductionc.Adductiond.ExtensionANS:AFlexion,orbendingalimbatajoint,isrequiredtomovethehandtothemouth.Extensionisstraighteningalimbatajoint.Movingalimbtowardthemidlineofthebodyiscalledadduction;abductionismovingalimbawayfromthemidlineofthebody.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation3.Thefunctionalunitsofthemusculoskeletalsystemarethe:a.Joints.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)338STUVIA.COMb.Bones.c.Muscles.d.Tendons.ANS:AJointsarethefunctionalunitsofthemusculoskeletalsystembecausetheypermitthemobilityneededtoperformtheactivitiesofdailyliving.Theskeleton(bones)istheframeworkofthebody.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General4.Whenreviewingthemusculoskeletalsystem,thenurserecallsthathematopoiesistakesplaceinthe:a.Liver.b.Spleen.c.Kidneys.d.Bonemarrow.NURSINGTB.COMANS:DThemusculoskeletalsystemfunctionstoencaseandprotecttheinnervitalorgans,tosupportthebody,toproduceredbloodcellsinthebonemarrow(hematopoiesis),andtostoreminerals.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General5.Fibrousbandsrunningdirectlyfromonebonetoanotherthatstrengthenthejointandhelppreventmovementinundesirabledirectionsarecalled:a.Bursa.b.Tendons.c.Cartilage.d.Ligaments.ANS:DFibrousbandsrunningdirectlyfromonebonetoanotherthatstrengthenthejointandhelppreventmovementPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)339STUVIA.COMinundesirabledirectionsarecalledligaments.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General6.Thenursenoticesthatawomaninanexerciseclassisunabletojumprope.Thenurseisawarethattojumprope,onesshoulderhastobecapableof:a.Inversion.b.Supination.c.Protraction.d.Circumduction.ANS:DCircumductionisdefinedasmovingthearminacirclearoundtheshoulder.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation7.Thearticulationofthemandibleandthetemporalboneisknownasthe:NURSINGTB.COMa.Intervertebralforamen.b.Condyleofthemandible.c.Temporomandibularjoint.d.Zygomaticarchofthetemporalbone.ANS:CThearticulationofthemandibleandthetemporalboneisthetemporomandibularjoint.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General8.Topalpatethetemporomandibularjoint,thenursesfingersshouldbeplacedinthedepressionoftheear.a.Distaltothehelixb.ProximaltothehelixPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)340STUVIA.COMc.Anteriortothetragusd.PosteriortothetragusANS:CThetemporomandibularjointcanbefeltinthedepressionanteriortothetragusoftheear.Theotherlocationsarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare9.Ofthe33vertebraeinthespinalcolumn,thereare:a.5lumbar.b.5thoracic.c.7sacral.d.12cervical.ANS:ANURSINGTB.COMThereare7cervical,12thoracic,5lumbar,5sacral,and3to4coccygealvertebraeinthespinalcolumn.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General10.Animaginarylineconnectingthehighestpointoneachiliaccrestwouldcrossthevertebra.a.Firstsacralb.Fourthlumbarc.Seventhcervicald.TwelfththoracicANS:BAnimaginarylineconnectingthehighestpointoneachiliaccrestcrossesthefourthlumbarvertebra.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General11.ThenurseisexplainingtoapatientthatthereareshockabsorbersinhisbacktocushionthespineandtoPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)341STUVIA.COMhelpitmove.Thenurseisreferringtohis:a.Vertebralcolumn.b.Nucleuspulposus.c.Vertebralforamen.d.Intervertebraldisks.ANS:DIntervertebraldisksareelasticfibrocartilaginousplatesthatcushionthespinesimilartoshockabsorbersandhelpitmove.Thevertebralcolumnisthespinalcolumnitself.Thenucleuspulposusislocatedinthecenterofeachdisk.Thevertebralforamenisthechannel,oropening,forthespinalcordinthevertebrae.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation12.Thenurseisprovidingpatienteducationforamanwhohasbeendiagnosedwitharotatorcuffinjury.Thenurseknowsthatarotatorcuffinjuryinvolvesthe:a.Nucleuspulposus.b.Articularprocesses.c.Medialepicondyle.d.Glenohumeraljoint.NURSINGTB.COMANS:DArotatorcuffinjuryinvolvestheglenohumeraljoint,whichisenclosedbyagroupoffourpowerfulmusclesandtendonsthatsupportandstabilizeit.Thenucleuspulposusislocatedinthecenterofeachintervertebraldisk.Thearticularprocessesareprojectionsineachvertebraldiskthatlockontothenextvertebra,therebystabilizingthespinalcolumn.Themedialepicondyleislocatedattheelbow.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation13.Duringaninterviewthepatientstates,IcanfeelthisbumponthetopofbothofmyshouldersitdoesnthurtbutIamcuriousaboutwhatitmightbe.Thenurseshouldtellthepatientthatitishis:a.Subacromialbursa.b.Acromionprocess.c.Glenohumeraljoint.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)342STUVIA.COMd.Greatertubercleofthehumerus.ANS:BThebumpofthescapulasacromionprocessisfeltattheverytopoftheshoulder.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation14.Thenurseischeckingtherangeofmotioninapatientskneeandknowsthatthekneeiscapableofwhichmovement(s)?a.Flexionandextensionb.Supinationandpronationc.Circumductiond.InversionandeversionANS:ANURSINGTB.COMThekneeisahingejoint,permittingflexionandextensionofthelowerlegonasingleplane.Thekneeisnotcapableoftheothermovementslisted.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation15.Apatientisvisitingtheclinicforanevaluationofaswollen,painfulknuckle.Thenursenoticesthattheknuckleabovehisringonthelefthandisswollenandthatheisunabletoremovehisweddingring.Thisjointiscalledthejoint.a.Interphalangealb.Tarsometatarsalc.Metacarpophalangeald.TibiotalarANS:CThejointlocatedjustabovetheringonthefingeristhemetacarpophalangealjoint.Theinterphalangealjointislocateddistaltothemetacarpophalangealjoint.Thetarsometatarsalandtibiotalarjointsarefoundinthefootandankle.DIF:CognitiveLevel:Understanding(Comprehension)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)343STUVIA.COMMSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation16.Thenurseisassessingapatientsischialtuberosity.Topalpatetheischialtuberosity,thenurseknowsthatitisbesttohavethepatient:a.Standing.b.Flexingthehip.c.Flexingtheknee.d.Lyinginthesupineposition.ANS:BTheischialtuberosityliesunderthegluteusmaximusmuscleandispalpablewhenthehipisflexed.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare17.Thenurseisexaminingthehipareaofapatientandpalpatesaflatdepressionontheupper,lateralsideofthethighwhenthepatientisstanding.Thenurseinterpretsthisfindingasthe:a.Ischialtuberosity.b.Greatertrochanter.c.Iliaccrest.d.Gluteusmaximusmuscle.NURSINGTB.COMANS:BThegreatertrochanterofthefemurispalpatedwhenthepersonisstanding,anditappearsasaflatdepressionontheupperlateralsideofthethigh.Theiliaccrestistheupperpartofthehipbone;theischialtuberosityliesunderthegluteusmaximusmuscleandispalpablewhenthehipisflexed;andthegluteusmuscleispartofthebuttocks.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation18.Theanklejointisthearticulationofthetibia,fibula,and:a.Talus.b.Cuboid.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)344STUVIA.COMc.Calcaneus.d.Cuneiformbones.ANS:ATheankleortibiotalarjointisthearticulationofthetibia,fibula,andtalus.Theotherboneslistedarefootbonesandnotpartoftheanklejoint.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General19.Thenurseisexplainingthemechanismofthegrowthoflongbonestoamotherofatoddler.Wheredoeslengtheningofthebonesoccur?a.Bursab.Calcaneusc.Epiphysesd.TuberositiesANS:CNURSINGTB.COMLengtheningoccursattheepiphyses,orgrowthplates.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance20.Awomanwhois8monthspregnantcommentsthatshehasnoticedachangeinherpostureandishavinglowerbackpain.Thenursetellsherthatduringpregnancy,womenhaveapostureshifttocompensatefortheenlargingfetus.Thisshiftinpostureisknownas:a.Lordosis.b.Scoliosis.c.Ankylosis.d.Kyphosis.ANS:ALordosiscompensatesfortheenlargingfetus,whichwouldshiftthecenterofbalanceforward.Thisshiftinbalance,inturn,createsastrainonthelowbackmuscles,feltaslowbackpainduringlatepregnancybysomewomen.Scoliosisislateralcurvatureofportionsofthespine;ankylosisisextremeflexionofthewrist,asobservedwithsevererheumatoidarthritis;andkyphosisisanenhancedthoraciccurvatureofthespine.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)345STUVIA.COMDIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance21.An85-year-oldpatientcommentsduringhisannualphysicalexaminationthatheseemstobegettingshorterasheages.Thenurseshouldexplainthatdecreasedheightoccurswithagingbecause:a.Longbonestendtoshortenwithage.b.Thevertebralcolumnshortens.c.Asignificantlossofsubcutaneousfatoccurs.d.Athickeningoftheintervertebraldisksdevelops.ANS:BPosturalchangesareevidentwithaging;decreasedheightismostnoticeableandisduetoshorteningofthevertebralcolumn.Longbonesdonotshortenwithage.Intervertebraldisksactuallygetthinnerwithage.Subcutaneousfatisnotlostbutisredistributedtotheabdomenandhips.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance22.Apatienthasbeendiagnosedwithosteoporosisandasksthenurse,Whatisosteoporosis?Thenurseexplainsthatosteoporosisisdefinedas:a.Increasedbonematrix.b.Lossofbonedensity.c.New,weakerbonegrowth.d.Increasedphagocyticactivity.NURSINGTB.COMANS:BAfterage40years,alossofbonematrix(resorption)occursmorerapidlythannewboneformation.Theneteffectisagraduallossofbonedensity,orosteoporosis.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation23.Thenurseisteachingaclassonpreventingosteoporosistoagroupofperimenopausalwomen.Whichoftheseactionsisthebestwaytopreventordelaybonelossinthisgroup?a.TakingcalciumandvitaminDsupplementsb.TakingmedicationstopreventosteoporosisPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)346STUVIA.COMc.Performingphysicalactivity,suchasfastwalkingd.AssessingbonedensityannuallyANS:CPhysicalactivity,suchasfastwalking,delaysorpreventsbonelossinperimenopausalwomen.Thefasterthepaceofwalking,thehigherthepreventiveeffectisontheriskofhipfracture.TheotheroptionsarenotcorrectDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance24.Ateenagegirlhasarrivedcomplainingofpaininherleftwrist.Shewasplayingbasketballwhenshefellandlandedonherlefthand.Thenurseexaminesherhandandwouldexpectafractureifthegirlcomplainsofa:a.Dullache.b.Deeppaininherwrist.c.Sharppainthatincreaseswithmovement.d.DullthrobbingpainthatincreasesNwUitRhSrIeNstG.TB.COMANS:CAfracturecausessharppainthatincreaseswithmovement.Theothertypesofpaindonotoccurwithafracture.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation25.Apatientiscomplainingofpaininhisjointsthatisworseinthemorning,betterafterhemovesaroundforawhile,andthengetsworseagainifhesitsforlongperiods.Thenurseshouldassessforothersignsofwhatproblem?a.Tendinitisb.Osteoarthritisc.Rheumatoidarthritisd.IntermittentclaudicationANS:CRheumatoidarthritisisworseinthemorningwhenapersonarises.Movementincreasesmostjointpain,excepPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)347STUVIA.COMthepainwithrheumatoidarthritis,whichdecreaseswithmovement.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation26.Apatientstates,IcanhearacrunchingorgratingsoundwhenIkneel.Shealsostatesthatitisverydifficulttogetoutofbedinthemorningbecauseofstiffnessandpaininmyjoints.Thenurseshouldassessforsignsofwhatproblem?a.Crepitationb.Bonespurc.Loosetendond.FluidinthekneejointANS:ACrepitationisanaudibleandpalpablecrunchingorgratingthataccompaniesmovementandoccurswhenarticularsurfacesinthejointsareroughened,aswithrheumatoidarthritis.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationNURSINGTB.COM27.Apatientisabletoflexhisrightarmforwardwithoutdifficultyorpainbutisunabletoabducthisarmbecauseofpainandmusclespasms.Thenurseshouldsuspect:a.Crepitation.b.Rotatorcufflesions.c.Dislocatedshoulder.d.Rheumatoidarthritis.ANS:BRotatorcufflesionsmaylimitrangeofmotionandcausepainandmusclespasmsduringabduction,whereasforwardflexionremainsfairlynormal.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation28.Aprofessionaltennisplayercomesintothecliniccomplainingofasoreelbow.Thenursewillassessfortendernessatthe:a.Olecranonbursa.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)348STUVIA.COMb.Annularligament.c.Baseoftheradius.d.Medialandlateralepicondyle.ANS:DTheepicondyles,theheadoftheradius,andthetendonsarecommonsitesofinflammationandlocaltenderness,commonlyreferredtoastenniselbow.Theotherlocationsarenotaffected.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation29.ThenursesuspectsthatapatienthascarpaltunnelsyndromeandwantstoperformthePhalentest.Toperformthistest,thenurseshouldinstructthepatientto:a.Dorsiflexthefoot.b.Plantarflexthefoot.c.Holdbothhandsbacktobackwhileflexingthewrists90degreesfor60seconds.d.HyperextendthewristswiththepaNlmURarSsINurGfaTcBe.CofObMothhandstouching,andwaitfor60seconds.ANS:CForthePhalentest,thenurseshouldaskthepersontoholdbothhandsbacktobackwhileflexingthewrists90degrees.Acuteflexionofthewristfor60secondsproducesnosymptomsinthenormalhand.ThePhalentestreproducesnumbnessandburninginapersonwithcarpaltunnelsyndrome.Theotheractionsarenotcorrectwhentestingforcarpaltunnelsyndrome.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation30.An80-year-oldwomanisvisitingtheclinicforacheckup.Shestates,IcantwalkasmuchasIusedto.Thenurseisobservingformotordysfunctioninherhipandshouldaskherto:a.Internallyrotateherhipwhilesheissitting.b.Abductherhipwhilesheislyingonherback.c.Adductherhipwhilesheislyingonherback.d.Externallyrotateherhipwhilesheisstanding.ANS:BPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)349STUVIA.COMLimitedabductionofthehipwhilesupineisthemostcommonmotiondysfunctionfoundinhipdisease.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation31.Thenursehascompletedthemusculoskeletalexaminationofapatientskneeandhasfoundapositivebulgesign.Thenurseinterpretsthisfindingtoindicate:a.Irregularbonymargins.b.Soft-tissueswellinginthejoint.c.Swellingfromfluidintheepicondyle.d.Swellingfromfluidinthesuprapatellarpouch.ANS:DApositivebulgesignconfirmsthepresenceofswellingcausedbyfluidinthesuprapatellarpouch.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationNURSINGTB.COM32.Duringanexamination,thenurseasksapatienttobendforwardfromthewaistandnoticesthatthepatienthaslateraltilting.Whenhislegisraisedstraightup,thepatientcomplainsofapaingoingdownhisbuttockintohisleg.Thenursesuspects:a.Scoliosis.b.Meniscustear.c.Herniatednucleuspulposus.d.Spasmofparavertebralmuscles.ANS:CLateraltiltingandsciaticpainwithstraightlegraisingarefindingsthatoccurwithaherniatednucleuspulposus.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation33.Thenurseisexamininga3-month-oldinfant.Whilethenurseholdshisorherthumbsontheinfantsinnermidthighsandthefingersontheoutsideoftheinfantships,touchingthegreatertrochanter,thenurseadductsthelegsuntilthehisorherthumbstouchandthenabductsthelegsuntiltheinfantskneestouchthetable.Thenursedoesnotnoticeanyclunkingsoundsandisconfidenttorecorda:PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)350STUVIA.COMa.PositiveAllistest.b.NegativeAllistest.c.PositiveOrtolanisign.d.NegativeOrtolanisign.ANS:DNormally,thismaneuverfeelssmoothandhasnosound.WithapositiveOrtolanisign,however,thenursewillfeelandhearaclunk,astheheadofthefemurpopsbackintoplace.ApositiveOrtolanisignalsoreflectshipinstability.TheAllistestalsotestsforhipdislocationbutisperformedbycomparingleglengths.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation34.Duringaneonatalexamination,thenursenoticesthatthenewborninfanthassixtoes.Thisfindingisdocumentedas:a.Unidactyly.b.Syndactyly.c.Polydactyly.d.Multidactyly.NURSINGTB.COMANS:CPolydactylyisthepresenceofextrafingersortoes.Syndactylyiswebbingbetweenadjacentfingersortoes.Theothertermsarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation35.Amotherbringshernewbornbabyboyinforacheckup;shetellsthenursethathedoesnotseemtobemovinghisrightarmasmuchashisleftandthatheseemstohavepainwhensheliftshimupunderthearms.Thenursesuspectsafracturedclavicleandwouldobservefor:a.NegativeAllistest.b.PositiveOrtolanisign.c.LimitedrangeofmotionduringtheMororeflex.d.LimitedrangeofmotionduringLasguetest.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)351STUVIA.COMANS:CForafracturedclavicle,thenurseshouldobserveforlimitedarmrangeofmotionandunilateralresponsetotheMororeflex.Theothertestsarenotappropriateforthistypeoffracture.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance36.A40-year-oldmanhascomeintotheclinicwithcomplaintsofextremepaininhistoes.Thenursenoticesthathistoesareslightlyswollen,reddened,andwarmtothetouch.Hiscomplaintswouldsuggest:a.Osteoporosis.b.Acutegout.c.Ankylosingspondylitis.d.Degenerativejointdisease.ANS:BClinicalfindingsforacutegoutconsistofredness,swelling,heat,andextremepainlikeacontinuousthrobbing.Goutisametabolicdisorderofdisturbedpurinemetabolism,associatedwithelevatedserumuricacid.DIF:CognitiveLevel:Analyzing(Analysis)NURSINGTB.COMMSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation37.Ayoungswimmercomestothesportscliniccomplainingofaverysoreshoulder.Hewasrunningatthepool,slippedonsomewetconcrete,andtriedtocatchhimselfwithhisoutstretchedhand.Helandedonhisoutstretchedhandandhasnotbeenabletomovehisshouldersince.Thenursesuspects:a.Jointeffusion.b.Tearofrotatorcuff.c.Adhesivecapsulitis.d.Dislocatedshoulder.ANS:DAdislocatedshoulderoccurswithtraumainvolvingabduction,extension,andexternalrotation(e.g.,fallingonanoutstretchedarmordivingintoapool).DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)352STUVIA.COM38.A68-year-oldwomanhascomeinforanassessmentofherrheumatoidarthritis,andthenursenoticesraised,firm,nontendernodulesattheolecranonbursaandalongtheulna.Thesenodulesaremostcommonlydiagnosedas:a.Epicondylitis.b.Goutyarthritis.c.Olecranonbursitis.d.Subcutaneousnodules.ANS:DSubcutaneousnodulesareraised,firm,andnontenderandoccurwithrheumatoidarthritisintheolecranonbursaandalongtheextensorsurfaceoftheulna.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation39.Awomanwhohashadrheumatoidarthritisforyearsisstartingtonoticethatherfingersaredriftingtotheside.Thenurseknowsthatthisconditioniscommonlyreferredtoas:a.Radialdrift.b.Ulnardeviation.c.Swan-neckdeformity.d.Dupuytrencontracture.NURSINGTB.COMANS:BFingersdrifttotheulnarsidebecauseofstretchingofthearticularcapsuleandmuscleimbalancecausedbychronicrheumatoidarthritis.Aradialdriftisnotobserved.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation40.Apatientwhohashadrheumatoidarthritisforyearscomestotheclinictoaskaboutchangesinherfingers.Thenursewillassessforsignsofwhatproblems?a.Heberdennodesb.Bouchardnodulesc.Swan-neckdeformitiesPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)353STUVIA.COMd.DupuytrencontracturesANS:CChangesinthefingerscausedbychronicrheumatoidarthritisincludeswan-neckandboutonnieredeformities.HeberdennodesandBouchardnodulesareassociatedwithosteoarthritis.Dupuytrencontracturesofthedigitsoccurbecauseofchronichyperplasiaofthepalmarfascia.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation41.Apatientsannualphysicalexaminationrevealsalateralcurvatureofthethoracicandlumbarsegmentsofhisspine;however,thiscurvaturedisappearswithforwardbending.Thenurseknowsthatthisabnormalityofthespineiscalled:a.Structuralscoliosis.b.Functionalscoliosis.c.Herniatednucleuspulposus.d.Dislocatedhip.ANS:BNURSINGTB.COMFunctionalscoliosisisflexibleandapparentwithstandingbutdisappearswithforwardbending.Structuralscoliosisisfixed;thecurvatureshowsbothwhenstandingandwhenbendingforward.Thesefindingsarenotindicativeofadislocatedhip.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation42.A14-year-oldboywhohasbeendiagnosedwithOsgood-Schlatterdiseasereportspainfulswellingjustbelowthekneeforthepast5months.Whichresponsebythenurseisappropriate?a.Ifthesesymptomspersist,youmayneedarthroscopicsurgery.b.Youareexperiencingdegenerationofyourknee,whichmaynotresolve.c.Yourdiseaseisduetorepeatedstressonthepatellartendon.Itisusuallyself-limited,andyoursymptomsshouldresolvewithrest.d.Increasingyouractivityandperformingknee-strengtheningexerciseswillhelpdecreasetheinflammationandmaintainmobilityintheknee.ANS:COsgood-Schlatterdiseaseisapainfulswellingofthetibialtuberclejustbelowthekneeandmostlikelyduetorepeatedstressonthepatellartendon.Itisusuallyself-limited,occurringduringrapidgrowthandmostoftenPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)354STUVIA.COMinboys.Thesymptomsresolvewithrest.Theotherresponsesarenotappropriate.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation43.Whenassessingmusclestrength,thenurseobservesthatapatienthascompleterangeofmotionagainstgravitywithfullresistance.Whatgradeofmusclestrengthshouldthenurserecordusinga0-to5-pointscale?a.2b.3c.4d.5ANS:DCompleterangeofmotionagainstgravityisnormalmusclestrengthandisrecordedasgrade5musclestrength.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation44.Thenurseisexamininga6-month-oldinfaNnUtaRnSdINpGlaTcBes.CthOeMinfantsfeetflatonthetableandflexeshiskneesup.Thenursenotesthattherightkneeissignificantlylowerthantheleft.Whichofthesestatementsistrueofthisfinding?a.ThisfindingisapositiveAllissignandsuggestshipdislocation.b.Theinfantprobablyhasadislocatedpatellaontherightknee.c.ThisfindingisanegativeAllissignandnormalforaninfantofthisage.d.Theinfantshouldreturntotheclinicin2weekstoseeifhisconditionhaschanged.ANS:AFindingonekneesignificantlylowerthantheotherisapositiveAllissignandsuggestshipdislocation.Normally,thetopsofthekneesareatthesameelevation.Theotherstatementsarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance45.Thenurseisassessinga1-week-oldinfantandistestinghismusclestrength.Thenurseliftstheinfantwithhandsundertheaxillaeandnoticesthattheinfantstartstoslipbetweenthehands.Thenurseshould:a.Suspectafracturedclavicle.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)355STUVIA.COMb.Suspectthattheinfantmayhaveadeformityofthespine.c.Suspectthattheinfantmayhaveweaknessoftheshouldermuscles.d.Concludethatthisisanormalfindingbecausethemusculatureofaninfantatthisageisundeveloped.ANS:CAninfantwhostartstoslipbetweenthenurseshandsshowsweaknessoftheshouldermuscles.Aninfantwithnormalmusclestrengthwedgessecurelybetweenthenurseshands.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance46.Thenurseisexamininga2-month-oldinfantandnoticesasymmetryoftheinfantsglutealfolds.Thenurseshouldassessforothersignsofwhatdisorder?a.Fracturedclavicleb.Downsyndromec.Spinabifidad.HipdislocationANS:DNURSINGTB.COMUnequalglutealfoldsmayaccompanyhipdislocationafter2to3monthsofage,butsomeasymmetrymayoccurinhealthychildren.Furtherassessmentisneeded.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare47.Thenurseshouldusewhichtesttocheckforlargeamountsoffluidaroundthepatella?a.Ballottementb.Tinelsignc.Phalentestd.McMurraytestANS:ABallottementofthepatellaisreliablewhenlargeamountsoffluidarepresent.TheTinelsignandthePhalentestareusedtocheckforcarpaltunnelsyndrome.TheMcMurraytestisusedtotestthekneeforatornPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)356STUVIA.COMmeniscus.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare48.Apatienttellsthenursethat,AllmylifeIvebeencalledknockknees.Thenurseknowsthatanothertermforknockkneesis:a.Genuvarum.b.Genuvalgum.c.Pesplanus.d.Metatarsusadductus.ANS:BGenuvalgumisalsoknownasknockkneesandispresentwhenmorethan2.5cmisbetweenthemedialmalleoliwhenthekneesaretogether.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation49.AmanwhohashadgoutforseveralyearsNcUomRSesINtoGTthBe.CclOinMicwithaproblemwithhistoe.Onexamination,thenursenoticesthepresenceofhard,painlessnodulesoverthegreattoe;onehasburstopenwithachalkydischarge.Thisfindingisknownas:a.Callus.b.Plantarwart.c.Bunion.d.Tophi.ANS:DTophiarecollectionsofmonosodiumuratecrystalsresultingfromchronicgoutinandaroundthejointthatcauseextremeswellingandjointdeformity.Theyappearashard,painlessnodules(tophi)overthemetatarsophalangealjointofthefirsttoeandtheysometimesburstwithachalkydischarge.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation50.Whenperformingamusculoskeletalassessment,thenurseknowsthatthecorrectapproachfortheexaminationshouldbe:a.Proximaltodistal.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)357STUVIA.COMb.Distaltoproximal.c.Posteriortoanterior.d.Anteriortoposterior.ANS:AThemusculoskeletalassessmentshouldbeperformedinanorderlyapproach,headtotoe,proximaltodistal,fromthemidlineoutward.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCareMULTIPLERESPONSE1.Thenurseisassessingthejointsofawomanwhohasstated,Ihavealongfamilyhistoryofarthritis,andmyjointshurt.Thenursesuspectsthatshehasosteoarthritis.Whichofthesearesymptomsofosteoarthritis?Selectallthatapply.a.Symmetricjointinvolvementb.AsymmetricjointinvolvementNURSINGTB.COMc.Painwithmotionofaffectedjointsd.Affectedjointsareswollenwithhard,bonyprotuberancese.Affectedjointsmayhaveheat,redness,andswellingANS:B,C,DInosteoarthritis,asymmetricjointinvolvementcommonlyaffectshands,knees,hips,andlumbarandcervicalsegmentsofthespine.Affectedjointshavestiffness,swellingwithhardbonyprotuberances,painwithmotion,andlimitationofmotion.Theotheroptionsreflectthesignsofrheumatoidarthritis.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)358STUVIA.COMChapter24:NeurologicSystemMULTIPLECHOICE1.Thetwopartsofthenervoussystemarethe:a.Motorandsensory.b.Centralandperipheral.c.Peripheralandautonomic.d.Hypothalamusandcerebral.ANS:BThenervoussystemcanbedividedintotwopartscentralandperipheral.Thecentralnervoussystemincludesthebrainandspinalcord.Theperipheralnervoussystemincludesthe12pairsofcranialnerves(CNs),the31pairsofspinalnerves,andalloftheirbranches.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General2.Thewifeofa65-year-oldmantellsthenursethatsheisconcernedbecauseshehasnoticedachangeinherhusbandspersonalityandabilitytounderstandN.UHReSaIlNsoGcTrBie.CsOveMryeasilyandbecomesangry.Thenurserecallsthatthecerebralloberesponsibleforthesebehaviorsisthelobe.a.Frontalb.Parietalc.Occipitald.TemporalANS:AThefrontallobehasareasresponsibleforpersonality,behavior,emotions,andintellectualfunction.Theparietallobehasareasresponsibleforsensation;theoccipitallobeisresponsibleforvisualreception;andthetemporallobeisresponsibleforhearing,taste,andsmell.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation3.Whichstatementconcerningtheareasofthebrainistrue?a.Thecerebellumisthecenterforspeechandemotions.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)359STUVIA.COMb.Thehypothalamuscontrolsbodytemperatureandregulatessleep.c.Thebasalgangliaareresponsibleforcontrollingvoluntarymovements.d.Motorpathwaysofthespinalcordandbrainstemsynapseinthethalamus.ANS:BThehypothalamusisavitalareawithmanyimportantfunctions:bodytemperaturecontroller,sleepcenter,anteriorandposteriorpituitaryglandregulator,andcoordinatorofautonomicnervoussystemactivityandemotionalstatus.Thecerebellumcontrolsmotorcoordination,equilibrium,andbalance.Thebasalgangliacontrolautonomicmovementsofthebody.Themotorpathwaysofthespinalcordsynapseinvariousareasofthespinalcord,notinthethalamus.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:General4.Theareaofthenervoussystemthatisresponsibleformediatingreflexesisthe:a.Medulla.b.Cerebellum.c.Spinalcord.d.Cerebralcortex.NURSINGTB.COMANS:CThespinalcordisthemainhighwayforascendinganddescendingfibertractsthatconnectthebraintothespinalnerves;itisresponsibleformediatingreflexes.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General5.Whilegatheringequipmentafteraninjection,anurseaccidentallyreceivedaprickfromanimproperlycappedneedle.Tointerpretthissensation,whichoftheseareasmustbeintact?a.Corticospinaltract,medulla,andbasalgangliab.Pyramidaltract,hypothalamus,andsensorycortexc.Lateralspinothalamictract,thalamus,andsensorycortexd.Anteriorspinothalamictract,basalganglia,andsensorycortexANS:CPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)360STUVIA.COMThespinothalamictractcontainssensoryfibersthattransmitthesensationsofpain,temperature,andcrudeorlighttouch.Fiberscarryingpainandtemperaturesensationsascendthelateralspinothalamictract,whereasthesensationsofcrudetouchformtheanteriorspinothalamictract.Atthethalamus,thefiberssynapsewithanothersensoryneuron,whichcarriesthemessagetothesensorycortexforfullinterpretation.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:General6.Apatientwithalackofoxygentohisheartwillhavepaininhischestandpossiblyintheshoulder,arms,orjaw.Thenurseknowsthatthebestexplanationwhythisoccursiswhichoneofthesestatements?a.Aproblemexistswiththesensorycortexanditsabilitytodiscriminatethelocation.b.Thelackofoxygeninhishearthasresultedindecreasedamountofoxygentotheareasexperiencingthepain.c.Thesensorycortexdoesnothavetheabilitytolocalizepainintheheart;consequently,thepainisfeltelsewhere.d.Alesionhasdevelopedinthedorsalroot,whichispreventingthesensationfrombeingtransmittednormally.ANS:CNURSINGTB.COMThesensorycortexisarrangedinaspecificpattern,formingacorrespondingmapofthebody.Painintherighthandisperceivedataspecificspotonthemap.Someorgans,suchastheheart,liver,andspleen,areabsentfromthebrainmap.Painoriginatingintheseorgansisreferredbecausenofeltimageexistsinwhichtohavepain.Painisfeltbyproxy,thatis,byanotherbodypartthatdoeshaveafeltimage.Theotherresponsesarenotcorrectexplanations.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:BasicCareandComfort7.Theabilitythathumanshavetoperformveryskilledmovementssuchaswritingiscontrolledbythe:a.Basalganglia.b.Corticospinaltract.c.Spinothalamictract.d.Extrapyramidaltract.ANS:BCorticospinalfibersmediatevoluntarymovement,particularlyveryskilled,discrete,andpurposefulmovements,suchaswriting.Thecorticospinaltract,alsoknownasthepyramidaltract,isanewer,highermotorsystemthathumanshavethatpermitsveryskilledandpurposefulmovements.Theotherresponsesarenotrelatedtoskilledmovements.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)361STUVIA.COMDIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:General8.A30-year-oldwomantellsthenursethatshehasbeenveryunsteadyandhashaddifficultyinmaintainingherbalance.Whichareaofthebrainthatisrelatedtothesefindingswouldconcernthenurse?a.Thalamusb.Brainstemc.Cerebellumd.ExtrapyramidaltractANS:CThecerebellarsystemcoordinatesmovement,maintainsequilibrium,andhelpsmaintainposture.Thethalamusistheprimaryrelaystationwheresensorypathwaysofthespinalcord,cerebellum,andbrainstemformsynapsesontheirwaytothecerebralcortex.Thebrainstemconsistsofthemidbrain,pons,andmedullaandhasvariousfunctions,especiallyconcerningautonomiccenters.Theextrapyramidaltractmaintainsmuscletoneforgrossautomaticmovements,suchaswalking.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationNURSINGTB.COM9.Whichofthesestatementsabouttheperipheralnervoussystemiscorrect?a.TheCNsenterthebrainthroughthespinalcord.b.Efferentfiberscarrysensoryinputtothecentralnervoussystemthroughthespinalcord.c.Theperipheralnervesareinsidethecentralnervoussystemandcarryimpulsesthroughtheirmotorfibers.d.Theperipheralnervescarryinputtothecentralnervoussystembyafferentfibersandawayfromthecentralnervoussystembyefferentfibers.ANS:DAnerveisabundleoffibersoutsideofthecentralnervoussystem.Theperipheralnervescarryinputtothecentralnervoussystembytheirsensoryafferentfibersanddeliveroutputfromthecentralnervoussystembytheirefferentfibers.Theotherresponsesarenotrelatedtotheperipheralnervoussystem.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General10.Apatienthasaseveredspinalnerveasaresultoftrauma.Whichstatementistrueinthissituation?a.Becausethereare31pairsofspinalnerves,noeffectresultsifonlyonenerveissevered.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)362STUVIA.COMb.Thedermatomeservedbythisnervewillnolongerexperienceanysensation.c.Theadjacentspinalnerveswillcontinuetocarrysensationsforthedermatomeservedbytheseverednerve.d.Aseveredspinalnervewillonlyaffectmotorfunctionofthepatientbecausespinalnerveshavenosensorycomponent.ANS:CAdermatomeisacircumscribedskinareathatisprimarilysuppliedfromonespinalcordsegmentthroughaparticularspinalnerve.Thedermatomesoverlap,whichisaformofbiologicinsurance;thatis,ifonenerveissevered,thenmostofthesensationscanbetransmittedbythespinalnerveaboveandthespinalnervebelowtheseverednerve.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation11.A21-year-oldpatienthasaheadinjuryresultingfromtraumaandisunconscious.Therearenootherinjuries.Duringtheassessmentwhatwouldthenurseexpecttofindwhentestingthepatientsdeeptendonreflexes?a.Reflexeswillbenormal.b.Reflexescannotbeelicited.NURSINGTB.COMc.Allreflexeswillbediminishedbutpresent.d.Somereflexeswillbepresent,dependingontheareaofinjury.ANS:AAreflexisadefensemechanismofthenervoussystem.Itoperatesbelowthelevelofconsciouscontrolandpermitsaquickreactiontopotentiallypainfulordamagingsituations.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare12.Amotherofa1-month-oldinfantasksthenursewhyittakessolongforinfantstolearntorollover.Thenurseknowsthatthereasonforthisis:a.Ademyelinatingprocessmustbeoccurringwithherinfant.b.Myelinisneededtoconducttheimpulses,andtheneuronsofanewbornarenotyetmyelinated.c.Thecerebralcortexisnotfullydeveloped;therefore,controlovermotorfunctiongraduallyoccurs.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)363STUVIA.COMd.Thespinalcordiscontrollingthemovementbecausethecerebellumisnotyetfullydeveloped.ANS:BTheinfantssensoryandmotordevelopmentproceedsalongwiththegradualacquisitionofmyelin,whichisneededtoconductmostimpulses.Verylittlecorticalcontrolexists,andtheneuronsarenotyetmyelinated.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance13.Duringanassessmentofan80-year-oldpatient,thenursenoticesthefollowing:aninabilitytoidentifyvibrationsatherankleandtoidentifythepositionofherbigtoe,aslowerandmoredeliberategait,andaslightlyimpairedtactilesensation.Allotherneurologicfindingsarenormal.Thenurseshouldinterpretthatthesefindingsindicate:a.CNdysfunction.b.Lesioninthecerebralcortex.c.Normalchangesattributabletoaging.d.Demyelinationofnervesattributabletoalesion.ANS:CNURSINGTB.COMSomeagingadultsshowaslowerresponsetorequests,especiallyforthosecallingforcoordinationofmovements.Thefindingslistedarenormalintheabsenceofothersignificantabnormalfindings.Theotherresponsesareincorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance14.A70-year-oldwomantellsthenursethateverytimeshegetsupinthemorningoraftershesbeensitting,shegetsreallydizzyandfeelslikesheisgoingtofallover.Thenursesbestresponsewouldbe:a.Haveyoubeenextremelytiredlately?b.Youprobablyjustneedtodrinkmoreliquids.c.Illreferyouforacompleteneurologicexamination.d.Youneedtogetupslowlywhenyouvebeenlyingdownorsitting.ANS:DAgingisaccompaniedbyaprogressivedecreaseincerebralbloodflow.Insomepeople,thisdecreasecausesdizzinessandalossofbalancewithapositionchange.Theseindividualsneedtobetaughttogetupslowly.Theotherresponsesareincorrect.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)364STUVIA.COMDIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance15.Duringthetakingofthehealthhistory,apatienttellsthenursethatitfeelsliketheroomisspinningaroundme.Thenursewoulddocumentthisfindingas:a.Vertigo.b.Syncope.c.Dizziness.d.Seizureactivity.ANS:ATruevertigoisrotationalspinningcausedbyaneurologicdysfunctionoraprobleminthevestibularapparatusorthevestibularnucleiinthebrainstem.Syncopeisasuddenlossofstrengthoratemporarylossofconsciousness.Dizzinessisalightheaded,swimmingsensation.Seizureactivityischaracterizedbyalteredorlossofconsciousness,involuntarymusclemovements,andsensorydisturbances.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation16.WhentakingthehealthhistoryonapatienNtUwRitShIaNsGeTizBu.rCeOdMisorder,thenurseassesseswhetherthepatienthasanaura.Whichofthesewouldbethebestquestionforobtainingthisinformation?a.Doesyourmuscletoneseemtenseorlimp?b.Aftertheseizure,doyouspendalotoftimesleeping?c.Doyouhaveanywarningsignbeforeyourseizurestarts?d.Doyouexperienceanycolorchangeorincontinenceduringtheseizure?ANS:CAuraisasubjectivesensationthatprecedesaseizure;itcouldbeauditory,visual,ormotor.Theotherquestionsdonotsolicitinformationaboutanaura.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation17.Whileobtainingahealthhistoryofa3-month-oldinfantfromthemother,thenurseasksabouttheinfantsabilitytosuckandgraspthemothersfinger.Whatisthenurseassessing?a.ReflexesPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)365STUVIA.COMb.Intelligencec.CNsd.CerebralcortexfunctionANS:AQuestionsregardingreflexesincludesuchquestionsas,Whathaveyounoticedabouttheinfantsbehavior,Aretheinfantssuckingandswallowingseemcoordinated,andDoestheinfantgraspyourfinger?Theotherresponsesareincorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance18.Inobtainingahealthhistoryona74-year-oldpatient,thenursenotesthathedrinksalcoholdailyandthathehasnoticedatremorinhishandsthataffectshisabilitytoholdthings.Withthisinformation,whatresponseshouldthenursemake?a.Doesyourfamilyknowyouaredrinkingeveryday?b.Doesthetremorchangewhenyoudrinkalcohol?c.Welldosometeststoseewhatiscausingthetremor.NURSINGTB.COMd.Youreallyshouldntdrinksomuchalcohol;itmaybecausingyourtremor.ANS:BSeniletremorisrelievedbyalcohol,althoughnotarecommendedtreatment.Thenurseshouldassesswhetherthepersonisabusingalcoholinanefforttorelievethetremor.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance19.A50-year-oldwomanisintheclinicforweaknessinherleftarmandlegthatshehasnoticedforthepastweek.Thenurseshouldperformwhichtypeofneurologicexamination?a.GlasgowComaScaleb.Neurologicrecheckexaminationc.Screeningneurologicexaminationd.CompleteneurologicexaminationANS:DPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)366STUVIA.COMThenurseshouldperformacompleteneurologicexaminationonanindividualwhohasneurologicconcerns(e.g.,headache,weakness,lossofcoordination)orwhoisshowingsignsofneurologicdysfunction.TheGlasgowComaScaleisusedtodefineapersonslevelofconsciousness.Theneurologicrecheckexaminationisappropriateforthosewhoaredemonstratingneurologicdeficits.Thescreeningneurologicexaminationisperformedonseeminglywellindividualswhohavenosignificantsubjectivefindingsfromthehealthhistory.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance20.DuringanassessmentoftheCNs,thenursefindsthefollowing:asymmetrywhenthepatientsmilesorfrowns,unevenliftingoftheeyebrows,saggingofthelowereyelids,andescapeofairwhenthenursepressesagainsttherightpuffedcheek.ThiswouldindicatedysfunctionofwhichoftheseCNs?a.MotorcomponentofCNIVb.MotorcomponentofCNVIIc.MotorandsensorycomponentsofCNXId.MotorcomponentofCNXandsensorycomponentofCNVIIANS:BThefindingslistedreflectadysfunctionofthemotorcomponentofthefacialnerve(CNVII).DIF:CognitiveLevel:Analyzing(Analysis)NURSINGTB.COMMSC:ClientNeeds:HealthPromotionandMaintenance21.ThenurseistestingthefunctionofCNXI.Whichstatementbestdescribestheresponsethenurseshouldexpectifthisnerveisintact?Thepatient:a.Demonstratestheabilitytohearnormalconversation.b.Sticksoutthetonguemidlinewithouttremorsordeviation.c.Followsanobjectwithhisorhereyeswithoutnystagmusorstrabismus.d.Movestheheadandshouldersagainstresistancewithequalstrength.ANS:DThefollowingnormalfindingsareexpectedwhentestingthespinalaccessorynerve(CNXI):Thepatientssternomastoidandtrapeziusmusclesareequalinsize;thepersoncanforciblyrotatetheheadbothwaysagainstresistanceappliedtothesideofthechinwithequalstrength;andthepatientcanshrugtheshouldersagainstresistancewithequalstrengthonbothsides.CheckingthepatientsabilitytohearnormalconversationchecksthefunctionofCNVIII.HavingthepatientstickoutthetonguechecksthefunctionofCNXII.TestingtheeyesfornystagmusorstrabismusisperformedtocheckCNsIII,IV,andVI.DIF:CognitiveLevel:Applying(Application)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)367STUVIA.COMMSC:ClientNeeds:HealthPromotionandMaintenance22.Duringtheneurologicassessmentofahealthy35-year-oldpatient,thenurseaskshimtorelaxhismusclescompletely.Thenursethenmoveseachextremitythroughfullrangeofmotion.Whichoftheseresultswouldthenurseexpecttofind?a.Firm,rigidresistancetomovementb.Mild,evenresistancetomovementc.Hypotonicmusclesasaresultoftotalrelaxationd.SlightpainwithsomedirectionsofmovementANS:BToneisthenormaldegreeoftension(contraction)involuntarilyrelaxedmuscles.Itshowsamildresistancetopassivestretching.Normally,thenursewillnoticeamild,evenresistancetomovement.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance23.Whenthenurseasksa68-year-oldpatienttostandwithhisfeettogetherandarmsathissidewithhiseyesclosed,hestartstoswayandmoveshisfeetfartherapart.Thenursewoulddocumentthisfindingas:NURSINGTB.COMa.Ataxia.b.Lackofcoordination.c.NegativeHomanssign.d.PositiveRombergsign.ANS:DAbnormalfindingsfortheRombergtestincludeswaying,falling,andawideningbaseofthefeettoavoidfalling.ApositiveRombergsignisalossofbalancethatisincreasedbytheclosingoftheeyes.Ataxiaisanuncoordinatedorunsteadygait.Homanssignisusedtotestthelegsfordeep-veinthrombosis.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance24.Thenurseisperforminganassessmentona29-year-oldwomanwhovisitsthecliniccomplainingofalwaysdroppingthingsandfallingdown.Whiletestingrapidalternatingmovements,thenursenoticesthatthewomanisunabletopatbothofherknees.Herresponseisextremelyslowandshefrequentlymisses.Whatshouldthenursesuspect?a.VestibulardiseasePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)368STUVIA.COMb.LesionofCNIXc.Dysfunctionofthecerebellumd.InabilitytounderstanddirectionsANS:CWhenapersontriestoperformrapid,alternatingmovements,responsesthatareslow,clumsy,andsloppyareindicativeofcerebellardisease.Theotherresponsesareincorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation25.Duringthetakingofthehealthhistoryofa78-year-oldman,hiswifestatesthatheoccasionallyhasproblemswithshort-termmemorylossandconfusion:Hecantevenrememberhowtobuttonhisshirt.Whenassessinghissensorysystem,whichactionbythenurseismostappropriate?a.Thenursewouldnottestthesensorysystemaspartoftheexaminationbecausetheresultswouldnotbevalid.b.Thenursewouldperformthetests,knowingthatmentalstatusdoesnotaffectsensoryability.c.ThenursewouldproceedwithaneNxUpRlaSnIaNtiGonTBo.fCeOaMchtest,makingcertainthatthewifeunderstands.d.Beforetesting,thenursewouldassessthepatientsmentalstatusandabilitytofollowdirections.ANS:DThenurseshouldensurethevalidityofthesensorysystemtestingbymakingcertainthatthepatientisalert,cooperative,comfortable,andhasanadequateattentionspan.Otherwise,thenursemayobtainmisleadingandinvalidresults.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance26.Theassessmentofa60-year-oldpatienthastakenlongerthananticipated.Intestinghispainperception,thenursedecidestocompletethetestasquicklyaspossible.Whenthenurseappliesthesharppointofthepinonhisarmseveraltimes,heisonlyabletoidentifytheseasoneverysharpprick.Whatwouldbethemostaccurateexplanationforthis?a.Thepatienthashyperesthesiaasaresultoftheagingprocess.b.Thisresponseismostlikelytheresultofthesummationeffect.c.Thenursewasprobablynotpokinghardenoughwiththepinintheotherareas.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)369STUVIA.COMd.Thepatientmostlikelyhasanalgesiainsomeareasofarmandhyperalgesiainothers.ANS:BAtleast2secondsshouldbeallowedtoelapsebetweeneachstimulustoavoidsummation.Withsummation,frequentconsecutivestimuliareperceivedasonestrongstimulus.Theotherresponsesareincorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare27.Thenurseisperforminganeurologicassessmentona41-year-oldwomanwithahistoryofdiabetes.Whentestingherabilitytofeelthevibrationsofatuningfork,thenursenoticesthatthepatientisunabletofeelvibrationsonthegreattoeoranklebilaterally,butsheisabletofeelvibrationsonbothpatellae.Giventhisinformation,whatwouldthenursesuspect?a.Hyperalgesiab.Hyperesthesiac.Peripheralneuropathyd.LesionofsensorycortexANS:CNURSINGTB.COMLossofvibrationsenseoccurswithperipheralneuropathy(e.g.,diabetesandalcoholism).Peripheralneuropathyisworseatthefeetandgraduallyimprovesastheexaminermovesuptheleg,asopposedtoaspecificnervelesion,whichhasaclearzoneofdeficitforitsdermatome.Theotherresponsesareincorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation28.Thenurseplacesakeyinthehandofapatientandheidentifiesitasapenny.Whattermwouldthenurseusetodescribethisfinding?a.Extinctionb.Astereognosisc.Graphesthesiad.TactilediscriminationANS:BStereognosisisthepersonsabilitytorecognizeobjectsbyfeelingtheirforms,sizes,andweights.Astereognosisisaninabilitytoidentifyobjectscorrectly,anditoccursinsensorycortexlesions.Tactilediscriminationtestsfinetouch.Extinctionteststhepersonsabilitytofeelsensationsonbothsidesofthebodyatthesamepoint.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)370STUVIA.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation29.Thenurseistestingthedeeptendonreflexesofa30-year-oldwomanwhoisintheclinicforanannualphysicalexamination.WhenstrikingtheAchillesheelandquadricepsmuscle,thenurseisunabletoelicitareflex.Thenursesnextresponseshouldbeto:a.Askthepatienttolockherfingersandpull.b.Completetheexamination,andthentestthesereflexesagain.c.Referthepatienttoaspecialistforfurthertesting.d.Documentthesereflexesas0onascaleof0to4+.ANS:ASometimesthereflexresponsefailstoappear.Documentingthereflexesasabsentisinappropriatethissoonintheexamination.Thenurseshouldtrytofurtherencouragerelaxation,varyingthepersonspositionorincreasingthestrengthoftheblow.Reinforcementisanothertechniquetorelaxthemusclesandenhancetheresponse.Thepersonshouldbeaskedtoperformanisometricexerciseinamusclegroupsomewhatawayfromtheonebeingtested.Forexample,toenhanceapatellarreflex,thepersonshouldbeaskedtolockthefingerstogetherandpull.DIF:CognitiveLevel:Applying(Application)NURSINGTB.COMMSC:ClientNeeds:HealthPromotionandMaintenance30.Inassessinga70-year-oldpatientwhohashadarecentcerebrovascularaccident,thenursenoticesright-sidedweakness.Whatmightthenurseexpecttofindwhentestinghisreflexesontherightside?a.Lackofreflexesb.Normalreflexesc.Diminishedreflexesd.HyperactivereflexesANS:DHyperreflexiaistheexaggeratedreflexobservedwhenthemonosynapticreflexarcisreleasedfromtheinfluenceofhighercorticallevels.Thisresponseoccurswithuppermotorneuronlesions(e.g.,acerebrovascularaccident).Theotherresponsesareincorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation31.Whenthenurseistestingthetricepsreflex,whatistheexpectedresponse?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)371STUVIA.COMa.Flexionofthehandb.Pronationofthehandc.Extensionoftheforearmd.FlexionoftheforearmANS:CThenormalresponseofthetricepsreflexisextensionoftheforearm.Thenormalresponseofthebicepsreflexcausesflexionoftheforearm.Theotherresponsesareincorrect.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare32.Thenurseistestingsuperficialreflexesonanadultpatient.Whenstrokingupthelateralsideofthesoleandacrosstheballofthefoot,thenursenoticestheplantarflexionofthetoes.Howshouldthenursedocumentthisfinding?a.PositiveBabinskisignb.Plantarreflexabnormalc.PlantarreflexpresentNURSINGTB.COMd.Plantarreflex2+onascalefrom0to4+ANS:CWiththesameinstrument,thenurseshoulddrawalightstrokeupthelateralsideofthesoleofthefootandacrosstheballofthefoot,similartoanupside-downJ.Thenormalresponseisplantarflexionofthetoesandsometimesoftheentirefoot.ApositiveBabinskisignisabnormalandoccurswiththeresponseofdorsiflexionofthebigtoeandfanningofalltoes.Theplantarreflexisnotgradedona0to4+scale.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare33.Intheassessmentofa1-month-oldinfant,thenursenoticesalackofresponsetonoiseorstimulation.Themotherreportsthatinthelastweekhehasbeensleepingallofthetime,andwhenheisawakeallhedoesiscry.Thenursehearsthattheinfantscriesareveryhighpitchedandshrill.Whatshouldbethenursesappropriateresponsetothesefindings?a.Refertheinfantforfurthertesting.b.Talkwiththemotherabouteatinghabits.c.Donothing;theseareexpectedfindingsforaninfantthisage.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)372STUVIA.COMd.Tellthemothertobringthebabybackin1weekforarecheck.ANS:AAhigh-pitched,shrillcryorcat-soundingscreechoccurswithcentralnervoussystemdamage.Lethargy,hyporeactivity,andhyperirritability,aswellastheparentsreportofsignificantchangesinbehaviorallwarrantreferral.Theotheroptionsarenotcorrectresponses.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance34.Whichofthesetestswouldthenurseusetocheckthemotorcoordinationofan11-month-oldinfant?a.DenverIIb.Stereognosisc.Deeptendonreflexesd.RapidalternatingmovementsANS:AToscreengrossandfinemotorcoordination,tNhUeRnuSrIsNeGsThBou.CldOuMsetheDenverIIwithitsage-specificdevelopmentalmilestones.Stereognosistestsapersonsabilitytorecognizeobjectsbyfeelingthemandisnotappropriateforan11-month-oldinfant.Testingthedeeptendonreflexesisnotappropriateforcheckingmotorcoordination.Testingrapidalternatingmovementsisappropriatefortestingcoordinationinadults.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance35.Toassesstheheadcontrolofa4-month-oldinfant,thenurseliftsuptheinfantinapronepositionwhilesupportinghischest.Thenurselooksforwhatnormalresponse?Theinfant:a.Raisesthehead,andarchestheback.b.Extendsthearms,anddropsdownthehead.c.Flexesthekneesandelbowswiththebackstraight.d.Holdstheheadat45degrees,andkeepsthebackstraight.ANS:AAt3monthsofage,theinfantraisestheheadandarchesthebackasifinaswandive.ThisresponseistheLandaureflex,whichpersistsuntil1yearsofage.Theotherresponsesareincorrect.DIF:CognitiveLevel:Applying(Application)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)373STUVIA.COMMSC:ClientNeeds:HealthPromotionandMaintenance36.Whileassessinga7-month-oldinfant,thenursemakesaloudnoiseandnoticesthefollowingresponse:abductionandflexionofthearmsandlegs;fanningofthefingers,andcurlingoftheindexfingerandthumbinaCposition,followedbytheinfantbringinginthearmsandlegstothebody.Whatdoesthenurseknowaboutthisresponse?a.Thisresponsecouldindicatebrachialnervepalsy.b.Thisreactionisanexpectedstartleresponseatthisage.c.Thisreflexshouldhavedisappearedbetween1and4monthsofage.d.Thisresponseisnormalaslongasthemovementsarebilaterallysymmetric.ANS:CTheMororeflexispresentatbirthandusuallydisappearsat1to4months.AbsenceoftheMororeflexinthenewbornoritspersistenceafter5monthsofageindicatesseverecentralnervoussysteminjury.Theotherresponsesareincorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance37.Totestforgrossmotorskillandcoordinationofa6-year-oldchild,whichofthesetechniqueswouldbeappropriate?Askthechildto:a.Hopononefoot.b.Standonhishead.c.Touchhisfingertohisnose.d.Makefunnyfacesatthenurse.NURSINGTB.COMANS:ANormally,achildcanhopononefootandcanbalanceononefootforapproximately5secondsby4yearsofageandcanbalanceononefootfor8to10secondsat5yearsofage.Childrenenjoyperformingthesetests.Failuretohopafter5yearsofageindicatesincoordinationofgrossmotorskills.Askingthechildtotouchhisorherfingertothenosechecksfinemotorcoordination;andaskingthechildtomakefunnyfacestestsCNVII.Askingachildtostandonhisorherheadisnotappropriate.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance38.Duringtheassessmentofan80-year-oldpatient,thenursenoticesthathishandsshowtremorswhenhereachesforsomethingandhisheadisalwaysnodding.Noassociatedrigidityisobservedwithmovement.Whichofthesestatementsismostaccurate?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)374STUVIA.COMa.Thesefindingsarenormal,resultingfromaging.b.Thesefindingscouldberelatedtohyperthyroidism.c.ThesefindingsaretheresultofParkinsondisease.d.Thispatientshouldbeevaluatedforacerebellarlesion.ANS:ASeniletremorsoccasionallyoccur.Thesebenigntremorsincludeanintentiontremorofthehands,headnodding(asifsayingyesorno),andtongueprotrusion.TremorsassociatedwithParkinsondiseaseincluderigidity,slowness,andaweaknessofvoluntarymovement.Theotherresponsesareincorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance39.Whilethenurseistakingthehistoryofa68-year-oldpatientwhosustainedaheadinjury3daysearlier,hetellsthenursethatheisonacruiseshipandis30yearsold.Thenurseknowsthatthisfindingisindicativeofa(n):a.Greatsenseofhumor.b.Uncooperativebehavior.c.Inabilitytounderstandquestions.d.Decreasedlevelofconsciousness.NURSINGTB.COMANS:DAchangeinconsciousnessmaybesubtle.Thenurseshouldnoticeanydecreasinglevelofconsciousness,disorientation,memoryloss,uncooperativebehavior,orevencomplacencyinapreviouslycombativeperson.Theotherresponsesareincorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation40.Thenurseiscaringforapatientwhohasjusthadneurosurgery.Toassessforincreasedintracranialpressure,whatwouldthenurseincludeintheassessment?a.CNs,motorfunction,andsensoryfunctionb.Deeptendonreflexes,vitalsigns,andcoordinatedmovementsc.Levelofconsciousness,motorfunction,pupillaryresponse,andvitalsignsd.Mentalstatus,deeptendonreflexes,sensoryfunction,andpupillaryresponsePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)375STUVIA.COMANS:CSomehospitalizedpersonshaveheadtraumaoraneurologicdeficitfromasystemicdiseaseprocess.Thesepeoplemustbecloselymonitoredforanyimprovementordeteriorationinneurologicstatusandforanyindicationofincreasingintracranialpressure.Thenurseshoulduseanabbreviationoftheneurologicexaminationinthefollowingsequence:levelofconsciousness,motorfunction,pupillaryresponse,andvitalsigns.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation41.Duringanassessmentofa22-year-oldwomanwhosustainedaheadinjuryfromanautomobileaccident4hoursearlier,thenursenoticesthefollowingchanges:pupilswereequal,butnowtherightpupilisfullydilatedandnonreactive,andtheleftpupilis4mmandreactstolight.Whatdothesefindingssuggest?a.Injurytotherighteyeb.Increasedintracranialpressurec.Testinaccuratelyperformedd.NormalresponseafteraheadinjuryANS:BNURSINGTB.COMInapersonwithabraininjury,asudden,unilateral,dilated,andnonreactivepupilisominous.CNIIIrunsparalleltothebrainstem.Whenincreasingintracranialpressurepushesdownthebrainstem(uncalherniation),itputspressureonCNIII,causingpupildilation.Theotherresponsesareincorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation42.A32-year-oldwomantellsthenursethatshehasnoticedverysudden,jerkymovementsmainlyinherhandsandarms.Shesays,Theyseemtocomeandgo,primarilywhenIamtryingtodosomething.IhaventnoticedthemwhenImsleeping.Thisdescriptionsuggests:a.Tics.b.Athetosis.c.Myoclonus.d.Chorea.ANS:DChoreaischaracterizedbysudden,rapid,jerky,purposelessmovementsthatinvolvethelimbs,trunk,orface.Choreaoccursatirregularintervals,andthemovementsareallaccentuatedbyvoluntaryactions.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)376STUVIA.COMDIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation43.Duringanassessmentofa62-year-oldman,thenursenoticesthepatienthasastoopedposture,shufflingwalkwithshortsteps,flatfacialexpression,andpill-rollingfingermovements.Thesefindingswouldbeconsistentwith:a.Parkinsonism.b.Cerebralpalsy.c.Cerebellarataxia.d.Musculardystrophy.ANS:AThestoopedposture,shufflingwalk,shortsteps,flatfacialexpression,andpill-rollingfingermovementsareallfoundinparkinsonism.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation44.Duringanassessmentofa32-year-oldpatientwitharecentheadinjury,thenursenoticesthatthepatientrespondstopainbyextending,adducting,andNinUtRerSnIaNllGyTrBot.CatOinMghisarms.Hispalmspronate,andhislowerextremitiesextendwithplantarflexion.Whichstatementconcerningthesefindingsismostaccurate?Thispatientsresponse:a.Indicatesalesionofthecerebralcortex.b.Indicatesacompletelynonfunctionalbrainstem.c.Isnormalandwillgoawayin24to48hours.d.Isaveryominoussignandmayindicatebrainsteminjury.ANS:DThesefindingsareallindicativeofdecerebraterigidity,whichisaveryominousconditionandmayindicateabrainsteminjury.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation45.A78-year-oldmanhasahistoryofacerebrovascularaccident.Thenursenotesthatwhenhewalks,hisleftarmisimmobileagainstthebodywithflexionoftheshoulder,elbow,wrist,andfingersandadductionoftheshoulder.Hisleftlegisstiffandextendedandcircumductswitheachstep.Whattypeofgaitdisturbanceisthisindividualexperiencing?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)377STUVIA.COMa.Scissorsgaitb.Cerebellarataxiac.Parkinsoniangaitd.SpastichemiparesisANS:DWithspastichemiparesis,thearmisimmobileagainstthebody.Flexionoftheshoulder,elbow,wrist,andfingersoccurs,andadductionoftheshoulder,whichdoesnotswingfreely,isobserved.Thelegisstiffandextendedandcircumductswitheachstep.Causesofthistypeofgaitincludecerebrovascularaccident.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation46.Inapersonwithanuppermotorneuronlesionsuchasacerebrovascularaccident,whichofthesephysicalassessmentfindingsshouldthenurseexpect?a.Hyperreflexiab.FasciculationsNURSINGTB.COMc.Lossofmuscletoneandflaccidityd.AtrophyandwastingofthemusclesANS:AHyperreflexia,diminishedorabsentsuperficialreflexes,andincreasedmuscletoneorspasticitycanbeexpectedwithuppermotorneuronlesions.Theotheroptionsreflectalesionoflowermotorneurons.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation47.A59-year-oldpatienthasaherniatedintervertebraldisk.Whichofthefollowingfindingsshouldthenurseexpecttoseeonphysicalassessmentofthisindividual?a.Hyporeflexiab.Increasedmuscletonec.PositiveBabinskisignd.PresenceofpathologicreflexesPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)378STUVIA.COMANS:AWithaherniatedintervertebraldiskorlowermotorneuronlesion,lossoftone,flaccidity,atrophy,fasciculations,andhyporeflexiaorareflexiaaredemonstrated.NoBabinskisignorpathologicreflexeswouldbeobserved.Theotheroptionsreflectalesionofuppermotorneurons.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation48.Apatientisunabletoperformrapidalternatingmovementssuchasrapidlypattingherknees.Thenurseshoulddocumentthisinabilityas:a.Ataxia.b.Astereognosis.c.Presenceofdysdiadochokinesia.d.Lossofkinesthesia.ANS:CSlowclumsymovementsandtheinabilitytoperformrapidalternatingmovementsoccurwithcerebellardisease.Theconditionistermeddysdiadochokinesia.Ataxiaisanuncoordinatedorunsteadygait.Astereognosisistheinabilitytoidentifyanobjectbyfeelingit.KinesthesiaisthepersonsabilitytoperceivepassivemovementoftheextremitiesorthelosNsUoRfSpIoNsGitiToBn.sCeOnMse.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation49.Thenurseknowsthatdeterminingwhetherapersonisorientedtohisorhersurroundingswilltestthefunctioningofwhichstructure(s)?a.Cerebrumb.Cerebellumc.CNsd.MedullaoblongataANS:AThecerebralcortexisresponsibleforthought,memory,reasoning,sensation,andvoluntarymovement.Theotherstructuresarenotresponsibleforapersonslevelofconsciousness.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCarePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)379STUVIA.COM50.Duringanexamination,thenursenoticesseverenystagmusinbotheyesofapatient.Whichconclusionbythenurseiscorrect?Severenystagmusinbotheyes:a.Isanormaloccurrence.b.Mayindicatediseaseofthecerebellumorbrainstem.c.Isasignthatthepatientisnervousabouttheexamination.d.Indicatesavisualproblem,andareferraltoanophthalmologistisindicated.ANS:BEnd-pointnystagmusatanextremelateralgazenormallyoccurs;however,thenurseshouldcarefullyassessanyothernystagmuses.Severenystagmusoccurswithdiseaseofthevestibularsystem,cerebellum,orbrainstem.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance51.Thenurseknowsthattestingkinesthesiaisatestofapersons:a.Finetouch.b.Positionsense.c.Motorcoordination.d.Perceptionofvibration.NURSINGTB.COMANS:BKinesthesia,orpositionsense,isthepersonsabilitytoperceivepassivemovementsoftheextremities.Theotheroptionsareincorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare52.Thenurseisreviewingapatientsmedicalrecordandnotesthatheisinacoma.UsingtheGlasgowComaScale,whichnumberindicatesthatthepatientisinacoma?a.6b.12c.15PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)380STUVIA.COMd.24ANS:AAfullyalert,normalpersonhasascoreof15,whereasascoreof7orlessreflectscomaontheGlasgowComaScale.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation53.Amanwhowasfoundwanderinginaparkat2AMhasbeenbroughttotheemergencydepartmentforanexamination;hesaidhefellandhithishead.Duringtheexamination,thenurseaskshimtousehisindexfingertotouchthenursesfinger,thenhisownnose,thenthenursesfingeragain(whichhasbeenmovedtoadifferentlocation).Thepatientisclumsy,unabletofollowtheinstructions,andovershootsthemark,missingthefinger.Thenurseshouldsuspectwhichofthefollowing?a.Cerebralinjuryb.Cerebrovascularaccidentc.Acutealcoholintoxicationd.PeripheralneuropathyANS:CNURSINGTB.COMDuringthefinger-to-fingertest,ifthepersonhasclumsymovementwithovershootingthemark,eitheracerebellardisorderoracutealcoholintoxicationshouldbesuspected.Thepersonsmovementsshouldbesmoothandaccurate.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation54.Thenurseisassessingtheneurologicstatusofapatientwhohasalate-stagebraintumor.Withthereflexhammer,thenursedrawsalightstrokeupthelateralsideofthesoleofthefootandinward,acrosstheballofthefoot.Inresponse,thepatientstoesfanout,andthebigtoeshowsdorsiflexion.Thenurseinterpretsthisresultas:a.NegativeBabinskisign,whichisnormalforadults.b.PositiveBabinskisign,whichisabnormalforadults.c.Clonus,whichisahyperactiveresponse.d.Achillesreflex,whichisanexpectedresponse.ANS:BDorsiflexionofthebigtoeandfanningofalltoesisapositiveBabinskisign,alsocalledup-goingtoes.ThisPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)381STUVIA.COMresponseoccurswithuppermotorneurondiseaseofthecorticospinal(orpyramidal)tractandisanabnormalfindingforadults.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationMULTIPLERESPONSE1.A69-year-oldpatienthasbeenadmittedtoanadultpsychiatricunitbecausehiswifethinksheisgettingmoreandmoreconfused.Helaughswhenheisfoundtobeforgetful,sayingImjustgettingold!Afterthenursecompletesathoroughneurologicassessment,whichfindingswouldbeindicativeofAlzheimerdisease?Selectallthatapply.a.Occasionallyforgettingnamesorappointmentsb.Difficultyperformingfamiliartasks,suchasplacingatelephonecallc.Misplacingitems,suchasputtingdishsoapintherefrigeratord.Sometimeshavingtroublefindingtherightworde.Rapidmoodswings,fromcalmtotears,fornoapparentreasonf.GettinglostinonesownneighborhoodNURSINGTB.COMANS:B,C,E,FDifficultyperformingfamiliartasks,misplacingitems,rapidmoodswings,andgettinglostinonesownneighborhoodcanbewarningsignsofAlzheimerdisease.Occasionallyforgettingnamesorappointments,andsometimeshavingtroublefindingtherightwordarepartofnormalaging.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationSHORTANSWER1.Duringtheassessmentofdeeptendonreflexes,thenursefindsthatapatientsresponsesarebilaterallynormal.Whatnumberisusedtoindicatenormaldeeptendonreflexeswhenthedocumentingthisfinding?+ANS:2Responsestoassessmentofdeeptendonreflexesaregradedona4-pointscale.Aratingof2+indicatesnormaloraverageresponse.Aratingof0indicatesnoresponse,andaratingof4+indicatesverybrisk,hyperactiveresponsewithclonus,whichisindicativeofdisease.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)382STUVIA.COMChapter25:MaleGenitourinarySystemMULTIPLECHOICE1.Theexternalmalegenitalstructuresincludethe:a.Testis.b.Scrotum.c.Epididymis.d.Vasdeferens.ANS:BTheexternalmalegenitalstructuresincludethepenisandscrotum.Thetestis,epididymis,andvasdeferensareinternalstructures.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General2.Anaccessoryglandularstructureforthemalegenitalorgansisthe:a.Testis.b.Scrotum.c.Prostate.d.Vasdeferens.NURSINGTB.COMANS:CGlandularstructuresaccessorytothemalegenitalorgansaretheprostate,seminalvesicles,andbulbourethralglands.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General3.Whichofthesestatementsistrueregardingthepenis?a.Theurethralmeatusislocatedontheventralsideofthepenis.b.Theprepuceisthefoldofforeskincoveringtheshaftofthepenis.c.Thepenisismadeupoftwocylindricalcolumnsoferectiletissue.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)383STUVIA.COMd.Thecorpusspongiosumexpandsintoaconeoferectiletissuecalledtheglans.ANS:DAtthedistalendoftheshaft,thecorpusspongiosumexpandsintoaconeoferectiletissue,theglans.Thepenisismadeupofthreecylindricalcolumnsoferectiletissue.Theskinthatcoverstheglansofthepenisistheprepuce.Theurethralmeatusformsatthetipoftheglans.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General4.Whenperformingagenitalexaminationona25-year-oldman,thenursenoticesdeeplypigmented,wrinkledscrotalskinwithlargesebaceousfollicles.Onthebasisofthisinformation,thenursewould:a.Squeezetheglanstocheckforthepresenceofdischarge.b.Considerthisfindingasnormal,andproceedwiththeexamination.c.Assessthetesticlesforthepresenceofmassesorpainlesslumps.d.Obtainamoredetailedhistory,focusingonanyscrotalabnormalitiesthepatienthasnoticed.ANS:BAfteradolescence,thescrotalskinisdeeplypNigUmReSnItNedGaTnBd.ChOasMlargesebaceousfolliclesandappearscorrugated.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance5.Whichstatementconcerningthetestesistrue?a.Thelymphaticvesselsofthetestesdrainintotheabdominallymphnodes.b.Thevasdeferensislocatedalongtheinferiorportionofeachtestis.c.Therighttestisislowerthantheleftbecausetherightspermaticcordislonger.d.Thecremastermusclecontractsinresponsetocoldanddrawsthetesticlesclosertothebody.ANS:DWhenitiscold,thecremastermusclecontracts,whichraisesthescrotalsacandbringsthetestesclosertothebodytoabsorbheatnecessaryforspermviability.Thelymphaticvesselsofthetestesdrainintotheinguinallymphnodes.Thevasdeferensislocatedalongtheupperportionofeachtestis.Thelefttestisislowerthantherightbecausetheleftspermaticcordislonger.DIF:CognitiveLevel:Remembering(Knowledge)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)384STUVIA.COMMSC:ClientNeeds:General6.Amalepatientwithpossiblefertilityproblemsasksthenursewherespermisproduced.Thenurseknowsthatspermproductionoccursinthe:a.Testes.b.Prostate.c.Epididymis.d.Vasdeferens.ANS:ASpermproductionoccursinthetestes,notintheotherstructureslisted.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PhysiologicIntegrity7.A62-year-oldmanstatesthathisphysiciantoldhimthathehasaninguinalhernia.Heasksthenursetoexplainwhataherniais.Thenurseshould:a.Tellhimnottoworryandthatmostmenhisagedevelophernias.NURSINGTB.COMb.Explainthataherniaisoftentheresultofprenatalgrowthabnormalities.c.Referhimtohisphysicianforadditionalconsultationbecausethephysicianmadetheinitialdiagnosis.d.Explainthataherniaisaloopofbowelprotrudingthroughaweakspotintheabdominalmuscles.ANS:DAherniaisaloopofbowelprotrudingthroughaweakspotinthemusculature.Theotheroptionsarenotcorrectresponsestothepatientsquestion.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity8.Themotherofa10-year-oldboyasksthenursetodiscusstherecognitionofpuberty.Thenurseshouldreplybysaying:a.Pubertyusuallybeginsaround15yearsofage.b.Thefirstsignofpubertyisanenlargementofthetestes.c.Thepenissizedoesnotincreaseuntilabout16yearsofage.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)385STUVIA.COMd.Thedevelopmentofpubichairprecedestesticularorpenisenlargement.ANS:BPubertybeginssometimebetweenage9forAfricanAmericansandage10forCaucasiansandHispanics.Thefirstsignisanenlargementofthetestes.Pubichairappearsnext,andthenpenissizeincreases.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance9.Duringanexaminationofanagingman,thenurserecognizesthatnormalchangestoexpectwouldbe:a.Enlargedscrotalsac.b.Increasedpubichair.c.Decreasedpenissize.d.Increasedrugaeoverthescrotum.ANS:CIntheagingman,theamountofpubichairdecreases,thepenissizedecreases,andtherugaeoverthescrotalsacdecreases.ThescrotalsacdoesnotenlargeN.URSINGTB.COMDIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance10.Anoldermanisconcernedabouthissexualperformance.Thenurseknowsthatintheabsenceofdisease,awithdrawalfromsexualactivitylaterinlifemaybeattributableto:a.Sideeffectsofmedications.b.Decreasedlibidowithaging.c.Decreasedspermproduction.d.Decreasedpleasurefromsexualintercourse.ANS:AIntheabsenceofdisease,awithdrawalfromsexualactivitymaybeattributabletosideeffectsofmedicationssuchasantihypertensives,antidepressants,sedatives,psychotropics,antispasmotics,tranquilizersornarcotics,andestrogens.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenancePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)386STUVIA.COM11.A59-year-oldpatienthasbeendiagnosedwithprostatitisandisbeingseenattheclinicforcomplaintsofburningandpainduringurination.Heisexperiencing:a.Dysuria.b.Nocturia.c.Polyuria.d.Hematuria.ANS:ADysuria(burningwithurination)iscommonwithacutecystitis,prostatitis,andurethritis.Nocturiaisvoidingduringthenight.Polyuriaisvoidinginexcessivequantities.Hematuriaisvoidingwithbloodintheurine.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation12.A45-year-oldmotheroftwochildrenisseenattheclinicforcomplaintsoflosingmyurinewhenIsneeze.Thenursedocumentsthatsheisexperiencing:a.Urinaryfrequency.b.Enuresis.c.Stressincontinence.d.Urgeincontinence.NURSINGTB.COMANS:CStressincontinenceisinvoluntaryurinelosswithphysicalstrain,sneezing,orcoughingthatoccursasaresulttoweaknessofthepelvicfloor.Urinaryfrequencyisurinatingmoretimesthanusual(morethanfivetosixtimesperday).Enuresisisinvoluntarypassageofurineatnightafterage5to6years(bedwetting).Urgeincontinenceisinvoluntaryurinelossfromoveractivedetrusormuscleinthebladder.Itcontracts,causinganurgentneedtovoid.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation13.Whenthenurseisconductingsexualhistoryfromamaleadolescent,whichstatementwouldbemostappropriatetouseatthebeginningoftheinterview?a.Doyouusecondoms?b.Youdontmasturbate,doyou?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)387STUVIA.COMc.Haveyouhadsexinthelast6months?d.Oftenadolescentsyouragehavequestionsaboutsexualactivity.ANS:DTheinterviewshouldbeginwithapermissionstatement,whichconveysthatitisnormalandacceptabletothinkorfeelacertainway.Soundingjudgmentalshouldbeavoided.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance14.Whichofthesestatementsismostappropriatewhenthenurseisobtainingagenitourinaryhistoryfromanolderman?a.Doyouneedtogetupatnighttourinate?b.Doyouexperiencenocturnalemissions,orwetdreams?c.Doyouknowhowtoperformatesticularself-examination?d.Hasanyoneevertouchedyourgenitalswhenyoudidnotwantthemto?ANS:ANURSINGTB.COMTheoldermalepatientshouldbeaskedaboutthepresenceofnocturia.Awakingatnighttourinatemaybeattributabletoadiureticmedication,fluidretentionfrommildheartfailureorvaricoseveins,orfluidingestion3hoursbeforebedtime,especiallycoffeeandalcohol.Theotherquestionsaremoreappropriateforyoungermen.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance15.Whenthenurseisperformingagenitalexaminationonamalepatient,thepatienthasanerection.Thenursesmostappropriateactionorresponseisto:a.Askthepatientifhewouldlikesomeoneelsetoexaminehim.b.Continuewiththeexaminationasthoughnothinghashappened.c.Stoptheexamination,leavetheroomwhilestatingthattheexaminationwillresumeatalatertime.d.Reassurethepatientthatthisisanormalresponseandcontinuewiththeexamination.ANS:DWhenthemalepatienthasanerection,thenurseshouldreassurethepatientthatthisisanormalphysiologicresponsetotouchandproceedwiththerestoftheexamination.TheotherresponsesarenotcorrectandmaybePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)388STUVIA.COMperceivedasjudgmental.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity16.Thenurseisexaminingtheglansandknowswhichfindingisnormalforthisarea?a.Themeatusmayhaveaslightdischargewhentheglansiscompressed.b.Hairiswithoutpestinhabitants.c.Theskiniswrinkledandwithoutlesions.d.Smegmamaybepresentundertheforeskinofanuncircumcisedmale.ANS:DTheglanslookssmoothandwithoutlesionsanddoesnothavehair.Themeatusshouldnothaveanydischargewhentheglansiscompressed.Somecheesysmegmamayhavecollectedundertheforeskinofanuncircumcisedmale.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare17.WhenperformingagenitourinaryassessmNenUtR,tShIeNnGuTrBse.CnOotMicesthattheurethralmeatusisventrallypositioned.Thisfindingis:a.Calledhypospadias.b.Aresultofphimosis.c.Probablyduetoastricture.d.Oftenassociatedwithaging.ANS:ANormally,theurethralmeatusispositionedjustaboutcentrally.Hypospadiasistheventrallocationoftheurethralmeatus.Thepositionofthemeatusdoesnotchangewithaging.Phimosisistheinabilitytoretracttheforeskin.Astrictureisanarrowopeningofthemeatus.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare18.Thenurseisperformingagenitalexaminationonamalepatientandnoticesurethraldrainage.Whencollectingurethraldischargeformicroscopicexaminationandculture,thenurseshould:a.Askthepatienttourinateintoasterilecup.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)389STUVIA.COMb.Askthepatienttoobtainaspecimenofsemen.c.Insertacotton-tippedapplicatorintotheurethra.d.Compresstheglansbetweentheexaminersthumbandforefinger,andcollectanydischarge.ANS:DIfurethraldischargeisnoticed,thentheexaminershouldcollectasmearformicroscopicexaminationandculturebycompressingtheglansanteroposteriorlybetweenthethumbandforefinger.Theotheroptionsarenocorrectactions.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare19.Whenassessingthescrotumofamalepatient,thenursenoticesthepresenceofmultiplefirm,nontender,yellow1-cmnodules.Thenurseknowsthatthesenodulesaremostlikely:a.Fromurethritis.b.Sebaceouscysts.c.Subcutaneousplaques.NURSINGTB.COMd.Fromaninflammationoftheepididymis.ANS:BSebaceouscystsarecommonlyfoundonthescrotum.Theseyellowish1-cmnodulesarefirm,nontender,andoftenmultiple.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation20.Whenperformingascrotalassessment,thenursenoticesthatthescrotalcontentsshowaredglowwithtransillumination.Onthebasisofthisfindingthenursewould:a.Assessthepatientforthepresenceofahernia.b.Suspectthepresenceofserousfluidinthescrotum.c.Considerthisfindingnormal,andproceedwiththeexamination.d.Referthepatientforevaluationofamassinthescrotum.ANS:BNormalscrotalcontentsdonotallowlighttopassthroughthescrotum.However,serousfluiddoesPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)390STUVIA.COMtransilluminateandshowsasaredglow.Neitheramassnoraherniawouldtransilluminate.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation21.Whenthenurseisperformingagenitalexaminationonamalepatient,whichactioniscorrect?a.Auscultatingforthepresenceofabruitoverthescrotumb.Palpatingfortheverticalchainoflymphnodesalongthegroin,inferiortotheinguinalligamentc.Palpatingtheinguinalcanalonlyifabulgeispresentintheinguinalregionduringinspectiond.Havingthepatientshifthisweightontotheleft(unexamined)legwhenpalpatingforaherniaontherightsideANS:DWhenpalpatingforthepresenceofaherniaontherightside,themalepatientisaskedtoshifthisweightontotheleft(unexamined)leg.Auscultatingforabruitoverthescrotumisnotappropriate.Whenpalpatingforlymphnodes,thehorizontalchainispalpated.Theinguinalcanalshouldbepalpatedwhetherabulgeispresentornot.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareENnUvRirSoInNmGeTnBt:.CMOaMnagementofCare22.Thenurseisawareofwhichstatementtobetrueregardingtheincidenceoftesticularcancer?a.Testicularcanceristhemostcommoncancerinmenaged30to50years.b.Theearlysymptomsoftesticularcancerarepainandinduration.c.Menwithahistoryofcryptorchidismareatthegreatestriskforthedevelopmentoftesticularcancer.d.Thecureratefortesticularcancerislow.ANS:CMenwithundescendedtesticles(cryptorchidism)areatthegreatestriskforthedevelopmentoftesticularcancer.Theoverallincidenceoftesticularcancerisrare.Althoughtesticularcancerhasnoearlysymptoms,whendetectedearlyandtreatedbeforemetastasizing,thecurerateisalmost100%.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance23.Thenurseisdescribinghowtoperformatesticularself-examinationtoapatient.Whichstatementismostappropriate?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)391STUVIA.COMa.Agoodtimetoexamineyourtesticlesisjustbeforeyoutakeashower.b.Ifyounoticeanenlargedtesticleorapainlesslump,callyourhealthcareprovider.c.Thetesticleiseggshapedandmovable.Itfeelsfirmandhasalumpyconsistency.d.Performatesticularexaminationatleastonceaweektodetecttheearlystagesoftesticularcancer.ANS:BIfthepatientnoticesafirmpainlesslump,ahardarea,oranoverallenlargedtesticle,thenheshouldcallhishealthcareproviderforfurtherevaluation.Thetesticlenormallyfeelsrubberywithasmoothsurface.Agoodtimetoexaminethetesticlesisduringtheshowerorbath,whenoneshandsarewarmandsoapyandthescrotumiswarm.Testicularself-examinationshouldbeperformedonceamonth.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance24.A2-month-olduncircumcisedinfanthasbeenbroughttotheclinicforawell-babycheckup.Howwouldthenurseproceedwiththegenitalexamination?a.Elicitingthecremastericreflexisrecommended.b.Theglansisassessedforrednessorlesions.NURSINGTB.COMc.Retractingtheforeskinshouldbeavoideduntiltheinfantis3monthsold.d.Anydirtorsmegmathathascollectedundertheforeskinshouldbenoted.ANS:CIfuncircumcised,thentheforeskinisnormallytightduringthefirst3monthsandshouldnotberetractedbecauseoftheriskoftearingthemembraneattachingtheforeskintotheshaft.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare25.A2-year-oldboyhasbeendiagnosedwithphysiologiccryptorchidism.Consideringthisdiagnosis,duringassessmentthenursewillmostlikelyobserve:a.Testesthatarehardandpainfultopalpation.b.Atrophicscrotumandabilateralabsenceofthetestis.c.Absenceofthetestisinthescrotum,butthetestiscanbemilkeddown.d.Testesthatmigrateintotheabdomenwhenthechildsquatsorsitscross-legged.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)392STUVIA.COMANS:CMigratorytestes(physiologiccryptorchidism)arecommonbecauseofthestrengthofthecremastericreflexandthesmallmassoftheprepubertaltestes.Theaffectedsidehasanormallydevelopedscrotumandthetestiscanbemilkeddown.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation26.Thenurseknowsthatacommonassessmentfindinginaboyyoungerthan2yearsoldis:a.Inflamedandtenderspermaticcord.b.Presenceofaherniainthescrotum.c.Penisthatlookslargeinrelationtothescrotum.d.Presenceofahydrocele,orfluidinthescrotum.ANS:DAcommonscrotalfindinginboysyoungerthan2yearsofageisahydrocele,orfluidinthescrotum.Theotheoptionsarenotcorrect.NURSINGTB.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance27.Duringanexaminationofanagingman,thenurserecognizesthatnormalchangestoexpectwouldbe:a.Changeinscrotalcolor.b.Decreaseinthesizeofthepenis.c.Enlargementofthetestesandscrotum.d.Increaseinthenumberofrugaeoverthescrotalsac.ANS:BWhenassessingthegenitalsofanolderman,thenursemaynoticethinner,grayingpubichairandadecreaseinthesizeofthepenis.Thesizeofthetestesmaybedecreased,theymayfeellessfirm,andthescrotalsacispendulouswithlessrugae.Nochangeinscrotalcolorisobserved.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance28.Whenperformingagenitalassessmentonamiddle-agedman,thenursenoticesmultiplesoft,moist,painlesspapulesintheshapeofcauliflower-likepatchesscatteredacrosstheshaftofthepenis.TheselesionsPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)393STUVIA.COMarecharacteristicof:a.Carcinoma.b.Syphiliticchancres.c.Genitalherpes.d.Genitalwarts.ANS:DThelesionsofgenitalwartsaresoft,pointed,moist,fleshy,painlesspapulesthatmaybesingleormultipleinacauliflower-likepatch.Theyoccurontheshaftofthepenis,behindthecorona,oraroundtheanus,wheretheymaygrowintolargegrapelikeclusters.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation29.A15-year-oldboyisseenintheclinicforcomplaintsofdullpainandpullinginthescrotalarea.Onexamination,thenursepalpatesasoft,irregularmassposteriortoandabovethetestisontheleft.Thismasscollapseswhenthepatientissupineandrefillswhenheisupright.Thisdescriptionisconsistentwith:a.Epididymitis.b.Spermatocele.c.Testiculartorsion.d.Varicocele.NURSINGTB.COMANS:DAvaricoceleconsistsofdilated,tortuousvaricoseveinsinthespermaticcordcausedbyincompetentvalveswithinthevein.Symptomsincludedullpainoraconstantpullingordraggingfeeling,ortheindividualmaybeasymptomatic.Whenpalpatingthemass,theexaminerwillfeelasoft,irregularmassposteriortoandabovethetestisthatcollapseswhentheindividualissupineandrefillswhentheindividualisupright.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation30.Whenperformingagenitourinaryassessmentona16-year-oldmaleadolescent,thenursenoticesaswellinginthescrotumthatincreaseswithincreasedintra-abdominalpressureanddecreaseswhenheislyingdown.Thepatientcomplainsofpainwhenstraining.Thenurseknowsthatthisdescriptionismostconsistentwitha(n)hernia.a.Femoralb.IncisionalPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)394STUVIA.COMc.Directinguinald.IndirectinguinalANS:DWithindirectinguinalhernias,painoccurswithstrainingandasoftswellingincreaseswithincreasedintra-abdominalpressure,whichmaydecreasewhenthepatientliesdown.Thesefindingsdonotdescribetheotherhernias.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation31.Whenthenurseisperformingatesticularexaminationona25-year-oldman,whichfindingisconsiderednormal?a.Nontendersubcutaneousplaquesb.Scrotalareathatisdry,scaly,andnodularc.Testesthatfeelovalandmovableandareslightlysensitivetocompressiond.Single,hard,circumscribed,movaNblUeRmSaIsNsG,lTeBss.CthOaMn1cmunderthesurfaceofthetestesANS:CTestesnormallyfeeloval,firmandrubbery,smooth,andbilaterallyequalandarefreelymovableandslightlytendertomoderatepressure.Thescrotalskinshouldnotbedry,scaly,ornodularorcontainsubcutaneousplaques.Anymasswouldbeanabnormalfinding.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare32.Thenurseisinspectingthescrotumandtestesofa43-year-oldman.Whichfindingwouldrequireadditionalfollow-upandevaluation?a.Skinonthescrotumistaut.b.Lefttesticlehangslowerthantherighttesticle.c.Scrotalskinhasyellowish1-cmnodulesthatarefirmandnontender.d.Testesmoveclosertothebodyinresponsetocoldtemperatures.ANS:AScrotalswellingmaycausetheskintobetautandtodisplaypittingedema.Normalscrotalskinisrugae,andPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)395STUVIA.COMasymmetryisnormalwiththeleftscrotalhalfusuallylowerthantheright.Thetestesmaymoveclosertothebodyinresponsetocoldtemperatures.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation33.A55-year-oldmanisexperiencingseverepainofsuddenonsetinthescrotalarea.Itissomewhatrelievedbyelevation.Onexaminationthenursenoticesanenlarged,redscrotumthatisverytendertopalpation.Distinguishingtheepididymisfromthetestisisdifficult,andthescrotalskinisthickandedematous.Thisdescriptionisconsistentwithwhichofthese?a.Varicoceleb.Epididymitisc.Spermatoceled.TesticulartorsionANS:BEpididymitispresentsasseverepainofsuddenonsetinthescrotumthatissomewhatrelievedbyelevation.Onexamination,thescrotumisenlarged,reddened,andexquisitelytender.Theepididymisisenlargedandinduratedandmaybehardtodistinguishfromthetestis.Theoverlyingscrotalskinmaybethickandedematous.DIF:CognitiveLevel:Analyzing(Analysis)NURSINGTB.COMMSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation34.Thenurseisperformingagenitourinaryassessmentona50-year-oldobesemalelaborer.Onexamination,thenursenoticesapainlessroundswellingclosetothepubisintheareaoftheinternalinguinalringthatiseasilyreducedwhentheindividualissupine.Thesefindingsaremostconsistentwitha(n)hernia.a.Scrotalb.Femoralc.Directinguinald.IndirectinguinalANS:CDirectinguinalherniasoccurmostofteninmenovertheageof40years.Itisanacquiredweaknessbroughtonbyheavylifting,obesity,chroniccough,orascites.Thedirectinguinalherniaisusuallyapainless,roundswellingclosetothepubisintheareaoftheinternalinguinalringthatiseasilyreducedwhentheindividualissupine.DIF:CognitiveLevel:Analyzing(Analysis)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)396STUVIA.COMMSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation35.Thenurseisprovidingpatientteachingaboutanerectiledysfunctiondrug.Oneofthedrugspotentialsideeffectsisprolonged,painfulerectionofthepeniswithoutsexualstimulation,whichisknownas:a.Orchitis.b.Stricture.c.Phimosis.d.Priapism.ANS:DPriapismisprolonged,painfulerectionofthepeniswithoutsexualdesire.Orchitisisinflammationofthetestes.Strictureisanarrowingoftheopeningoftheurethralmeatus.Phimosisistheinabilitytoretracttheforeskin.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation36.Duringanexamination,thenursenoticesthatamalepatienthasared,round,superficialulcerwithayellowishserousdischargeonhispenis.Onpalpation,thenursefindsanontenderbasethatfeelslikeasmallbuttonbetweenthethumbandfingers.Atthispointthenursesuspectsthatthispatienthas:NURSINGTB.COMa.Genitalwarts.b.Herpesinfection.c.Syphiliticchancre.d.Carcinomalesion.ANS:CThislesionindicatessyphiliticchancre,whichbeginswithin2to4weeksofinfection.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation37.Duringahealthhistory,apatienttellsthenursethathehastroubleinstartinghisurinestream.Thisproblemisknownas:a.Urgency.b.Dribbling.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)397STUVIA.COMc.Frequency.d.Hesitancy.ANS:DHesitancyistroubleinstartingtheurinestream.Urgencyisthefeelingthatonecannotwaittourinate.Dribblingisthelastoftheurinebeforeorafterthemainactofurination.Frequencyisurinatingmoreoftenthanusual.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation38.Duringagenitalexamination,thenursenoticesthatamalepatienthasclustersofsmallvesiclesontheglans,surroundedbyerythema.Thenurserecognizesthattheselesionsare:a.Peyroniedisease.b.Genitalwarts.c.Genitalherpes.d.Syphiliticcancer.NURSINGTB.COMANS:CGenitalherpes,orherpessimplexvirus2(HSV-2),infectionsareindicatedwithclustersofsmallvesicleswithsurroundingerythema,whichareoftenpainfulanderuptontheglansorforeskin.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation39.Duringaphysicalexamination,thenursefindsthatamalepatientsforeskinisfixedandtightandwillnotretractovertheglans.Thenurserecognizesthatthisconditionis:a.Phimosis.b.Epispadias.c.Urethralstricture.d.Peyroniedisease.ANS:AWithphimosis,theforeskinisnonretractable,formingapointytipofthepeniswithatinyorificeattheendoftheglans.Theforeskinisadvancedandsotightthatitisimpossibletoretractovertheglans.Thisconditionmaybecongenitaloracquiredfromadhesionsrelatedtoinfection.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)398STUVIA.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationMULTIPLERESPONSE1.A55-year-oldmanisintheclinicforayearlycheckup.Heisworriedbecausehisfatherdiedofprostatecancer.Thenurseknowswhichtestsshouldbeperformedatthistime?Selectallthatapply.a.Bloodtestforprostate-specificantigen(PSA)b.Urinalysisc.Transrectalultrasoundd.Digitalrectalexamination(DRE)e.ProstatebiopsyANS:A,DProstatecanceristypicallydetectedbytestingthebloodforPSAorbyaDRE.ItisrecommendedthatbothPSAandDREbeofferedtomenannually,beginningatage50years.IfthePSAiselevated,thenfurtherlaboratoryworkoratransrectalultrasound(TRUS)andbiopsymayberecommended.DIF:CognitiveLevel:Applying(Application)NURSINGTB.COMMSC:ClientNeeds:HealthPromotionandMaintenance2.A16-year-oldboyisbroughttotheclinicforaproblemthatherefusedtolethismothersee.Thenurseexamineshim,andfindsthathehasscrotalswellingontheleftside.Hehadthemumpsthepreviousweek,andthenursesuspectsthathehasorchitis.Whichofthefollowingassessmentfindingssupportthisdiagnosis?Selectallthatapply.a.Swollentestisb.Massthattransilluminatesc.Massthatdoesnottransilluminated.Scrotumthatisnontenderuponpalpatione.Scrotumthatistenderuponpalpationf.ScrotalskinthatisreddenedANS:A,C,E,FWithorchitis,thetestisisswollen,withafeelingofweight,andistenderorpainful.Themassdoesnottransilluminate,andthescrotalskinisreddened.Transilluminationofamassoccurswithahydrocele,notPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)399STUVIA.COMNURSINGTB.COMorchitis.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenancePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)400STUVIA.COMChapter26:Anus,Rectum,andProstateMULTIPLECHOICE1.Whichstatementconcerningtheanalcanalistrue?Theanalcanal:a.Isapproximately2cmlongintheadult.b.Slantsbackwardtowardthesacrum.c.Containshairandsebaceousglands.d.Istheoutletforthegastrointestinaltract.ANS:DTheanalcanalistheoutletforthegastrointestinaltractandisapproximately3.8cmlongintheadult.Itislinedwithamodifiedskinthatdoesnotcontainhairorsebaceousglands,anditslantsforwardtowardtheumbilicus.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General2.Whichstatementconcerningthesphinctersiscorrect?NURSINGTB.COMa.Theinternalsphincterisundervoluntarycontrol.b.Theexternalsphincterisundervoluntarycontrol.c.Bothsphinctersremainslightlyrelaxedatalltimes.d.Theinternalsphinctersurroundstheexternalsphincter.ANS:BTheexternalsphinctersurroundstheinternalsphincterbutalsohasasmallsectionoverridingthetipoftheinternalsphincterattheopening.Theexternalsphincterisundervoluntarycontrol.Exceptforthepassingoffecesandgas,thesphincterskeeptheanalcanaltightlyclosed.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General3.Thenurseisperforminganexaminationoftheanusandrectum.Whichofthesestatementsiscorrectandimportanttorememberduringthisexamination?a.Therectumisapproximately8cmlong.b.Theanorectaljunctioncannotbepalpated.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)401STUVIA.COMc.Abovetheanalcanal,therectumturnsanteriorly.d.Nosensorynervesareintheanalcanalorrectum.ANS:BTheanalcolumnsarefoldsofmucosathatextendverticallydownfromtherectumandendintheanorectaljunction.Thisjunctionisnotpalpablebutisvisibleonproctoscopy.Therectumis12cmlong;justabovetheanalcanal,therectumdilatesandturnsposteriorly.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare4.Thestructurethatsecretesathin,milkyalkalinefluidtoenhancetheviabilityofspermisthe:a.Cowpergland.b.Prostategland.c.Mediansulcus.d.Bulbourethralgland.ANS:BNURSINGTB.COMInmen,theprostateglandsecretesathinmilkyalkalinefluidthatenhancesspermviability.TheCowperglands(alsoknownasbulbourethralglands)secreteaclear,viscidmucus.Themediansulcusisagroovethatdividesthelobesoftheprostateglandanddoesnotsecretefluid.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General5.A46-year-oldmanrequiresanassessmentofhissigmoidcolon.Whichinstrumentortechniqueismostappropriateforthisexamination?a.Proctoscopeb.Ultrasoundc.Colonoscoped.RectalexaminationwithanexaminingfingerANS:CThesigmoidcolonis40cmlong,andthenurseknowsthatitisaccessibletoexaminationonlywiththecolonoscope.Theotherresponsesarenotappropriateforanexaminationoftheentiresigmoidcolon.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)402STUVIA.COMDIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare6.Thenurseiscaringforanewborninfant.Thirtyhoursafterbirth,theinfantpassesadarkgreenmeconiumstool.Thenurserecognizesthisisimportantbecausethe:a.Stoolindicatesanalpatency.b.Darkgreencolorindicatesoccultbloodinthestool.c.Meconiumstoolcanbereflectiveofdistressinthenewborn.d.Newbornshouldhavepassedthefirststoolwithin12hoursafterbirth.ANS:AThefirststoolpassedbythenewbornisdarkgreenmeconiumandoccurswithin24to48hoursofbirth,indicatinganalpatency.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance7.Duringtheassessmentofan18-month-oldinfant,themotherexpressesconcerntothenurseabouttheinfantsinabilitytotoilettrain.Whatwouldbethenursesbestresponse?NURSINGTB.COMa.Somechildrenarejustmoredifficulttotrain,soIwouldntworryaboutityet.b.Haveyouconsideredreadinganyofthebooksontoilettraining?Theycanbeveryhelpful.c.Thiscouldmeanthatthereisaprobleminyourbabysdevelopment.Wellwatchhercloselyforthenextfewmonths.d.Thenervesthatwillallowyourbabytohavecontroloverthepassingofstoolsarenotdevelopeduntilatleast18to24monthsofage.ANS:DTheinfantpassesstoolsbyreflex.Voluntarycontroloftheexternalanalsphinctercannotoccuruntilthenervessupplyingtheareahavebecomefullymyelinated,usuallyaround1to2yearsofage.Toilettrainingusuallystartsaftertheageof2years.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance8.A60-year-oldmanhasjustbeentoldthathehasbenignprostatichypertrophy(BPH).Hehasafriendwhojustdiedfromcanceroftheprostate.Heisconcernedthiswillhappentohim.Howshouldthenurserespond?a.Theswellinginyourprostateisonlytemporaryandwillgoaway.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)403STUVIA.COMb.Wewilltreatyouwithchemotherapysowecancontrolthecancer.c.Itwouldbeveryunusualforamanyouragetohavecanceroftheprostate.d.Theenlargementofyourprostateiscausedbyhormonalchanges,andnotcancer.ANS:DTheprostateglandcommonlystartstoenlargeduringthemiddleadultyears.BPHispresentin1in10menattheageof40yearsandincreaseswithage.Itisbelievedthatthehypertrophyiscausedbyhormonalimbalancethatleadstotheproliferationofbenignadenomas.Theotherresponsesarenotappropriate.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance9.A30-year-oldwomanisvisitingtheclinicbecauseofpaininmybottomwhenIhaveabowelmovement.Thenurseshouldassessforwhichproblem?a.Pinwormsb.Hemorrhoidsc.Coloncancerd.FecalincontinenceNURSINGTB.COMANS:BHavingpainfulbowelmovements,knownasdyschezia,maybeattributabletoalocalcondition(hemorrhoidorfissure)orconstipation.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation10.Apatientwhoisvisitingthecliniccomplainsofhavingstomachpainsfor2weeksanddescribeshisstoolsasbeingsoftandblackforapproximatelythelast10days.Hedeniestakinganymedications.Thenurseisawarethatthesesymptomsaremostlyindicativeof:a.Excessivefatcausedbymalabsorption.b.Increasedironintake,resultingfromachangeindiet.c.Occultblood,resultingfromgastrointestinalbleeding.d.Absentbilepigmentfromliverproblems.ANS:CPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)404STUVIA.COMBlackstoolsmaybetarryasaresultofoccultblood(melena)fromgastrointestinalbleedingornontarryfromingestionofironmedications(notdiet).Excessivefatcausesthestooltobecomefrothy.Theabsenceofbilepigmentcausesclay-coloredstools.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation11.Aftercompletinganassessmentofa60-year-oldmanwithafamilyhistoryofcoloncancer,thenursediscusseswithhimearlydetectionmeasuresforcoloncancer.Thenurseshouldmentiontheneedfora(n):a.Annualproctoscopy.b.Colonoscopyevery10years.c.Fecaltestforbloodevery6months.d.DREsevery2years.ANS:BEarlydetectionmeasuresforcoloncancerincludeaDREperformedannuallyafterage50years,anannualfecaloccultbloodtestafterage50years,asigmoidoscopicexaminationevery5yearsoracolonoscopyevery10yearsafterage50years,andaPSAbloodtestannuallyformenover50yearsold,exceptbeginningatage45yearsforblackmen(AmericanCancerSociety,2006).DIF:CognitiveLevel:Applying(Application)NURSINGTB.COMMSC:ClientNeeds:HealthPromotionandMaintenance12.Themotherofa5-year-oldgirltellsthenursethatshehasnoticedherdaughterscratchingatherbottomalotthelastfewdays.Duringtheassessment,thenursefindsrednessandraisedskinintheanalarea.Thisfindingmostlikelyindicates:a.Pinworms.b.Chickenpox.c.Constipation.d.Bacterialinfection.ANS:AInchildren,pinwormsareacommoncauseofintenseitchingandirritatedanalskin.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation13.Thenurseisexaminingonlytherectalareaofawomanandshouldplacethewomaninwhatposition?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)405STUVIA.COMa.Lithotomyb.Pronec.Leftlateraldecubitusd.BendingoverthetablewhilestandingANS:CThenurseshouldplacethefemalepatientinthelithotomypositionifthegenitaliaarebeingexaminedaswell.Theleftlateraldecubituspositionisusedfortherectalareaalone.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare14.Whileperforminganassessmentoftheperianalareaofapatient,thenursenoticesthatthepigmentationofanusisdarkerthanthesurroundingskin,theanalopeningisclosed,andaskinsacthatisshinyandblueisnoted.Thepatientmentionedthathehashadpainwithbowelmovementsandhasoccasionallynotedsomespotsofblood.Whatwouldthisassessmentandhistorymostlikelyindicate?a.Analfistulab.Pilonidalcystc.Rectalprolapsed.ThrombosedhemorrhoidNURSINGTB.COMANS:DTheanusnormallylooksmoistandhairless,withcoarsefoldedskinthatismorepigmentedthantheperianalskin,andtheanalopeningistightlyclosed.Theshinyblueskinsacindicatesathrombosedhemorrhoid.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation15.Thenurseispreparingtopalpatetherectumandshouldusewhichofthesetechniques?Thenurseshould:a.Flexthefinger,andslowlyinsertittowardtheumbilicus.b.Firstinstructthepatientthatthisprocedurewillbepainful.c.Insertanextendedindexfingeratarightangletotheanus.d.Placethefingerdirectlyintotheanustoovercomethetightsphincter.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)406STUVIA.COMANS:AThenurseshouldgentlyplacethepadoftheindexfingeragainsttheanalverge.Thenursewillfeelthesphinctertightenandthenrelax.Asitrelaxes,thenurseshouldflexthetipofthefingerandslowlyinsertitintotheanalcanalinadirectiontowardtheumbilicus.Thenurseshouldneverapproachtheanusatrightangleswiththeindexfingerextended;doingsowouldcausepain.Thenurseshouldinstructthepatientthatpalpationisnotpainfulbutmayfeellikeneedingtomovethebowels.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare16.Whileperformingarectalexamination,thenursenoticesafirm,irregularlyshapedmass.Whatshouldthenursedonext?a.Continuewiththeexamination,anddocumentthefindinginthechart.b.Instructthepatienttoreturnforarepeatassessmentin1month.c.Tellthepatientthatamasswasfelt,butitisnothingtoworryabout.d.Reportthefinding,andreferthepatienttoaspecialistforfurtherexamination.ANS:DAfirmorhardmasswithanirregularshapeorrollededgesmaysignifycarcinoma.AnymassthatisdiscoveredshouldbepromptlyreportedforfuNrtUheRrSeIxNaGmTiBna.CtiOonM.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance17.Duringanassessmentofthenewborn,thenurseexpectstoseewhichfindingwhentheanalareaisslightlystroked?a.Jerkingofthelegsb.Flexionofthekneesc.Quickcontractionofthesphincterd.RelaxationoftheexternalsphincterANS:CToassesssphinctertone,thenurseshouldchecktheanalreflexbygentlystrokingtheanalareaandnoticingaquickcontractionofthesphincter.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenancePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)407STUVIA.COM18.A13-year-oldgirlisvisitingtheclinicforasportsphysicalexamination.Thenurseshouldremembertoincludewhichofthesetestsintheexamination?a.Testingforoccultbloodb.Valsalvamaneuverc.Internalpalpationoftheanusd.InspectionoftheperianalareaANS:DTheperianalregionoftheschool-agedchildandadolescentshouldbeinspectedduringtheexaminationofthegenitalia.Internalpalpationisnotroutinelyperformedatthisage.TestingforoccultbloodandperformingtheValsalvamaneuverarealsonotnecessary.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance19.Duringanassessmentofa20-year-oldman,thenursefindsasmallpalpablelesionwithatuftofhairlocateddirectlyoverthecoccyx.Thenurseknowsthatthislesionwouldmostlikelybea:a.Rectalpolyp.b.Pruritusani.c.Carcinoma.d.Pilonidalcyst.NURSINGTB.COMANS:DApilonidalcystorsinusisahair-containingcystorsinuslocatedinthemidlineoverthecoccyxorlowersacrum.Itoftenopensasadimplewithavisibletuftofhairand,possibly,anerythematoushalo.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation20.Duringanexamination,thenurseasksthepatienttoperformtheValsalvamaneuverandnoticesthatthepatienthasamoist,red,doughnut-shapedprotrusionfromtheanus.Thenurseknowsthatthisfindingisconsistentwitha:a.Rectalpolyp.b.Hemorrhoid.c.Rectalfissure.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)408STUVIA.COMd.Rectalprolapse.ANS:DInrectalprolapse,therectalmucousmembraneprotrudesthroughtheanus,appearingasamoistreddoughnutwithradiatinglines.ItoccursafteraValsalvamaneuver,suchasstrainingatpassingstoolorwithexercising.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation21.A70-year-oldmanisvisitingtheclinicfordifficultyinpassingurine.Inthehealthhistory,heindicatesthathehastourinatefrequently,especiallyatnight.Hehasburningwhenheurinatesandhasnoticedpaininhisback.Consideringthishistory,whatmightthenurseexpecttofindduringthephysicalassessment?a.Asymmetric,hard,andfixedprostateglandb.Occultbloodandperianalpaintopalpationc.Symmetricallyenlarged,softprostateglandd.SoftnoduleprotrudingfromtherectalmucosaANS:ANURSINGTB.COMSubjectivesymptomsofcarcinomaoftheprostateincludefrequency,nocturia,hematuria,weakstream,hesitancy,painorburningonurination,andcontinuouspaininlowerback,pelvis,andthighs.Objectivesymptomsofcarcinomaoftheprostateincludeamalignantneoplasmthatoftenstartsasasinglehardnoduleontheposteriorsurface,producingasymmetryandachangeinconsistency.Asitinvadesnormaltissue,multiplehardnodulesappear,ortheentireglandfeelsstonehardandfixed.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation22.A40-year-oldblackmanisintheofficeforhisannualphysicalexamination.WhichstatementregardingthePSAbloodtestistrue,accordingtotheAmericanCancerSociety?ThePSA:a.Shouldbeperformedwiththisvisit.b.Shouldbeperformedatage45years.c.Shouldbeperformedatage50years.d.Isonlynecessaryifafamilyhistoryofprostatecancerexists.ANS:BAccordingtotheAmericanCancerSociety(2006),thePSAbloodtestshouldbeperformedannuallyforblackmenbeginningatage45yearsandannuallyforallothermenoverage50years.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)409STUVIA.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance23.A62-year-oldmanisexperiencingfever,chills,malaise,urinaryfrequency,andurgency.Healsoreportsurethraldischargeandadullachingpainintheperinealandrectalarea.Thesesymptomsaremostconsistentwithwhichcondition?a.Prostatitisb.Polypsc.Carcinomaoftheprostated.BPHANS:AThecommonpresentingsymptomsofprostatitisarefever,chills,malaise,andurinaryfrequencyandurgency.Theindividualmayalsohavedysuria,urethraldischarge,andadullachingpainintheperinealandrectalarea.Thesesymptomsarenotconsistentwithpolyps.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation24.DuringadiscussionforamenshealthgrouNpU,RthSeINnuGrTseB.rCelOatMesthatthegroupwiththehighestincidenceofprostatecanceris:a.AsianAmericans.b.Blacks.c.AmericanIndians.d.Hispanics.ANS:BAccordingtotheAmericanCancerSociety(2010),blackmenhaveahigherrateofprostatecancerthanotherracialgroups.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential25.Whichcharacteristicoftheprostateglandwouldthenurserecognizeasanabnormalfindingwhilepalpatingtheprostateglandthroughtherectum?a.PalpablecentralgroovePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)410STUVIA.COMb.Tendernesstopalpationc.Heartshapedd.ElasticandrubberyconsistencyANS:BThenormalprostateglandshouldfeelsmooth,elastic,andrubbery;slightlymovable;heart-shapedwithapalpablecentralgroove;andnotbetendertopalpation.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance26.Thenursenoticesthatapatienthashadapale,yellow,greasystool,orsteatorrhea,andrecallsthatthisiscausedby:a.Occultbleeding.b.Absentbilepigment.c.Increasedfatcontent.d.Ingestionofbismuthpreparations.NURSINGTB.COMANS:CSteatorrhea(pale,yellow,greasystool)iscausedbyincreasedfatcontentinthestools,asinmalabsorptionsyndrome.Occultbleedingandingestionofbismuthproductscauseablackstool,andabsentbilepigmentcausesagray-tanstool.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation27.Duringahealthhistoryofapatientwhocomplainsofchronicconstipation,thepatientasksthenurseabouthigh-fiberfoods.Thenurserelatesthatanexampleofahigh-fiberfoodwouldbe:a.Broccoli.b.Hamburger.c.Iceberglettuce.d.Yogurt.ANS:AHigh-fiberfoodsareeithersolubletype(e.g.,beans,prunes,barley,broccoli)orinsolubletype(e.g.,cereals,PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)411STUVIA.COMwheatgerm).Theotherexamplesarenotconsideredhigh-fiberfoods.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance28.Whileassessingapatientwhoishospitalizedandbedridden,thenursenoticesthatthepatienthasbeenincontinentofstool.Thestoolislooseandgray-tanincolor.Thenurserecognizesthatthisfindingindicateswhichofthefollowing?a.Occultbloodb.Inflammationc.Absentbilepigmentd.IngestionofironpreparationsANS:CThepresenceofgray-tanstoolindicatesabsentbilepigment,whichcanoccurwithobstructivejaundice.Theingestionofironpreparationsandthepresenceofoccultbloodturnsthestoolstoablackcolor.Jellylikemucusshredsmixedinthestoolwouldindicateinflammation.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhNysUioRlSoIgNicGATBda.CpOtaMtion29.Duringadigitalexaminationoftherectum,thenursenoticesthatthepatienthashardfecesintherectum.Thepatientcomplainsoffeelingfull,hasadistendedabdomen,andstatesthatshehasnothadabowelmovementforseveraldays.Thenursesuspectswhichcondition?a.Rectalpolypb.Fecalimpactionc.Rectalabscessd.RectalprolapseANS:BAfecalimpactionisacollectionofhard,desiccatedfecesintherectum.Theobstructionoftenresultsfromdecreasedbowelmotility,inwhichmorewaterisreabsorbedfromthestool.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation30.Duringthetakingofahealthhistory,thepatientstates,Itreallyhurtsbackthere,andsometimesititches,too.IhaveevenseenbloodonthetissuewhenIhaveabowelmovement.Istheresomethingthere?Thenurseshouldexpecttoseewhichoftheseuponexaminationoftheanus?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)412STUVIA.COMa.Rectalprolapseb.Internalhemorrhoidc.Externalhemorrhoidthathasresolvedd.ExternalhemorrhoidthatisthrombosedANS:DThesesymptomsareconsistentwithanexternalhemorrhoid.Anexternalhemorrhoid,whenthrombosed,containsclottedbloodandbecomesapainful,swollen,shinybluemassthatitchesandbleedswithdefecation.Whentheexternalhemorrhoidresolves,itleavesaflabby,painlessskinsacaroundtheanalorifice.AninternalhemorrhoidisnotpalpablebutmayappearasaredmucosalmasswhenthepersonperformsaValsalvamaneuver.Arectalprolapseappearsasamoist,reddoughnutwithradiatinglines.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationMULTIPLERESPONSE1.Thenurseisperformingadigitalexaminationofapatientsprostateglandandnoticesthatanormalprostateglandincludeswhichofthefollowingcharacteristics?Selectallthatapply.a.1cmprotrusionintotherectumNURSINGTB.COMb.Heart-shapedwithapalpablecentralgroovec.Flatshapewithnopalpablegrooved.Boggywithasoftconsistencye.Smoothsurface,elastic,andrubberyconsistencyf.FixedmobilityANS:A,B,EThesizeofanormalprostateglandshouldbe2.5cmlongby4cmwideandshouldnotprotrudemorethan1cmintotherectum.Theprostateshouldbeheart-shaped,withapalpablecentralgroove,asmoothsurface,andelasticwitharubberyconsistency.Abnormalfindingsincludeaflatshapewithnopalpablegroove,boggywithasoftconsistency,andfixedmobility.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenancePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)413STUVIA.COMChapter27:FemaleGenitourinarySystemMULTIPLECHOICE1.Duringahealthhistory,a22-yearoldwomanasks,CanIgetthatvaccineforhumanpapillomavirus(HPV)?IhavegenitalwartsandIdlikethemtogoaway!Whatisthenursesbestresponse?a.TheHPVvaccineisforgirlsandwomenages9to26years,sowecanstartthattoday.b.Thisvaccineisonlyforgirlswhohavenotyetstartedtobecomesexuallyactive.c.Letscheckwiththephysiciantoseeifyouareacandidateforthisvaccine.d.ThevaccinecannotprotectyouifyoualreadyhaveanHPVinfection.ANS:DTheHPVvaccineisappropriateforgirlsandwomenage9to26yearsandisadministeredtopreventcervicalcancerbypreventingHPVinfectionsbeforegirlsbecomesexuallyactive.However,itcannotprotectthewomanifanHPVinfectionisalreadypresent.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:General2.Duringanexamination,thenurseobservesNaUfeRmSaIlNeGpTatBie.CnOtsMvestibuleandexpectstoseethe:a.Urethralmeatusandvaginalorifice.b.Vaginalorificeandvestibular(Bartholin)glands.c.Urethralmeatusandparaurethral(Skene)glands.d.Paraurethral(Skene)andvestibular(Bartholin)glands.ANS:AThelabialstructuresencircleaboat-shapedspace,orcleft,termedthevestibule.Withinthevestibulearenumerousopenings.Theurethralmeatusandvaginalorificearevisible.Theductsoftheparaurethral(Skene)glandsandthevestibular(Bartholin)glandsarepresentbutnotvisible.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation3.Duringaspeculuminspectionofthevagina,thenursewouldexpecttoseewhatattheendofthevaginalcanal?a.CervixPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)414STUVIA.COMb.Uterusc.Ovariesd.FallopiantubesANS:AAttheendofthecanal,theuterinecervixprojectsintothevagina.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation4.Theuterusisusuallypositionedtiltingforwardandsuperiortothebladder.Thispositionisknownas:a.Antevertedandanteflexed.b.Retrovertedandanteflexed.c.Retrovertedandretroflexed.d.Superiorvertedandanteflexed.ANS:ANURSINGTB.COMTheuterusisfreelymovable,notfixed,andusuallytiltsforwardandsuperiortothebladder(apositionlabeledasantevertedandanteflexed).DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General5.An11-year-oldgirlisintheclinicforasportsphysicalexamination.Thenursenoticesthatshehasbeguntodevelopbreasts,andduringtheconversationthegirlrevealsthatsheisworriedaboutherdevelopment.Thenurseshouldusewhichofthesetechniquestobestassisttheyounggirlinunderstandingtheexpectedsequencefordevelopment?Thenurseshould:a.UsetheTannerscaleonthefivestagesofsexualdevelopment.b.Describeherdevelopmentandcompareitwiththatofothergirlsherage.c.UsetheJacobsentableonexpecteddevelopmentonthebasisofheightandweightdata.d.Reassureherthatherdevelopmentiswithinnormallimitsandtellhernottoworryaboutthenextstep.ANS:ATheTannerscaleonthefivestagesofpubichairdevelopmentishelpfulinteachinggirlstheexpectedPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)415STUVIA.COMsequenceofsexualdevelopment.Theotherresponsesarenotappropriate.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance6.Awomanwhois8weekspregnantisintheclinicforacheckup.Thenursereadsonherchartthathercervixissoftenedandlookscyanotic.Thenurseknowsthatthewomanisexhibitingsignandsign.a.Tanner;Hegarb.Hegar;Goodellc.Chadwick;Hegard.Goodell;ChadwickANS:DShortlyafterthefirstmissedmenstrualperiod,thefemalegenitaliashowsignsofthegrowingfetus.Thecervixsoftens(Goodellsign)at4to6weeks,andthevaginalmucosaandcervixlookcyanotic(Chadwicksign)at8to12weeks.Thesechangesoccurbecauseofincreasedvascularityandedemaofthecervixandhypertrophyandhyperplasiaofthecervicalglands.Hegarsignoccurswhentheisthmusoftheuterussoftensat6to8weeks.Tannersignisnotacorrectresponse.DIF:CognitiveLevel:Understanding(ComprNehUeRnSsiIoNnG)TB.COMMSC:ClientNeeds:HealthPromotionandMaintenance7.Generally,thechangesnormallyassociatedwithmenopauseoccurbecausethecellsinthereproductivetractare:a.Aging.b.Becomingfibrous.c.Estrogendependent.d.Abletorespondtoestrogen.ANS:CBecausecellsinthereproductivetractareestrogendependent,decreasedestrogenlevelsduringmenopausebringdramaticphysicalchanges.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:HealthPromotionandMaintenance8.Thenurseisreviewingthechangesthatoccurwithmenopause.Whichchangesareassociatedwithmenopause?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)416STUVIA.COMa.Uterineandovarianatrophy,alongwithathinningofthevaginalepitheliumb.Ovarianatrophy,increasedvaginalsecretions,andincreasingclitoralsizec.Cervicalhypertrophy,ovarianatrophy,andincreasedacidityofvaginalsecretionsd.Vaginalmucosafragility,increasedacidityofvaginalsecretions,anduterinehypertrophyANS:ATheuterusshrinksbecauseofitsdecreasedmyometrium.Theovariesatrophyto1to2cmandarenotpalpableaftermenopause.Thesacralligamentsrelax,andthepelvicmusculatureweakens;consequently,theuterusdroops.Thecervixshrinksandlookspalerwithathickglisteningepithelium.Thevaginalepitheliumatrophies,becomingthinner,drier,anditchy.ThevaginalpHbecomesmorealkaline,andsecretionsaredecreased,whichresultsinafragilemucosalsurfacethatisatriskforvaginitis.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance9.A54-year-oldwomanwhohasjustcompletedmenopauseisintheclinictodayforayearlyphysicalexamination.Whichofthesestatementsshouldthenurseincludeinpatienteducation?Apostmenopausalwoman:a.Isnotatanygreaterriskforheartdiseasethanayoungerwoman.NURSINGTB.COMb.Shouldbeawarethatsheisatincreasedriskfordyspareuniabecauseofdecreasedvaginalsecretions.c.Hasonlystoppedmenstruating;therereallyarenoothersignificantchangeswithwhichsheshouldbeconcerned.d.Islikelytohavedifficultywithsexualpleasureasaresultofdrasticchangesinthefemalesexualresponsecycle.ANS:BDecreasedvaginalsecretionsleavethevaginadryandatriskforirritationandpainwithintercourse(dyspareunia).Theotherstatementsareincorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance10.Awomanisintheclinicforanannualgynecologicexamination.Thenurseshouldplantobegintheinterviewwiththe:a.Menstrualhistory,becauseitisgenerallynonthreatening.b.Obstetrichistory,becauseitincludesthemostimportantinformation.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)417STUVIA.COMc.Urinarysystemhistory,becauseproblemsmaydevelopinthisareaaswell.d.Sexualhistory,becausediscussingitfirstwillbuildrapport.ANS:AMenstrualhistoryisusuallynonthreateningandthereforeagoodtopicwithwhichtobegintheinterview.Obstetric,urinary,andsexualhistoriesarealsopartoftheinterviewbutnotnecessarilythebesttopicswithwhichtostart.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare11.Apatienthashadthreepregnanciesandtwolivebirths.Thenursewouldrecordthisinformationasgrav,para,AB.a.2;2;1b.3;2;0c.3;2;1d.3;3;1NURSINGTB.COMANS:CGravida(grav)isthenumberofpregnancies.Paraisthenumberofbirths.Abortionsareinterruptedpregnancies,includingelectiveabortionsandspontaneousmiscarriages.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare12.Duringtheinterviewwithafemalepatient,thenursegathersdatathatindicatethepatientisperimenopausal.Whichofthesestatementsmadebythispatientleadstothisconclusion?a.IhavenoticedthatmymusclesacheatnightwhenIgotobed.b.IwillbeveryhappywhenIcanstopworryingabouthavingaperiod.c.IhavebeennoticingthatIsweatalotmorethanIusedto,especiallyatnight.d.Ihaveonlybeenpregnanttwice,butbothtimesIhadbreasttendernessasmyfirstsymptom.ANS:CHormoneshiftsoccurduringtheperimenopausalperiod,andassociatedsymptomsofmenopausemayoccur,suchashotflashes,nightsweats,numbnessandtingling,headache,palpitations,drenchingsweats,moodswings,vaginaldryness,anditching.Theotherresponsesarenotcorrect.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)418STUVIA.COMDIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance13.A50-year-oldwomancallstheclinicbecauseshehasnoticedsomechangesinherbodyandbreastsandwondersifthesechangescouldbeattributabletothehormonereplacementtherapy(HRT)shestarted3monthsearlier.Thenurseshouldtellher:a.HRTisatsuchalowdosethatsideeffectsareveryunusual.b.HRThasseveralsideeffects,includingfluidretention,breasttenderness,andvaginalbleeding.c.VaginalbleedingwithHRTisveryunusual;Isuggestyoucomeintotheclinicimmediatelytohavethisevaluated.d.Itsoundsasifyourdoseofestrogenistoohigh;Ithinkyoumayneedtodecreasetheamountyouaretakingandthencallbackinaweek.ANS:BSideeffectsofHRTincludefluidretention,breastpain,andvaginalbleeding.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PharmacologicandParenteralTherapiesNURSINGTB.COM14.A52-year-oldpatientstatesthatwhenshesneezesorcoughsshewetsherselfalittle.Sheisveryconcernedthatsomethingmaybewrongwithher.Thenursesuspectsthattheproblemis:a.Dysuria.b.Stressincontinence.c.Hematuria.d.Urgeincontinence.ANS:BStressincontinenceisinvoluntaryurinelosswithphysicalstrain,sneezing,orcoughing.Dysuriaispainorburningwithurination.Hematuriaisbleedingwithurination.Urgeincontinenceisinvoluntaryurinelossthatoccursasaresultofanoveractivedetrusormuscleinthebladderthatcontractsandcausesanurgentneedtovoid.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation15.Duringtheinterview,apatientrevealsthatshehassomevaginaldischarge.Sheisworriedthatitmaybeasexuallytransmittedinfection.Thenursesmostappropriateresponsetothiswouldbe:PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)419STUVIA.COMa.Oh,dontworry.Somecyclicvaginaldischargeisnormal.b.Haveyoubeenengaginginunprotectedsexualintercourse?c.Idlikesomeinformationaboutthedischarge.Whatcolorisit?d.Haveyouhadanyurinaryincontinenceassociatedwiththedischarge?ANS:CQuestionsthathelpthepatientrevealmoreinformationabouthersymptomsshouldbeaskedinanonthreateningmanner.Askingabouttheamount,color,andodorofthevaginaldischargeprovidestheopportunityforfurtherassessment.Normalvaginaldischargeissmall,clearorcloudy,andalwaysnonirritating.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation16.Awomanstatesthat2weeksagoshehadaurinarytractinfectionthatwastreatedwithanantibiotic.Asapartoftheinterview,thenurseshouldask,Haveyounoticedany:a.Changesinyoururinationpatterns?b.Excessivevaginalbleeding?NURSINGTB.COMc.Unusualvaginaldischargeoritching?d.Changesinyourdesireforintercourse?ANS:CSeveralmedicationsmayincreasetheriskofvaginitis.Broad-spectrumantibioticsalterthebalanceofnormalflora,whichmayleadtothedevelopmentofvaginitis.Theotherquestionsarenotappropriate.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PharmacologicandParenteralTherapies17.Whichstatementwouldbemostappropriatewhenthenurseisintroducingthetopicofsexualrelationshipsduringaninterview?a.Now,itistimetotalkaboutyoursexualhistory.Whendidyoufirsthaveintercourse?b.Womenoftenfeeldissatisfiedwiththeirsexualrelationships.Woulditbeokaytodiscussthisnow?c.Womenoftenhavequestionsabouttheirsexualrelationshipandhowitaffectstheirhealth.Doyouhaveanyquestions?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)420STUVIA.COMd.Mostwomenyouragehavehadmorethanonesexualpartner.Howmanywouldyousayyouhavehad?ANS:CThenurseshouldbeginwithanopen-endedquestiontoassessindividualneeds.Thenurseshouldincludeappropriatequestionsasaroutinepartofthehealthhistory,becausedoingsocommunicatesthatthenurseacceptstheindividualssexualactivityandbelievesitisimportant.Thenursescomfortwiththediscussionpromptsthepatientsinterestand,possibly,reliefthatthetopichasbeenintroduced.Theinitialdiscussionestablishesadatabaseforcomparisonwithanyfuturesexualactivitiesandprovidesanopportunitytoscreensexualproblems.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity18.A22-year-oldwomanhasbeenconsideringusingoralcontraceptives.Asapartofherhealthhistory,thenurseshouldask:a.Doyouhaveahistoryofheartmurmurs?b.Willyoubeinamonogamousrelationship?c.Haveyoucarefullythoughtthischoicethrough?d.Ifyousmoke,howmanycigarettesdoyousmokeperday?NURSINGTB.COMANS:DOralcontraceptives,togetherwithcigarettesmoking,increasetheriskforcardiovascularsideeffects.Ifcigarettesareused,thenthenurseshouldassessthepatientssmokinghistory.Theotherquestionsarenotappropriate.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PharmacologicandParenteralTherapies19.Amarriedcouplehascometotheclinicseekingadviceonpregnancy.Theyhavebeentryingtoconceivefor4monthsandhavenotbeensuccessful.Whatshouldthenursedofirst?a.Ascertainwhethereitherofthemhasbeenusingbroad-spectrumantibiotics.b.Explainthatcouplesareconsideredinfertileafter1yearofunprotectedintercourse.c.Immediatelyreferthewomantoanexpertinpelvicinflammatorydiseasethemostcommoncauseofinfertility.d.Explainthatcouplesareconsideredinfertileafter3monthsofengaginginunprotectedintercourseandthattheywillneedareferraltoafertilityexpert.ANS:BPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)421STUVIA.COMInfertilityisconsideredafter1yearofengaginginunprotectedsexualintercoursewithoutconceiving.Theotheractionsarenotappropriate.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity20.Anurseisassessingapatientsriskofcontractingasexuallytransmittedinfection(STI).Anappropriatequestiontoaskwouldbe:a.Youknowthatitsimportanttousecondomsforprotection,right?b.Doyouuseacondomwitheachepisodeofsexualintercourse?c.Doyouhaveasexuallytransmittedinfection?d.Youareawareofthedangersofunprotectedsex,arentyou?ANS:BInreviewingapatientsriskforSTIs,thenurseshouldaskinanonconfrontationalmannerwhethercondomsarebeingusedduringeachepisodeofsexualintercourse.Askingapersonwhetherheorshehasaninfectiondoesnotaddresstherisk.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:ReNduUcRtiSoInNoGfTRBi.sCkOPMotential21.Whenthenurseisinterviewingapreadolescentgirl,whichopeningquestionwouldbeleastthreatening?a.Doyouhaveanyquestionsaboutgrowingup?b.Whathasyourmothertoldyouaboutgrowingup?c.Whendidyounoticethatyourbodywaschanging?d.IrememberbeingveryscaredwhenIgotmyperiod.Howdoyouthinkyoullfeel?ANS:COpen-endedquestionssuchas,Whendidyou?ratherthanDoyou?shouldbeasked.Open-endedquestionsarelessthreateningbecausetheyimplythatthetopicisnormalandunexceptional.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity22.Whenthenurseisdiscussingsexualityandsexualissueswithanadolescent,apermissionstatementhelpsconveythatitisnormaltothinkorfeelacertainway.Whichstatementisthebestexampleofapermissionstatement?a.Itisokaythatyouhavebecomesexuallyactive.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)422STUVIA.COMb.Girlsyourageoftenhavequestionsaboutsexualactivity.Doyouhaveanyquestions?c.Ifitisokaywithyou,Idliketoaskyousomequestionsaboutyoursexualhistory.d.Girlsyourageoftenengageinsexualactivities.Itisokaytotellmeifyouhavehadintercourse.ANS:BTheexaminershouldstartwithapermissionstatementsuchas,GirlsyourageoftenexperienceApermissionstatementconveystheideathatitisnormaltothinkorfeelacertainway,andimplyingthatthetopicisnormalandunexceptionalisimportant.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PsychosocialIntegrity23.Thenurseispreparingtointerviewapostmenopausalwoman.Whichofthesestatementsistrueasitappliestoobtainingthehealthhistoryofapostmenopausalwoman?a.Thenurseshouldaskapostmenopausalwomanifshehaseverhadvaginalbleeding.b.Onceawomanreachesmenopause,thenursedoesnotneedtoaskanyhistoryquestions.c.ThenurseshouldscreenformonthNlyUbRrSeIaNstGtTenBd.CerOnMess.d.PostmenopausalwomenarenotatriskforcontractingSTIs;therefore,thesequestionscanbeomitted.ANS:APostmenopausalbleedingwarrantsfurtherworkupandreferral.Theotherstatementsarenottrue.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential24.Duringtheexaminationportionofapatientsvisit,shewillbeinlithotomyposition.Whichstatementreflectssomethingsthatthenursecandotomakethispositionmorecomfortableforher?a.Askhertoplaceherhandsandarmsoverherhead.b.Elevateherheadandshoulderstomaintaineyecontact.c.Allowhertochoosetohaveherfeetinthestirrupsorhavethemrestingsidebysideontheedgeofthetable.d.Allowhertokeepherbuttocksapproximately6inchesfromtheedgeofthetabletopreventherfromfeelingasifshewillfalloff.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)423STUVIA.COMANS:BThenurseshouldelevateherheadandshoulderstomaintaineyecontact.Thepatientsarmsshouldbeplacedathersidesoracrossthechest.Placingherhandsandarmsoverherheadonlytightenstheabdominalmuscles.Thefeetshouldbeplacedintothestirrups,kneesapart,andbuttocksattheedgeoftheexaminingtable.Thestirrupsareplacedsothatthelegsarenotabductedtoofar.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare25.An18-year-oldpatientishavingherfirstpelvicexamination.Whichactionbythenurseisappropriate?a.Invitinghermothertobepresentduringtheexaminationb.Avoidingthelithotomypositionforthisfirsttimebecauseitcanbeuncomfortableandembarrassingc.Raisingtheheadoftheexaminationtableandgivingheramirrorsothatshecanviewtheexaminationd.Fullydrapingher,leavingthedrapebetweenherlegselevatedtoavoidembarrassingherwitheyecontactANS:CThetechniquesoftheeducationalormirrorpeNlvUiRcSeIxNamGTinBa.tCioOnMshouldbeused.Thisisaroutineexaminationwithsomemodificationsinattitude,position,andcommunication.First,thewomanisconsideredanactiveparticipant,onewhoisinterestedinlearningandinsharingdecisionsaboutherownhealthcare.Thewomanpropsherselfupononeelbow,ortheheadofthetableisraised.Herotherhandholdsamirrorbetweenherlegs,abovetheexaminershands.Theyoungwomancanseeallthattheexaminerisdoingandhasafullviewofhergenitalia.Themirrorworkswellforteachingnormalanatomyanditsrelationshiptosexualbehavior.Theexaminercanaskherifshewouldliketohaveafamilymember,friend,orchaperonepresentfortheexamination.Thedrapeshouldbepusheddownbetweenthepatientslegssothatthenursecanseeherface.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare26.Thenursehasjustcompletedaninspectionofanulliparouswomansexternalgenitalia.Whichofthesewouldbeadescriptionofafindingwithinnormallimits?a.Rednessofthelabiamajorab.Multiplenontendersebaceouscystsc.Dischargethatisfoulsmellingandirritatingd.GapingandslightlyshriveledlabiamajoraANS:BPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)424STUVIA.COMNolesionsshouldbenoted,exceptfortheoccasionalsebaceouscysts,whichareyellowish1-cmnodulesthatarefirm,nontender,andoftenmultiple.Thelabiamajoraaredarkpink,moist,andsymmetric;rednessindicatesinflammationorlesions.Dischargethatisfoulsmellingandirritatingmayindicateinfection.Inthenulliparouswoman,thelabiamajorameetinthemidline,aresymmetricandplump.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare27.Thenurseispreparingforaninternalgenitaliaexaminationofawoman.Whichorderoftheexaminationiscorrect?a.Bimanual,speculum,andrectovaginalb.Speculum,rectovaginal,andbimanualc.Speculum,bimanual,andrectovaginald.Rectovaginal,bimanual,andspeculumANS:CThecorrectsequenceisspeculumexamination,thenbimanualexaminationafterremovingthespeculum,andthenrectovaginalexamination.Theexaminershouldchangeglovesbeforeperformingtherectovaginalexaminationtoavoidspreadinganypossibleinfection.DIF:CognitiveLevel:Analyzing(Analysis)NURSINGTB.COMMSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare28.Duringaninternalexaminationofawomansgenitalia,thenursewillusewhichtechniqueforproperinsertionofthespeculum?a.Thewomanisinstructedtobeardown,thespeculumbladesareopenedandappliedinaswift,upwardmovement.b.Thebladesofthespeculumareinsertedonahorizontalplane,turningthemtoa30-degreeanglewhilecontinuingtoinsertthem.Thewomanisaskedtobeardownafterthespeculumisinserted.c.Thewomanisinstructedtobeardown,thewidthofthebladesarehorizontallyturned,andthespeculumisinserteddownwardata45-degreeangletowardthesmallofthewomansback.d.Thebladesarelockedopenbyturningthethumbscrew.Oncethebladesareopen,pressureisappliedtotheintroitusandthebladesareinserteddownwardata45-degreeangletobringthecervixintoview.ANS:CTheexaminershouldinstructthewomantobeardown,turnthewidthofthebladeshorizontally,andinsertthespeculumata45-degreeangledownwardtowardthesmallofthewomansback.(SeethetextunderSpeculumExaminationformoredetail.)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)425STUVIA.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare29.Thenurseisexamininga35-year-oldfemalepatient.Duringthehealthhistory,thenursenoticesthatshehashadtwotermpregnancies,andbothbabiesweredeliveredvaginally.Duringtheinternalexamination,thenurseobservesthatthecervicalosisahorizontalslitwithsomehealedlacerationsandthatthecervixhassomenabothiancyststhataresmall,smooth,andyellow.Inaddition,thenursenoticesthatthecervicalsurfaceisgranularandred,especiallyaroundtheos.Finally,thenursenoticesthepresenceofstringy,opaque,odorlesssecretions.Whichofthesefindingsareabnormal?a.Nabothiancystsarepresent.b.Thecervicalosisahorizontalslit.c.Thecervicalsurfaceisgranularandred.d.Stringyandopaquesecretionsarepresent.ANS:CNormalfindings:Nabothiancystsmaybepresentonthecervixafterchildbirth.Thecervicalosisahorizontal,irregularslitintheparouswoman.Secretionsvaryaccordingtothedayofthemenstrualcycle,andmaybeclearandthinorthick,opaque,andstringy.Thesurfaceisnormallysmooth,butcervicaleversion,orectropion,mayoccurwheretheendocervicalcanalisrolledout.Abnormalfinding:Thecervicalsurfaceshouldnotbereddenedorgranular,whichmaNyUinRdSicINatGeTaBle.CsiOoMn.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance30.ApatientcallstheclinicforinstructionsbeforehavingaPapanicolaou(Pap)smear.Themostappropriateinstructionsfromthenurseare:a.Ifyouaremenstruating,pleaseusepadstoavoidplacinganythingintothevagina.b.Avoidintercourse,insertinganythingintothevagina,ordouchingwithin24hoursofyourappointment.c.Ifyoususpectthatyouhaveavaginalinfection,pleasegatherasampleofthedischargetobringwithyou.d.Wewouldlikeyoutouseamildsalinedouchebeforeyourexamination.Youmaypickthisupinouroffice.ANS:BWheninstructingapatientbeforePapsmearisobtained,thenurseshouldfollowtheseguidelines:Donotobtainduringthewomansmensesorifaheavyinfectiousdischargeispresent.Instructthewomannottodouche,haveintercourse,orputanythingintothevaginawithin24hoursbeforecollectingthespecimens.Anyspecimenswillbeobtainedduringthevisit,notbeforehand.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)426STUVIA.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance31.Duringanexamination,whichtestswillthenursecollecttoscreenforcervicalcancer?a.Endocervicalspecimen,cervicalscrape,andvaginalpoolb.Endocervicalspecimen,vaginalpool,andaceticacidwashc.Endocervicalspecimen,potassiumhydroxide(KOH)preparation,andaceticacidwashd.Cervicalscrape,aceticacidwash,salinemount(wetprep)ANS:ALaboratoriesmayvaryinmethod,butusuallythetestconsistsofthreespecimens:endocervicalspecimen,cervicalscrape,andvaginalpool.Theothertests(aceticacidwash,KOHpreparation,andsalinemount)areusedtotestforsexuallytransmittedinfections.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare32.Whenperformingthebimanualexamination,thenursenoticesthatthecervixfeelssmoothandfirm,isround,andisfixedinplace(doesnotmove).Whencervicalpalpationisperformed,thepatientcomplainsofsomepain.ThenursesinterpretationoftheserNeUsuRltSsINshGoTuBld.CbOeMwhichofthese?a.Thesefindingsareallwithinnormallimits.b.Cervicalconsistencyshouldbesoftandvelvetynotfirm.c.Thecervixshouldmovewhenpalpated;animmobilecervixmayindicatemalignancy.d.Painmayoccurduringpalpationofthecervix.ANS:CNormally,thecervixfeelssmoothandfirm,similartotheconsistencyofthetipofthenose.Itsoftensandfeelsvelvetyat5to6weeksofpregnancy(Goodellsign).Thecervixshouldbeevenlyrounded.Withafingeroneitherside,theexaminershouldbeabletomovethecervixgentlyfromsidetoside,anddoingsoshouldproducenopainforthepatient.Hardnessofthecervixmayoccurwithmalignancy.Immobilitymayoccurwithmalignancy,andpainmayoccurwithinflammationorectopicpregnancy.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance33.Thenurseispalpatingafemalepatientsadnexa.Thefindingsincludeafirm,smoothuterinewall;theovariesarepalpableandfeelsmoothandfirm.Thefallopiantubeisfirmandpulsating.Thenursesmostappropriatecourseofactionwouldbeto:PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)427STUVIA.COMa.Tellthepatientthatherexaminationisnormal.b.Giveheranimmediatereferraltoagynecologist.c.Suggestthatshereturninamonthforarechecktoverifythefindings.d.Tellthepatientthatshemayhaveanovariancystthatshouldbeevaluatedfurther.ANS:BNormally,theuterinewallfeelsfirmandsmooth,withthecontourofthefundusrounded.Ovariesarenotoftenpalpable,butwhentheyare,theynormallyfeelsmooth,firm,andalmondshapedandarehighlymovable,slidingthroughthefingers.Thefallopiantubeisnotnormallypalpable.Noothermassorpulsationshouldbefelt.Pulsationorpalpablefallopiantubesuggestsectopicpregnancy,whichwarrantsimmediatereferral.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance34.A65-year-oldwomanisintheofficeforroutinegynecologiccare.Shehadacompletehysterectomy3monthsagoaftercervicalcancerwasdetected.Whichstatementdoesthenurseknowtobetrueregardingthisvisit?a.Hercervicalmucosawillberedanddrylooking.b.ShewillnotneedtohaveaPapsmNeUarRpSeIrNfoGrTmBe.dC.OMc.Thenursecanexpecttofindthatheruteruswillbesomewhatenlargedandherovariessmallandhard.d.Thenurseshouldplantolubricatetheinstrumentsandtheexamininghandadequatelytoavoidapainfulexamination.ANS:DIntheagingadultwoman,naturallubricationisdecreased;therefore,toavoidapainfulexamination,thenurseshouldtakecaretolubricatetheinstrumentsandtheexamininghandadequately.Menopause,withtheresultingdecreaseinestrogenproduction,showsnumerousphysicalchanges.Thecervixshrinksandlookspaleandglistening.Withthebimanualexamination,theuterusfeelssmallerandfirmerandtheovariesarenotnormallypalpable.Womenshouldcontinuecervicalcancerscreeninguptoage65yearsiftheyhaveanintactcervixandareingoodhealth.Womenwhohavehadatotalhysterectomydonotneedcervicalcancerscreeningiftheyhave3consecutivenegativePaptestsor2ormoreconsecutivenegativeHIVandPaptestswithinthelast10years.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance35.Thenurseispreparingtoexaminetheexternalgenitaliaofaschool-agegirl.Whichpositionwouldbemostappropriateinthissituation?a.IntheparentslapPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)428STUVIA.COMb.Inafrog-legpositionontheexaminingtablec.Inthelithotomypositionwiththefeetinstirrupsd.LyingflatontheexaminingtablewithlegsextendedANS:BForschool-agechildren,placingthemontheexaminingtableinafrog-legpositionisbest.Withtoddlersandpreschoolers,havingthechildontheparentslapinafrog-legpositionisbest.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance36.Whenassessinganewborninfantsgenitalia,thenursenoticesthatthegenitaliaaresomewhatengorged.Thelabiamajoraareswollen,theclitorislookslarge,andthehymenisthick.Thevaginalopeningisdifficulttovisualize.Theinfantsmotherstatesthatsheisworriedaboutthelabiabeingswollen.Thenurseshouldreply:a.Thisisanormalfindinginnewbornsandshouldresolvewithinafewweeks.b.Thisfindingcouldindicateanabnormalityandmayneedtobeevaluatedbyaphysician.NURSINGTB.COMc.Wewillneedtohaveestrogenlevelsevaluatedtoensurethattheyarewithinnormallimits.d.Wewillneedtokeepclosewatchoverthenextfewdaystoseeifthegenitaliadecreaseinsize.ANS:AItisnormalforanewbornsgenitaliatobesomewhatengorged.Asanguineousvaginaldischargeorleukorrheaisnormalduringthefirstfewweeksbecauseofthematernalestrogeneffect.Duringtheearlyweeks,thegenitalengorgementresolves,andthelabiaminoraatrophyandremainsmalluntilpuberty.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance37.Duringavaginalexaminationofa38-year-oldwoman,thenursenoticesthatthevulvaandvaginaareerythematousandedematouswiththick,white,curdlikedischargeadheringtothevaginalwalls.Thewomanreportsintensepruritusandthickwhitedischargefromhervagina.Thenurseknowsthatthesehistoryandphysicalexaminationfindingsaremostconsistentwithwhichcondition?a.Candidiasisb.Trichomoniasisc.AtrophicvaginitisPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)429STUVIA.COMd.BacterialvaginosisANS:AThewomanwithcandidiasisoftenreportsintensepruritusandthickwhitedischarge.Thevulvaandvaginaareerythematousandedematous.Thedischargeisusuallythick,white,andcurdlike.Infectionwithtrichomoniasiscausesaprofuse,watery,gray-green,andfrothydischarge.Bacterialvaginosiscausesaprofusedischargethathasafoul,fishy,rottenodor.Atrophicvaginitismayhaveamucoiddischarge.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation38.A22-year-oldwomanisbeingseenattheclinicforproblemswithvulvarpain,dysuria,andfever.Onphysicalexamination,thenursenoticesclustersofsmall,shallowvesicleswithsurroundingerythemaonthelabia.Inguinallymphadenopathypresentisalsopresent.Themostlikelycauseoftheselesionsis:a.Pediculosispubis.b.Contactdermatitis.c.HPV.d.Herpessimplexvirustype2.ANS:DNURSINGTB.COMHerpessimplexvirustype2exhibitsclustersofsmall,shallowvesicleswithsurroundingerythemathateruptonthegenitalareas.Inguinallymphadenopathyisalsopresent.Thewomanreportslocalpain,dysuria,andfever.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation39.Whenperforminganexternalgenitaliaexaminationofa10-year-oldgirl,thenursenoticesthatnopubichairhasgrowninandthemonsandthelabiaarecoveredwithfinevellushair.Thesefindingsareconsistentwithstageofsexualmaturity,accordingtotheSexualMaturityRatingscale.a.1b.2c.3d.4ANS:ASexualMaturityRatingstage1isthepreadolescentstage.Thereisnopubichair,andthemonsandlabiaarecoveredwithfine,vellushairasontheabdomen.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)430STUVIA.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance40.A46-year-oldwomanisintheclinicforherannualgynecologicexamination.Shevoicesaconcernaboutovariancancerbecausehermotherandsisterdiedofit.Whichstatementdoesthenurseknowtobecorrectregardingovariancancer?a.Ovariancancerrarelyhasanysymptoms.b.ThePapsmeardetectsthepresenceofovariancancer.c.Womenathighriskforovariancancershouldhaveannualtransvaginalultrasonographyforscreening.d.Womenoverage40yearsshouldhaveathoroughpelvicexaminationevery3years.ANS:CWithovariancancer,thepatientmayhaveabdominalpain,pelvicpain,increasedabdominalsize,bloating,andnonspecificgastrointestinalsymptoms;orshemaybeasymptomatic.ThePapsmeardoesnotdetectthepresenceofovariancancer.Annualtransvaginalultrasonographymaydetectovariancanceratanearlierstageinwomenwhoareathighriskfordevelopingit.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMNaiUntReSnIaNncGeTB.COM41.Duringabimanualexamination,thenursedetectsasolidtumorontheovarythatisheavyandfixed,withapoorlydefinedmass.Thisfindingissuggestiveof:a.Ovariancyst.b.Endometriosis.c.Ovariancancer.d.Ectopicpregnancy.ANS:COvariantumorsthataresolid,heavy,andfixed,withpoorlydefinedmassaresuggestiveofmalignancy.Benignmassesmayfeelmobileandsolid.Anovariancystmayfeelsmooth,round,fluctuant,mobile,andnontender.Withanectopicpregnancy,theexaminermayfeelapalpable,tenderpelvicmassthatissolid,mobile,andunilateral.Endometriosismayhavemasses(invariouslocationsinthepelvicarea)thataresmall,firm,nodular,andtendertopalpation,withenlargedovaries.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation42.A25-year-oldwomancomestotheemergencydepartmentwithasuddenfeverof38.3CandabdominalPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)431STUVIA.COMpain.Uponexamination,thenursenoticesthatshehasrigid,boardlikelowerabdominalmusculature.Whenthenursetriestoperformavaginalexamination,thepatienthasseverepainwhentheuterusandcervixaremoved.Thenurseknowsthatthesesignsandsymptomsaresuggestiveof:a.Endometriosis.b.Uterinefibroids.c.Ectopicpregnancy.d.Pelvicinflammatorydisease.ANS:DThesesignsandsymptomsaresuggestiveofacutepelvicinflammatorydisease,alsoknownasacutesalpingitis.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation43.Duringanexternalgenitaliaexaminationofawoman,thenursenoticesseverallesionsaroundthevulva.Thelesionsarepink,moist,soft,andpointedpapules.Thepatientstatesthatsheisnotawareofanyproblemsinthatarea.Thenurserecognizesthattheselesionsmaybe:a.Syphiliticchancre.NURSINGTB.COMb.Herpessimplexvirustype2(herpesgenitalis).c.HPVorgenitalwarts.d.Pediculosispubis(crablice).ANS:CHPVlesionsarepainless,wartygrowthsthatthewomanmaynotnotice.Lesionsarepinkorfleshcolored,soft,pointed,moist,wartypapulesthatoccurinsingleormultiplecauliflower-likepatchesaroundthevulva,introitus,anus,vagina,orcervix.Herpeticlesionsarepainfulclustersofsmall,shallowvesicleswithsurroundingerythema.Syphiliticchancresbeginasasolitarysilverypapulethaterodesintoared,roundorovalsuperficialulcerwithayellowishdischarge.Pediculosispubiscausessevereperinealitchingandexcoriationsanderythematousareas.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation44.Duringanexamination,thenursewouldexpectthecervicalosofawomanwhohasneverhadchildrentoappear:a.Stellate.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)432STUVIA.COMb.Smallandround.c.Asahorizontalirregularslit.d.Everted.ANS:BThecervicalosinanulliparouswomanissmallandround.Intheparouswoman,itisahorizontal,irregularslitthatalsomayshowhealedlacerationsonthesides.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance45.AwomanhasjustbeendiagnosedwithHPVorgenitalwarts.Thenurseshouldcounselhertoreceiveregularexaminationsbecausethisvirusmakesheratahigherriskforcancer.a.Uterineb.Cervicalc.Ovariand.EndometrialNURSINGTB.COMANS:BHPVisthevirusresponsibleformostcasesofcervicalcancer,nottheotheroptions.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance46.Duringaninternalexamination,thenursenoticesthatthecervixbulgesoutsidetheintroituswhenthepatientisaskedtostrain.Thenursewilldocumentthisas:a.Uterineprolapse,gradedfirstdegree.b.Uterineprolapse,gradedseconddegree.c.Uterineprolapse,gradedthirddegree.d.Anormalfinding.ANS:BThecervixshouldnotbefoundtobulgeintothevagina.Uterineprolapseisgradedasfollows:firstdegreethecervixappearsattheintroituswithstraining;seconddegreethecervixbulgesoutsidetheintroituswithstraining;andthirddegreethewholeuterusprotrudes,evenwithoutstraining(essentially,theuterusisinsidePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)433STUVIA.COMout).DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation47.A35-year-oldwomanisattheclinicforagynecologicexamination.Duringtheexamination,sheasksthenurse,HowoftendoIneedtohavethisPaptestdone?Whichreplybythenurseiscorrect?a.Itdepends.Doyousmoke?b.APaptestneedstobeperformedannuallyuntilyouare65yearsofage.c.IfyouhavetwoconsecutivenormalPaptests,thenyoucanwait5yearsbetweentests.d.Afterage30years,ifyouhavethreeconsecutivenormalPaptests,thenyoumaybescreenedevery2to3years.ANS:DCervicalcancerscreeningwiththePaptestcontinuesannuallyuntilage30years.Afterage21,regardlessofsexualhistoryoractivity,womenshouldbescreenedevery3yearsuntilage30,thenevery5yearsuntilage65.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMNaiUntReSnIaNncGeTB.COMMULTIPLERESPONSE1.Thenurseispalpatinganovarianmassduringaninternalexaminationofa63-year-oldwoman.Whichfindingsofthemassscharacteristicswouldsuggestthepresenceofanovariancyst?Selectallthatapply.a.Heavyandsolidb.Mobileandfluctuantc.Mobileandsolidd.Fixede.Smoothandroundf.PoorlydefinedANS:B,EAnovariancyst(fluctuantovarianmass)isusuallyasymptomaticandwouldfeellikeasmooth,round,fluctuant,mobile,nontendermassontheovary.Amassthatisheavy,solid,fixed,andpoorlydefinedsuggestsmalignancy.Abenignmassmayfeelmobileandsolid.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)434STUVIA.COMNURSINGTB.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)435STUVIA.COMChapter28:TheCompleteHealthAssessment:AdultMULTIPLECHOICE1.An85-year-oldmanhascomeinforaphysicalexamination,andthenursenoticesthatheusesacane.Whendocumentinggeneralappearance,thenurseshoulddocumentthisinformationunderthesectionthatcovers:a.Posture.b.Mobility.c.Moodandaffect.d.Physicaldeformity.ANS:BUseofassistivedeviceswouldbedocumentedunderthemobilitysection.Theotherresponsesareallothercategoriesofthegeneralappearancesectionofthehealthhistory.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare2.Thenurseisperformingavisionexamination.Whichofthesechartsismostwidelyusedforvisionexaminations?a.Snellenb.Shetllenc.Smoollend.SchwellonNURSINGTB.COMANS:ATheSnelleneyechartismostwidelyusedforvisionexaminations.Theotheroptionsarenottestsforvisionexaminations.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare3.Afterthehealthhistoryhasbeenobtainedandbeforebeginningthephysicalexamination,thenurseshouldfirstaskthepatientto:a.Emptythebladder.b.Completelydisrobe.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)436STUVIA.COMc.Lieontheexaminationtable.d.Walkaroundtheroom.ANS:ABeforebeginningtheexamination,thenurseshouldaskthepersontoemptythebladder(savethespecimenifneeded),disrobeexceptforunderpants,putonagown,andsitwiththelegsdanglingoffsideofthebedortable.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare4.Duringacompletehealthassessment,howwouldthenursetestthepatientshearing?a.Observinghowthepatientparticipatesinnormalconversationb.Usingthewhisperedvoicetestc.UsingtheWeberandRinnetestsd.TestingwithanaudiometerNURSINGTB.COMANS:BDuringthecompletehealthassessment,thenurseshouldtesthearingwiththewhisperedvoicetest.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare5.Apatientstates,WheneverIopenmymouthrealwide,Ifeelthispoppingsensationinfrontofmyears.Tofurtherexaminethis,thenursewould:a.Placethestethoscopeoverthetemporomandibularjoint,andlistenforbruits.b.Placethehandsoverhisears,andaskhimtoopenhismouthreallywide.c.Placeonehandonhisforeheadandtheotheronhisjaw,andaskhimtotrytoopenhismouth.d.Placeafingeronhistemporomandibularjoint,andaskhimtoopenandclosehismouth.ANS:DThenurseshouldpalpatethetemporomandibularjointbyplacinghisorherfingersoverthejointasthepersonopensandclosesthemouth.DIF:CognitiveLevel:Applying(Application)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)437STUVIA.COMMSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare6.Thenursehasjustcompletedanexaminationofapatientsextraocularmuscles.Whendocumentingthefindings,thenurseshoulddocumenttheassessmentofwhichcranialnerves?a.II,III,andVIb.II,IV,andVc.III,IV,andVd.III,IV,andVIANS:DExtraocularmusclesareinnervatedbycranialnervesIII,IV,andVI.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare7.Apatientsuvularaisesmidlinewhenshesaysahh,andshehasapositivegagreflex.Thenursehasjusttestedwhichcranialnerves?a.IXandXb.IXandXIIc.XandXIId.XIandXIINURSINGTB.COMANS:ACranialnervesIXandXarebeingtestedbyhavingthepatientsayahh,notingthemobilityoftheuvula,andwhenassessingthepatientsgagreflex.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare8.Duringanexamination,thenursenoticesthatapatientisunabletostickouthistongue.Whichcranialnerveisinvolvedwiththesuccessfulperformanceofthisaction?a.Ib.Vc.XIPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)438STUVIA.COMd.XIIANS:DCranialnerveXIIenablesthepersontostickouthisorhertongue.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare9.Apatientisunabletoshrughershouldersagainstthenursesresistanthands.Whatcranialnerveisinvolvedwithsuccessfulshouldershrugging?a.VIIb.IXc.XId.XIIANS:CCranialnerveXIenablesthepatienttoshrughershouldersagainstresistance.DIF:CognitiveLevel:Understanding(ComprNehUeRnSsiIoNnG)TB.COMMSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare10.Duringanexamination,apatienthasjustsuccessfullycompletedthefinger-to-noseandtherapid-alternating-movementstestsandisabletoruneachheeldowntheoppositeshin.Thenursewillconcludethatthepatientsfunctionisintact.a.Occipitalb.Cerebralc.Temporald.CerebellarANS:DThenurseshouldtestcerebellarfunctionoftheupperextremitiesbyusingthefinger-to-nosetestorrapid-alternating-movementstest.Thenurseshouldtestcerebellarfunctionofthelowerextremitiesbyaskingthepersontoruneachheeldowntheoppositeshin.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare11.Whenthenurseperformstheconfrontationtest,thenursehasassessed:PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)439STUVIA.COMa.Extraoculareyemuscles(EOMs).b.Pupils(pupilsequal,round,reactivetolight,andaccommodation[PERRLA]).c.Nearvision.d.Visualfields.ANS:DTheconfrontationtestassessesvisualfields.Theotheroptionsarenottestedwiththeconfrontationtest.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare12.Whichstatementistrueregardingthecompletephysicalassessment?a.Themalegenitaliashouldbeexaminedinthesupineposition.b.Thepatientshouldbeinthesittingpositionforexaminationoftheheadandneck.c.Thevitalsigns,height,andweightshouldbeobtainedattheendoftheexamination.NURSINGTB.COMd.Topromoteconsistencybetweenpatients,theexaminershouldnotvarytheorderoftheassessment.ANS:BTheheadandneckshouldbeexaminedinthesittingpositiontobestpalpatethethyroidandlymphnodes.Themalepatientshouldstandduringanexaminationofthegenitalia.Vitalsignsaremeasuredearlyintheassessment.Thesequenceoftheassessmentmayneedtovaryaccordingtodifferentpatientsituations.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare13.Whichoftheseisincludedinanassessmentofgeneralappearance?a.Heightb.Weightc.Skincolord.VitalsignsPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)440STUVIA.COMANS:CGeneralappearanceincludesitemssuchaslevelofconsciousness,skincolor,nutritionalstatus,posture,mobility,facialexpression,moodandaffect,speech,hearing,andpersonalhygiene.Height,weight,andvitalsignsareconsideredmeasurements.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare14.Thenurseshouldwearglovesforwhichoftheseexaminations?a.Measuringvitalsignsb.Palpationofthesinusesc.Palpationofthemouthandtongued.InspectionoftheeyewithanophthalmoscopeANS:CGlovesshouldbewornwhentheexaminerisexposedtothepatientsbodyfluids.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareENnUvRirSoInNmGeTnBt:.CSaOfMetyandInfectionControl15.Thenurseshouldusewhichlocationforelicitingdeeptendonreflexes?a.Achillesb.Femoralc.Scapulard.AbdominalANS:ADeeptendonreflexesareelicitedinthebiceps,triceps,brachioradialis,patella,andAchillesheel.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare16.Duringaninspectionofapatientsface,thenursenoticesthatthefacialfeaturesaresymmetric.Thisfindingindicateswhichcranialnerveisintact?a.VIIPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)441STUVIA.COMb.IXc.XId.XIIANS:ACranialnerveVIIisresponsibleforfacialsymmetry.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare17.Duringinspectionoftheposteriorchest,thenurseshouldassessfor:a.Symmetricexpansion.b.Symmetryofshouldersandmuscles.c.Tactilefremitus.d.Diaphragmaticexcursion.ANS:BNURSINGTB.COMDuringaninspectionoftheposteriorchest,thenurseshouldinspectforsymmetryofshouldersandmuscles,configurationofthethoraciccage,andskincharacteristics.Symmetricexpansionandtactilefremitusareassessedwithpalpation;diaphragmaticexcursionisassessedwithpercussion.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare18.Duringanexamination,thepatienttellsthenursethatshesometimesfeelsasifobjectsarespinningaroundher.Thenursewoulddocumentthatsheoccasionallyexperiences:a.Vertigo.b.Tinnitus.c.Syncope.d.Dizziness.ANS:AVertigoisthesensationofapersonmovingaroundinspace(subjective)orofthepersonsensingobjectsmovingaroundhimorher(objective)andisaresultofadisturbanceofequilibratoryapparatus(seeChapter24).PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)442STUVIA.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare19.Apatienttellsthenurse,SometimesIwakeupatnightandIhaverealtroublebreathing.Ihavetositupinbedtogetagoodbreath.Whendocumentingthisinformation,thenursewouldnote:a.Orthopnea.b.Acuteemphysema.c.Paroxysmalnocturnaldyspnea.d.Acuteshortnessofbreathepisode.ANS:CParoxysmalnocturnaldyspneaoccurswhenthepatientawakensfromsleepwithshortnessofbreathandneedstobeuprighttoachievecomfort(seeChapter19).DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare20.Duringtheexaminationofapatient,thenursenoticesthatthepatienthasseveralsmall,flatmaculesontheposteriorportionofherthorax.Thesemaculesarelessthan1cmwide.Anothernameforthesemaculesis:NURSINGTB.COMa.Warts.b.Bullae.c.Freckles.d.Papules.ANS:CAmaculeissolelyalesionwithcolorchange,flatandcircumscribed,lessthan1cm.Maculesarealsoknownasfreckles(seeChapter13).DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare21.Duringanexamination,thenursenoticesthatapatientslegsturnwhitewhentheyareraisedabovethepatientshead.Thenurseshouldsuspect:a.Lymphedema.b.Raynauddisease.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)443STUVIA.COMc.Chronicarterialinsufficiency.d.Chronicvenousinsufficiency.ANS:CElevationalpallor(striking)indicatesarterialinsufficiency(seeChapter21).DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare22.Thenursedocumentsthatapatienthascoarse,thickenedskinandbrowndiscolorationoverthelowerlegs.Pulsesarepresent.Thisfindingisprobablytheresultof:a.Lymphedema.b.Raynauddisease.c.Chronicarterialinsufficiency.d.Chronicvenousinsufficiency.ANS:DNURSINGTB.COMChronicvenousinsufficiencywouldexhibitfirmbrawnyedema,coarsethickenedskin,normalpulses,andbrowndiscoloration(seeChapter21).DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare23.Thenursenoticesthatapatienthasulcerationsonthetipsofthetoesandonthelateralaspectoftheankles.Thisfindingindicates:a.Lymphedema.b.Raynauddisease.c.Arterialinsufficiency.d.Venousinsufficiency.ANS:CUlcerationsonthetipsofthetoesandlateralaspectoftheanklesareindicativeofarterialinsufficiency(seeChapter21).DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCarePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)444STUVIA.COM24.Thenursehasjustrecordedapositiveiliopsoastestonapatientwhohasabdominalpain.Thistestisusedtoconfirma(n):a.Inflamedliver.b.Perforatedspleen.c.Perforatedappendix.d.Enlargedgallbladder.ANS:CAninflamedorperforatedappendixirritatestheiliopsoasmuscle,producingpainintheRLQ.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare25.Thenursewillmeasureapatientsnearvisionwithwhichtool?a.Snelleneyechartwithlettersb.SnellenEchartc.Jaegercardd.OphthalmoscopeNURSINGTB.COMANS:CTheJaegercardisusedtomeasurenearvision(seeChapter15).DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare26.IfthenurserecordstheresultstotheHirschbergtest,thenursehas:a.Testedthepatellarreflex.b.Assessedforappendicitis.c.Testedthecorneallightreflex.d.Assessedforthrombophlebitis.ANS:CPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)445STUVIA.COMTheHirschbergtestassessesthecorneallightreflex(seeChapter15).DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare27.Duringtheexaminationofapatientsmouth,thenurseobservesanodularbonyridgedownthemiddleofthehardpalate.Thenursewouldchartthisfindingas:a.Cheilosis.b.Leukoplakia.c.Ankyloglossia.d.Toruspalatinus.ANS:DAnormalvariationofthehardpalateisanodularbonyridgedownthemiddleofthehardpalate;thisvariationistermedtoruspalatinus(seeChapter17).DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare28.Duringexamination,thenursefindsthataNpUatRieSnItNiGsTuBna.CblOeMtodistinguishobjectsplacedinhishand.Thenursewoulddocument:a.Stereognosis.b.Astereognosis.c.Graphesthesia.d.Agraphesthesia.ANS:BAstereognosisistheinabilitytoidentifycorrectlyanobjectplacedinthehand(seeChapter24).DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare29.Aftertheexaminationofaninfant,thenursedocumentsopisthotonos.Thenurserecognizesthatthisfindingoftenoccurswith:a.Cerebralpalsy.b.Meningealirritation.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)446STUVIA.COMc.Lowermotorneuronlesion.d.Uppermotorneuronlesion.ANS:BOpisthotonosisaformofspasminwhichtheheadisarchedback,andastiffnessoftheneckandanextensionofthearmsandlegsareobserved.Opisthotonusoccurswithmeningealorbrainstemirritation(seeChapter23).DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare30.Afterassessingafemalepatient,thenursenoticesflesh-colored,soft,pointed,moist,papulesinacauliflower-likepatcharoundherintroitus.Thisfindingismostlikely:a.Urethralcaruncle.b.Syphiliticchancre.c.Herpessimplexvirus.d.Humanpapillomavirus.NURSINGTB.COMANS:DHumanpapillomavirusappearsinaflesh-colored,soft,moist,cauliflower-likepatchofpapules(seeChapter27).DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare31.Whilerecordinginapatientsmedicalrecord,thenursenoticesthatapatientsHematestresultsarepositive.Thisfindingmeansthatthereis(are):a.Crystalsinhisurine.b.Parasitesinhisstool.c.Occultbloodinhisstool.d.Bacteriainhissputum.ANS:CIfastoolisHematestpositive,thenitindicatesthepresenceofoccultblood(seeChapter22).PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)447STUVIA.COMDIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare32.Whileexamininga48-year-oldpatientseyes,thenursenoticesthathehadtomovethehandheldvisionscreenerfartherawayfromhisface.Thenursewouldsuspect:a.Myopia.b.Omniopia.c.Hyperopia.d.Presbyopia.ANS:DPresbyopia,thedecreaseinpowerofaccommodationwithaging,issuggestedwhenthehandheldvisionscreenercardismovedfartheraway(seeChapter15).DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCareNURSINGTB.COMPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)448STUVIA.COMChapter29:TheCompletePhysicalAssessment:Infant,Child,andAdolescentMULTIPLECHOICE1.A5-year-oldchildisintheclinicforacheckup.Thenursewouldexpecthimto:a.Needtobeheldonhismotherslap.b.Beabletositontheexaminationtable.c.Beabletostandonthefloorfortheexamination.d.Beabletoremainaloneintheexaminationroom.ANS:BAt4or5yearsold,achildusuallyfeelscomfortableontheexaminationtable.Olderinfantsandyoungchildrenaged6monthsto2or3yearsshouldbepositionedintheparentslap.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare2.Whichstatementistrueregardingtherecordingofdatafromthehistoryandphysicalexamination?NURSINGTB.COMa.Uselong,descriptivesentencestodocumentfindings.b.Recordthedataassoonaspossibleaftertheinterviewandphysicalexamination.c.Iftheinformationisnotdocumented,thenitcanbeassumedthatitwasdoneasastandardofcare.d.Theexaminershouldavoidtakinganynotesduringthehistoryandexaminationbecauseofthepossibilityofdecreasingtherapportwiththepatient.ANS:BThedatafromthehistoryandphysicalexaminationshouldberecordedassoonaftertheeventaspossible.Fromalegalperspective,ifitisnotdocumented,thenitwasnotdone.Briefnotesshouldbetakenduringtheexamination.Whendocumenting,thenurseshoulduseshort,clearphrasesandavoidredundantphrasesanddescriptions.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare3.Whenassessingtheneonate,thenurseshouldtestforhipstabilitywithwhichmethod?a.ElicitingtheMororeflexPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)449STUVIA.COMb.PerformingtheRombergtestc.CheckingfortheOrtolanisignd.AssessingthesteppingreflexANS:CThenurseshouldtestforhipstabilityintheneonatebytestingfortheOrtolanisign.Theothertestsarenotappropriatefortestinghipstability.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance4.Afemalepatienttellsthenursethatshehasfourchildrenandhashadthreepregnancies.Howshouldthenursedocumentthis?a.Gravida3,para4b.Gravida4,para3c.Thisinformationcannotbedocumentedusingthetermsgravidaandpara.d.ThepatientseemstobeconfusedaNbUouRtShINowGTmBa.CnyOMtimesshehasbeenpregnant.ANS:AGravidareferstothenumberofpregnancies,andparareferstothenumberofchildren.Onepregnancywaswithtwins.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare5.Thenurseisdocumentingtheassessmentofaninfant.Duringtheabdominalassessment,thenursenoticedaveryloudsplashauscultatedovertheupperabdomenwhenthenurserockedherfromsidetoside.Thisfindingwouldindicate:a.Epigastrichernia.b.Pyloricobstruction.c.Hypoactivebowelsounds.d.Hyperactivebowelsounds.ANS:DAsuccussionsplash,whichisunrelatedtoperistalsis,isaveryloudsplashauscultatedovertheupperabdomenPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)450STUVIA.COMwhentheinfantisrockedsidetoside.Itindicatesincreasedairandfluidinthestomachasobservedwithpyloricobstructionorlargehiatushernia(seeChapter21).DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare6.Whichoftheseactionsismostappropriatetoperformona9-month-oldinfantatawell-childcheckup?a.TestingforOrtolanisignb.Assessmentforstereognosisc.Bloodpressuremeasurementd.AssessmentforthepresenceofthestartlereflexANS:AUntiltheageof12months,theinfantshouldbeassessedforOrtolanisign.IfOrtolanisignispresent,thenitcouldindicatethepresenceofadislocatedhip.Theothertestsarenotappropriatefora9-month-oldchild.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCareNURSINGTB.COMPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)451STUVIA.COMChapter30:BedsideAssessmentandElectronicDocumentationMULTIPLECHOICE1.Atthebeginningofroundswhenenteringtheroom,whatshouldthenursedofirst?a.Checktheintravenous(IV)infusionsiteforswellingorredness.b.Checktheinfusionpumpsettingsforaccuracy.c.Makeeyecontactwiththepatient,andintroducehimorherselfasthepatientsnurse.d.Offerthepatientsomethingtodrink.ANS:CWhenenteringapatientsroom,thenurseshouldmakedirecteyecontact,withoutbeingdistractedbyIVpumpsandotherequipment,andintroducehimorherselfasthepatientsnurse.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare2.Duringanassessment,thenurseisunabletopalpatepulsesintheleftlowerleg.Whatshouldthenursedonext?NURSINGTB.COMa.Documentthatthepulsesarenonpalpable.b.Reassessthepulsesin1hour.c.Askthepatientturntotheside,andthenpalpateforthepulsesagain.d.UseaDopplerdevicetoassessthepulses.ANS:DThenurseshouldbepreparedtoassesspulsesinthelowerextremitiesbyDopplermeasurementiftheycannotbedetectedbypalpation.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare3.Duringamorningassessment,thenursenoticesthatapatientsurineoutputisbelowtheexpectedamount.Whatshouldthenursedonext?a.ObtainanorderforaFoleycatheter.b.Obtainanorderforastraightcatheter.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)452STUVIA.COMc.Performabladderscantest.d.Referthepatienttoanurologist.ANS:CIfurineoutputisbelowtheexpectedvalue,thenthenurseshouldperformabladderscanaccordingtoinstitutionalpolicytocheckforretention.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare4.Whatshouldthenurseassessbeforeenteringthepatientsroomonmorningrounds?a.Postedconditions,suchasisolationprecautionsb.Patientsinputandoutputchartfromthepreviousshiftc.Patientsgeneralappearanced.PresenceofanyvisitorsintheroomANS:ANURSINGTB.COMOnthewaytothepatientsroom,thenurseshouldassessthepresenceofconditionssuchasisolationprecautions,latexallergies,orfallprecautions.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:SafetyandInfectionControl5.ThenursehasadministeredapainmedicationtoapatientbyanIVinfusion.Thenurseshouldreassessthepatientsresponsetothepainmedicationwithinminutes.a.5b.15c.30d.60ANS:BIfpainmedicationisgiven,thenthenurseshouldreassessthepatientsresponsein15minutesforIVadministrationor1hourfororaladministration.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PharmacologicandParenteralTherapiesPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)453STUVIA.COM6.Duringanassessmentofahospitalizedpatient,thenursepinchesafoldofskinundertheclavicleorontheforearmtotestthe:a.Mobilityandturgor.b.Patientsresponsetopain.c.Percentageofthepatientsfat-to-muscleratio.d.Presenceofedema.ANS:APinchingafoldofskinundertheclavicleorontheforearmisdonebythenursetodeterminemobilityandturgor.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare7.Whenassessingtheneurologicsystemofahospitalizedpatientduringmorningrounds,thenurseshouldincludewhichoftheseduringtheassessment?a.BloodpressureNURSINGTB.COMb.Patientsratingofpainonascaleof1to10c.Patientsabilitytocommunicated.PatientspersonalhygienelevelANS:CAssessmentofapatientsabilitytocommunicateispartoftheneurologicassessment.Bloodpressureandpainratingaremeasurements,andpersonalhygieneisassessedundergeneralappearance.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare8.Whenassessingapatientsgeneralappearance,thenurseshouldincludewhichquestion?a.Isthepatientsmusclestrengthequalinbotharms?b.Isptosisorfacialdrooppresent?c.Doesthepatientappropriatelyrespondtoquestions?d.Arethepupilsequalinreactionandsize?PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)454STUVIA.COMANS:CAssessingwhetherthepatientappropriatelyrespondstoquestionsisacomponentofanassessmentofthepatientsgeneralappearance.Theotheranswersreflectcomponentsoftheneurologicexamination.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare9.Whenassessingapatientinthehospitalsetting,thenurseknowswhichstatementtobetrue?a.Thepatientwillneedabriefassessmentatleastevery4hours.b.Thepatientwillneedaconsistent,specializedexaminationevery8hoursthatfocusesoncertainparameters.c.Thepatientwillneedacompletehead-to-toephysicalexaminationevery24hours.d.Mostpatientsrequireaminimalexaminationeachshiftunlesstheyareincriticalcondition.ANS:BInahospitalsetting,thepatientdoesnotrequireacompletehead-to-toephysicalexaminationduringevery24-hourstay.Thepatientdoes,however,requireaconsistentspecializedexaminationevery8hoursthatfocusesoncertainparameters.NURSINGTB.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare10.Thenurseisgivingreporttothenextshiftandisusingthesituation,background,assessment,recommendation(SBAR)frameworkforcommunication.WhichofthesestatementsreflectstheBackgroundportionofthereport?a.Imworriedthathisgastrointestinalbleedingisgettingworse.b.Weneedanorderforoxygen.c.MynameisMs.Smith,andImgivingthereportonMrs.Xinroom1104.d.Heis4dayspostoperative,andhisincisionisopentoair.ANS:DDuringtheBackgroundportion,thenurseshouldstatedatapertinenttothemomentsproblemsuchastheconditionofthepatientsincision.DuringtheSituationportion,thenurseprovideshisorhernameandthepatientsname.DuringtheAssessmentportion,thenursestateswhatheorshethinksishappening(e.g.,gastrointestinalbleeding).DuringtheRecommendationportion,thenurseshouldofferprobablesolutionsorordersthatmaybeimplemented.DIF:CognitiveLevel:Analyzing(Analysis)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)455STUVIA.COMMSC:ClientNeeds:SafeandEffectiveCareEnvironment:SafetyandInfectionControlMULTIPLERESPONSE1.ThenurseisassessingtheIVinfusionatthebeginningoftheshift.Whichfactorsshouldbeincludedintheassessmentoftheinfusion?Selectallthatapply.a.ProperIVsolutionisinfusing,accordingtothephysiciansorders.b.TheIVsolutionisinfusingattheproperrate,accordingtophysiciansorders.c.Theinfusionisproper,accordingtothenursesassessmentofthepatientsneeds.d.Capillaryrefillinthefingersischeckedandnoted.e.TheIVsitedateisnoted.f.Whetherthepatientissufficientlyvoidingisnoted.ANS:A,B,C,EThenurseshouldverifythattheproperIVsolutionishangingandisflowingattheproperrateaccordingtothephysiciansordersandthenursesownassessmentofthepatientsneeds.Inaddition,thenurseshouldnotethedateoftheIVsiteandsurroundingskincondition.Checkingcapillaryrefillispartofthecardiovascularassessment;checkingthepatientsvoidingispNarUtRofSItNheGgTeBn.iCtoOuMrinaryassessment.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PharmacologicandParenteralTherapies2.Thenurseiscompletinganassessmentonapatientwhowasjustadmittedfromtheemergencydepartment.Whichassessmentfindingswouldrequireimmediateattention?Selectallthatapply.a.Temperature:38.6Cb.Systolicbloodpressure:150mmHgc.Respiratoryrate:22breathsperminuted.Heartrate:130beatsperminutee.Oxygensaturation:95%f.SuddenrestlessnessANS:A,D,FThefollowingexaminationfindingsrequireimmediateattention:PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)456STUVIA.COMNURSINGTB.COMHighorlowtemperature:(36.1Cor37.8C)Highorlowbloodpressure:(systolicpressure90mmHgor160mmHg)Highorlownumberofrespirations:(12or28breathsperminute)Highorlowheartrate:(60or90beatsperminute)Oxygensaturation:92%Suddenrestlessnessoranxiety,alteredlevelofconsciousness,confusion,ordifficultyinarousingDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)457STUVIA.COMChapter31:ThePregnantWomanMULTIPLECHOICE1.Whichofthesestatementsbestdescribestheactionofthehormoneprogesteroneduringpregnancy?a.Progesteroneproducesthehormonehumanchorionicgonadotropin.b.Ductformationinthebreastisstimulatedbyprogesterone.c.Progesteronepromotessloughingoftheendometrialwall.d.Progesteronemaintainstheendometriumaroundthefetus.ANS:DProgesteronepreventsthesloughingoftheendometrialwallandmaintainstheendometriumaroundthefetus.Progesteroneincreasesthealveoliinthebreastandkeepstheuterusinaquiescentstate.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:General2.Afemalepatienthasnausea,breasttenderness,fatigue,andamenorrhea.Herlastmenstrualperiodwas6weeksago.ThenurseinterpretsthatthispatieNntUisRSexINpeGrTieBn.cCiOngMsignsofpregnancy.a.Positiveb.Possiblec.Probabled.PresumptiveANS:DPresumptivesignsofpregnancyarethosethatthewomanexperiencesandincludeamenorrhea,breasttenderness,fatigue,nausea,andincreasedurinaryfrequency.Probablesignsarethosethataredetectedbytheexaminer,suchasanenlargeduterusorchangesinthecervix.Positivesignsofpregnancyarethosethatdocumentdirectevidenceofthefetussuchasfetalhearttonesorpositivecardiacactivityonultrasound.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance3.Awomanwhois8weekspregnantisvisitingtheclinicforacheckup.Hersystolicbloodpressureis30mmHghigherthanherprepregnancysystolicbloodpressure.Thenurseshould:a.Considerthisanormalfinding.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)458STUVIA.COMb.Expectthebloodpressuretodecreaseastheestrogenlevelsincreasethroughoutthepregnancy.c.Considerthisanabnormalfindingbecausebloodpressureistypicallyloweratthispointinthepregnancy.d.Recommendthatshedecreasehersaltintakeinanattempttodecreaseherperipheralvascularresistance.ANS:CDuringtheseventhgestationalweek,bloodpressurebeginstodropasaresultoffallingperipheralvascularresistance.Earlyinthefirsttrimester,bloodpressurevaluesaresimilartothoseofprepregnancymeasurements.Inthiscase,thewomansbloodpressureishigherthanitshouldbe.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance4.Apatientisbeingseenattheclinicforher10-weekprenatalvisit.Sheaskswhenshewillbeabletohearthebabysheartbeat.Thenurseshouldreply:a.Thebabysheartbeatisnotusuallyhearduntilthesecondtrimester.b.Thebabysheartbeatmaybeheardanywherefromtheninthtothetwelfthweek.c.ItisoftendifficulttohearthehearNtbUeaRtSaItNtGhiTsBp.oCiOntM,butwecantry.d.Itisnormaltoheartheheartbeatat6weeks.Wemaybeabletohearittoday.ANS:BFetalhearttonescanbeheardwiththeuseoftheDopplerdevicebetween9and12weeks.Theotherresponsesareincorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance5.Apatientwhoisinherfirsttrimesterofpregnancytellsthenursethatsheisexperiencingsignificantnauseaandvomitingandaskswhenitwillimprove.Thenurseshouldreply:a.Didyourmotherhavesignificantnauseaandvomiting?b.Manywomenexperiencenauseaandvomitinguntilthethirdtrimester.c.Usually,bythebeginningofthesecondtrimester,thenauseaandvomitingimprove.d.Atapproximatelythetimeyoubegintofeelthebabymove,thenauseaandvomitingwillsubside.ANS:CPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)459STUVIA.COMThenausea,vomiting,andfatigueofpregnancyimprovebythe12thweek.Quickening,whenthemotherrecognizesfetalmovement,occursatapproximately18to20weeks.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation6.Duringtheexaminationofawomaninhersecondtrimesterofpregnancy,thenursenoticesthepresenceofasmallamountofyellowdrainagefromthenipples.Thenurseknowsthatthisis:a.Anindicationthatthewomansmilkiscomingin.b.Asignofpossiblebreastcancerinapregnantwoman.c.Mostlikelycolostrumandconsideredanormalfindingatthisstageofthepregnancy.d.Tooearlyinthepregnancyforlactationtobeginandrefersthewomantoaspecialist.ANS:CDuringthesecondtrimester,colostrum,theprecursorofmilk,maybeexpressedfromthenipples.Colostrumisyellowandcontainsmoremineralsandproteinbutlesssugarandfatthanmaturemilk.Theotheroptionsareincorrect.DIF:CognitiveLevel:Analyzing(Analysis)NURSINGTB.COMMSC:ClientNeeds:HealthPromotionandMaintenance7.Awomaninhersecondtrimesterofpregnancycomplainsofheartburnandindigestion.Whendiscussingthiswiththewoman,thenurseconsiderswhichexplanationfortheseproblems?a.Toneandmotilityofthegastrointestinaltractincreaseduringthesecondtrimester.b.Sluggishemptyingofthegallbladder,resultingfromtheeffectsofprogesterone,oftencausesheartburn.c.Lowerbloodpressureatthistimedecreasesbloodflowtothestomachandgastrointestinaltract.d.Enlarginguterusandalteredesophagealsphinctertonepredisposethewomantohaveheartburn.ANS:DStomachdisplacementfromtheenlarginguterusplusalteredesophagealsphincterandgastrictoneasaresultofprogesteronepredisposethewomantoheartburn.Thetoneandmotilityofthegastrointestinaltractaredecreased,notincreased,duringpregnancy.Emptyingofthegallbladdermaybecomemoresluggishduringpregnancybutisnotrelatedtoindigestion.Rather,somewomenarepredisposedtogallstoneformation.Alowerbloodpressuremayoccurduringthesecondsemester,butitdoesnotaffectdigestion.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)460STUVIA.COM8.Apatientwhois20weekspregnanttellsthenursethatshefeelsmoreshortnessofbreathasherpregnancyprogresses.Thenurserecognizeswhichstatementtobetrue?a.Highlevelsofestrogencauseshortnessofbreath.b.Feelingsofshortnessofbreathareabnormalduringpregnancy.c.Hormonesofpregnancycauseanincreasedrespiratoryeffort.d.Thepatientshouldgetmoreexerciseinanattempttoincreaseherrespiratoryreserve.ANS:CProgesteroneandestrogencauseanincreaseinrespiratoryeffortduringpregnancybyincreasingtidalvolume.Increasedtidalvolumecausesaslightdropinpartialpressureofarterialcarbondioxide(PaCO2),causingthewomantohavedyspneaoccasionally.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation9.Thenurseauscultatesafunctionalsystolicmurmur,gradeII/IV,onawomaninweek30ofherpregnancy.Theremainderofherphysicalassessmentiswithinnormallimits.Thenursewould:a.Considerthisfindingabnormal,andreferherforadditionalconsultation.NURSINGTB.COMb.Askthewomantorunbrieflyinplaceandthenassessforanincreaseinintensityofthemurmur.c.Knowthatthisfindingisnormalandisaresultoftheincreaseinbloodvolumeduringpregnancy.d.Askthewomantorestrictheractivitiesandreturntotheclinicin1weekforre-evaluation.ANS:CBecauseoftheincreaseinbloodvolume,afunctionalsystolicmurmur,gradeII/IVorless,canbeheardin95%ofpregnantwomen.Theotheractionsarenotappropriate.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance10.Awomanwhois28weekspregnanthasbilateraledemainherlowerlegsafterworking8hoursadayasacashieratalocalgrocerystore.Sheisworriedaboutherlegs.Whatisthenursesbestresponse?a.Youwillbeatriskfordevelopmentofvaricoseveinswhenyourlegsareedematous.b.Iwouldliketolistentoyourheartsounds.Edemacanindicateaproblemwithyourheart.c.Edemaisusuallytheresultoftoomuchsaltandfluidsinyourdiet.Youmayneedtocutdownonsaltyfoods.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)461STUVIA.COMd.Asyourbabygrows,itslowsbloodreturnfromyourlegs,causingtheswelling.Thisoftenoccurswithprolongedstanding.ANS:DEdemaofthelowerextremitiesoccursbecauseoftheenlargingfetus,whichimpairsvenousreturn.Prolongedstandingworsenstheedema.Typically,thebilateral,dependentedemaexperiencedwithpregnancyisnottheresultofacardiacpathologiccondition.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance11.Whenassessingawomanwhoisinherthirdtrimesterofpregnancy,thenurselooksfortheclassicsymptomsassociatedwithpreeclampsia,whichinclude:a.Edema,headaches,andseizures.b.Elevatedbloodpressureandproteinuria.c.Elevatedliverenzymesandhighplateletcounts.d.Decreasedbloodpressureandedema.NURSINGTB.COMANS:BTheclassicsymptomsofpreeclampsiaarehypertensionandproteinuria.Headachesmayoccurwithworseningsymptoms,andseizuresmayoccurifpreeclampsiaisleftuntreatedandleadstoeclampsia.Aseriousvariantofpreeclampsia,thehemolysis,elevatedliverenzymes,lowplateletcount(HELLP)syndrome,isanominouspicture.Edemaisacommonoccurrenceinpregnancy.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation12.Thenurseknowsthatthebesttimetoassessawomansbloodpressureduringaninitialprenatalvisitis:a.Attheendoftheexaminationwhenshewillbethemostrelaxed.b.Atthebeginningoftheinterviewasanonthreateningmethodofgainingrapport.c.Duringthemiddleofthephysicalexaminationwhensheisthemostcomfortable.d.Beforebeginningthepelvicexaminationbecauseherbloodpressurewillbehigherafterthepelvicexamination.ANS:AAssessingthewomansbloodpressureattheendoftheexamination,whenitishopedthatshewillbemostrelaxed,isthebesttimetoassessbloodpressure.Theotheroptionsarenotcorrect.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)462STUVIA.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare13.Whenexaminingthefaceofawomanwhois28weekspregnant,thenursenoticesthepresenceofabutterfly-shapedincreaseinpigmentationontheface.Thepropertermforthisfindinginthedocumentationis:a.Striae.b.Chloasma.c.Lineanigra.d.Maskofpregnancy.ANS:BChloasmaisabutterfly-shapedincreaseinpigmentationontheface.Itisknownasthemaskofpregnancy,butwhendocumenting,thenurseshouldusethecorrectmedicalterm,chloasma.Striaeisthetermforstretchmarks.Thelineanigraisahyperpigmentedlinethatbeginsatthesternalnotchandextendsdowntheabdomenthroughtheumbilicustothepubis.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare14.WhichfindingisconsiderednormalandexNpUeRctSeIdNwGhTeBn.CthOeMnurseisperformingaphysicalexaminationonapregnantwoman?a.Palpable,fullthyroidb.Edemainonelowerlegc.Significantdiffuseenlargementofthethyroidd.PalemucousmembranesofthemouthANS:AThethyroidmaybepalpableduringpregnancy.Itshouldfeelfull,butsmooth.Significantdiffuseenlargementoccurswithhyperthyroidism,thyroiditis,andhypothyroidism.Palemucousmembranesmayindicateanemia.Bilaterallowerextremityedemaiscommoninpregnancy,butedemawithpaininonlyonelegoccurswithdeepveinthrombosis.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance15.Whenauscultatingtheanteriorthoraxofapregnantwoman,thenursenoticesthepresenceofamurmuroverthesecond,third,andfourthintercostalspaces.Themurmuriscontinuousbutcanbeobliteratedbypressurewiththestethoscopeorfingeronthethoraxjustlateraltothemurmur.Thenurseinterpretsthisfindingtobe:PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)463STUVIA.COMa.Murmurofaorticstenosis.b.Mostlikelyamammarysouffle.c.Associatedwithaorticinsufficiency.d.Indicationofapatentductusarteriosus.ANS:BBloodflowthroughthebloodvessels,specificallytheinternalmammaryartery,canoftenbeheardoverthesecond,third,andfourthintercostalspaces.Thisfindingiscalledamammarysouffle,butitmaybemistakenforacardiacmurmur.Theotheroptionsareincorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:HealthPromotionandMaintenance16.Whenthenurseisassessingthedeeptendonreflexes(DTRs)onawomanwhois32weekspregnant,whichofthesewouldbeconsideredanormalfindingona0to4+scale?a.AbsentDTRsb.2+c.4+NURSINGTB.COMd.BriskreflexesandthepresenceofclonusANS:BNormallyduringpregnancy,theDTRsare1+to2+andbilaterallyequal.Briskorgreaterthan2+DTRsandthepresenceofclonusareabnormalandmaybeassociatedwithanelevatedbloodpressureandcerebraledemainthepreeclampticwoman.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance17.Whenperforminganexaminationofawomanwhois34weekspregnant,thenursenoticesamidlinelinearprotrusionintheabdomenovertheareaoftherectusabdominismusclesasthewomanraisesherheadandshouldersoffofthebed.Whichresponsebythenurseiscorrect?a.Thepresenceofdiastasisrectishouldbedocumented.b.Thisconditionshouldbediscussedwiththephysicianbecauseitwillmostlikelyneedtobesurgicallyrepaired.c.Thepossibilitythatthewomanhasaherniaattributabletotheincreasedpressurewithintheabdomenfromthepregnancyshouldbesuspected.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)464STUVIA.COMd.Thewomanshouldbetoldthatshemayhaveadifficulttimewithdeliverybecauseoftheweaknessinherabdominalmuscles.ANS:ATheseparationoftheabdominalmusclesiscalleddiastasisrectiandfrequentlyoccursduringpregnancy.Therectusabdominismuscleswillreturntogetherafterpregnancywithabdominalexercise.Thisconditionisnotatruehernia.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance18.Thenurseispalpatingthefundusofapregnantwoman.Whichstatementaboutpalpationofthefundusistrue?a.Thefundusshouldbehardandslightlytendertopalpationduringthefirsttrimester.b.Fetalmovementmaynotbefeltbytheexamineruntiltheendofthesecondtrimester.c.After20weeksgestation,thenumberofcentimetersshouldapproximatethenumberofweeksgestation.d.Fundalheightisusuallylessthanthenumberofweeksgestation,unlessanabnormalconditionsuchasexcessiveamnioticfluidisNpUreRsSeInNt.GTB.COMANS:CAfter20weeksgestation,thenumberofcentimetersshouldapproximatethenumberofweeksgestation.Inaddition,at20weeksgestation,theexaminermaybeabletofeelfetalmovementandtheheadcanbeballoted.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance19.Thenurseispalpatingtheabdomenofawomanwhois35weekspregnantandnoticesthatthefetalheadisfacingdownwardtowardthepelvis.Thenursewoulddocumentthisasfetal:a.Lie.b.Variety.c.Attitude.d.Presentation.ANS:DFetalpresentationdescribesthepartofthefetusthatisenteringthepelvisfirst.Fetallieisorientationofthefetalspinetothematernalspine.Fetalattitudeisthepositionoffetalpartsinrelationtoeachother,andfetalPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)465STUVIA.COMvarietyisthelocationofthefetalbacktothematernalpelvis.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance20.Thenurseispalpatingtheuterusofawomanwhois8weekspregnant.Whichfindingwouldbeconsideredtobemostconsistentwiththisstageofpregnancy?a.Theuterusseemsslightlyenlargedandsoftened.b.Itreachesthepelvicbrimandisapproximatelythesizeofagrapefruit.c.Theuterusrisesabovethepelvicbrimandisapproximatelythesizeofacantaloupe.d.Itisaboutthesizeofanavocado,approximately8cmacrossthefundus.ANS:DThe8-weekpregnantuterusisapproximatelythesizeofanavocado,7to8cmacrossthefundus.The6-weekpregnantuterusisslightlyenlargedandsoftened.The10-weekpregnantuterusisapproximatelythesizeofagrapefruitandmayreachthepelvicbrim.The12-weekpregnantuteruswillfillthepelvis.At12weeks,theuterusissizedfromtheabdomen.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMNaiUntReSnIaNncGeTB.COM21.Whichofthesecorrectlydescribestheaveragelengthofpregnancy?a.38weeksb.9lunarmonthsc.280daysfromthelastdayofthelastmenstrualperiodd.280daysfromthefirstdayofthelastmenstrualperiodANS:DTheaveragelengthofpregnancyis280daysfromthefirstdayofthelastmenstrualperiod,whichisequalto40weeks,10lunarmonths,orroughly9calendarmonths.DIF:CognitiveLevel:Remembering(Knowledge)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation22.Apatientspregnancytestispositive,andshewantstoknowwhenthebabyisdue.ThefirstdayofherlastmenstrualperiodwasJune14,andthatperiodendedJune20.UsingtheNgelerule,whatisherexpecteddateofdelivery?a.March7PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)466STUVIA.COMb.March14c.March21d.March27ANS:CTodeterminetheexpecteddateofdeliveryusingtheNgelerule,7daysareaddedtothefirstdayofthelastmenstrualperiod;then3monthsaresubtracted.Therefore,adding7daystoJune14wouldbeJune21andsubtracting3monthswouldmaketheexpecteddeliverydateMarch21.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare23.Duringtheassessmentofawomaninher22ndweekofpregnancy,thenurseisunabletohearfetalhearttoneswiththefetoscope.Thenurseshould:a.Immediatelynotifythephysician,thenwait10minutesandtryagain.b.Askthewomanifshehasfeltthebabymovetoday.c.Wait10minutes,andtryagain.NURSINGTB.COMd.Useultrasoundtoverifycardiacactivity.ANS:DIfnofetalhearttonesareheardduringauscultationwithafetoscope,thenthenurseshouldverifycardiacactivityusingultrasonography.Anultrasoundshouldbeimmediatelydoneandbeforenotifyingthephysicianorcausingthewomandistressbyaskingaboutfetalmovement.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation24.Apatientwhois24weekspregnantasksaboutwearingaseatbeltwhiledriving.Whichresponsebythenurseiscorrect?a.Seatbeltsshouldnotbewornduringpregnancy.b.Placethelapbeltbelowtheuterusandusetheshoulderstrapatthesametime.c.Placethelapbeltbelowtheuterusbutomittheshoulderstrapduringpregnancy.d.Placethelapbeltatyourwaistabovetheuterusandusetheshoulderstrapatthesametime.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)467STUVIA.COMANS:BFormaternalandfetalsafety,thenurseshouldinstructthewomantoplacethelapbeltbelowtheuterusandtousetheshoulderstrap.Theotherinstructionsareincorrect.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential25.Duringahealthhistoryinterview,a38-year-oldwomansharesthatsheisthinkingabouthavinganotherbaby.Thenurseknowswhichstatementtobetrueregardingpregnancyafter35yearsofage?a.Fertilitydoesnotstarttodeclineuntilage40years.b.OccurrenceofDownsyndromeissignificantlymorefrequentaftertheageof35years.c.Geneticcounselingandprenatalscreeningarenotroutineuntilafterage40years.d.Womenolderthan35yearswhoarepregnanthavethesamerateofpregnancy-relatedcomplicationsasthosewhoareyoungerthan35years.ANS:BTheriskofDownsyndromeincreasesasthewomanages,fromapproximately1in1250atage25yearsto1in400atage35years.Fertilitydeclineswithadvancingmaternalage.Women35yearsandolderorwithahistoryofageneticabnormalityareofferedgeneticcounselingandtheoptionsofprenataldiagnosticscreeningtests.BecausetheincidenceofchronicdiseaseNsUinRcSrIeNasGeTsBw.CitOhMage,womenolderthan35yearswhoarepregnantmoreoftenhavemedicalcomplicationssuchasdiabetes,obesity,andhypertension.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential26.A25-year-oldwomanisintheclinicforherfirstprenatalvisit.Thenursewillpreparetoobtainwhichlaboratoryscreeningtestatthistime?a.Urinetoxicologyb.Completebloodcellcountc.Alpha-fetoproteind.CarrierscreeningforcysticfibrosisANS:BAttheonsetofpregnancy,aroutineprenatalpanelusuallyincludesacompletebloodcellcount,serologictesting,rubellaantibodies,hepatitisBscreening,bloodtypeandRhesusfactor,andantibodyscreen.Aclean-catchurinesampleiscollectedforurinalysistoruleoutcystitis.Urinetoxicology,althoughbeneficialforwomenifactivesubstanceabuseissuspectedorknown,isnotroutinelyperformed.Inthesecondtrimester,maternalserumisanalyzedforalpha-fetoprotein.Carrierscreeningforcysticfibrosisisofferedtocheckwhetherapersoncarriestheabnormalgenethatcausescysticfibrosisbutisnotpartofroutinetesting.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)468STUVIA.COMDIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare27.Awomanat25weeksgestationcomestotheclinicforherprenatalvisit.Thenursenoticesthatherfaceandlowerextremitiesareswollen,andherbloodpressureis154/94mmHg.Thewomanstatesthatshehashadheadachesandblurryvisionbutthoughtshewasjusttired.Whatshouldthenursesuspect?a.Eclampsiab.Preeclampsiac.Diabetestype1d.PretermlaborANS:BClassicsymptomsofpreeclampsiaincludeelevatedbloodpressure(greaterthan140mmHgsystolicor90mmHgdiastolicinawomanwithpreviouslynormalbloodpressure)andproteinuria.Onsetandworseningsymptomsmaybesudden,andsubjectivesignsincludeheadachesandvisualchanges.Eclampsiaismanifestedbygeneralizedtonic-clonicseizures.Thesesymptomsarenotindicativeofdiabetesmellitus(type1or2)orpretermlabor.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareENnUvRirSoInNmGeTnBt:.CMOaMnagementofCare28.Duringauscultationoffetalhearttones(FHTs),thenursedeterminesthattheheartrateis136beatsperminute.Thenursesnextactionshouldbeto:a.Documenttheresults,whicharewithinnormalrange.b.Takethematernalpulsetoverifythesefindingsastheuterinesouffle.c.HavethepatientchangepositionsandcounttheFHTsagain.d.Immediatelynotifythephysicianforpossiblefetaldistress.ANS:AThenormalfetalheartrateisbetween110and160beatsperminute.Thenurseshoulddocumenttheresultsaswithinthenormalrange.Theotheroptionsarenotcorrect.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare29.Duringawomans34thweekofpregnancy,sheistoldthatshehaspreeclampsia.Thenurseknowswhichstatementconcerningpreeclampsiaistrue?a.Preeclampsiahaslittleeffectonthefetus.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)469STUVIA.COMb.Edemaisoneofthemainindicationsofpreeclampsia.c.Eclampsiaonlyoccursbeforedeliveryofthebaby.d.Untreatedpreeclampsiamaycontributetorestrictionoffetalgrowth.ANS:DUntreatedpreeclampsiamayprogresstoeclampsia,whichismanifestedbygeneralizedtonic-clonicseizures.Eclampsiamaydevelopaslateas10dayspostpartum.Beforethesyndromebecomesclinicallymanifested,itisaffectingtheplacentathroughvasospasmandaseriesofsmallinfarctions.Theplacentascapacitytodeliveroxygenandnutrientsmaybeseriouslydiminished,andfetalgrowthmayberestricted.Edemaiscommoninpregnancyandisnotanindicatorofpreeclampsia.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptationMULTIPLERESPONSE1.Duringagroupprenatalteachingsession,thenurseteachesKegelexercises.Whichstatementswouldbeappropriateforthisteachingsession?Selectallthatapply.a.Kegelexerciseshelpkeepyouruterusstrongduringthepregnancy.NURSINGTB.COMb.Kegelexercisesshouldbeperformedtwiceaday.c.Kegelexercisesshouldbeperformed50to100timesaday.d.ToperformKegelexercises,slowlysqueezetoapeakatthecountofeight,andthenslowlyreleasetoacountofeight.e.ToperformKegelexercises,rapidlyperformalternatingsqueeze-releaseexercisesuptothecountofeight.ANS:C,DKegelexercisescanbeperformedtoprepareforandtorecoverfrombirth.Thenurseshoulddirectthewomantosqueezeslowlytoapeakatthecountofeightandthentoreleaseslowlytothecountofeight.Thenursecanprescribethisexercisetobeperformed50to100timesaday.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenancePHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)470STUVIA.COMChapter32:FunctionalAssessmentoftheOlderAdultMULTIPLECHOICE1.Thenurseisassessinganolderadultsfunctionalability.Whichdefinitioncorrectlydescribesonesfunctionaability?Functionalability:a.Isthemeasureoftheexpectedchangesofagingthatoneisexperiencing.b.Referstotheindividualsmotivationtoliveindependently.c.Referstothelevelofcognitionpresentinanolderperson.d.Referstoonesabilitytoperformactivitiesnecessarytoliveinmodernsociety.ANS:DFunctionalabilityreferstoonesabilitytoperformactivitiesnecessarytoliveinmodernsocietyandcanincludedriving,usingthetelephone,orperformingpersonaltaskssuchasbathingandtoileting.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance2.Thenurseispreparingtoperformafunctionalassessmentofanolderpatientandknowsthatagoodapproachwouldbeto:NURSINGTB.COMa.Observethepatientsabilitytoperformthetasks.b.Askthepatientswifehowhedoeswhenperformingtasks.c.Reviewthemedicalrecordforinformationonthepatientsabilities.d.Askthepatientsphysicianforinformationonthepatientsabilities.ANS:ATwoapproachesareusedtoperformafunctionalassessment:(1)askingindividualsabouttheirabilitytoperformthetasks(self-reports),or(2)actuallyobservingtheirabilitytoperformthetasks.Forpersonswithmemoryproblems,theuseofsurrogatereporters(proxyreports),suchasfamilymembersorcaregivers,maybenecessary,keepinginmindthattheymayeitheroverestimateorunderestimatethepersonsactualabilities.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare3.Thenurseneedstoassessapatientsabilitytoperformactivitiesofdailyliving(ADLs)andshouldchoosewhichtoolforthisassessment?a.DirectAssessmentofFunctionalAbilities(DAFA)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)471STUVIA.COMb.LawtonInstrumentalActivitiesofDailyLiving(IADL)scalec.BarthelIndexd.OlderAmericansResourcesandServicesMultidimensionalFunctionalAssessmentQuestionnaireIADL(OMFAQ-IADL)ANS:CTheBarthelIndexisusedtoassessADLs.TheotheroptionsareusedtomeasureIADLs.DIF:CognitiveLevel:Understanding(Comprehension)MSC:ClientNeeds:HealthPromotionandMaintenance4.ThenurseispreparingtousetheLawtonIADLinstrumentaspartofanassessment.WhichstatementabouttheLawtonIADLinstrumentistrue?a.Thenurseusesdirectobservationtoimplementthistool.b.TheLawtonIADLinstrumentisdesignedasaself-reportmeasureofperformanceratherthanability.c.Thisinstrumentisnotusefulintheacutehospitalsetting.NURSINGTB.COMd.Thistoolisbestusedforthoseresidinginaninstitutionalsetting.ANS:BTheLawtonIADLinstrumentisdesignedasaself-reportmeasureofperformanceratherthanability.Directtestingisoftennotfeasible,suchasdemonstratingtheabilitytopreparefoodwhileahospitalinpatient.Attentiontothefinalscoreislessimportantthanidentifyingapersonsstrengthsandareaswhereassistanceisneeded.Theinstrumentisusefulinacutehospitalsettingsfordischargeplanningandcontinuouslyinoutpatientsettings.Itwouldnotbeusefulforthoseresidingininstitutionalsettingsbecausemanyofthesetasksarealreadybeingmanagedfortheresident.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare5.Thenurseisassessinganolderadultsadvancedactivitiesofdailyliving(AADLs),whichwouldinclude:a.Recreationalactivities.b.Mealpreparation.c.Balancingthecheckbook.d.Self-groomingactivities.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)472STUVIA.COMANS:AAADLsareactivitiesthatanolderadultperformssuchasoccupationalandrecreationalactivities.Self-groomingactivitiesarebasicADLs;mealpreparationandbalancingthecheckbookareconsideredIADLs.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenance6.WhenusingthevariousinstrumentstoassessanolderpersonsADLs,thenurseneedstorememberthatadisadvantageoftheseinstrumentsincludes:a.Reliabilityofthetools.b.Selforproxyreportingoffunctionalactivities.c.Lackofconfidentialityduringtheassessment.d.Insufficientdetailsconcerningthedeficienciesidentified.ANS:BAdisadvantageofmanyoftheADLandIADLinstrumentsistheselforproxyreportingoffunctionalactivities.Theotherresponsesarenotcorrect.DIF:CognitiveLevel:Understanding(Comprehension)NURSINGTB.COMMSC:ClientNeeds:HealthPromotionandMaintenance7.Apatientwillbereadytobedischargedfromthehospitalsoon,andthepatientsfamilymembersareconcernedaboutwhetherthepatientisabletowalksafelyoutsidealone.Thenursewillperformwhichtesttoassessthis?a.GetUpandGoTestb.PerformanceADLsc.PhysicalPerformanceTestd.TinettiGaitandBalanceEvaluationANS:ATheGetUpandGoTestisareliableandvalidtesttoquantifyfunctionalmobility.Thetestisquick,requireslittletrainingandnospecialequipment,andisappropriatetouseinmanysettingsincludinghospitalsandclinics.Thisinstrumenthasbeenshowntopredictapersonsabilitytogosafelyoutsidealone.ThePerformanceofADLstesthasatrainedobserveractuallyobservingasapatientperformsvariousADLs.ThePhysicalPerformanceTestassessesupperbodyfinemotorandcoarsemotoractivities,aswellasbalance,mobility,coordination,andendurance.TheTinettiGaitandBalanceEvaluationassessesgaitandbalanceandprovidesinformationaboutfallrisk.DIF:CognitiveLevel:Understanding(Comprehension)PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)473STUVIA.COMMSC:ClientNeeds:HealthPromotionandMaintenance8.Thenurseisassessingtheformsofsupportanolderpatienthasbeforesheisdischarged.Whichoftheseexamplesisaninformalsourceofsupport?a.Localseniorcenterb.PatientsMedicarecheckc.MealsonWheelsmealdeliveryserviced.Patientsneighbor,whovisitswithherdailyANS:DInformalsupportincludesfamilyandclose,long-timefriendsandisusuallyprovidedfreeofcharge.Formalsupportsincludeprogramssuchassocialwelfareandothersocialserviceandhealthcaredeliveryagenciessuchashomehealthcare.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity9.An85-year-oldmanhasbeenhospitalizedafterafallathome,andhis86-year-oldwifeisathisbedside.Shetellsthenursethatsheishisprimarycaregiver.Thenurseshouldassessthecaregiverforsignsofpossiblecaregiverburnout,suchas:NURSINGTB.COMa.Depression.b.Weightgain.c.Hypertension.d.Socialphobias.ANS:ACaregiverburdenistheperceivedstrainbythepersonwhocaresforanolderadultorforapersonwhoischronicallyillordisabled.Caregiverburnoutislinkedtothecaregiversabilitytocopeandhandlestress.Signsofpossiblecaregiverburnoutincludemultiplesomaticcomplaints,increasedstressandanxiety,socialisolation,depression,andweightloss.Screeningcaregiversfordepressionmayalsobeappropriate.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity10.Duringamorningassessment,thenursenoticesthatanolderpatientislessattentiveandisunabletorecallyesterdaysevents.Whichtestisappropriateforassessingthepatientsmentalstatus?a.GeriatricDepressionScale,shortformPHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)474STUVIA.COMb.RapidDisabilityRatingScale-2c.Mini-Cogd.GetUpandGoTestANS:CFornursesinvarioussettings,cognitiveassessmentsprovidecontinuingcomparisonstotheindividualsbaselinetodetectanyacutechangesinmentalstatus.TheMini-Cogisamentalstatustestthattestsimmediateanddelayedrecallandvisuospatialabilities.TheGeriatricDepressionScale,shortform,assessesfordepressionandchangesinthelevelofdepression,notmentalstatus.TheRapidDisabilityRatingScale-2measureswhatthepersoncanactuallydoversuswhatheorshecoulddo,butnotmentalstatus.TheGetUpandGoTestassessesfunctionalmobility,notmentalstatus.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity11.Anolderpatienthasbeenadmittedtotheintensivecareunit(ICU)afterfallingathome.Within8hours,hisconditionhasstabilizedandheistransferredtoamedicalunit.Thefamilyiswonderingwhetherhewillbeabletogobackhome.Whichassessmentinstrumentismostappropriateforthenursetochooseatthistime?a.LawtonIADLinstrumentb.HospitalAdmissionRiskProfile(HARP)NURSINGTB.COMc.Mini-Cogd.NEECHAMConfusionScaleANS:BHospital-acquiredfunctionaldeclinemayoccurwithin2daysofahospitaladmission.TheHARPhelpsidentifyolderadultswhoareatgreatestriskoflosingtheirabilitytoperformADLsormobilityatthiscriticaltime.TheLawtonIADLmeasuresinstrumentalactivitiesofdailyliving,whichmaybedifficulttoobserveinthehospitalsetting.TheMini-Cogisanassessmentofmentalstatus.TheNEECHAMConfusionScaleisusedtoassessfordelirium.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:PsychosocialIntegrity12.Duringafunctionalassessmentofanolderpersonshomeenvironment,whichstatementorquestionbythenurseismostappropriateregardingcommonenvironmentalhazards?a.Theselowtoiletseatsaresafebecausetheyarenearertothegroundincaseoffalls.b.Doyouhavearelativeorfriendwhocanhelptoinstallgrabbarsinyourshower?c.Thesesmallrugsareidealforpreventingyoufromslippingonthehardfloor.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)475STUVIA.COMd.Itwouldbesafertokeepthelightinglowinthisroomtoavoidglareinyoureyes.ANS:BEnvironmentalhazardswithinthehomecanbeapotentialconstraintontheolderpersonsday-to-dayfunctioning.Commonenvironmentalhazards,includinginadequatelighting,loosethrowrugs,curledcarpetedges,obstructedhallways,cordsinwalkways,lackofgrabbarsintubandshower,andlowandloosetoiletseats,arehazardsthatcouldleadtoanincreasedriskoffallsandfractures.Environmentalmodificationscanpromotemobilityandreducethelikelihoodoftheolderadultfalling.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:SafeandEffectiveCareEnvironment:SafetyandInfectionControl13.Whenbeginningtoassessapersonsspirituality,whichquestionbythenursewouldbemostappropriate?a.DoyoubelieveinGod?b.Howdoesyourspiritualityrelatetoyourhealthcaredecisions?c.Whatreligiousfaithdoyoufollow?d.Doyoubelieveinthepowerofprayer?ANS:BNURSINGTB.COMOpen-endedquestionsprovideafoundationforfuturediscussions.Theotherresponsesareeasilyansweredbyone-wordrepliesandareclosedquestions.DIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PsychosocialIntegrity14.Thenurseispreparingtoassessanolderadultanddiscoversthattheolderadultisinseverepain.Whichstatementaboutpainandtheolderadultistrue?a.Painisinevitablewithaging.b.Olderadultswithcognitiveimpairmentsfeellesspain.c.Alleviatingpainshouldbeapriorityoverotheraspectsoftheassessment.d.Theassessmentshouldtakeprioritysothatcaredecisionscanbemade.ANS:CIftheolderadultisexperiencingpainordiscomfort,thenthedepthofknowledgegatheredthroughtheassessmentswillsuffer.Alleviatingpainshouldbeapriorityoverotheraspectsoftheassessment.Rememberingthatolderadultswithcognitiveimpairmentdonotfeellesspainisparamount.PHYSICALEXAMINATIONANDHEALTHASSESSMENT9THEDITIONJARVISTESTBANKTestBank-PhysicalExaminationandHealthAssessment9e(byJarvis)476STUVIA.COMDIF:CognitiveLevel:Analyzing(Analysis)MSC:ClientNeeds:PhysiologicIntegrity:BasicCareandComfortMULTIPLERESPONSE1.Thenurseisassessingtheabilitiesofanolderadult.WhichactivitiesareconsideredIADLs?Selectallthatapply.a.Feedingoneselfb.Preparingamealc.Balancingacheckbookd.Walkinge.Toiletingf.GroceryshoppingANS:B,C,FTypically,IADLtasksincludeshopping,mealpreparation,housekeeping,laundry,managingfinances,takingmedications,andusingtransportation.TheothNeUroRpStIiNonGsTlBis.tCeOdMareADLsrelatedtoself-care.DIF:CognitiveLevel:Applying(Application)MSC:ClientNeeds:HealthPromotionandMaintenanceThanksforyourPurchase,andWelcometoourstore:Testsbanknursing.com