. JARVIS TESTBANK... All Combined—Jarvis Final Exam. Test Bank Questions and answers. All Examinable Quizzes.

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All Combined—Jarvis Final Exam. Test Bank Questions and answers. All Examinable Quizzes. The nurse is preparing to conduct a health history. Which of these statements best describes the purp... ose of a health history? a. To provide an opportunity for interaction between the patient and the nurse b. To provide a form for obtaining the patients biographic information c. To document the normal and abnormal findings of a physical assessment d. To provide a database of subjective information about the patients past and current health - ✔✔D When the nurse is evaluating the reliability of a patients responses, which of these statements would be correct? The patient: a. Has a history of drug abuse and therefore is not reliable. b. Provided consistent information and therefore is reliable. c. Smiled throughout interview and therefore is assumed reliable. d. Would not answer questions concerning stress and therefore is not reliable. - ✔✔B A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having black stools for the last 24 hours. How would the nurse best document his reason for seeking care? a. J.M. is a 59-year-old man seeking treatment for ulcerative colitis. b. J.M. came into the clinic complaining of having black stools for the past 24 hours. c. J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it checked. d. J.M. is a 59-year-old man who states that he has been having black stools for the past 24 hours. - ✔✔D A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurses best response? a. Can you point to where it hurts? b. Well talk more about that later in the interview. c. What have you had to eat in the last 24 hours? d. Have you ever had any surgeries on your abdomen? - ✔✔A A 29-year-old woman tells the nurse that she has excruciating pain in her back. Which would be the nurses appropriate response to the womans statement? a. How does your family react to your pain? b. The pain must be terrible. You probably pinched a nerve. c. Ive had back pain myself, and it can be excruciating. d. How would you say the pain affects your ability to do your daily activities? - ✔✔D In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate? a. Patient denies usual childhood illnesses. b. Patient states he was a very healthy child. c. Patient states his sister had measles, but he didnt. d. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat. - ✔✔D A female patient tells the nurse that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the nurse record this information? a. P-6, B-4, (S)Ab-2 b. Grav 6, Term 4, (S)Ab-2, Living 4 c. Patient has had four living babies. d. Patient has been pregnant six times. - ✔✔B A patient tells the nurse that he is allergic to penicillin. What would be the nurses best response to this information? a. Are you allergic to any other drugs? b. How often have you received penicillin? c. Ill write your allergy on your chart so you wont receive any penicillin. d. Describe what happens to you when you take penicillin. - ✔✔D The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include: a. Emphysema. b. Head trauma. c. Mental illness. d. Fractured bones. - ✔✔C The review of systems provides the nurse with: a. Physical findings related to each system. b. Information regarding health promotion practices. c. An opportunity to teach the patient medical terms. d. Information necessary for the nurse to diagnose the patients medical problem. - ✔✔B Which of these statements represents subjective data the nurse obtained from the patient regarding the patients skin? a. Skin appears dry. b. No lesions are obvious. c. Patient denies any color change. d. Lesion is noted on the lateral aspect of the right arm. - ✔✔C The nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient? a. Do you perform testicular self-examinations? b. Have you ever noticed any pain in your testicles? c. Have you had any problems with passing urine? d. Do you have any history of sexually transmitted diseases? - ✔✔A Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast? a. I broke my right leg in a car accident 2 weeks ago. b. The pain is decreasing, but I still need to take acetaminophen. c. I check the color of my toes every evening just like I was taught. d. Im able to transfer myself from the wheelchair to the bed without help. - ✔✔D In response to a question about stress, a 39-year-old woman tells the nurse that her husband and mother both died in the past year. Which response by the nurse is most appropriate? a. This has been a difficult year for you. b. I dont know how anyone could handle that much stress in 1 year! c. What did you do to cope with the loss of both your husband and mother? d. That is a lot of stress; now lets go on to the next section of your history. - ✔✔C In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information? a. This information is necessary to determine the patients reliability. b. Alcohol can interact with all medications and can make some diseases worse. c. The nurse needs to be able to teach the patient about the dangers of alcohol use. d. This information is not necessary unless a drinking problem is obvious. - ✔✔B The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response? a. Maybe she is just teething. b. I will check her ear for an ear infection. c. Are you sure she is really having pain? d. Describe what she is doing to indicate she is having pain. - ✔✔D During an assessment of a patients family history, the nurse constructs a genogram. Which statement best describes a genogram? a. List of diseases present in a persons near relatives b. Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family members c. Drawing that depicts the patients family members up to five generations back d. Description of the health of a persons children and grandchildren - ✔✔B A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure? a. Childs birth weight b. Age at which he crawled c. Whether the child has had the measles d. Childs reactions to previous hospitalizations - ✔✔D As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at 15 months of age. What recommendation should the nurse make? a. No further MMR immunizations are needed. b. MMR vaccination needs to be repeated at 4 to 6 years of age. c. MMR immunization needs to be repeated every 4 years until age 21 years. d. A recommendation cannot be made until the physician is consulted. - ✔✔B In obtaining a review of systems on a healthy 7-year-old girl, the health care provider knows that it would be important to include the: a. Last glaucoma examination. b. Frequency of breast self-examinations. c. Date of her last electrocardiogram. d. Limitations related to her involvement in sports activities. - ✔✔D When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of the assessment is being performed? a. Family history b. Review of systems c. Functional assessment d. Reason for seeking care - ✔✔C The nurse is obtaining a health history on an 87-year-old woman. Which of the following areas of questioning would be most useful at this time? a. Obstetric history b. Childhood illnesses c. General health for the past 20 years d. Current health promotion activities - ✔✔D The nurse is performing a review of systems on a 76-year-old patient. Which of these statements is correct for this situation? a. The questions asked are identical for all ages. b. The interviewer will start incorporating different questions for patients 70 years of age and older. c. Questions that are reflective of the normal effects of aging are added. d. At this age, a review of systems is not necessarythe focus should be on current problems. - ✔✔C A 90-year-old patient tells the nurse that he cannot remember the names of the medications he is taking or for what reason he is taking them. An appropriate response from the nurse would be: a. Can you tell me what they look like? b. Dont worry about it. You are only taking two medications. c. How long have you been taking each of the pills? d. Would you have a family member bring in your medications? - ✔✔D The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask? a. Do you wear glasses? b. Are you able to dress yourself? c. Do you have any thyroid problems? d. How many times a day do you have a bowel movement? - ✔✔B The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? a. The functional assessment assesses how the individual is coping with life at home. b. It determines how children are meeting developmental milestones. c. The functional assessment can identify any problems with memory the individual may be experiencing. d. It helps determine how a person is managing day-to-day activities. - ✔✔D The nurse is asking a patient for his reason for seeking care and asks about the signs and symptoms he is experiencing. Which of these is an example of a symptom? a. Chest pain b. Clammy skin c. Serum potassium level at 4.2 mEq/L d. Body temperature of 100 F - ✔✔A A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms? a. It is a sharp, burning pain in my stomach. b. I also have the sweats and nausea when I feel this pain. c. I think this pain is telling me that something bad is wrong with me. d. This pain happens every time I sit down to use the computer. - ✔✔D During an assessment, the nurse uses the CAGE test. The patient answers yes to two of the questions. What could this be indicating? a. The patient is an alcoholic. b. The patient is annoyed at the questions. c. The patient should be thoroughly examined for possible alcohol withdrawal symptoms. d. The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment. - ✔✔D The nurse is incorporating a persons spiritual values into the health history. Which of these questions illustrates the community portion of the FICA (faith and belief, importance and influence, community, and addressing or applying in care) questions? a. Do you believe in God? b. Are you a part of any religious or spiritual congregation? c. Do you consider yourself to be a religious or spiritual person? d. How does your religious faith influence the way you think about your health? - ✔✔B The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins? a. Please stay during the interview; you can answer for her if she does not know the answer. b. It would help to interview the three of you together. c. While I interview your daughter, will you please stay in the room and complete these family health history questionnaires? d. While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires? - ✔✔D The nurse is assessing a new patient who has recently immigrated to the United States. Which question is appropriate to add to the health history? a. Why did you come to the United States? b. When did you come to the United States and from what country? c. What made you leave your native country? d. Are you planning to return to your home? - ✔✔B The nurse is conducting an interview with a woman who has recently learned that she is pregnant and who has come to the clinic today to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs loudly. Considering the concept of communication, which statement does the nurse know to be most accurate? The woman is: a. Excited about her pregnancy but nervous about the labor. b. Exhibiting verbal and nonverbal behaviors that do not match. c. Excited about her pregnancy, but her husband is not and this is upsetting to her. d. Not excited about her pregnancy but believes the nurse will negatively respond to her if she states this. - ✔✔B Receiving is a part of the communication process. Which receiver is most likely to misinterpret a message sent by a health care professional? a. Well-adjusted adolescent who came in for a sports physical b. Recovering alcoholic who came in for a basic physical examination c. Man whose wife has just been diagnosed with lung cancer d. Man with a hearing impairment who uses sign language to communicate and who has an interpreter with him - ✔✔C The nurse makes which adjustment in the physical environment to promote the success of an interview? a. Reduces noise by turning off televisions and radios b. Reduces the distance between the interviewer and the patient to 2 feet or less c. Provides a dim light that makes the room cozy and helps the patient relax d. Arranges seating across a desk or table to allow the patient some personal space - ✔✔A In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking? a. Note-taking may impede the nurses observation of the patients nonverbal behaviors. b. Note-taking allows the patient to continue at his or her own pace as the nurse records what is said. c. Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level. d. Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort. - ✔✔A The nurse asks, I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here. This question is found at the __________ phase of the interview process. a. Summary b. Closing c. Body d. Opening or introduction - ✔✔D A woman has just entered the emergency department after being battered by her husband. The nurse needs to get some information from her to begin treatment. What is the best choice for an opening phase of the interview with this patient? a. Hello, Nancy, my name is Mrs. C. b. Hello, Mrs. H., my name is Mrs. C. It sure is cold today! c. Mrs. H., my name is Mrs. C. How are you? d. Mrs. H., my name is Mrs. C. Ill need to ask you a few questions about what happened. - ✔✔D During an interview, the nurse states, You mentioned having shortness of breath. Tell me more about that. Which verbal skill is used with this statement? a. Reflection b. Facilitation c. Direct question d. Open-ended question - ✔✔D A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data? a. Mr. Y., at your age, surely you have been hospitalized before! b. Mr. Y., I just need permission to get your medical records from County Medical. c. Mr. Y., you mentioned that you have been hospitalized on several occasions. Would you tell me more about that? d. Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain? - ✔✔D In using verbal responses to assist the patients narrative, some responses focus on the patients frame of reference and some focus on the health care providers perspective. An example of a verbal response that focuses on the health care providers perspective would be: a. Empathy. b. Reflection. c. Facilitation. d. Confrontation. - ✔✔D When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurses best response to this behavior? a. Be silent, and allow him to continue when he is ready. b. Smile at him and say, Dont worry about all of this. Im sure we can find out why youre having these pains. c. Lean back in the chair and ask, You are looking at me kind of funny; there isnt anything wrong, is there? d. Stand up and say, I can see that this interview is uncomfortable for you. We can continue it another time. - ✔✔A A woman is discussing the problems she is having with her 2-year-old son. She says, He wont go to sleep at night, and during the day he has several fits. I get so upset when that happens. The nurses best verbal response would be: a. Go on, Im listening. b. Fits? Tell me what you mean by this. c. Yes, it can be upsetting when a child has a fit. d. Dont be upset when he has a fit; every 2 year old has fits. - ✔✔B A 17-year-old single mother is describing how difficult it is to raise a 3-year-old child by herself. During the course of the interview she states, I cant believe my boyfriend left me to do this by myself! What a terrible thing to do to me! Which of these responses by the nurse uses empathy? a. You feel alone. b. You cant believe he left you alone? c. It must be so hard to face this all alone. d. I would be angry, too; raising a child alone is no picnic. - ✔✔C A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, I quit smoking after my wife died 7 years ago. However, the nurse notices an open pack of cigarettes in his shirt pocket. Using confrontation, the nurse could say: a. Mr. K., I know that you are lying. b. Mr. K., come on, tell me how much you smoke. c. Mr. K., I didnt realize your wife had died. It must be difficult for you at this time. Please tell me more about that. d. Mr. K., you have said that you dont smoke, but I see that you have an open pack of cigarettes in your pocket. - ✔✔D The nurse has used interpretation regarding a patients statement or actions. After using this technique, it would be best for the nurse to: a. Apologize, because using interpretation can be demeaning for the patient. b. Allow time for the patient to confirm or correct the inference. c. Continue with the interview as though nothing has happened. d. Immediately restate the nurses conclusion on the basis of the patients nonverbal response. - ✔✔B During an interview, a woman says, I have decided that I can no longer allow my children to live with their fathers violence, but I just cant seem to leave him. Using interpretation, the nurses best response would be: a. You are going to leave him? b. If you are afraid for your children, then why cant you leave? c. It sounds as if you might be afraid of how your husband will respond. d. It sounds as though you have made your decision. I think it is a good one. - ✔✔C A pregnant woman states, I just know labor will be so painful that I wont be able to stand it. I know it sounds awful, but I really dread going into labor. The nurse responds by stating, Oh, dont worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain. Which statement is true regarding this response? The nurses reply was a: a. Therapeutic response. By sharing something personal, the nurse gives hope to this woman. b. Nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the womans fears. c. Therapeutic response. By providing information about the medications available, the nurse is giving information to the woman. d. Nontherapeutic response. The nurse is essentially giving the message to the woman that labor cannot be tolerated without medication. - ✔✔B . During a visit to the clinic, a patient states, The doctor just told me he thought I ought to stop smoking. He doesnt understand how hard Ive tried. I just dont know the best way to do it. What should I do? The nurses most appropriate response in this case would be: a. Id quit if I were you. The doctor really knows what he is talking about. b. Would you like some information about the different ways a person can quit smoking? c. Stopping your dependence on cigarettes can be very difficult. I understand how you feel. d. Why are you confused? Didnt the doctor give you the information about the smoking cessation program we offer? - ✔✔B As the nurse enters a patients room, the nurse finds her crying. The patient states that she has just found out that the lump in her breast is cancer and says, Im so afraid of, um, you know. The nurses most therapeutic response would be to say in a gentle manner: a. Youre afraid you might lose your breast? b. No, Im not sure what you are talking about. c. Ill wait here until you get yourself under control, and then we can talk. d. I can see that you are very upset. Perhaps we should discuss this later. - ✔✔A A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, You dont smoke, drink, or take drugs, do you? This question is an example of: a. Talking too much. b. Using confrontation. c. Using biased or leading questions. d. Using blunt language to deal with distasteful topics. - ✔✔C When observing a patients verbal and nonverbal communication, the nurse notices a discrepancy. Which statement is true regarding this situation? The nurse should: a. Ask someone who knows the patient well to help interpret this discrepancy. b. Focus on the patients verbal message, and try to ignore the nonverbal behaviors. c. Try to integrate the verbal and nonverbal messages and then interpret them as an average. d. Focus on the patients nonverbal behaviors, because these are often more reflective of a patients true feelings. - ✔✔D During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his sons treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This changed posture would suggest that the parent is: a. Simply changing positions. b. More comfortable in this position. c. Tired and needs a break from the interview. d. Uncomfortable talking about his sons treatment. - ✔✔D A mother brings her 28-month-old daughter into the clinic for a well-child visit. At the beginning of the visit, the nurse focuses attention away from the toddler, but as the interview progresses, the toddler begins to warm up and is smiling shyly at the nurse. The nurse will be most successful in interacting with the toddler if which is done next? a. Tickle the toddler, and get her to laugh. b. Stoop down to her level, and ask her about the toy she is holding. c. Continue to ignore her until it is time for the physical examination. d. Ask the mother to leave during the examination of the toddler, because toddlers often fuss less if their parent is not in view. - ✔✔B During an examination of a 3-year-old child, the nurse will need to take her blood pressure. What might the nurse do to try to gain the childs full cooperation? a. Tell the child that the blood pressure cuff is going to give her arm a big hug. b. Tell the child that the blood pressure cuff is asleep and cannot wake up. c. Give the blood pressure cuff a name and refer to it by this name during the assessment. d. Tell the child that by using the blood pressure cuff, we can see how strong her muscles are. - ✔✔D A 16-year-old boy has just been admitted to the unit for overnight observation after being in an automobile accident. What is the nurses best approach to communicating with him? a. Use periods of silence to communicate respect for him. b. Be totally honest with him, even if the information is unpleasant. c. Tell him that everything that is discussed will be kept totally confidential. d. Use slang language when possible to help him open up. - ✔✔B A 75-year-old woman is at the office for a preoperative interview. The nurse is aware that the interview may take longer than interviews with younger persons. What is the reason for this? a. An aged person has a longer story to tell. b. An aged person is usually lonely and likes to have someone with whom to talk. c. Aged persons lose much of their mental abilities and require longer time to complete an interview. d. As a person ages, he or she is unable to hear; thus the interviewer usually needs to repeat much of what is said - ✔✔A The nurse is interviewing a male patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient? a. Determine the communication method he prefers. b. Avoid using facial and hand gestures because most hearing-impaired people find this degrading. c. Request a sign language interpreter before meeting with him to help facilitate the communication. d. Speak loudly and with exaggerated facial movement when talking with him because doing so will help him lip read. - ✔✔A During a prenatal check, a patient begins to cry as the nurse asks her about previous pregnancies. She states that she is remembering her last pregnancy, which ended in miscarriage. The nurses best response to her crying would be: a. Im so sorry for making you cry! b. I can see that you are sad remembering this. It is all right to cry. c. Why dont I step out for a few minutes until youre feeling better? d. I can see that you feel sad about this; why dont we talk about something else? - ✔✔B A female nurse is interviewing a man who has recently immigrated. During the course of the interview, he leans forward and then finally moves his chair close enough that his knees are nearly touching the nurses knees. The nurse begins to feel uncomfortable with his proximity. Which statement most closely reflects what the nurse should do next? a. The nurse should try to relax; these behaviors are culturally appropriate for this person. b. The nurse should discreetly move his or her chair back until the distance is more comfortable, and then continue with the interview. c. These behaviors are indicative of sexual aggression, and the nurse should confront this person about his behaviors. d. The nurse should laugh but tell him that he or she is uncomfortable with his proximity and ask him to move away. - ✔✔A A female American Indian has come to the clinic for follow-up diabetic teaching. During the interview, the nurse notices that she never makes eye contact and speaks mostly to the floor. Which statement is true regarding this situation? a. The woman is nervous and embarrassed. b. She has something to hide and is ashamed. c. The woman is showing inconsistent verbal and nonverbal behaviors. d. She is showing that she is carefully listening to what the nurse is saying. - ✔✔D The nurse is performing a health interview on a patient who has a language barrier, and no interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation? a. Do you take medicine? b. Do you sterilize the bottles? c. Do you have nausea and vomiting? d. You have been taking your medicine, havent you? - ✔✔A A man arrives at the clinic for his annual wellness physical. He is experiencing no acute health problems. Which question or statement by the nurse is most appropriate when beginning the interview? a. How is your family? b. How is your job? c. Tell me about your hypertension. d. How has your health been since your last visit? - ✔✔D . The nurse makes this comment to a patient, I know it may be hard, but you should do what the doctor ordered because she is the expert in this field. Which statement is correct about the nurses comment? a. This comment is inappropriate because it shows the nurses bias. b. This comment is appropriate because members of the health care team are experts in their area of patient care. c. This type of comment promotes dependency and inferiority on the part of the patient and is best avoided in an interview situation. d. Using authority statements when dealing with patients, especially when they are undecided about an issue, is necessary at times. - ✔✔C A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice? a. Trained interpreter b. Male family member c. Female family member d. Volunteer college student from the foreign language studies department - ✔✔A . During a follow-up visit, the nurse discovers that a patient has not been taking his insulin on a regular basis. The nurse asks, Why havent you taken your insulin? Which statement is an appropriate evaluation of this question? a. This question may place the patient on the defensive. b. This question is an innocent search for information. c. Discussing his behavior with his wife would have been better. d. A direct question is the best way to discover the reasons for his behavior. - ✔✔A The nurse is nearing the end of an interview. Which statement is appropriate at this time? a. Did we forget something? b. Is there anything else you would like to mention? c. I need to go on to the next patient. Ill be back. d. While Im here, lets talk about your upcoming surgery. - ✔✔B During the interview portion of data collection, the nurse collects __________ data. a. Physical b. Historical c. Objective d. Subjective - ✔✔D During an interview, the nurse would expect that most of the interview will take place at what distance? a. Intimate zone b. Personal distance c. Social distance d. Public distance - ✔✔C A female nurse is interviewing a male patient who is near the same age as the nurse. During the interview, the patient makes an overtly sexual comment. The nurses best reaction would be: a. Stop that immediately! b. Oh, you are too funny. Lets keep going with the interview. c. Do you really think I would be interested? d. It makes me uncomfortable when you talk that way. Please stop. - ✔✔D The nurse is reviewing the development of culture. Which statement is correct regarding the development of ones culture? Culture is: a. Genetically determined on the basis of racial background. b. Learned through language acquisition and socialization. c. A nonspecific phenomenon and is adaptive but unnecessary. d. Biologically determined on the basis of physical characteristics. - ✔✔B During a class on the aspects of culture, the nurse shares that culture has four basic characteristics. Which statement correctly reflects one of these characteristics? a. Cultures are static and unchanging, despite changes around them. b. Cultures are never specific, which makes them hard to identify. c. Culture is most clearly reflected in a persons language and behavior. d. Culture adapts to specific environmental factors and available natural resources. - ✔✔D During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating the specific and distinct knowledge, beliefs, skills, and customs acquired by members of a society reflects which term? a. Mores b. Norms c. Culture d. Social learning - ✔✔C When discussing the use of the term subculture, the nurse recognizes that it is best described as: a. Fitting as many people into the majority culture as possible. b. Defining small groups of people who do not want to be identified with the larger culture. c. Singling out groups of people who suffer differential and unequal treatment as a result of cultural variations. d. Identifying fairly large groups of people with shared characteristics that are not common to all members of a culture. - ✔✔D When reviewing the demographics of ethnic groups in the United States, the nurse recalls that the largest and fastest growing population is: a. Hispanic. b. Black. c. Asian. d. American Indian. - ✔✔A During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate? a. Ask the patient about the item and its significance. b. Ask the patient to lock the item with other valuables in the hospitals safe. c. Tell the patient that a family member should take valuables home. d. No action is necessary. - ✔✔A The nurse manager is explaining culturally competent care during a staff meeting. Which statement accurately describes the concept of culturally competent care? The caregiver: a. Is able to speak the patients native language. b. Possesses some basic knowledge of the patients cultural background. c. Applies the proper background knowledge of a patients cultural background to provide the best possible health care. d. Understands and attends to the total context of the patients situation. - ✔✔D The nurse recognizes that an example of a person who is heritage consistent would be a: a. Woman who has adapted her clothing to the clothing style of her new country. b. Woman who follows the traditions that her mother followed regarding meals. c. Man who is not sure of his ancestors country of origin. d. Child who is not able to speak his parents native language. - ✔✔B After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of the concept of ethnicity with which statement? a. Ethnicity is dynamic and ever changing. b. Ethnicity is the belief in a higher power. c. Ethnicity pertains to a social group within the social system that claims shared values and traditions. d. Ethnicity is learned from birth through the processes of language acquisition and socialization. - ✔✔C The nurse is comparing the concepts of religion and spirituality. Which of the following is an appropriate component of ones spirituality? a. Belief in and the worship of God or gods b. Attendance at a specific church or place of worship c. Personal effort made to find purpose and meaning in life d. Being closely tied to ones ethnic background - ✔✔C . A woman who has lived in the United States for a year after moving from Europe has learned to speak English and is almost finished with her college studies. She now dresses like her peers and says that her family in Europe would hardly recognize her. This nurse recognizes that this situation illustrates which concept? a. Assimilation b. Heritage consistency c. Biculturalism d. Acculturation - ✔✔A The nurse is conducting a heritage assessment. Which question is most appropriate for this assessment? a. What is your religion? b. Do you mostly participate in the religious traditions of your family? c. Do you smoke? d. Do you have a history of heart disease? - ✔✔B In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this difference is true, probably because Mexican-Americans: a. Have less efficient immune systems and are often ill. b. Consider these symptoms part of normal living, not symptoms of ill health. c. Come from Mexico, and coughing is normal and healthy there. d. Are usually in a lower socioeconomic group and are more likely to be sick - ✔✔B The nurse is reviewing theories of illness. The germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions, is a basic belief of which theory of illness? a. Holistic b. Biomedical c. Naturalistic d. Magicoreligious - ✔✔B An Asian-American woman is experiencing diarrhea, which is believed to be cold or yin. The nurse expects that the woman is likely to try to treat it with: a. Foods that are hot or yang. b. Readings and Eastern medicine meditations. c. High doses of medicines believed to be cold. d. No treatment is tried because diarrhea is an expected part of life. - ✔✔A Many Asians believe in the yin/yang theory, which is rooted in the ancient Chinese philosophy of Tao. Which statement most accurately reflects health in an Asian with this belief? a. A person is able to work and produce. b. A person is happy, stable, and feels good. c. All aspects of the person are in perfect balance. d. A person is able to care for others and function socially. - ✔✔C Illness is considered part of lifes rhythmic course and is an outward sign of disharmony within. This statement most accurately reflects the views about illness from which theory? a. Naturalistic b. Biomedical c. Reductionist d. Magicoreligious - ✔✔A An individual who takes the magicoreligious perspective of illness and disease is likely to believe that his or her illness was caused by: a. Germs and viruses. b. Supernatural forces. c. Eating imbalanced foods. d. An imbalance within his or her spiritual nature. - ✔✔B If an American Indian woman has come to the clinic to seek help with regulating her diabetes, then the nurse can expect that she: a. Will comply with the treatment prescribed. b. Has obviously given up her belief in naturalistic causes of disease. c. May also be seeking the assistance of a shaman or medicine man. d. Will need extra help in dealing with her illness and may be experiencing a crisis of faith. - ✔✔C An older Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally sensitive nurse would: a. Contact the hospital administrator about the best course of action. b. Automatically get a curandero for her, because requesting one herself is not culturally appropriate. c. Further assess the patients cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires. d. Ask the family what they would like to do because Mexican-Americans traditionally give control of decision making to their families. - ✔✔C A 63-year-old Chinese-American man enters the hospital with complaints of chest pain, shortness of breath, and palpitations. Which statement most accurately reflects the nurses best course of action? a. The nurse should focus on performing a full cardiac assessment. b. The nurse should focus on psychosomatic complaints because the patient has just learned that his wife has cancer. c. This patient is not in any danger at present; therefore, the nurse should send him home with instructions to contact his physician. d. It is unclear what is happening with this patient; consequently, the nurse should perform an assessment in both the physical and the psychosocial realms. - ✔✔D Symptoms, such as pain, are often influenced by a persons cultural heritage. Which of the following is a true statement regarding pain? a. Nurses attitudes toward their patients pain are unrelated to their own experiences with pain. b. Nurses need to recognize that many cultures practice silent suffering as a response to pain. c. A nurses area of clinical practice will most likely determine his or her assessment of a patients pain. d. A nurses years of clinical experience and current position are strong indicators of his or her response to patient pain. - ✔✔B The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain? a. All patients will behave the same way when in pain. b. Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain. c. Cultural norms have very little to do with pain tolerance, because pain tolerance is always biologically determined. d. A patients expression of pain is largely dependent on the amount of tissue injury associated with the pain. - ✔✔B During a class on religion and spirituality, the nurse is asked to define spirituality. Which answer is correct? Spirituality: a. Is a personal search to discover a supreme being. b. Is an organized system of beliefs concerning the cause, nature, and purpose of the universe. c. Is a belief that each person exists forever in some form, such as a belief in reincarnation or the afterlife. d. Arises out of each persons unique life experience and his or her personal effort to find purpose in life. - ✔✔D The nurse recognizes that working with children with a different cultural perspective may be especially difficult because: a. Children have spiritual needs that are influenced by their stages of development. b. Children have spiritual needs that are direct reflections of what is occurring in their homes. c. Religious beliefs rarely affect the parents perceptions of the illness. d. Parents are often the decision makers, and they have no knowledge of their childrens spiritual needs. - ✔✔A . A 30-year-old woman has recently moved to the United States with her husband. They are living with the womans sister until they can get a home of their own. When company arrives to visit with the womans sister, the woman feels suddenly shy and retreats to the back bedroom to hide until the company leaves. She explains that her reaction to guests is simply because she does not know how to speak perfect English. This woman could be experiencing: a. Culture shock. b. Cultural taboos. c. Cultural unfamiliarity. d. Culture disorientation. - ✔✔A After a symptom is recognized, the first effort at treatment is often self-care. Which of the following statements about self-care is true? Self-care is: a. Not recognized as valuable by most health care providers. b. Usually ineffective and may delay more effective treatment. c. Always less expensive than biomedical alternatives. d. Influenced by the accessibility of over-the-counter medicines. - ✔✔D The nurse is reviewing the hot/cold theory of health and illness. Which statement best describes the basic tenets of this theory? a. The causation of illness is based on supernatural forces that influence the humors of the body. b. Herbs and medicines are classified on their physical characteristics of hot and cold and the humors of the body. c. The four humors of the body consist of blood, yellow bile, spiritual connectedness, and social aspects of the individual. d. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors of the body. - ✔✔D In the hot/cold theory, illnesses are believed to be caused by hot or cold entering the body. Which of these patient conditions is most consistent with a cold condition? a. Patient with diabetes and renal failure b. Teenager with an abscessed tooth c. Child with symptoms of itching and a rash d. Older man with gastrointestinal discomfort - ✔✔D . When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American-Indian patient? a. Are you of the Christian faith? b. Do you want to see a medicine man? c. How often do you seek help from medical providers? d. What cultural or spiritual beliefs are important to you? - ✔✔D . During a class on cultural practices, the nurse hears the term cultural taboo. Which statement illustrates the concept of a cultural taboo? a. Believing that illness is a punishment of sin b. Trying prayer before seeking medical help c. Refusing to accept blood products as part of treatment d. Stating that a childs birth defect is the result of the parents sins - ✔✔C The nurse recognizes that categories such as ethnicity, gender, and religion illustrate the concept of: a. Family. b. Cultures. c. Spirituality. d. Subcultures. - ✔✔D After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be: a. Objective. b. Reflective. c. Subjective. d. Introspective. - ✔✔A A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be: a. Objective. b. Reflective. c. Subjective. d. Introspective. - ✔✔C The patients record, laboratory studies, objective data, and subjective data combine to form the: a. Data base. b. Admitting data. c. Financial statement. d. Discharge summary. - ✔✔A When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next action should be to: a. Immediately notify the patients physician. b. Document the sound exactly as it was heard. c. Validate the data by asking a coworker to listen to the breath sounds. d. Assess again in 20 minutes to note whether the sound is still present. - ✔✔C The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using: a. Intuition. b. A set of rules. c. Articles in journals. d. Advice from supervisors. - ✔✔B Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as: a. Intuition. b. The nursing process. c. Clinical knowledge. d. Diagnostic reasoning. - ✔✔A The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP? a. EBP relies on tradition for support of best practices. b. EBP is simply the use of best practice techniques for the treatment of patients. c. EBP emphasizes the use of best evidence with the clinicians experience. d. The patients own preferences are not important with EBP. - ✔✔C The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem? a. Patient with postoperative pain b. Newly diagnosed patient with diabetes who needs diabetic teaching c. Individual with a small laceration on the sole of the foot d. Individual with shortness of breath and respiratory distress - ✔✔D When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects? a. Low self-esteem b. Lack of knowledge c. Abnormal laboratory values d. Severely abnormal vital signs - ✔✔C Which critical thinking skill helps the nurse see relationships among the data? a. Validation b. Clustering related cues c. Identifying gaps in data d. Distinguishing relevant from irrelevant - ✔✔B The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the __________ diagnosis. a. Nursing b. Medical c. Admission d. Collaborative - ✔✔A The nursing process is a sequential method of problem solving that nurses use and includes which steps? a. Assessment, treatment, planning, evaluation, discharge, and follow-up b. Admission, assessment, diagnosis, treatment, and discharge planning c. Admission, diagnosis, treatment, evaluation, and discharge planning d. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation - ✔✔D A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems? a. Breathing, pain, and sleep b. Breathing, sleep, and pain c. Sleep, breathing, and pain d. Sleep, pain, and breathing - ✔✔A Which of these would be formulated by a nurse using diagnostic reasoning? a. Nursing diagnosis b. Medical diagnosis c. Diagnostic hypothesis d. Diagnostic assessment - ✔✔C Barriers to incorporating EBP include: a. Nurses lack of research skills in evaluating the quality of research studies. b. Lack of significant research studies. c. Insufficient clinical skills of nurses. d. Inadequate physical assessment skills. - ✔✔A What step of the nursing process includes data collection by health history, physical examination, and interview? a. Planning b. Diagnosis c. Evaluation d. Assessment - ✔✔D During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence-based clinical decision making into their practice. Which suggestion by the nurse manager would best help these problems? a. Form a committee to conduct research studies. b. Post published research studies on the units bulletin boards. c. Encourage the nurses to visit the library to review studies. d. Teach the nurses how to conduct electronic searches for research studies. - ✔✔D When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these? a. Disease originates from the external environment. b. The individual human is a closed system. c. Nurses are responsible for a patients health state. d. Holistic health views the mind, body, and spirit as interdependent. - ✔✔D The nurse recognizes that the concept of prevention in describing health is essential because: a. Disease can be prevented by treating the external environment. b. The majority of deaths among Americans under age 65 years are not preventable. c. Prevention places the emphasis on the link between health and personal behavior. d. The means to prevention is through treatment provided by primary health care practitioners. - ✔✔C The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the: a. Patients history of allergies. b. Patients use of medications at home. c. Last menstrual period 1 month ago. d. 2 5 cm scar on the right lower forearm. - ✔✔D A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting? a. A follow-up data base to evaluate changes at appropriate intervals b. An episodic data base because of the continuing, complex medical problems of this patient c. A complete health data base because of the nurses primary responsibility for monitoring the patients health d. An emergency data base because of the need to collect information and make accurate diagnoses rapidly - ✔✔C Which situation is most appropriate during which the nurse performs a focused or problem-centered history? a. Patient is admitted to a long-term care facility. b. Patient has a sudden and severe shortness of breath. c. Patient is admitted to the hospital for surgery the following day. d. Patient in an outpatient clinic has cold and influenza-like symptoms. - ✔✔D A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should: a. Collect a follow-up data base and then check her blood pressure. b. Ask her to read her health record and indicate any changes since her last visit. c. Check only her blood pressure because her complete health history was documented 2 months ago. d. Obtain a complete health history before checking her blood pressure because much of her history information may have changed. - ✔✔A A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection? a. Collect history information first, then perform the physical examination and institute life-saving measures. b. Simultaneously ask history questions while performing the examination and initiating life-saving measures. c. Collect all information on the history form, including social support patterns, strengths, and coping patterns. d. Perform life-saving measures and delay asking any history questions until the patient is transferred to the intensive care unit. - ✔✔B A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his health assessment is important to: a. Identify the cause of his illness. b. Make accurate disease diagnoses. c. Provide cultural health rights for the individual. d. Provide culturally sensitive and appropriate care. - ✔✔D In the health promotion model, the focus of the health professional includes: a. Changing the patients perceptions of disease. b. Identifying biomedical model interventions. c. Identifying negative health acts of the consumer. d. Helping the consumer choose a healthier lifestyle. - ✔✔D The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action? a. Establish priorities. b. Identify expected outcomes. c. Evaluate the individuals condition, and compare actual outcomes with expected outcomes. d. Interpret data, and then identify clusters of cues and make inferences. - ✔✔C Which statement best describes a proficient nurse? A proficient nurse is one who: a. Has little experience with a specified population and uses rules to guide performance. b. Has an intuitive grasp of a clinical situation and quickly identifies the accurate solution. c. Sees actions in the context of daily plans for patients. d. Understands a patient situation as a whole rather than a list of tasks and recognizes the long-term goals for the patient. - ✔✔D . The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply. a. Inspiratory wheezes noted in left lower lobes b. Hypoactive bowel sounds c. Nonproductive cough d. Edema, +2, noted on left hand e. Patient reports dyspnea upon exertion f. Rate of respirations 16 breaths per minute - ✔✔A C E F a. A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer. b. A teenager who was stung by a bee during a soccer match is having trouble breathing. c. An older adult with a urinary tract infection is also showing signs of confusion and agitation. problem - ✔✔1. a = First-level priority problem 2. b = Second-level priority problem 3. c = Third-level priority 1. The nurse is assessing an older adult's functional ability. Which definition correctly describes one's functional ability? Functional ability: A. Is the measure of the expected changes of aging that one is experiencing. B. Refers to the individual's motivation to live independently. C. Refers to the level of cognition present in an older person. D. Refers to one's ability to perform activities necessary to live in modern society. - ✔✔ANS: D Functional ability refers to one's ability to perform activities necessary to live in modern society and can include driving, using the telephone, or performing personal tasks such as bathing and toileting. 2. The nurse is preparing to perform a functional assessment of an older patient and knows that a good approach would be to: A. Observe the patient's ability to perform the tasks. B. Ask the patient's wife how he does when performing tasks. C. Review the medical record for information on the patient's abilities. D. Ask the patient's physician for information on the patient's abilities. - ✔✔ANS: A There are two approaches for performing a functional assessment, asking individuals about their abilities to perform the tasks (using self-reports) or actually observing their ability to perform the tasks. For persons with memory problems, the use of surrogate reporters (proxy reports) such as family members or caregivers may be necessary, keeping in mind that they may either overestimate or underestimate their actual abilities. 3. The nurse needs to assess a patient's ability to perform activities of daily living and should choose which tool for this assessment? A. Direct Assessment of Functional Abilities (DAFA) B. Lawton IADL C. Barthel Index D. Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire-IADL (OARS-IADL) - ✔✔ANS: C The Barthel Index is used to assess activities of daily living. The other options are used to measure instrumental activities of daily living 4. The nurse is preparing to use the Lawton IADL instrument as part of an assessment. Which statement about the Lawton IADL instrument is true? A. The nurse uses direct observation to implement this tool. B. It is designed as a self-report measure of performance rather than ability. C. It is not useful in the acute hospital setting. D. It is best used for those residing in an institutional setting - ✔✔ANS: B The Lawton IADL instrument is designed as a self-report measure of performance rather than ability. Direct testing is often not feasible, such as demonstrating the ability to prepare food while a hospital inpatient. Attention to the final score is less important than identifying a person's strengths and areas where assistance is needed. The instrument is useful in acute hospital settings for discharge planning and continuously in outpatient settings. It would not be useful for those residing in institutional settings because many of these tasks are already being managed for the resident. 5. The nurse is assessing an older adult's advanced activities of daily living, which would include: A. Recreational activities. B. Meal preparation. C. Balancing the checkbook. D. Self-grooming activities. - ✔✔ANS: A Advanced activities of daily living (AADL) are activities that an older adult performs such as occupational and recreational activities. Self-grooming activities are basic activities of daily living (ADLs); meal preparation and balancing the checkbook are considered instrumental activities of daily living (IADLs) 6. When using the various instruments to assess an older person's activities of daily living (ADLs), the nurse needs to remember that a disadvantage of these instruments includes: A. The reliability of the tools. B. Self or proxy report of functional activities. C. Lack of confidentiality during the assessment. D. Insufficient detail about the deficiencies identified. - ✔✔ANS: B A disadvantage of many of the ADL and IADL instruments is the self or proxy report of functional activities. The other responses are not correct. 7. The nurse is administering a test that is timed over 15 minutes and assesses a patient's upper body fine motor and coarse motor activities, balance, mobility, coordination, and endurance. During this test, activities such as dressing and stair climbing are timed. Which test is described by these activities? A. The Get Up and Go Test B. The Performance Activities of Daily Living C. The Physical Performance Test D. Tinetti Gait and Balance Evaluation - ✔✔ANS: C The Physical Performance Test is appropriate for use with community-dwelling older adults. The test requires approximately 15 minutes to complete and assesses upper body fine motor and coarse motor activities, balance, mobility, coordination, and endurance. Activities such as eating, dressing and transferring, and stair climbing are simulated and timed. 8. A patient will be ready to be discharged from the hospital soon, and the patient's family membersare concerned about whether the patient is able to walk outside alone safely. The nurse will perform which test to assess this? A. The Get Up and Go Test B. The Performance Activities of Daily Living C. The Physical Performance Test D. Tinetti Gait and Balance Evaluation - ✔✔ANS: A The Get Up and Go Test is a reliable and valid test to quantify functional mobility. The test is quick, requires little training and no special equipment, and is appropriate to use in many settingsincluding hospitals and clinics. This instrument has been shown to predict a person's ability to gooutside alone safely. The Performance of Activities of Daily Living test has a trained observer actually observing as a patient performs various ADLs. The Physical Performance Test assesses upper body fine motor and coarse motor activities, as well as balance, mobility, coordination, andendurance. The Tinetti Gait and Balance Evaluation assesses gait and balance and provides information about fall risk 9. The nurse is assessing the forms of support an older patient has before she is discharged. Which of these examples is an informal source of support? A. The local senior center B. Her Medicare check C. Meals on Wheels meal delivery service D. Her neighbor, who visits with her daily - ✔✔ANS: D Informal support includes family and close long-time friends and is usually provided free of charge. Another example of informal support is a neighbor who has daily contact with the client and shares food and company. Formal supports include programs such as social welfare and other social service and health care delivery agencies such as home health care. Semi formal supports such as church societies, neighborhood groups, and senior centers also form an important role in social support. 10. An 85-year-old man has been hospitalized after a fall at home, and his 86-year-old wife is at his bedside. She tells the nurse that she is his primary caregiver. The nurse should assess the caregiver for signs of possible caregiver burnout, such as: A. Depression. B. Weight gain. C. Hypertension. D. Social phobias - ✔✔ANS: A Caregiver burden is the perceived strain by the person who cares for an elderly, chronically ill, or disabled person. Caregiver burnout is linked to the caregiver's ability to cope and handle stress. Signs of possible caregiver burnout include multiple somatic complaints, increased stress and anxiety, social isolation, depression, and weight loss. Screening caregivers for depression may also be appropriate. 11. During a morning assessment, the nurse notices that an older patient is less attentive and is unable to recall yesterday's events. Which test is appropriate for assessing the patient's mental status? A. Geriatric Depression Scale, Short Form B. The Physical Performance Test C. Mini-Cog D. The Get Up and Go Test - ✔✔ANS: C For nurses in various settings, cognitive assessments provide continuing comparisons to the individual's baseline to detect any acute changes in mental status. The Mini-Cog is a mental status test that tests immediate and delayed recall and visuospatial ability. The Geriatric Depression Scale, Short Form assess for depression and changes in the level of depression, not mental status. The Physical Performance Test assesses activities such as eating, dressing, transferring, and stair climbing, but not mental status. The Get Up and Go Test assesses functional mobility, not mental status. 12. An elderly patient has been admitted to the intensive care unit (ICU) after falling at home. Within 8 hours, his condition has stabilized and he is transferred to a medical unit. The family is wondering whether he will be able to go back home. Which assessment instrument is most appropriate for the nurse to choose at this time? A. The Lawton IADL instrument B. Hospital Admission Risk Profile (HARP) C. The Mini-Cog D. The NEECHAM Confusion Scale - ✔✔ANS: B Hospital-acquired functional decline may occur within two days of a hospital admission. The HARP helps to identify older adults who are at greatest risk for loss of ADLs or mobility at this critical time. The Lawton IADL measures instrumental activities of daily living, which may be difficult to observe in the hospital setting. The Mini-Cog is an assessment of mental status. The NEECHAM Confusion Scale is used to assess for delirium. 13. During a functional assessment of an older person's home environment, which statement or question by the nurse is most appropriate regarding common environmental hazards? A. "These low toilet seats are safe because they are nearer to the ground in case of falls." B. "Do you have a relative or friend who can help to install grab bars in your shower?" C. "These small rugs are ideal for preventing you from slipping on the hard floor." D. "It would be safer to keep the lighting low in this room to avoid glare in your eyes." - ✔✔ANS: B Environmental hazards within the home can be a potential constraint on the older person's day-to-day functioning. Common environmental hazards including inadequate lighting, loose throw rugs, curled carpet edges, obstructed hallways, cords in walkways, lack of grab bars in tub and shower, and low and loose toilet seats are hazards that could lead to an increased risk of falls and fractures. Environmental modifications can promote mobility and reduce the likelihood of the older adult falling. 14. When beginning to assess a person's spirituality, which question by the nurse would be most appropriate? A. "Do you believe in God?" B. "How does your spirituality relate to your health care decisions?" C. "What religious faith do you follow?" D. "Do you believe in the power of prayer?" - ✔✔ANS: B Open-ended questions provide a foundation for future dialog. The other responses are easily answered by one-word replies, and they are closed questions. 15. The nurse is preparing to assess an older adult and discovers that the older adult is in severe pain.Which statement about pain and the older adult is true? A. Pain is inevitable with aging. B. Older adults with cognitive impairments feel less pain. C. Alleviating pain should be a priority over other aspects of the assessment. D. The assessment should take priority so that care decisions can be made. - ✔✔ANS: C If the older adult is experiencing pain or discomfort, then the depth of knowledge gathered through the assessments will suffer. Alleviating pain should be a priority over other aspects of the assessment. It is paramount to remember that older adults with cognitive impairment do not feel less pain. 16. The nurse is assessing the abilities of an older adult. Which of these following activities are considered instrumental activities of daily living? Select all that apply. A. Feeding oneself B. Preparing a meal C. Balancing a checkbook D. Walking E. Toileting F. Grocery shopping - ✔✔ANS: B, C, F Typically, instrumental activities of daily living tasks include shopping, meal preparation, housekeeping, laundry, managing finances, taking medications, and using transportation. The others listed are activities of daily living related to self-care. An 85-year-old man has come in for a physical examination, and the nurse notices that he uses a cane. When documenting general appearance, the nurse should document this information under the section that covers: A) posture. B) mobility. C) mood and affect. D) physical deformity. - ✔✔ANS: B Use of assistive devices would be documented under the mobility section. The other responses are all other categories of the general appearance section of the health history. Page: 764 The nurse is performing a vision examination. Which of these charts is most widely used for vision examinations? A) Snellen B) Shetllen C) Smoollen D) Schwellon - ✔✔ANS: A The Snellen eye chart is most widely used for vision examinations. The other options are not tests for vision examinations. Page: 764 After the health history has been obtained, and before beginning the physical examination, the nurse should ask the patient to first: A) empty the bladder. B) completely disrobe. C) lie on the examination table. D) walk around the room. - ✔✔ANS: A Before beginning the examination, the nurse should ask the person to empty the bladder (save the specimen if needed), disrobe except for underpants, put on a gown, and sit with legs dangling off side of the bed or table. Page: 764 During a complete health assessment, how would the nurse test the patient's hearing? A) By observing how the patient participates in normal conversation B) Using the whispered voice test C) Using the Weber and Rinne tests D) Testing with an audiometer - ✔✔ANS: B During the complete health assessment, the nurse should test hearing with the whispered voice test. The other options are not correct. Page: 765 A patient states, "Whenever I open my mouth real wide, I feel this popping sensation in front of my ears." To further examine this, the nurse would: A) place the stethoscope over the temporomandibular joint and listen for bruits. B) place the hands over his ears and ask him to open his mouth "really wide." C) place one hand on his forehead and the other on his jaw and ask him to try to open his mouth. D) place a finger on his temporomandibular joint and ask him to open and close his mouth. - ✔✔ANS: D The nurse should palpate the temporomandibular joint by placing your fingers over it as the person opens and closes the mouth. Page: 765 The nurse has just completed an examination of a patient's extraocular muscles. When documenting the findings, the nurse should document the assessment of which cranial nerves? A) II, III, VI B) II, IV, V C) III, IV, V D) III, IV, VI - ✔✔ANS: D Extraocular muscles are innervated by cranial nerves III, IV, and VI. Page: 765 A patient's uvula rises midline when she says "ahh" and she has a positive gag reflex. The nurse has just tested which cranial nerves? A) IX, X B) IX, XII C) X, XII D) XI, XII - ✔✔ANS: A Cranial nerves IX and X are being tested by having the patient say "ahh," noting the mobility of the uvula, and when assessing the patient's gag reflex. Page: 766 During an examination, the nurse notices that a patient is unable to stick out his tongue. Which cranial nerve is involved with successful performance of this action? A) I B) V C) XI D) XII - ✔✔ANS: D Cranial nerve XII enables the person to stick out his or her tongue. Page: 766 A patient is unable to shrug her shoulders against the nurse's resistant hands. What cranial nerve is involved with successful shoulder shrugging? A) VII B) IX C) XI D) XII - ✔✔ANS: C Cranial nerve XI enables the patient to shrug her shoulders against resistance. Page: 766 During an examination, a patient has just successfully completed the finger-to-nose and the rapid-alternating-movements tests and is able to run each heel down the opposite shin. The nurse will conclude that the patient's ____ function is intact. A) occipital B) cerebral C) temporal D) cerebellar - ✔✔ANS: D The nurse should test cerebellar function of the upper extremities by using the finger-to-nose test or rapid-alternating-movements test. The nurse should test cerebellar function of the lower extremities by asking the person to run each heel down the opposite shin. Pages: 769-770 A 5-year old child is in the clinic for a checkup. The nurse would expect him to: A) have to be held on his mother's lap. B) be able to sit on the examination table. C) be able to stand on the floor for the examination. D) be able to remain alone in the examination room - ✔✔ANS: B At 4 or 5 years old, a child usually feels comfortable on the examination table. Older infants and young children aged 6 months to 2 or 3 years should be positioned in the parent's lap. Pages: 777-778 When the nurse performs the confrontation test, the nurse has assessed: A) extraocular eye muscles (EOMs). B) pupils (PERRLA). C) near vision. D) visual fields. - ✔✔ANS: D The confrontation test assesses visual fields. The other options are not tested with the confrontation test. Page: 765 Which of these statements is true regarding the complete physical assessment? A) The male genitalia should be examined in the supine position. B) The patient should be in the sitting position for examination of the head and neck. C) The vital signs, height, and weight should be obtained at the end of the examination. D) To promote consistency between patients, the examiner should not vary the order of the assessment. - ✔✔ANS: B The head and neck should be examined in the sitting position to best palpate the thyroid and lymph nodes. The male patient should stand during examination of the genitalia. Vital signs are measured early in the assessment. The sequence of the assessment may need to vary according to different patient situations. Page: 764 Which of these statements is true regarding the recording of data from the history and physical examination? A) Use long, descriptive sentences to document findings. B) Record the data as soon as possible after the interview and physical examination. C) If the information is not documented, then it can be assumed that it was done as a standard of care. D) The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing rapport with the patient. - ✔✔ANS: B The data from the history and physical examination should be recorded as soon after the event as possible. From a legal perspective, if it is not documented, it was not done. Brief notes should be taken during the examination. When documenting, the nurse should use short clear phrases and should avoid redundant phrases and descriptions. Page: 781 Which of these is included in assessment of general appearance? A) Height B) Weight C) Skin color D) Vital signs - ✔✔ANS: C General appearance includes items such as level of consciousness, skin color, nutritional status, posture, mobility, facial expression, mood and affect, speech, hearing, and personal hygiene. Height, weight, and vital signs are considered measurements. Page: 764 The nurse should wear gloves for which of these examinations? A) Measuring vital signs B) Palpation of the sinuses C) Palpation of the mouth and tongue D) Inspection of the eye with an ophthalmoscope - ✔✔ANS: C Gloves should be worn when the examiner is exposed to the patient's body fluids. Page: 766 The nurse should use which location for eliciting deep tendon reflexes? A) Achilles B) Femoral C) Scapular D) Abdominal - ✔✔ANS: A Deep tendon reflexes are elicited in the biceps, triceps, brachioradialis, patella, and Achilles. Pages: 769-770 During inspection of a patient's face, the nurse notices that the facial features are symmetric. This finding indicates that which cranial nerve is intact? A) VII B) IX C) XI D) XII - ✔✔ANS: A Cranial nerve VII is responsible for facial symmetry. Page: 766 During inspection of the posterior chest, the nurse should assess for: A) symmetric expansion. B) symmetry of shoulders and muscles. C) tactile fremitus. D) diaphragmatic excursion. - ✔✔ANS: B During inspection of the posterior chest, the nurse should inspect for symmetry of shoulders and muscles, configuration of the thoracic cage, and skin characteristics. Symmetric expansion and tactile fremitus are assessed with palpation; diaphragmatic excursion is assessed with percussion. Page: 766 When assessing the neonate, the nurse should test for hip stability with which method? A) Eliciting the Moro reflex B) Performing the Romberg's test C) Checking for the Ortolani's sign D) Assessing the stepping reflex - ✔✔ANS: C The nurse should test for hip stability in the neonate by testing for the Ortolani's sign. The other tests are not appropriate for testing hip stability. Pages: 775-776 A female patient tells the nurse that she has four children and has had three pregnancies. How should the nurse document this? A) Gravida 3, para 4 B) Gravida 4, para 3 C) This information cannot be documented using the terms gravida and para. D) "The patient seems to be confused about how many times she has been pregnant." - ✔✔ANS: A Gravida refers to the number of pregnancies, and para refers to the number of children. One pregnancy was with twins. Page: 781 During an examination, the patient tells the nurse that she sometimes feels as if objects are spinning around her. The nurse would document that she occasionally experiences: A) vertigo. B) tinnitus. C) syncope. D) dizziness. - ✔✔ANS: A Vertigo is the sensation of moving around in space (subjective) or of having objects move about the person (objective) and is a result of a disturbance of equilibratory apparatus. See Chapter 23. Pages: 621-678 A patient tells the nurse that "sometimes I wake up at night and I have real trouble breathing. I have to sit up in bed to get a good breath." When documenting this information, the nurse would note: A) orthopnea. B) acute emphysema. C) paroxysmal nocturnal dyspnea. D) acute shortness of breath episode. - ✔✔ANS: C Paroxysmal nocturnal dyspnea occurs when the patient awakens from sleep with shortness of breath and needs to be upright to achieve comfort. See Chapter 18. Pages: 411-454 During the examination of a patient, the nurse notices that the patient has several small, flat macules on the posterior portion of her thorax. These macules are less than 1 cm wide. Another name for these macules is: A) warts. B) bullae. C) freckles. D) papules. - ✔✔ANS: C A macule is solely a lesion with color change, flat and circumscribed, less than 1 cm. Macules are also known as freckles. See Chapter 12. Pages: 203-250 During an examination, the nurse notices that a patient's legs turn white when they are raised above the patient's head. The nurse should suspect: A) lymphedema. B) Raynaud's disease. C) chronic arterial insufficiency. D) chronic venous insufficiency. - ✔✔ANS: C Elevational pallor (marked) indicates arterial insufficiency. See Chapter 20. Pages: 499-525 The nurse documents that a patient has coarse, thickened skin and brown discoloration over the lower legs. Pulses are present. This finding is probably the result of: A) lymphedema. B) Raynaud's disease. C) chronic arterial insufficiency. D) chronic venous insufficiency. - ✔✔ANS: D Chronic venous insufficiency would present as firm brawny edema, coarse thickened skin, normal pulses, and brown discoloration. See Chapter 20. Pages: 499-525 The nurse notices that a patient has ulcerations on the tips of the toes and on the lateral aspect of the ankles. This finding indicates: A) lymphedema. B) Raynaud's disease. C) arterial insufficiency. D) venous insufficiency. - ✔✔ANS: C Ulcerations on the tips of the toes and lateral aspect of the ankles are indicative of arterial insufficiency. See Chapter 20. Pages: 499-525 When the nurse flexes the patient's knee and gently compresses the gastrocnemius muscle anteriorly against the tibia, the patient indicates that he is having calf pain. The nurse should document _____ sign. A) positive Allen's B) negative Allen's C) positive Homans' D) negative Homans' - ✔✔ANS: C Calf pain with these maneuvers is a positive Homans' sign, which occurs in some cases of deep vein thrombosis. See Chapter 20. Pages: 499-525 The nurse has just recorded a positive obturator test on a patient who has abdominal pain. This test is used to confirm a(n): A) inflamed liver. B) perforated spleen. C) perforated appendix. D) enlarged gallbladder. - ✔✔ANS: C A perforated appendix irritates the obturator muscle, producing pain. See Chapter 21. Pages: 527-564 The nurse is documenting the assessment of an infant. During the abdominal assessment, the nurse noticed a very loud splash auscultated over the upper abdomen when the nurse rocked her from side to side. This finding would indicate: A) epigastric hernia. B) pyloric obstruction. C) hypoactive bowel sounds. D) hyperactive bowel sounds. - ✔✔ANS: D A succussion splash, which is unrelated to peristalsis, is a very loud splash auscultated over the upper abdomen when the infant is rocked side to side. It indicates increased air and fluid in the stomach as seen with pyloric obstruction or large hiatus hernia. See Chapter 21. Pages: 527-564 The nurse will measure a patient's near vision with which tool? A) Snellen eye chart with letters B) Snellen "E" chart C) Jaeger card D) Ophthalmoscope - ✔✔ANS: C The Jaeger card is used to measure near vision. See Chapter 14. Pages: 279-322 If the nurse records the results to the Hirschberg test, the nurse has: A) tested the patellar reflex. B) assessed for appendicitis. C) tested the corneal light reflex. D) assessed for thrombophlebitis. - ✔✔ANS: C The Hirschberg test assesses the corneal light reflex. See Chapter 14. Pages: 279-322 During the examination of a patient's mouth, the nurse observes a nodular bony ridge down the middle of the hard palate. The nurse would chart this finding as: A) cheilosis. B) leukoplakia. C) ankyloglossia. D) torus palatinus. - ✔✔ANS: D A normal variation of the hard palate is a nodular bony ridge down the middle of the hard palate, a torus palatinus. See Chapter 16. Pages: 351-382 During examination, the nurse finds that a patient is unable to distinguish objects placed in his hand. The nurse would document: A) stereognosis. B) astereognosis. C) graphesthesia. D) agraphesthesia. - ✔✔ANS: B Astereognosis is the inability to identify correctly an object placed in the hand. See Chapter 23. Pages: 621-678 After the examination of an infant, the nurse documents opisthotonos. The nurse recognizes that this finding often occurs with: A) cerebral palsy. B) meningeal irritation. C) a lower motor neuron lesion. D) a upper motor neuron lesion. - ✔✔ANS: B Opisthotonos is a form of spasm in which the head is arched back, and there is stiffness of the neck and extension of the arms and legs. It occurs with meningeal or brainstem irritation. See Chapter 23 Pages: 621-678 After assessing a female patient, the nurse notices flesh-colored, soft, pointed, moist, papules in a cauliflower-like patch around her introitus. This finding is most likely: A) urethral caruncle. B) syphilitic chancre. C) herpes. D) human papillomavirus. - ✔✔ANS: D Human papillomavirus appears in a flesh-colored, soft, moist, cauliflower-like patch of papules. See Chapter 26. Pages: 725-762 While recording in a patient's medical record, the nurse notices that a patient's Hematest results are positive. This means that there: A) are crystals in his urine. B) are parasites in his stool. C) is occult blood in his stool. D) are bacteria in his sputum. - ✔✔ANS: C If a stool is Hematest positive, then it indicates the presence of occult blood. See Chapter 21. Pages: 527-564 While examining a 48-year-old patient's eyes, the nurse notices that he had to move the handheld vision screener farther away from his face. The nurse would suspect: A) myopia. B) omniopia. C) hyperopia. D) presbyopia. - ✔✔ANS: D Presbyopia, the decrease in power of accommodation with aging, is suggested when the handheld vision screener card is moved farther away. See Chapter 14. Pages: 279-322 Which of these actions is most appropriate to perform on a 9-month-old infant at a well-child checkup? A) Testing for Ortolani's sign B) Assessment for stereognosis C) Blood pressure measurement D) Assessment for the presence of the startle reflex - ✔✔ANS: A Until the age of 12 months, the infant should be assessed for Ortolani's sign. If Ortolani's sign is present, it could indicate the presence of a dislocated hip. The other tests are not appropriate for a 9-month-old child. Pages: 565-620 For the abdominal assessment, place these assessment techniques in the correct order, with A being performed first and E being performed last. A. Deep palpation, all quadrants B. Light palpation, all quadrants C Auscultate bowel sounds D. Inspect abdomen for contour, skin characteristics, and pulsations E. Percuss all quadrants - ✔✔ANS: D, C, E, B, A After inspection, first perform auscultation of bowel sounds so that the sounds are not altered by percussion and palpation. Follow auscultation by percussion, then light palpation, then deep palpation. See Chapter 21. Pages: 527-564 Which of these statements about the anal canal is true? The anal canal: A) is about 2 cm long in the adult. B) slants backward toward the sacrum. C) contains hair and sebaceous glands. D) is the outlet for the gastrointestinal tract. - ✔✔ANS: D The anal canal is the outlet for the gastrointestinal tract, and it is about 3.8 cm long in the adult. It is lined with a modified skin that does not contain hair or sebaceous glands, and it slants forward toward the umbilicus. Which of these statements about the sphincters is correct? A) The internal sphincter is under voluntary control. B) The external sphincter is under voluntary control. C) Both sphincters remain slightly relaxed at all times. D) The internal sphincter surrounds the external sphincter. - ✔✔ANS: B The external sphincter surrounds the internal sphincter but also has a small section overriding the tip of the internal sphincter at the opening. The external sphincter is under voluntary control. Except for the passing of feces and gas, the sphincters keep the anal canal tightly closed. The nurse is performing an examination of the anus and rectum. Which of these statements is correct and important to remember during this examination? A) The rectum is about 8 cm long. B) The anorectal junction cannot be palpated. C) Above the anal canal, the rectum turns anteriorly. D) There are no sensory nerves in the anal canal or rectum. - ✔✔ANS: B The anal columns are folds of mucosa that extend vertically down from the rectum and end in the anorectal junction. This junction is not palpable, but it is visible on proctoscopy. The rectum is 12 cm long, and just above the anal canal, the rectum dilates and turns posteriorly. The structure that secretes a thin, milky alkaline fluid to enhance the viability of sperm is the: A) Cowper's gland. B) prostate gland. C) median sulcus. D) bulbourethral gland. - ✔✔ANS: B In men, the prostate gland secretes a thin milky alkaline fluid that enhances sperm viability. The Cowper's glands (also known as bulbourethral glands) secrete a clear, viscid mucus. The median sulcus is a groove dividing the lobes of the prostate gland and does not secrete fluid. A 46-year-old man requires assessment of his sigmoid colon. The nurse is aware that which of these is most appropriate for this examination? A) Proctoscope B) Ultrasound C) Colonoscope D) Rectal exam with an examining finger - ✔✔ANS: C The sigmoid colon is 40 cm long and is accessible to examination only with the colonoscope. The other responses are not appropriate for examination of the entire sigmoid colon. The nurse is caring for a newborn infant. Thirty hours after birth, the infant passes a dark green meconium stool. The nurse recognizes that this is important because: A) this stool would indicate anal patency. B) the dark green color could indicate occult blood in the stool. C) meconium stool can be reflective of distress in the newborn. D) the newborn should have passed the first stool within 12 hours after birth. - ✔✔ANS: A The first stool passed by the newborn is dark green meconium and occurs within 24 to 48 hours of birth, indicating anal patency. The other responses are not correct During the assessment of an 18-month-old child, the mother expresses concern to the nurse about the infant's inability to toilet train. What would be the nurse's best response? A) "Some children are just more difficult to train, so I wouldn't worry about it yet." B) "Have you considered reading any of the books on toilet training? They can be very helpful." C) "This could mean there is a problem in your baby's development. We'll watch her closely for the next few months." D) "The nerves that will allow your baby to have control over the passing of stools are not developed until at least 18 to 24 months of age." - ✔✔ANS: D The infant passes stools by reflex. Voluntary control of the external anal sphincter cannot occur until the nerves supplying the area have become fully myelinated, usually around 1 1/2 to 2 years of age. Toilet training usually starts after the age of 2. A 60-year-old man has just been told he has benign prostatic hypertrophy. He has a friend who just died from cancer of the prostate, and he is concerned this will happen to him. How should the nurse respond? A) "The swelling in your prostate is only temporary and will go away." B) "We will treat you with chemotherapy so we can control the cancer." C) "It would be very unusual for a man your age to have cancer of the prostate." D) "The enlargement of your prostate is caused by hormone changes and not cancer." - ✔✔ANS: D The prostate gland commonly starts to enlarge during the middle adult years. This benign prostatic hypertrophy (BPH) is present in 1 out of 10 males at the age of 40 years and increases with age. It is thought that the hypertrophy is caused by hormonal imbalance that leads to the proliferation of benign adenomas. The other responses are not appropriate. A 30-year-old woman is visiting the clinic because of "pain in my bottom when I have a bowel movement." The nurse should assess for which problem? A) Pinworms B) Hemorrhoids C) Colon cancer D) Fecal incontinence - ✔✔ANS: B Having painful bowel movements, known as dyschezia, may be due to a local condition (hemorrhoid or fissure) or constipation. The other responses are not correct. A patient who is visiting the clinic complains of having "stomach pains for 2 weeks" and describes his stools as being "soft and black" for about the last 10 days. He denies taking any medications. The nurse is aware that these symptoms are most indicative of: A) excessive fat caused by malabsorption. B) increased iron intake resulting from a change in diet. C) occult blood resulting from gastrointestinal bleeding. D) absent bile pigment from liver problems. - ✔✔ANS: C Black stools may be tarry due to occult blood (melena) from gastrointestinal bleeding or nontarry from ingestion of iron medications (not diet). Excessive fat causes the stool to become frothy; absence of bile pigment causes clay-colored stools. After completing an assessment of a 60-year-old man with a family history of colon cancer, the nurse discusses with him early detection measures for colon cancer. The nurse should mention the need for a(n): A) annual proctoscopy. B) colonoscopy every 10 years. C) fecal test for blood every 6 months. D) digital rectal examinations every 2 years. - ✔✔ANS: B Early detection measures for colon cancer include a digital rectal examination performed annually after age 50 years, a fecal occult blood test annually after age 50 years, sigmoidoscopy every 5 years or colonoscopy every 10 years after age 50 years; and a PSA blood test annually for men over 50 years old, except black men beginning at age 45 years (American Cancer Society, 2006). The mother of a 5-year-old girl tells the nurse that she has noticed her daughter "scratching at her bottom a lot the last few days." During the assessment, the nurse finds redness and raised skin in the anal area. This most likely indicates: A) pinworms. B) chickenpox. C) constipation. D) bacterial infection. - ✔✔ANS: A In children, pinworms are a common cause of intense itching and irritated anal skin. The other options are not correct. The nurse is examining only the rectal area of a woman and should place the woman in what position? A) Lithotomy position B) Prone position C) Left lateral decubitus position D) Bending over the table while standing - ✔✔ANS: C The nurse should place the female patient in lithotomy position if examining genitalia as well; use the left lateral decubitus position for the rectal area alone. While doing an assessment of the perianal area of a patient, the nurse notices that the pigmentation of anus is darker than surrounding skin, the anal opening is closed, and there is a skin sac that is shiny and blue. The patient mentioned that he has had pain with bowel movements and has noted some spots of blood occasionally. What would this assessment and history be most likely to indicate? A) Anal fistula B) Pilonidal cyst C) Rectal prolapse D) Thrombosed hemorrhoid - ✔✔ANS: D The anus normally looks moist and hairless, with coarse folded skin that is more pigmented than the perianal skin. The anal opening is tightly closed. The shiny blue skin sac indicates a thrombosed hemorrhoid. The nurse is preparing to palpate the rectum and should use which of these techniques? A) Flex the finger and insert slowly toward the umbilicus. B) Instruct the patient first that this will be a painful procedure. C) Insert an extended index finger at a right angle to the anus. D) Place the finger directly into the anus to overcome the tight sphincter. - ✔✔ANS: A The nurse should place the pad of the index finger gently against the anal verge. The nurse will feel the sphincter tighten and then relax. As it relaxes, the nurse should flex the tip of the finger and slowly insert it into the anal canal in a direction toward the umbilicus. The nurse should never approach the anus at right angles with the index finger extended—this would cause pain. The nurse should instruct the patient that palpation is not painful but may feel like needing to move the bowels. While performing a rectal examination, the nurse notices a firm, irregularly shaped mass. What should the nurse do next? A) Continue with the examination and document the finding in the chart. B) Instruct patient to return for repeat assessment in 1 month. C) Tell the patient that a mass was felt but it is nothing to worry about. D) Report the finding and refer the patient to a specialist for further examination. - ✔✔ANS: D A firm or hard mass with irregular shape or rolled edges may signify carcinoma. Promptly report any mass that is discovered for further examination. The other responses are not correct When testing stool for occult blood, the nurse is aware that a false-positive result may occur with: A) absent bile pigment. B) increased fat content. C) increased ingestion of iron medication. D) a large amount of red meat within the last 3 days. - ✔✔ANS: D When testing for occult blood, a false-positive finding may occur if the person has ingested significant amounts of red meat within 3 days of the test. Absent bile pigment causes the stools to be gray or tan in color. Increased fat content causes the stool to be pale, yellow, and greasy. Increased ingestion of iron medication causes the stool to be black in color. During an assessment of the newborn, the nurse expects to see which finding when the anal area is slightly stroked? A) A jerking of the legs B) Flexion of the knees C) A quick contraction of the sphincter D) Relaxation of the external sphincter - ✔✔ANS: C To assess sphincter tone, the nurse should check the anal reflex by gently stroking the anal area and noticing a quick contraction of the sphincter. The other responses are not correct. A 13-year-old girl is visiting the clinic for a sports physical. The nurse should remember to include which of these tests in the examination? A) Test for occult blood B) The Valsalva maneuver C) Internal palpation of the anus D) Inspection of the perianal area - ✔✔ANS: D Inspect the perianal region of the school-aged child and adolescent during examination of the genitalia. Internal palpation is not performed routinely at this age. Testing for occult blood and doing the Valsalva maneuver are also not necessary. During an assessment of a 20-year-old man, the nurse finds a small palpable lesion with a tuft of hair located directly over the coccyx. The nurse knows that this lesion would most likely be a: A) polyp. B) pruritus ani. C) carcinoma. D) pilonidal cyst. - ✔✔ANS: D A pilonidal cyst or sinus is a hair-containing cyst or sinus located in the midline over the coccyx or lower sacrum. It often opens as a dimple with a visible tuft of hair and, possibly, an erythematous halo. See Table 25-1 for more information, and also for description of pruritus ani. See Table 25-2 for descriptions of rectal polyps and carcinoma. During an examination, the nurse asks the patient to perform the Valsalva maneuver and notices that the patient has a moist, red, doughnut-shaped protrusion from the anus. The nurse knows that this would be consistent with: A) a rectal polyp. B) hemorrhoids. C) a rectal fissure. D) rectal prolapse. - ✔✔ANS: D In rectal prolapse, the rectal mucous membrane protrudes through the anus, appearing as a moist red doughnut with radiating lines. It occurs following a Valsalva maneuver, such as straining at stool, or with exercise. See Table 25-1. For a description of rectal polyps, see Table 25-2. See Table 25-1 for descriptions of rectal fissure and hemorrhoids. A 70-year-old man is visiting the clinic for difficulty in passing urine. In the history he indicates he has to urinate frequently, especially at night. He has burning when he urinates and has noticed pain in his back. Given this history, what might the nurse expect to find during the physical assessment? A) Asymmetric, hard, fixed prostate gland B) Occult blood and perianal pain to palpation C) Symmetrically enlarged, soft prostate gland D) A soft nodule protruding from rectal mucosa - ✔✔ANS: A Subjective symptoms of carcinoma of the prostate include frequency, nocturia, hematuria, weak stream, hesitancy, pain or burning on urination, and continuous pain in lower back, pelvis, and thighs. Objective symptoms of carcinoma of the prostate include a malignant neoplasm often starts as a single hard nodule on the posterior surface, producing asymmetry and a change in consistency. As it invades normal tissue, multiple hard nodules appear, or the entire gland feels stone hard and fixed. A 40-year-old black man is in the office for his annual physical. Which statement regarding the prostate-specific antigen (PSA) blood test is true, according to the American Cancer Society? The PSA: A) should be done with this visit. B) should be done at age 45 years. C) should be done at age 50 years. D) is only necessary if there is a family history of prostate cancer. - ✔✔ANS: B According to the American Cancer Society (2006) the PSA blood test should be done annually for black men beginning at age 45 years, and annually for all other men over age 50 years. A 62-year-old man is experiencing fever, chills, malaise, urinary frequency, and urgency. He also reports urethral discharge and a dull aching pain in the perineal and rectal area. These symptoms are most consistent with which of the following? A) Prostatitis B) A polyp C) Carcinoma of the prostate D) Benign prostatic hypertrophy (BPH) - ✔✔ANS: A The common presenting symptoms of prostatitis are fever, chills, malaise, and urinary frequency and urgency. The individual may also have dysuria, urethral discharge, and a dull aching pain in the perineal and rectal area. See Table 25-3 for descriptions of carcinoma of the prostate and BPH. These are not the symptoms of a polyp. During a discussion for a men's health group, the nurse relates that the group with the highest incidence of prostate cancer is: A) Asian Americans. B) African-Americans. C) American Indians. D) Hispanics. - ✔✔ANS: B [Show More]

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