Nursing Assessment Winter

37 Questions

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Nursing Quizzes & Trivia

Winter week 2-13


Questions and Answers
  • 1. 
    Which statement is true regarding the eyes?
    • A. 

      There are 8 extraocular muscles attached to the eyeball and they are the superior oblique, inferior oblique, superior rectus, inferior rectus, medial rectus, lateral rectus, superior longus and inferior longus

    • B. 

      When the eyes move, the axes always remain parallel because the brain can only tolerate seeing one image

    • C. 

      The palpebral fissure is the border between the cornea and sclera

    • D. 

      There are 4 cranial nerves that stimulate the extraocular muscles and they are the cranial nerve VI, cranial IV, cranial III and cranial nerve II

  • 2. 
    The 3 concentric coats of the eye is the
    • A. 

      Sclera, cornea, and pupil

    • B. 

      Pupil, lens, and anterior/posterior chamber

    • C. 

      Sclera, choroid, and retina

    • D. 

      Lens, optic disc, and retinal vessels

  • 3. 
    The confrontation test 
    • A. 

      Compares the persons peripheral vision with your own, assuming yours is normal

    • B. 

      Assess the parallel alignment of the eye axes by shining a light toward the persons eye

    • C. 

      Detects small degrees of deviated alignment by interrupting the fusion reflex that normally keeps the two eyes parallel

    • D. 

      Tests muscle weakness during movement of the eye

  • 4. 
    Nerve impulses are carried from the eye to the brain by 
    • A. 

      Rods and cone cells

    • B. 

      Bipolar cells

    • C. 

      Cornea

    • D. 

      Optic nerve

  • 5. 
    Which part of the ear helps us maintain equilibrium so we do not stagger/spin?
    • A. 

      External ear

    • B. 

      Middle ear

    • C. 

      Inner ear

    • D. 

      Ear does not function this way

  • 6. 
    Which of these bones is not found in the middle ear?
    • A. 

      Ulmar

    • B. 

      Incus

    • C. 

      Malleus

    • D. 

      Stapes

  • 7. 
    Vertigo is 
    • A. 

      Genetically determined and comes in two types: dry vertigo, flaky and grey and frequently forms a thin mass in the ear canal, and wet vertigo that is honey brown and moist.

    • B. 

      A ringing and crackling, or buzzing in the ears

    • C. 

      The feeling that the room is spinning around/ yourself is spinning

    • D. 

      The coiled snail like shell in the inner ear which contains the central hearing apparatus

  • 8. 
    When inspecting Mr. K's, who is 37 year old, ears with and otoscope the nurse should
    • A. 

      Pull the pinna down

    • B. 

      Pull the pinna up and back

    • C. 

      Release traction once the otoscope is in the ear

    • D. 

      Never rotate the otoscope as this may cause injury to the ear canal

  • 9. 
    What are some objective data in regard to the breasts and regional lymphatics 
    • A. 

      Client says "I feel pain in my breast" "family history of breast cancer" and "im planning to breast feed"

    • B. 

      Slight asymmetry, no retraction, no dimpling, and no edema

    • C. 

      Ask questions, inspect the breast, palpate the breast, then teach breast self examination

    • D. 

      First move finger down the chest wall in aline from the middle of the axilla then along the anterior border of the axilla, then along the posterior border and finally along the inner aspect of the upper are

  • 10. 
    The tail of spence 
    • A. 

      Is in the upper outer quadrant

    • B. 

      Is the superior lateral corner of the breast tissue

    • C. 

      Is the beginning of menstruation.

    • D. 

      Is in the bottom medial corner of the breast tissue

  • 11. 
    The difference between the male breasts and female breasts is that: 
    • A. 

      The male breasts are the accessory reproductive organs

    • B. 

      The male breasts contain areola that is undeveloped and the nipple is larger

    • C. 

      The male breasts consist of think disk of undeveloped tissue under the nipple

    • D. 

      Males don't have breasts

  • 12. 
    Which of the four groups of axillary nodes receive lymph from the other three groups of nodes?
    • A. 

      Lateral

    • B. 

      Subscapular (posterior)

    • C. 

      Pectoral (anterior)

    • D. 

      Central axillary nodes

  • 13. 
    Where is most breast tumors found? 
    • A. 

      Upper outer quadrant

    • B. 

      Tail of spence

    • C. 

      Lower outer quadrant

    • D. 

      Upper inner quadrant

  • 14. 
    A supernumerary nipple is 
    • A. 

      An elevated nipple

    • B. 

      An inverted nipple

    • C. 

      An extra nipple

    • D. 

      A missing nipple

  • 15. 
    Who is at a higher risk for breast cancer?
    • A. 

      A female who started menopause at 44, is now 53. Her grandmother had breast cancer. She breast fed all her children.

    • B. 

      An obese female aged 60 states she went into menopause just last year and her mother had breast cancer.

    • C. 

      A female aged 20 who started menstruation at 14 whose grandmother had breast cancer

    • D. 

      A female in her 30s who started menstruation at 13, breast fed both her child, and is now drinking 3 cups of wine a week

  • 16. 
    Gynecomastia in male 
    • A. 

      Is an enlargement of the breast tissue

    • B. 

      Occurs during puberty

    • C. 

      Feels like a smooth firm movable disc

    • D. 

      All of the above

  • 17. 
    Which of the following are the solid viscera 
    • A. 

      Liver, stomach, kidneys, and intestine

    • B. 

      Bladder, colon, and gall bladder

    • C. 

      Bladder, stomach, and liver

    • D. 

      Kidneys, ovaries, spleen, and pancreas

  • 18. 
    When inspecting the clients abdomen the nurse should 
    • A. 

      Tell the patient to place his hands over the head to relax the abdomen

    • B. 

      Keep the room cool

    • C. 

      Tell the client to keep his bladder filled, allow for easier finding of the organs

    • D. 

      Distract the client

  • 19. 
    When inspecting the client skin, the nurse notices striae on the skin. Striae may occurs due to
    • A. 

      Scars from surgery

    • B. 

      Physical abuse

    • C. 

      Severe scratching of the skin

    • D. 

      Pregnancy

  • 20. 
    Organs that are located in the RUQ include 
    • A. 

      Right ovary and appendix

    • B. 

      Right kidney and spleen

    • C. 

      Stomach and spleen

    • D. 

      Liver and head of pancreas

  • 21. 
    What are the 3 central quadrants
    • A. 

      Xyphoid process, linea alba, symphysis pubis

    • B. 

      Epigastric, umbilical, suprapubic/hypogastric

    • C. 

      Aorta, uterus, bladder

    • D. 

      None of the above

  • 22. 
    What is the step in assessment of the abdomen?
    • A. 

      Inspect, auscultate, percuss, palpate

    • B. 

      Inspect, percuss, palpate, auscultate

    • C. 

      Percuss, palpate, auscultate, inspect

    • D. 

      Palpate, auscultate, inspect, percuss

  • 23. 
    Why is auscultation of the abdomen before percussion and palpation ?
    • A. 

      Auscultation of abdomen does not occur before percussion and palpation

    • B. 

      The stethoscope may become too cold and if used on the patient, it may tense up their abdomen

    • C. 

      Peristalsis may occur after auscultation and it'll make percussion and palpation easier

    • D. 

      It prevents distortion of the bowel sound that may occur after percussion or palpation

  • 24. 
    Select the correct statement regarding aging adults 
    • A. 

      Increased deposit of adipose tissue to the abdomen and hips

    • B. 

      Esophageal emptying is delayed

    • C. 

      Older people frequently report constipation

    • D. 

      All of the above

  • 25. 
    A nurse is conducting a complete health assessment on a client and notes his general appearance. Which of these are part of  general appearance?
    • A. 

      Weight, height, vision using snellen eye chart

    • B. 

      Appears stated age, skin colour, mobility

    • C. 

      Radial pulse, respiration, blood pressure

    • D. 

      All of the above

  • 26. 
    A nurse visits a family in there home who was earlier in rehab. She notices that the mother locked her child in the closest  and as he continues to cry she yells at him saying "If you do not behave I will send you away". This is an example of 
    • A. 

      Physical abuse

    • B. 

      Sexual abuse and exploitation

    • C. 

      Emotional abuse

    • D. 

      Neglect

  • 27. 
    When assessing for IPV (interpersonal violence) the nurse should A. Listen B.Anticipate abuse C. Assess collaboratively  D. Call the social work
    • A. 

      A and B

    • B. 

      B and C

    • C. 

      A, B, and C

    • D. 

      All of it

  • 28. 
    Clinical depression, acute and chronic symptom of anxierty; serious sleep disturbance, PTSD are examples of
    • A. 

      Direct effects of IPV

    • B. 

      Chronic physical health problems of IPV

    • C. 

      Mental health problems of IPV

    • D. 

      Indirect effects of IPV

  • 29. 
    You (the nurse) and a family are talking about circumcision for a new born. They wanted to know why the new born should get circumcised. You should tell them..
    • A. 

      It is recommended newborn should not get circumcised

    • B. 

      Hygiene practice would be easier

    • C. 

      It'll avoid later need for circumcision

    • D. 

      Early circumcision is a lower risk for complications such as sepsis

  • 30. 
    In order of first to last, what is the order for maturation of the male genitourinary system? 1.) Growth of hair over medial thigh, penis and scrotum is adult size 2.) sparse growth of hair over pubis, penis enlarge and scrotum is further enlarged 3.) Few straight hair at base of penis, little or no enlargement, testes and scrotum enlarge 4.) Vellus hair, pre adolecent size 5.) Thick growth of hair over pubic area, penis enlarge, and testes almost fully grown
    • A. 

      1,2,3,4,5

    • B. 

      4,3,2,5,1

    • C. 

      5,3,4,1,2

    • D. 

      3,4,2,1,5

  • 31. 
    Which of these statement regarding the anal canal is true?
    • A. 

      It lies in Front of the anterior wall of the rectum and 2 cm behind the symphysis pubis

    • B. 

      It is about 3.8 cm long in the adult

    • C. 

      It is 12 cm long

    • D. 

      They are folds of mucosa

  • 32. 
    What is/are the position(s) for rectal exam?
    • A. 

      Left lateral and Breech

    • B. 

      Standing, Right lateral, and Breech

    • C. 

      Standing, lithotomy and left lateral

    • D. 

      Lithotomy and Right lateral

  • 33. 
    A female is doing a physical examination of her female genitourinary system. The nurse notes adult hair type in a small area. Which state of growth is this female in?
    • A. 

      Stage 2

    • B. 

      Stage 3

    • C. 

      Stage 4

    • D. 

      Stage 5

  • 34. 
    When estrogen level decline, it reduces the amount of vaginal secretion and lubrication. This is a physiological change of which phase?
    • A. 

      Plateau

    • B. 

      Resolution

    • C. 

      Orgasm

    • D. 

      Excitement

  • 35. 
    The nurse is assessing Mrs. L who is pregnant and Mrs. L states she has decrease feeling of nausea, vomiting, fatigue and urinary frequency. Mrs. L also notices that the veins in her breast is becoming more visible. Which stage of pregnancy is this?
    • A. 

      First trimester

    • B. 

      Second trimester

    • C. 

      Third trimester

    • D. 

      Fourth trimester

  • 36. 
    During assessment, the nurse performs Leopold's maneouvre to determine fetal lie, presentation, attitude, position, variety, and engagement. The first manouvre 
    • A. 

      Assists in determining engagement and , in the vertex presentation, to differentiate shoulder from vertex

    • B. 

      Also called pawlik's manoeuvre, requires the women to bend her knees up slightly

    • C. 

      Is performed by facing the woman's head and placing your finger tips around the top of the fundus

    • D. 

      Feels the side of the uterus, noting whether small parts or a long, firm surface are palpable on the woman's left or right side.

  • 37. 
    When assessing the clients skin, you note the presense of a linea nigra. Linea nigra is/are
    • A. 

      A butterfly shaped pigmentation on the face

    • B. 

      A hyper pigmented line that begins at the sternal notch and extends down the abdomen through the umbilicus to pubis

    • C. 

      Stretch marks in area of weight gain, particularly on the abdomen and breasts

    • D. 

      Silvery grey lines located over the abdomen and breasts