Health Assessment: Performing a Physical Examination

Identify the choice that best completes the statement or answers the question.

____ 1. A mother brings her 6-month-old infant to the clinic for a well-baby checkup. How should the nurse proceed when weighing the patient?

1)
Have the mother remain outside the room.
2)
Ask the mother to remove the infant’s clothing and diaper.
3)
Weigh the infant with the diaper only.
4)
Place the infant supine on the scale with his knees extended.

____ 2. Where should the nurse assess skin color changes in the dark-skinned patient?

1)
Nailbeds
2)
Any exposed area
3)
Oral mucosa
4)
Palms of the hands

____ 3. While the nurse assesses a newborn of African American descent, the mother points out a blue-black Mongolian spot on the newborn’s back and asks, “What’s that? Is something wrong with my baby?” Which response by the nurse is best?

1)
“I’ll ask the physician to look at the spot.”
2)
“Those spots are quite common and typically fade with time.”
3)
“You may want a plastic surgeon to look at that.”
4)
“That spot is benign so it’s nothing you need to worry about.”

____ 4. An older adult comes to the clinic complaining of pain in the left foot. While assessing the patient, the nurse notes smooth, shiny skin that contains no hair on the client’s lower legs. Which condition does this finding suggest?

1)
Venous insufficiency
2)
Hyperthyroidism
3)
Arterial insufficiency
4)
Dehydration

____ 5. Which skin assessment finding would cause the nurse to suspect dehydration in a middle-aged patient admitted to the hospital with traveler’s diarrhea?

1)
Edema
2)
Hyperhidrosis
3)
Pallor
4)
Tenting

____ 6. A female patient has excessive facial hair. The nurse should document this finding as:

1)
Alopecia.
2)
Albinism.
3)
Hirsutism.
4)
Lanugo.

____ 7. The nurse should assess skin temperature by using the:

1)
Dorsum of the hand.
2)
Pad of the fingertip.
3)
Palm of the hand.
4)
Dorsum of the wrist.

____ 8. While assessing an older adult patient, the nurse notes clubbing of the fingers. This finding is a sign of:

1)
Fungal infection.
2)
Poor circulation.
3)
Iron deficiency.
4)
Long-term hypoxia.

____ 9. A 6-week-old infant is brought to the pediatrician’s office for a well-baby checkup. The nurse notes a flattening of the skull. Flattening of the skull in the infant might suggest:

1)
The baby has been lying in the same position for several hours a day.
2)
A disorder associated with excessive growth hormone.
3)
An accumulation of excessive cerebrospinal fluid.
4)
Temporomandibular joint syndrome.

____ 10. The nurse notes ptosis in a patient who just arrived in the emergency department. The nurse quickly triages the patient because she knows that this finding, along with other symptoms, might suggest:

1)
Hyperthyroidism.
2)
Stroke.
3)
Glaucoma.
4)
Macular degeneration.

____ 11. Small hemorrhages are noted under the nailbed of a patient with a history of intravenous drug abuse. This finding is associated with:

1)
Low albumin levels.
2)
Zinc deficiency.
3)
Renal disease.
4)
Bacterial endocarditis.

____ 12. A patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease. Which finding might the nurse expect when assessing the patient’s nails?

1)
Soft, boggy nails
2)
Brittle nails
3)
Thickened nails
4)
Thick nail with yellowing

____ 13. A patient’s ankles appear swollen. When the nurse assesses the edema, the skin depresses 6 mm, and the depression lasts 2 minutes. The nurse should document this finding as:

1)
Trace edema.
2)
+1 edema.
3)
+2 edema.
4)
+3 edema.

____ 14. Which abnormal laboratory value is associated with icteric sclera?

1)
Bleeding time
2)
Bilirubin
3)
Hemoglobin
4)
Glucose

____ 15. The left pupil of a patient fails to accommodate. This finding may reflect an abnormality in which cranial nerve?

1)
CN III
2)
CN V
3)
CN VIII
4)
CN X

____ 16. When testing near vision, the nurse should position printed text how many inches away from the patient?

1)
20
2)
18
3)
16
4)
14

____ 17. A 48-year-old patient comes to the physician’s office complaining of diminished near vision, which the nurse confirms with testing. She should document this finding as:

1)
Myopia.
2)
Diplopia.
3)
Presbyopia.
4)
Mydriasis.

____ 18. Which portion of the ear is responsible for maintaining equilibrium?

1)
External ear
2)
Inner ear
3)
Middle ear
4)
Ossicles

____ 19. Which statement best describes the procedure used to assess capillary refill?

1)
Briefly press the tip of the nail with firm, steady pressure, then release and observe for changes in color.
2)
Press firmly with your fingertip for 5 seconds over a bony area, release pressure, and observe the skin for the reaction.
3)
Tap on the skin with short strokes from your fingers.
4)
Lift a fold of skin, and allow it to return to its normal position.

____ 20. Which of the following is an abnormal capillary refill finding that the nurse should report?

1)
1 second
2)
2 seconds
3)
3 seconds
4)
4 seconds

____ 21. Which of the following is a correct developmental outcome for an infant? The infant’s anterior fontanel (soft spot) typically fuses:

1)
At about 8 weeks.
2)
At about 14 months.
3)
By 6 months of age.
4)
Before 1 year of age.

____ 22. The nurse assesses a 4-year-old child’s vision as 20/40. This finding is considered:

1)
Myopia.
2)
Hyperopia.
3)
Normal.
4)
Presbyopia.

____ 23. Which test should the patient undergo when the Weber test is positive?

1)
Romberg test
2)
Rinne test
3)
Pure tone audiometry
4)
Tympanometry

____ 24. The nurse is performing an otoscopic examination on an adult patient. She has the patient tilt his head to the side not being examined and looks into the ear canal to make sure a foreign body is not present. Which step should she perform next?

1)
Straighten the ear canal by pulling the helix up and back.
2)
Insert the speculum into the ear canal slowly.
3)
Test the mobility of the tympanic membrane.
4)
Straighten the ear canal by pulling the helix down and back.

____ 25. An 85-year-old patient is brought to the emergency department with lethargy and hypotension. When the nurse assesses the patient’s tongue, she notes that it appears dry and furry. This finding suggests:

1)
Fungal infection.
2)
Dehydration.
3)
Allergy.
4)
Iron deficiency.

____ 26. Which assessment should the nurse perform if she notes a palpable thyroid gland?

1)
Illuminate the thyroid gland for the presence of fluid.
2)
Auscultate the thyroid gland for bruits.
3)
Percuss the thyroid gland for mass size.
4)
Measure the thyroid gland to assess change.

____ 27. While palpating the anterior chest, the nurse notes crackling in the skin around the patient’s chest tube insertion site. The nurse recognizes this finding is:

1)
Tactile fremitus.
2)
Egophony.
3)
Bronchophony.
4)
Crepitus.

____ 28. Bronchovesicular breath sounds are best heard over which area?

1)
Midline over the trachea just below the larynx
2)
Fourth intercostal space, in the midclavicular line
3)
First and second intercostal spaces next to the sternum
4)
At the base of the lungs near the diaphragm

____ 29. High-pitched breath sounds produced by airway narrowing are known as:

1)
Rales.
2)
Crackles.
3)
Rhonchi.
4)
Wheezing.

____ 30. The nurse notes a small pulsation at the fifth intercostal space midclavicular line. This should be documented as a:

1)
Thrill.
2)
Murmur.
3)
Normal finding.
4)
Heave.

____ 31. The nurse notes an S3 heart sound while performing an assessment on a patient admitted with an acute myocardial infarction. The nurse notifies the physician of the finding, which most likely suggests:

1)
Heart failure.
2)
Coronary artery disease.
3)
Hypertension.
4)
Pulmonic stenosis.

____ 32. The admission assessment form indicates that the patient has pedal pulses that are rated 1 in amplitude. This documentation indicates that the patient’s pulses are:

1)
Bounding.
2)
Normal.
3)
Full.
4)
Diminished.

____ 33. A patient’s jugular venous pressure measures 5 cm. This finding indicates:

1)
A normal finding.
2)
Hypovolemia.
3)
Heart failure.
4)
Dehydration.

____ 34. The nurse is caring for a patient who underwent abdominal surgery 24 hours ago and has a nasogastric tube to intermittent suction. How should the nurse proceed when performing an abdominal assessment on this patient?

1)
Avoid palpating the patient’s abdomen.
2)
Turn off the suction before auscultating bowel sounds.
3)
Listen for bowel sounds for 2 minutes in each quadrant.
4)
Percuss the abdomen before auscultating bowel sounds.

____ 35. Abdominal palpation should be avoided in a child who has which disorder?

1)
Appendicitis
2)
Wilms’ tumor
3)
Crohn’s disease
4)
Small bowel obstruction

____ 36. A father brings his 18-month-old child to the pediatrician’s office for a well-baby checkup. The father tells the nurse that he is concerned because his child’s legs are bowed. Which response by the nurse is appropriate?

1)
“Your child will most likely require physical therapy.”
2)
“You should consider having your child seen by an orthopedic surgeon.”
3)
“This is a normal finding in children for 1 year after they begin walking.”
4)
“Your child is walking fine, so you don’t need to worry.”

____ 37. The nurse asks the patient to spread his fingers and then bring them together again. Which of the following is the nurse testing when asking to bring his fingers together?

1)
Abduction
2)
Adduction
3)
Flexion
4)
Extension

____ 38. An adult admitted to the hospital after a stroke does not respond to verbal stimuli. What should the nurse do next to try to provoke a response?

1)
Apply pressure to the mandible at the jaw.
2)
Rub the patient’s sternum.
3)
Squeeze the trapezius muscle.
4)
Gently shake the patient’s shoulder.

____ 39. Which assessment question helps assess immediate memory?

1)
“How did you get to the hospital today?”
2)
“Can you repeat the numbers 2, 7, 9 for me?”
3)
“Do you recall the three items I mentioned earlier?”
4)
“What was your birth date including the year?”

____ 40. Assuming that all are accurate, which documentation about a patient’s level of consciousness is best?

1)
Patient is lethargic and slept when undisturbed.
2)
Patient responds to tactile stimulation; falls back to sleep immediately after tactile and verbal stimulation are stopped.
3)
Patient slept throughout the day, missing his meals and bath.
4)
Patient appears to be tired as he slept throughout the day except when bathed.

____ 41. Based on developmental stage, how should the nurse modify the comprehensive physical examination of an older adult?

1)
Work rapidly to finish as quickly as possible.
2)
Sequence the exam to limit position changes.
3)
Demonstrate equipment before using it.
4)
Omit portions of the exam that may be tiring.

____ 42. The nurse applies resistance to the top of the client’s foot and asks him to pull his toes toward his knee. The nurse observes active motion against some, but not against full, resistance. How should the nurse document this finding?

1)
5: Normal
2)
4: Slight weakness
3)
3: Weakness
4)
2: Poor ROM

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

____ 1. The nurse obtains vital signs for a 56-year-old patient who underwent surgery yesterday. Which finding(s) require(s) further assessment? Select all that apply.

1)
Blood pressure 110/64 mm Hg
2)
Pulse rate 118 beats/minute
3)
Respiratory rate 35 breaths/minute
4)
Oral temperature 98.6°F (37°C)

____ 2. Which disorder(s) might limit a patient’s visual field? Select all that apply.

1)
Diabetes
2)
Advanced glaucoma
3)
Peripheral vascular disease
4)
Cataracts

Chapter 19. Health Assessment: Performing a Physical Examination

Answer Section

MULTIPLE CHOICE

1. ANS: 2

The nurse should ask the mother to remove the infant’s clothing and diaper before weighing and measuring the infant. An older child can be examined in his underwear; infants should be undressed. Infants are typically more comfortable with the parent close by so the mother should remain in the room. The infant should be supine with knees extended on the examination table when being measured, not when being weighed.

PTS: 1 DIF: Moderate REF: V1, p. 377 | V2, p. 239

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application

2. ANS: 3

In dark-skinned patients, look for color changes in the conjunctiva or oral mucosa. They should be pink and moist. In dark-skinned patients, skin color changes may not be apparent in nailbeds, palms of the hands, and other exposed areas.

PTS: 1 DIF: Easy REF: V2, p. 241

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall

3. ANS: 2

The best response by the nurse is to explain that Mongolian spots are common in dark-skinned newborns and typically fade over time. The nurse should report the finding in the patient health record, but there is no need to notify the physician immediately. It is inappropriate for the nurse to recommend that the mother take her newborn to a plastic surgeon; Mongolian spots do not require treatment. Although it contains correct information, “. . . nothing you need to worry about” is condescending.

PTS: 1 DIF: Moderate REF: V1, p. 380

KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application

4. ANS: 3

Peripheral arterial insufficiency is associated with smooth, thin, shiny skin with little or no hair. Venous insufficiency leads to thick, rough skin that is commonly hyperpigmented. Hyperthyroidism is associated with abnormally warm skin. Decreased turgor would be seen in dehydration.

PTS: 1 DIF: Moderate REF: V1, p. 381

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application

5. ANS: 4

Tenting, skin that takes several seconds to return to normal after lifting up a fold, may be a sign of dehydration. Edema, an excessive amount of fluid in the tissues, may be a sign of heart failure, kidney disease, peripheral vascular disease, or low albumin levels. Hyperhidrosis is a term for excessive sweating, which may be a sign of thyrotoxicosis. Pallor, abnormal loss of skin color, may be a sign of anemia or blood loss.

PTS: 1 DIF: Moderate REF: V1, p. 381

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

6. ANS: 3

The nurse should document this finding as hirsutism, excess facial or trunk hair. Hair loss should be documented as alopecia. Albinism is a condition caused by lack of pigment in which the patient has white hair and very pale skin. Lanugo is the fine, downy growth of hair that covers the body of a newborn.

PTS: 1 DIF: Moderate REF: V1, p. 382

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

7. ANS: 1

The dorsum of the hand should be used to assess skin temperature. The nurse should compare the temperature of the hands with that of the feet and compare the right side of the body with the left.

PTS: 1 DIF: Easy REF: V1, p. 376

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall

8. ANS: 4

Clubbing (when the nail plate angle is 180° or more) is associated with long-term hypoxic states such as chronic lung disease. A thick nail with yellowing indicates a fungal infection. Spoon-shaped nails may result from iron-deficiency anemia. Brittle nails are commonly seen with malnutrition, hyperthyroidism, and malnutrition.

PTS: 1 DIF: Moderate REF: V1, p. 383

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

9. ANS: 1

Abnormal flattening of the skull in infants may result from placing the baby in the same position for several hours every day. A large head in an adolescent or adult may be associated with acromegaly, a disorder associated with excess growth hormone. In infants and children, a head that is growing disproportionately faster than the body may be a sign of hydrocephalus, which is fluid collection in the cavity within the brain. Irregular jaw movement and cracking of the jaw in adults may indicate temporomandibular joint (TMJ) syndrome.

PTS: 1 DIF: Moderate REF: V1, p. 384

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

10. ANS: 2

Ptosis, or drooping of the eyelid, may be seen in a patient who experienced Bell’s palsy or a stroke. Exophthalmos is associated with hyperthyroidism. Mydriasis may be seen with glaucoma. Macular degeneration has no outward signs.

PTS: 1 DIF: Moderate REF: V1, p. 384

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application

11. ANS: 4

Small hemorrhages under the nailbed, known as splinter hemorrhages, are associated with bacterial endocarditis, a complication of IV drug abuse. A distal band of reddish-pink covering 20% to 60% of the nail (half and half nails) is seen in patients with low albumin levels and renal disease. White spots may indicate zinc deficiency.

PTS: 1 DIF: Difficult REF: V1, p. 383

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis

12. ANS: 1

Soft, boggy nails are seen with poor oxygenation. Brittle nails are seen with hypothyroidism, malnutrition, calcium, and iron deficiency. Thickened nails may result from poor circulation. A thick nail with yellowing is an indication of fungal infection known as onychomycosis.

PTS: 1 DIF: Moderate REF: V1, p. 383

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

13. ANS: 4

To assess edema, the nurse presses firmly with her fingertip for 5 seconds over a bony area. Trace appears as a minimal depression; +1 appears as a 2-mm depression with a rapid return of skin to position; +2 reveals a 4-mm depression, which disappears in 10 to 15 seconds; +3 displays a 6-mm depression that lasts 1 to 2 minutes, and +4 demonstrates an 8-mm depression that persists for 2 to 3 minutes. The area is grossly edematous.

PTS: 1 DIF: Moderate REF: V1, p. 382

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

14. ANS: 2

Icteric sclera are associated with elevated bilirubin levels. Low hemoglobin would indicate anemia. High hemoglobin is polycythemia, which is like thick blood. Low glucose is hypoglycemia, and high sugar is hyperglycemia.

PTS: 1 DIF: Easy REF: V1, p. 384

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Recall

15. ANS: 1

CN III, the oculomotor nerve, is responsible for accommodation. Failure of a pupil to accommodate reflects an abnormality in this cranial nerve. CN V, the trigeminal nerve, controls the corneal reflex, chewing, and biting. CN VIII, the acoustic nerve, plays a role in hearing and the sense of balance. CN X, the vagus nerve, affects heart rate, peristalsis, swallowing, and the gag reflex.

PTS: 1 DIF: Moderate REF: V1, p. 385 | V2, p. 257

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

16. ANS: 4

Test near vision by having the client read text from a distance of 14 inches.

PTS: 1 DIF: Easy REF: V1, p. 385 | V2, p. 252

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall

17. ANS: 3

Diminished near vision in a patient over age 40 or so years is known as presbyopia. Diminished distant vision is known as myopia. Double vision is known as diplopia. Mydriasis or enlarged pupils may be seen with glaucoma.

PTS: 1 DIF: Moderate REF: V1, p. 385

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall

18. ANS: 2

The inner ear is responsible for hearing and equilibrium. The middle ear, which contains the ossicles (auditory structures), conducts sound waves to the inner ear. The external ear collects and conveys sound waves to the middle ear.

PTS: 1 DIF: Easy REF: V1, p. 386 KEY: Cognitive level: Recall

19. ANS: 1

To assess capillary refill, the nurse should briefly press the tip of the nail with firm, steady pressure, then release, and observe for changes in skin color. “Tapping the skin . . .” describes the procedure for performing percussion. “Lifting a fold of skin . . .” demonstrates the procedure for assessing for tenting. The nurse should press firmly with her fingertip for 5 seconds over a bony area, then release her finger, and observe the skin for the reaction to grade edema.

PTS: 1 DIF: Moderate REF: V2, pp. 249-250

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall

20. ANS: 4

Normal capillary refill is less than 3 seconds; therefore, the nurse should report a capillary refill of 4 seconds.

PTS: 1 DIF: Easy REF: V2, p. 250

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall

21. ANS: 2

The large soft spot on the top of the head, known as the anterior fontanel, typically fuses at about 12 to 18 months. The infant should be able to hold up his head by age 6 months. The posterior fontanel fuses at about 8 weeks of age.

PTS: 1 DIF: Moderate REF: V2, p. 251

KEY: Nursing process: Planning | Client need: HPM | Cognitive level: Comprehension

22. ANS: 3

Children typically do not have 20/20 vision until the ages of 6 or 7 years. A finding of 20/60 in a 4-year-old child is considered normal. Myopia is diminished distant vision, which is associated with Snellen chart reading of 20/100. Hyperopia is diminished near vision and is represented by a large fraction, such as 20/15; when found in people over age 45 it is known as presbyopia.

PTS: 1 DIF: Moderate REF: V2, p. 253

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Analysis

23. ANS: 2

If the Weber test is positive, the patient should undergo the Rinne test to assess the type of hearing loss. The Romberg test is performed to test equilibrium. Pure tone audiometry uses a machine to hear sounds at different volumes while the patient wears a headset. Tympanometry assesses pressure in the ear; it does not assess hearing.

PTS: 1 DIF: Moderate REF: V1, p. 387 | V2, p. 263

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall

24. ANS: 1

Next, the nurse should straighten the ear canal by pulling the helix up and back. In a preschool child, the nurse should straighten the ear canal by pulling the helix down and back. After straightening the ear canal, the nurse should slowly insert the speculum and observe the ear canal.

PTS: 1 DIF: Moderate REF: V2, p. 261

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application

25. ANS: 2

A dry, furry tongue is associated with dehydration. A black, hairy tongue is characteristic of a fungal infection. Absence of papillae, reddened mucosa, and ulcerations may indicate allergy. Patients who have a deficiency of iron may have a smooth, red tongue.

PTS: 1 DIF: Moderate REF: V1, p. 389

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

26. ANS: 2

Normally, the thyroid gland is smooth, firm, and nontender. It is often nonpalpable. If the thyroid gland is palpable, the nurse should auscultate it for bruits. It is not necessary to measure or illuminate the thyroid gland. The thyroid gland should not be percussed.

PTS: 1 DIF: Moderate REF: V1, p. 389

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

27. ANS: 4

The nurse should document this finding as crepitus, crackling skin caused by air leaking into the subcutaneous tissues. Tactile fremitus involves palpating for vibrations as the client says “99,” which indicates the presence of fluid in the chest. Bronchophony is present if the words “1, 2, 3” are clearly heard over the lungs as the nurse listens while the patient says those words. Egophony is present if the sound heard is “ay” when the nurse listens over the lung fields as the patient says “eee.”

PTS: 1 DIF: Easy REF: V2, p. 278

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

28. ANS: 3

Bronchovesicular breath sounds are best heard over the first and second intercostal spaces adjacent to the sternum on the anterior chest.

PTS: 1 DIF: Moderate REF: V1, p. 392

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall

29. ANS: 4

Wheezing is a high-pitched sound produced by narrowing of an airway. Rales and crackles are crackling sounds that indicate atelectasis, pulmonary edema, or pneumonia. Rhonchi are low-pitched snoring or rumbling sounds that result from mucous secretions in the large airways.

PTS: 1 DIF: Easy REF: V2, p. 281

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall

30. ANS: 3

A small pulsation at the fifth intercostal space midclavicular line is known as the point of maximal impulse (PMI) and is considered a normal finding. A thrill is a vibration or pulsation palpated in any area except the PMI. A murmur occurs when structural defects in the heart’s chambers or valves cause turbulent blood flow. A heave, which is a visible palpation, is associated with an enlarged ventricle.

PTS: 1 DIF: Moderate REF: V1, p. 394

KEY: Nursing process: Implementation | Client need: PHSI | Cognitive level: Application

31. ANS: 1

A third heart sound, commonly referred to as S3, is heard with heart failure or volume overload. S4 heart sound may be auscultated with coronary artery disease, hypertension, and pulmonic stenosis.

PTS: 1 DIF: Difficult REF: V1, p. 394

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

32. ANS: 4

Pulses documented as 1 are diminished and barely palpable; 2 are normal; 3 are full and increased; and 4 are bounding.

PTS: 1 DIF: Moderate REF: V2, p. 311

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

33. ANS: 3

Normal jugular venous pressure is less than 3 cm. A jugular venous pressure of 5 cm is elevated and suggests heart failure.

PTS: 1 DIF: Moderate REF: V2, p. 283

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Comprehension

34. ANS: 2

The sound of suction attached to a nasogastric tube can be mistaken for bowel sounds; therefore, the nurse should discontinue the suction or clamp off the tube while auscultating bowel sounds. Light palpation can be performed in the postoperative patient. The nurse should listen for bowel sounds for at least 5 minutes before determining that they are absent. Auscultation should be performed before percussion in examining the abdomen.

PTS: 1 DIF: Moderate REF: V1, p. 397

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

35. ANS: 2

Abdominal palpation should be avoided in the child who has Wilms’ tumor, large diffuse pulsation, or a history of organ transplant. Abdominal palpation can be performed with appendicitis, Crohn’s disease, and small bowel obstruction.

PTS: 1 DIF: Moderate REF: V2, p. 292

KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall

36. ANS: 3

Genu varum, or bowlegs, is a normal finding in children for 1 year after they begin walking and the bones of the legs become more ossified with development and weight-bearing. However, assessment over time is important to be sure the gait and positioning develops normally. The nurse should allay the father’s concerns by providing him with this information. The child shows no signs, in the scenario above, that physical therapy is needed. It is not appropriate for the nurse to recommend an orthopedic surgeon; physician referrals are given by the physician or advanced practice nurse when appropriate. “Your child is walking fine . . .” is condescending and does not appropriately address the father’s concerns.

PTS: 1 DIF: Moderate REF: V2, p. 295

KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Application

37. ANS: 2

Asking the patient to spread his fingers tests abduction; asking him to bring them together assesses adduction. Asking the patient to make a fist tests flexion, whereas asking him to extend the hand tests extension.

PTS: 1 DIF: Moderate REF: V2, p. 299

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall

38. ANS: 4

If the patient does not respond to verbal stimuli, the nurse should try tactile stimuli by gently shaking the patient’s shoulder. If the patient does not respond to tactile stimuli, the nurse should try painful stimuli by squeezing the trapezius muscle, rubbing the sternum, applying pressure on the mandible at the angle of the jaw, or applying pressure over the moon of the nail. But do not start out with painful stimulation before you are sure the patient is not going to react to a less invasive approach.

PTS: 1 DIF: Moderate REF: V1, p. 399

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis

39. ANS: 2

The nurse can assess immediate memory by asking the patient to repeat a series of three numbers and gradually increasing the length of the series until the patient cannot repeat the series correctly. The nurse can assess recent memory by asking the patient how he got to the hospital or by asking the patient to repeat three items that the nurse mentioned earlier in the examination. The nurse can assess remote memory by asking the patient his birth date or the date of a significant historical event.

PTS: 1 DIF: Moderate REF: V2, p. 303

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application

40. ANS: 2

The option that includes the most detailed information provides the most accurate description of the patient’s level of consciousness. The other documentation provides little information about the level of consciousness. From those descriptions, the patient might have a decreased level of consciousness or could simply be exhausted.

PTS: 1 DIF: Moderate

REF: V1, pp. 399-400; High-level question; answer not stated verbatim

KEY: Nursing process: Implementation | Client need: PHSI | Cognitive level: Analysis

41. ANS: 2

Because older adults may tire easily and because they may have stiff muscles and arthritic joints, the nurse should arrange the sequence of the exam to limit position changes. The nurse should work efficiently; however, speed is not the goal, and the nurse should observe the patient’s energy level and stop for periods of rest as needed. It is appropriate to demonstrate equipment for school-age children but is not usually necessary for older adults, who have probably experienced other physical examinations. Because this is a comprehensive exam, it is not appropriate to omit portions of the exam because they may be tiring. As discussed, the patient should rest and then the nurse should return to the examination.

PTS: 1 DIF: Moderate REF: V1, p. 378

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

42. ANS: 2

The nurse should document 4: Slight weakness. The following is the muscle strength rating scale:

Rating
Criteria
Classification
5
Active motion against full resistance
Normal
4
Active motion against some resistance
Slight weakness
3
Active motion against gravity
Weakness
2
Passive ROM
Poor ROM
1
Slight flicker of contraction
Severe weakness
0
No muscular contraction
Paralysis

PTS: 1 DIF: Difficult REF: V2, p. 301

KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Application

MULTIPLE RESPONSE

1. ANS: 2, 3

The pulse rate of 118 beats/minute and the respiratory rate of 35 breaths/minute are abnormally elevated and require further assessment. Blood pressure 110/64 mm Hg and oral temperature 98.6°F (37°C) are considered normal and do not require further assessment.

PTS: 1 DIF: Easy REF: V2, p. 239

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis

2. ANS: 1, 2, 4

Poorly controlled diabetes, cataracts, macular degeneration, and advanced glaucoma may limit the visual field. Peripheral vascular disease may be associated with diabetes, but it occurs in the extremities, not the eyes.

PTS: 1 DIF: Moderate REF: V1, pp. 385-386

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall