Physical Assessment, Part II, 50

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Physical Assessment, Part II, 50 - Quiz

From Foundations of Nursing by Christensen Kockrow, pages 93 through 120.


Questions and Answers
  • 1. 

    The consumption of alcohol, tobacco, caffeine, or herbal products are important in health history and which are part of what?

    • A.

      Illegal activity

    • B.

      Habits and lifestyle patterns

    • C.

      Fun and pleasure

    • D.

      Rest and recreation

    Correct Answer
    B. Habits and lifestyle patterns
    Explanation
    page 104

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  • 2. 

    Which of the following are true regarding cultural sensitivity

    • A.

      All members of one cultural group behave in exactly the same manner

    • B.

      As a nurse, it is important to identify and examine our own cultural and ethnic beliefs

    • C.

      Cultural and ethnic diversity have no impact in health care

    • D.

      Patient's response to signs and symptoms are independent of their cultural values

    Correct Answer
    B. As a nurse, it is important to identify and examine our own cultural and ethnic beliefs
    Explanation
    page 104

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  • 3. 

    We know that the nurse knows the right time to do a physical assessment when she says:

    • A.

      "I will do it as soon as possible"

    • B.

      "I think the next shift will have to do it"

    • C.

      "After I give the medication"

    • D.

      "Maybe later, when I am done with others"

    Correct Answer
    A. "I will do it as soon as possible"
    Explanation
    page 106

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  • 4. 

    The difference between a "head to toe" assessment and a "focused assessment"

    • A.

      Head to toe is systemic while focused concentrates on regional parts

    • B.

      Head to toe is completed when the patient is admitted; focused concentrates on a particular part of a body

    • C.

      Head to toe is done on every shift while focused is done when the person is admitted

    • D.

      Both RN's and LPN's should do head to toe assessments as well as focused assessments

    Correct Answer
    B. Head to toe is completed when the patient is admitted; focused concentrates on a particular part of a body
    Explanation
    page 106 When to perform a Nursing Physical Assessment

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  • 5. 

    The nurse tells a 75 year old patient that she will have to do a "head to toe" assessment on him. The patient asks, "what is that"? Her best answer would be ...

    • A.

      I will need to determine the etiology of any pathologic symptoms you might have.

    • B.

      Oh nothing, it is just something that we do.

    • C.

      It is a way for us to know how we are going to take care of you later

    • D.

      Maybe you can tell me how you got here.

    Correct Answer
    C. It is a way for us to know how we are going to take care of you later
    Explanation
    page 106 - Older Adults - Why do you think this is the right answer? Simplicity, clarity and directness of response.

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  • 6. 

    A person who is just being admitted complains of pain on his right foot. What is the proper way to provide this patient a proper physical assessment?  

    • A.

      Do a focused assessment on the foot first and do the complete physical assessment later

    • B.

      If a complete physical assessment is necessary, it is best to assess any painful areas last.

    • C.

      Focus on the pain and provide comfort before anything else.

    • D.

      Since the patient is a new admit, concentrate on the general physical assesment only

    Correct Answer
    B. If a complete physical assessment is necessary, it is best to assess any painful areas last.
    Explanation
    page 106, Methods of performing a nursing physical assessment

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  • 7. 

    In the interview portion of the physical assessment, since we are not actually touching the patient, there is no need to wash our hands. 

    • A.

      True

    • B.

      False

    Correct Answer
    B. False
    Explanation
    page 107, Always wash your hands before beginning the physical assessment. The interview portion is only a portion of the physical assessment. After or during the interview, the rest of the physical assessment process will require contact.

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  • 8. 

    Before the beginning of a physical examination, to make the patient more comfortable, what should be done first

    • A.

      Give patient a warm blanket

    • B.

      Ask if patient wants a glass of water

    • C.

      Offer patient to empty his/her bladder

    • D.

      Provide a small

    Correct Answer
    C. Offer patient to empty his/her bladder
    Explanation
    page 107

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  • 9. 

    When performing a head-to-toe assessment, we normally begin with a neurologic assessment . What is the next? 

    • A.

      Skin, hair, head and neck including eyes, ear, nose and mouth

    • B.

      Chest, back, arm, abdomen

    • C.

      Perineal area, legs and feet

    • D.

      Eyes and ears alone

    Correct Answer
    A. Skin, hair, head and neck including eyes, ear, nose and mouth
    Explanation
    page 107

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  • 10. 

    Which of the following are included in the neurologic assessment?

    • A.

      Motor function

    • B.

      Range of motion

    • C.

      Level of consiousness

    • D.

      Pupillary response

    Correct Answer(s)
    A. Motor function
    C. Level of consiousness
    D. Pupillary response
    Explanation
    page 107-109

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  • 11. 

    In the mnemonic used for assessments, what does PS stand for in ABC in and out, PS? 

    • A.

      Painful sensation

    • B.

      Problem and solution

    • C.

      Pain and safety

    • D.

      Pernicious stimulation

    Correct Answer
    C. Pain and safety
    Explanation
    page 108

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  • 12. 

    PERRLA refers to 

    • A.

      Motor function

    • B.

      Order of assessment

    • C.

      Level of consciousness

    • D.

      Pupillary response

    Correct Answer
    D. Pupillary response
    Explanation
    page 109

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  • 13. 

    A neurologic examination pertaining to the sensations of body movements and awareness of posture and cerebellar function

    • A.

      Deep tendon reflexes

    • B.

      Proprioception

    • C.

      Cranial nerve assessment

    • D.

      Pupillary reflex

    Correct Answer
    B. Proprioception
    Explanation
    page 109

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  • 14. 

    Vital signs are reliable even when there is a central nervous system deficit. 

    • A.

      True

    • B.

      False

    Correct Answer
    B. False
    Explanation
    Pulse and Blood pressure are not reliable indicators of central nervous system deficits. page 109

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  • 15. 

    What do the signs and symptoms of Cushing's triad include? They are typical of someone who had traumatic brain injury 

    • A.

      Increase in systolic blood pressure

    • B.

      Bradycardia

    • C.

      Irregular breathing pattern

    • D.

      Widening pulse pressure

    Correct Answer(s)
    A. Increase in systolic blood pressure
    B. Bradycardia
    C. Irregular breathing pattern
    D. Widening pulse pressure
    Explanation
    page 109

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  • 16. 

    Standardized objective measurement of the level of consiousness

    • A.

      Glasgow Coma Scale

    • B.

      PERRLA

    • C.

      Rhomberg Test

    • D.

      Motor function assessment

    Correct Answer
    A. Glasgow Coma Scale
    Explanation
    page 109

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  • 17. 

    A patient has just been admitted. During physical assessment, it was observed that patient had decreased skin turgor  and dried  outer lips. What would be the most appropriate thing to offer this patient while the physical assessment is going on?

    • A.

      A chair to sit on

    • B.

      Medication

    • C.

      Water

    • D.

      Some snacks

    Correct Answer
    C. Water
    Explanation
    pate 109. The patient is showing signs of dehydration as manifested by decreased skin turgor.

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  • 18. 

    A patient with increased turgor in his lower extremities manifested by smooth, taut, shiny skin that cannot be grasped or raised is most likely to have: 

    • A.

      Enema

    • B.

      Decubitus

    • C.

      Edema

    • D.

      Infection

    Correct Answer
    C. Edema
    Explanation
    page 109

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  • 19. 

    Abnormal swishing sounds heard over organs, glands and arteries and results from an abnormality in an artery resulting from narrow or partially occluded artery such as those in atherosclerosis

    • A.

      Thrill

    • B.

      Crackles

    • C.

      Bruits

    • D.

      Wheezes

    Correct Answer
    C. Bruits
    Explanation
    page 110

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  • 20. 

    A vibrating sensation perceived when an artery is palpated and is not expected when examining a carotid pulse. 

    • A.

      Bruit

    • B.

      Thrill

    • C.

      Crackles

    • D.

      Rhonci

    Correct Answer
    B. Thrill
    Explanation
    page 110

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  • 21. 

    An abnormal cycle of respiration that begin with slow, shallow respiration that become rapid, then become slower and are followed by periods of apnea (20 seconds). Normally caused by hear failure, opioid overdose, renal failure, meningitis, and severe head ache. 

    • A.

      Kussmaul

    • B.

      Cheyne-stokes

    • C.

      Botte's

    • D.

      Whooping sneeze

    Correct Answer
    B. Cheyne-stokes
    Explanation
    page 110

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  • 22. 

    Indicative of acute or chronic respiratory distress

    • A.

      Height

    • B.

      Posture

    • C.

      Weight

    • D.

      Hair loss

    Correct Answer
    B. Posture
    Explanation
    page 110

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  • 23. 

    Teaching patients to perform breast self-exams is only directly related to females

    • A.

      True

    • B.

      False

    Correct Answer
    B. False
    Explanation
    page 111 - Breast self-exams is related to both males and females

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  • 24. 

    When auscultating for lung sounds, which part of the stethoscope is designed to transmit the higher pitch of abnormal sounds 

    • A.

      Ear piece

    • B.

      Bell

    • C.

      Diaphragm

    • D.

      Tubes

    Correct Answer
    C. Diaphragm
    Explanation
    page 111

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  • 25. 

    When doing a respiratory assessment to a patient, which of the following is the most appropriate technique? 

    • A.

      Use a stethoscope over the clothing of a patient who feels cold

    • B.

      Instruct patient to breathe through his or her mouth quietly and more deeply and slowly than in a usual respiration

    • C.

      Allow a patient with a slight lower back pain to lie supine on bed

    • D.

      Listen to the heart sound at the same time that your are listening to the lung sounds

    Correct Answer
    B. Instruct patient to breathe through his or her mouth quietly and more deeply and slowly than in a usual respiration
    Explanation
    page 111

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  • 26. 

    When auscultating for lung sounds, place the stethoscope  firmly and tightly on the skin, and listen for one full inspiratory-expiratory cycle at each point.  

    • A.

      True

    • B.

      False

    Correct Answer
    B. False
    Explanation
    firmly, but not tightly ...page 111

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  • 27. 

    Rubbing, grating or squeaky sound upon auscultation; as if two pieces of leather are being rubbed together

    • A.

      Pulmonary friction

    • B.

      Pleural friction rub

    • C.

      Pulmonary bruising

    • D.

      Whooping cough

    Correct Answer
    B. Pleural friction rub
    Explanation
    page 112

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  • 28. 

    Exaggeration of the posterior curvature of the thoracic spine

    • A.

      Spina Bifida

    • B.

      Kyphosis

    • C.

      Lordosis

    • D.

      Scoliosis

    Correct Answer
    B. Kyphosis
    Explanation
    page 113

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  • 29. 

    A swayback, an increased lumbar curvature

    • A.

      Spina Bifida

    • B.

      Kyphosis

    • C.

      Lordosis

    • D.

      Scoliosis

    Correct Answer
    C. Lordosis
    Explanation
    page 113

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  • 30. 

    Lateral spinal curvature

    • A.

      Spina Bifida

    • B.

      Kyphosis

    • C.

      Lordosis

    • D.

      Scoliosis

    Correct Answer
    D. Scoliosis
    Explanation
    page 113

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  • 31. 

    Lubb-dubb is caused by

    • A.

      Closure of the atrioventricular and semilunar valves respectively

    • B.

      Closure of the semilunar and atrioventricular valves respectively

    • C.

      Closure of the atrioventricular and semilunar valves simultaneously

    • D.

      Closure of the atrioventricular valve and opening of the semilunar valve respectively

    Correct Answer
    A. Closure of the atrioventricular and semilunar valves respectively
    Explanation
    page 113

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  • 32. 

    The first normal heart sound S1 occurs when? 

    • A.

      Closure of the AV valves and signals the start of systole

    • B.

      Closure of the AV valves and signals the end of systole

    • C.

      Opening of the AV valves and signals the start of systole

    • D.

      Opening of the AV valves and signlas the end of systole

    Correct Answer
    A. Closure of the AV valves and signals the start of systole
    Explanation
    page 113

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  • 33. 

    Where is S1 auscultated most clearly?

    • A.

      Apex of the heart

    • B.

      Base of heart

    • C.

      Around the heart

    • D.

      All over the heart

    Correct Answer
    A. Apex of the heart
    Explanation
    page 113

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  • 34. 

    When does normal heart sound S2 occur?

    • A.

      With the closure of the AV valve and signals the end of systole

    • B.

      With the opening of the AV valve and signals opening of systole

    • C.

      With the opening of the semilunar valves and signals the beginning of systole.

    • D.

      With the closure of the semilunar valves and signals the end of systole

    Correct Answer
    D. With the closure of the semilunar valves and signals the end of systole
    Explanation
    page 113

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  • 35. 

    Where is S2 auscultated more clearly?

    • A.

    Explanation
    page 113

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  • 36. 

    Heard in patients with coronary artery disease after MI (myocardial infarction), heard late in diastole when the atria contracts. 

    • A.

      S1

    • B.

      S2

    • C.

      S3

    • D.

      S4

    Correct Answer
    D. S4
    Explanation
    page 113

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  • 37. 

    Which of the following is not a peripheral pulse?

    • A.

      Ulnar

    • B.

      Femoral

    • C.

      Brachial

    • D.

      Humoral

    Correct Answer
    D. Humoral
    Explanation
    page 114

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  • 38. 

    This happens when there is a decreased supply of oxygenated blood to the tissues often caused by a narrowing of an artery 

    • A.

      Ischemia

    • B.

      Claudication

    • C.

      Hypoventilation

    • D.

      Atelactesis

    Correct Answer
    A. Ischemia
    Explanation
    page 114

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  • 39. 

    Cramp-like pain in the lower extremities usually after walking

    • A.

      Ischemia

    • B.

      Claudication

    • C.

      Hypoventilation

    • D.

      Atelactesis

    Correct Answer
    B. Claudication
    Explanation
    page 114

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  • 40. 

    In person with good cardiac function and distal perfusion, how long should a capillary refill take place?   

    • A.

      Less than 3 seconds

    • B.

      More than 3 seconds

    • C.

      More than 5 seconds

    • D.

      Around 5 seconds

    Correct Answer
    A. Less than 3 seconds
    Explanation
    page 115

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  • 41. 

    Which of the following is not a symptom? 

    • A.

      Soreness

    • B.

      Pruritus

    • C.

      Flatus

    • D.

      Pain

    Correct Answer
    C. Flatus
    Explanation
    page 115

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  • 42. 

    Two significant alterations in bowel sounds:

    • A.

      Decreased and increased bowel sounds

    • B.

      Loud and quiet bowel sounds

    • C.

      Fetid and scentless bowel sounds

    • D.

      Noisy and loud bowel sounds

    Correct Answer
    A. Decreased and increased bowel sounds
    Explanation
    page 116

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