NUR 101 - Test 3 - Physical Assessment From Fundamentals Of Success

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Questions from Fundamental of Success by Patricia Nugent and Barbara Vitale


Questions and Answers
  • 1. 

    Most indicative of shock?

    • A.

      Hyperemia

    • B.

      Hypotension

    • C.

      Irregular pulse

    • D.

      Slow Respiration

    Correct Answer
    B. Hypotension
    Explanation
    a) During the compensatory stage of shock, blood is shunted away from, not toward, the periphery. Hyperemia is an increase in blood flow to an area where the overlying skin becomes reddened and warm.

    b) The circulating blood volume is reduced by 25 to 35% during the compensatory stage of shock and 35 to 50% during the progressive stage of shock as the peripheral vessels constrict to increase blood flow to vital organs. This shunting of blood causes hypotension

    c) With shock, the heart rate increases (tachycardia); it is not irregular. The heart rate increases during the compensatory stage of shock to maintain adequate blood flow to body tissues.

    d) During the compensatory stage of shock respiratory rate increases, not decreases, to maintain adequate oxygenation of body cells.

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  • 2. 

    When the patient has an irregular pulse the nurse should first monitor the pulse

    • A.

      At the carotid

    • B.

      With a doppler

    • C.

      For a full minute

    • D.

      At two different sites

    Correct Answer
    C. For a full minute
    Explanation
    a) The apical, not the carotid, pulse should be obtained when the pulse is irregular.

    b) This is unnecessary because a stethoscope is adequate.

    c) This is necessary to obtain an accurate count. Taking the pulse for 15 seconds and multiplying by 4 or taking the pulse for 30 seconds and multiplying by 2 will result in inaccurate readings and is unsafe.

    d) Initially the response should be to obtain an apical rate. Ultimately, the apical and radial rates are compared to determine if there is a pulse deficit.

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  • 3. 

    At what time of day could we have the highest temperature? 

    • A.

      12-2 am

    • B.

      6-8 am

    • C.

      4-6 pm

    • D.

      8-10 pm

    Correct Answer
    D. 8-10 pm
    Explanation
    a) The body temperature is on the decline during this time.
    b) The body temperature is just beginning to rise from its lowest level, which occurs between 4 and 6 AM.
    c) Although the body temperature is rising, it has not reached its peak at this time.
    d) Diurnal variations (circadian rhythms) vary throughout the day with the highest body temperature usually occurring between 8 PM and midnight.

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  • 4. 

    When assessing for borborygmi (noise caused by movement of gas in the intestines), which physical examination method  should be used? 

    • A.

      Auscultation

    • B.

      Percussion

    • C.

      Inspection

    • D.

      Palpation

    Correct Answer
    A. Auscultation
    Explanation
    Auscultation is the correct physical examination method to assess for borborygmi. Borborygmi refers to the noise caused by the movement of gas in the intestines, and auscultation involves listening to these sounds using a stethoscope. Percussion involves tapping on the body to assess underlying structures, inspection involves visually examining the body for any abnormalities, and palpation involves using touch to feel for abnormalities or assess the texture of organs. However, in the case of borborygmi, listening for the sounds with a stethoscope is the most appropriate method.

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  • 5. 

    A patient has a temperature of 102 degrees F and complains of feeling cold. Which additional adaptation would the nurse expect during this onset stage of fever?

    • A.

      Flushed skin

    • B.

      Dehydration

    • C.

      Diaphoresis

    • D.

      Shivering

    Correct Answer
    D. Shivering
    Explanation
    During the onset stage of fever, the body tries to increase its temperature to match the set point in the hypothalamus. Shivering is a physiological response to generate heat by increasing muscle activity. This additional adaptation helps to raise the body temperature.

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  • 6. 

    Method of examination to take a radial pulse

    • A.

      Palpation

    • B.

      Inspection

    • C.

      Percussion

    • D.

      Auscultation

    Correct Answer
    A. Palpation
    Explanation
    The correct answer is palpation because when taking a radial pulse, the examiner uses their fingers to feel the pulse at the radial artery, which is located on the inner wrist. This method allows the examiner to assess the rate, rhythm, and strength of the pulse. Inspection, percussion, and auscultation are not appropriate methods for assessing a radial pulse.

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  • 7. 

    Which nursing action is common to all instruments when taking a temperature?

    • A.

      Identify that the reading is below 96 degrees F before insertion

    • B.

      Wash with cool soap and water after use

    • C.

      Place a disposable sheath over the probe

    • D.

      Ensure that the instrument is clean

    Correct Answer
    D. Ensure that the instrument is clean
    Explanation
    The nursing action that is common to all instruments when taking a temperature is to ensure that the instrument is clean. This is a crucial step to prevent the spread of infection and ensure accurate readings. Keeping the instrument clean helps maintain hygiene standards and ensures the safety of the patient. It is important for nurses to follow proper cleaning protocols before and after using any instrument to maintain a sterile environment and minimize the risk of contamination.

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  • 8. 

    It would be most important to assess vital signs when a patient:...

    • A.

      Sits on the side of the bed after surgery for the first time

    • B.

      Finish ambulating in the hallway

    • C.

      Is coughing and sneezing

    • D.

      Complains of pressure in the chest

    Correct Answer
    D. Complains of pressure in the chest
    Explanation
    Assessing vital signs is important when a patient complains of pressure in the chest because it could be a symptom of a serious cardiac condition such as a heart attack. Monitoring vital signs such as blood pressure, heart rate, and oxygen saturation can provide crucial information about the patient's cardiovascular health and help determine the appropriate course of action.

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  • 9. 

    What is a defining characteristic associated with the nursing diagnosis of hyperthermia?

    • A.

      Mental confusion

    • B.

      Increased appetite

    • C.

      Decreased heart rate

    • D.

      Rectal temperature of 101 degrees Fahrenheit

    Correct Answer
    D. Rectal temperature of 101 degrees Fahrenheit
    Explanation
    A defining characteristic associated with the nursing diagnosis of hyperthermia is a rectal temperature of 101 degrees Fahrenheit. Hyperthermia refers to an elevated body temperature, and a rectal temperature of 101 degrees Fahrenheit indicates a fever. This symptom helps in identifying the nursing diagnosis of hyperthermia as it is a key indicator of increased body temperature. Mental confusion, increased appetite, and decreased heart rate are not specific defining characteristics associated with hyperthermia.

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  • 10. 

    Which assessment takes priority when engaging in an emergency assessment of a patient?

    • A.

      Blood pressure

    • B.

      Airway clearance

    • C.

      Breathing Pattern

    • D.

      Circulatory Status

    Correct Answer
    B. Airway clearance
    Explanation
    During an emergency assessment of a patient, airway clearance takes priority. This is because a clear and open airway is essential for the patient's breathing and overall survival. If the airway is blocked or compromised, it can lead to respiratory distress or failure. Therefore, ensuring the patient's airway is clear and unobstructed is the first and most crucial step in providing immediate care and support.

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  • 11. 

    What should the nurse do before obtaining a urine specimen from a patient with a urinary retention (Foley) catheter? 

    • A.

      Cleanse the exit tube at the bottom of the drainage bag with an alcohol swab

    • B.

      Clamp the tubing immediately distal to the collection port

    • C.

      Position the patient in a semi-Fowler's position

    • D.

      Wear a pair of clean gloves

    Correct Answer
    D. Wear a pair of clean gloves
    Explanation
    Before obtaining a urine specimen from a patient with a urinary retention (Foley) catheter, the nurse should wear a pair of clean gloves. Wearing gloves is necessary to maintain proper hygiene and prevent the spread of infection. It also helps to protect the nurse from any potential contact with bodily fluids during the procedure.

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  • 12. 

    Most important to document when taking a blood pressure. 

    • A.

      Staff member who took the blood pressure

    • B.

      Patient's tolerance to having the blood pressure taken

    • C.

      Position of the patient if the patient is not in a sitting position

    • D.

      Difference between the palpated and auscultated systolic readings

    Correct Answer
    C. Position of the patient if the patient is not in a sitting position
    Explanation
    When taking a blood pressure, it is important to document the position of the patient if the patient is not in a sitting position. This is because the position of the patient can affect the accuracy of the blood pressure reading. The standard position for measuring blood pressure is with the patient sitting upright with their arm supported at heart level. If the patient is in a different position, such as lying down or standing, it can lead to inaccurate readings. Therefore, documenting the position of the patient ensures that the blood pressure reading is taken correctly and can be accurately interpreted by healthcare providers.

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  • 13. 

    Which is a recommended cancer screening guideline for people?

    • A.

      Prostate-specific antigens yearly lor men 30 years of age and older

    • B.

      Mammograms annually for women 30 years of age and older

    • C.

      Pap smears annually for females 13 years of age and older

    • D.

      Sigmoidoscopies every 5 years for patients 50 years of age and older

    Correct Answer
    C. Pap smears annually for females 13 years of age and older
    Explanation
    Pap smears are recommended as a cancer screening guideline for females aged 13 and older. Pap smears are used to detect abnormal cells in the cervix, which can be an early sign of cervical cancer. Regular screening can help detect cervical cancer at an early stage when it is most treatable. Other options mentioned, such as prostate-specific antigens for men, mammograms for women, and sigmoidoscopies for patients, are not recommended as routine cancer screening guidelines for the general population.

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  • 14. 

    Which would increase heat production?

    • A.

      Vasodilation

    • B.

      Evaporation

    • C.

      Shivering

    • D.

      Radiation

    Correct Answer
    C. Shivering
    Explanation
    Shivering would increase heat production because it is a physiological response in which the muscles rapidly contract and relax to generate heat. This increased muscular activity generates heat, which helps to raise the body's temperature.

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  • 15. 

    Which series of vital signs is most reflective of hypovolemic shock?

    • A.

      P 100, R 24, BP 140/170

    • B.

      P 80, R 22, BP 110/80

    • C.

      P 60, R 20, BP 100/170

    • D.

      P 110, R 26, BP 80/60

    Correct Answer
    D. P 110, R 26, BP 80/60
    Explanation
    The series of vital signs P 110, R 26, BP 80/60 is most reflective of hypovolemic shock because the heart rate (P) is increased, the respiratory rate (R) is increased, and the blood pressure (BP) is decreased. In hypovolemic shock, there is a decrease in blood volume, which leads to a compensatory increase in heart rate and respiratory rate to try to maintain oxygen delivery to the body. The decreased blood pressure is a result of the decreased blood volume.

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  • 16. 

    Which pulse site should not be assessed on both sides of the body at the same time?

    • A.

      Radial

    • B.

      Carotid

    • C.

      Femoral

    • D.

      Brachial

    Correct Answer
    B. Carotid
    Explanation
    The carotid pulse site should not be assessed on both sides of the body at the same time because it is located in the neck, close to major blood vessels that supply blood to the brain. Assessing the carotid pulse on both sides simultaneously could potentially disrupt blood flow to the brain and cause dizziness or fainting. It is important to assess the carotid pulse on one side at a time to ensure accurate and safe measurements.

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  • 17. 

    Who would most likely have the highest temperature?

    • A.

      A newborn infant

    • B.

      A person with a blood infection

    • C.

      An adolescent who has been doing aerobic exercises

    • D.

      All older adult who just spent 10 minutes in a warm shower

    Correct Answer
    B. A person with a blood infection
    Explanation
    A person with a blood infection would most likely have the highest temperature because infections can cause the body to release chemicals that raise the body's temperature. This is known as a fever, which is a common symptom of many infections. Newborn infants and adolescents who have been doing aerobic exercises may also have slightly elevated temperatures, but a blood infection would likely cause a higher and more significant increase in body temperature. Older adults who have just spent 10 minutes in a warm shower may experience a temporary increase in body temperature, but it would not be as high as that of a person with a blood infection.

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  • 18. 

    A recurrence of symptoms associated with a chronic disease

    • A.

      Variance

    • B.

      Remission

    • C.

      Adaptation

    • D.

      Exacerbation

    Correct Answer
    D. Exacerbation
    Explanation
    Exacerbation refers to a worsening or flare-up of symptoms associated with a chronic disease. It is characterized by an increase in the severity or frequency of symptoms, which can be temporary or long-lasting. This term is commonly used in the medical field to describe the recurrence or intensification of symptoms in conditions such as asthma, arthritis, or multiple sclerosis. Therefore, exacerbation is the most appropriate term to describe the given scenario of a recurrence of symptoms associated with a chronic disease.

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  • 19. 

    A rectal temperature is used best for which of these patients?

    • A.

      A mouth breather

    • B.

      History of vomiting

    • C.

      An adult with an IQ of a 7 year old

    • D.

      Someone who cannot tolerate a semi-Fowler's position

    Correct Answer
    A. A mouth breather
    Explanation
    A rectal temperature is used best for a mouth breather because this method provides the most accurate measurement of core body temperature. Oral temperature may not be accurate for a mouth breather due to open mouth breathing, which can affect the reading. Rectal temperature is considered the gold standard for accurate core body temperature measurement as it reflects the internal temperature of the body.

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  • 20. 

    When assessing for cyanosis in a dark-skinned person, the nurse should assess the:

    • A.

      Sclera of the eyes

    • B.

      Nail beds of the toes

    • C.

      Lining of the eye lids

    • D.

      Color of the lower legs

    Correct Answer
    C. Lining of the eye lids
    Explanation
    In dark-skinned individuals, the color of the skin may not accurately reflect the presence of cyanosis. Therefore, assessing the lining of the eyelids is a more reliable method to detect cyanosis in these individuals. The lining of the eyelids is usually a lighter shade compared to the surrounding skin, making it easier to identify any bluish discoloration that may indicate cyanosis. This is an important assessment to make, as cyanosis can be a sign of inadequate oxygenation and can indicate a serious underlying health condition.

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  • 21. 

    What action could result in a blood pressure error?

    • A.

      Placing the diaphragm of the stethoscope over the brachial artery

    • B.

      Applying the center of the bladder of the cuff directly over an artery

    • C.

      Ensuring that the bladder of the cuff encircles less than 25% of the arm

    • D.

      Inserting the ear pieces of the stethoscope so that they tilt slightly forwards

    Correct Answer
    C. Ensuring that the bladder of the cuff encircles less than 25% of the arm
    Explanation
    Ensuring that the bladder of the cuff encircles less than 25% of the arm can result in a blood pressure error because it can lead to an inaccurate measurement. The bladder of the cuff needs to fully encircle the arm in order to accurately measure blood pressure. If it does not cover enough of the arm, the pressure reading may be lower than the actual blood pressure.

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Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.

  • Current Version
  • Mar 21, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Feb 18, 2013
    Quiz Created by
    Arnoldjr2
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