1. A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for a patient, the new graduate nurse begins to explain to the
... [Show More] patient the purpose of completing a physical assessment. Which of the following statements made by the new graduate nurse prompts the preceptor to intervene?
a. “I will use the information from my assessment to figure out if your antihypertensive medication is working effectively.”
b. “Nursing assessment data are used only to provide information about the effectiveness of your medical care.”
c. “Nurses use data from their patient’s physical assessment to determine a patient’s educational needs.”
d. “Information gained from physical assessment helps nurses better understand their patients’ emotional needs.”
ANS: B
Nursing assessment data are used to evaluate the effectiveness of all aspects of a patient’s care, not just the patient’s medical care. Assessment data help the nurse evaluate the effectiveness of medications and determine a patient’s health care needs, including the need for patient education. Nurses also use assessment data to identify patients’ psychosocial and cultural needs.
DIF: Evaluate REF: 61N2 R I GOBBJ:.DiC scMuss the purposes of physical assessment.
TOP: Communication and DocuUmenStatioNn T O
MSC: CPNRE: Foundations of Practice
2. For a weak patient with bilateral basilar pneumonia, which is the best position for a complete geriatric physical examination?
a. Prone position.
b. Sims’s position.
c. Supine position.
d. Lateral recumbent position.
ANS: C
The supine position is the most normally relaxed position. It will not further compromise the patient’s breathing. If the patient becomes short of breath easily, the head of the bed can be raised. This position would be easiest for weak older person to get into for an examination. Lateral recumbent and prone positions cause respiratory difficulty for any patient with respiratory difficulties. Sims’s position is used for assessment of the rectum and the vagina.
DIF: Understand REF: 617, Table 32-3
OBJ: List techniques for preparing a patient physically and psychologically before and during an examination. TOP: Planning MSC: CPNRE: Foundations of Practice
3. During an annual gynecological examination, a college student discusses her upcoming college break at a tropical location. After the student receives an oral contraceptive prescription, the nurse identifies the importance of skin cancer prevention education by discussing which evidence-informed prevention technique?
a. Applying water-based sunscreen only before swimming.
b. Using tanning bed daily for 7 days before college break trip.
c. Applying broad-spectrum sunscreen of SPF 5.
d. Taking extra precautions in the sun secondary to the prescription.
ANS: D
Oral contraceptives can make the skin more sensitive to the sun. For this reason, the patient should be educated about the need for sun protection with such techniques as the use of
wide-brimmed hats, use of broad-spectrum sunscreen of SPF 15 or greater, not tanning during midday, and not using tanning beds. Broad-spectrum sunscreens should be applied 15 minutes before a person goes out into the sun and after swimming or perspiring.
DIF: Understand REF: 628, Box 32-9
OBJ: Discuss ways to incorporate health promotion and health teaching into the examination. TOP: Planning MSC: CPNRE: Foundations of Practice
4. A head and neck physical examination is completed on a 50-year-old woman. All physical findings are normal except that she has fine, brittle hair. On the basis of the physical findings, which of the following laboratory tests would the nurse expect to be ordered?
a. Liver function test.
b. Lead level.
c. Thyroid-stimulating hormone test.
d. Complete blood cell counNt (CRBCI).
G B.C M
ANS: C
U S N T O
Thyroid disease can make hair thin and brittle. Liver function testing is indicated for a patient who has jaundice. Lead levels and a CBC are not indicated for the presence of brittle hair.
DIF: Understand REF: 627
OBJ: Identify how nurses use physical assessment skills during routine nursing care. TOP: Planning MSC: CPNRE: Foundations of Practice
5. A febrile preschool-aged child presents to the after-hours clinic. Varicella is diagnosed on the basis of the illness history and the presence of small, circumscribed skin lesions filled with serous fluid. The nurse documents the varicella lesions as which type of skin lesion?
a. Vesicle.
b. Wheal.
c. Papule.
d. Pustule.
ANS: A
Vesicles are circumscribed, elevated skin lesions filled with serous fluid that are smaller than 1 cm in diameter. Wheals are irregularly shaped, elevated areas of superficial localized edema that vary in size. They are common with bug bites and hives. Papules are palpable, circumscribed, solid elevations in the skin that are smaller than 1 cm in diameter. Pustules are elevations of skin similar to vesicles, but they are filled with pus.
DIF: Understand REF: 626, Box 32-7
OBJ: Describe physical measurements made in assessing each body system. TOP: Assessment MSC: CPNRE: Foundations of Practice
6. A school nurse recognizes a belt buckle–shaped ecchymosis on a 7-year-old student. When privately asked about how the injury occurred, the student described falling on the playground. Upon suspecting abuse, the school nurse’s best next action is which of the following?
a. Interviewing the patient in the presence of his/her teacher.
b. Ignoring the findings because child abuse is a declining problem.
c. Realizing that abuse victims usually report abusive situations.
d. Contacting Social Services and reporting suspected abuse.
ANS: D
Most provinces and territories mandate a report to a social service centre if nurses suspect abuse or neglect. When abuse is suspected, the nurse interviews the patient in private. Abuse of children, women, and older persons is a growing health problem. It is difficult to detect abuse because victims often will not complain or report that they are in an abusive situation.
DIF: Apply REF: 620
OBJ: Identify how nurses use physical assessment skills during routine nursing care. TOP: Implementation MSC: CPNRE: Foundations of Practice
7. A nurse identifies Pediculosis humanus capitis. Considering the possible complications of treatment, the nurse knows to not use which of the following treatment products?
a. Fine-toothed comb.
b. Pediculicide.
c. Lindane-based shampoo.
d. Vinegar hair rinse.
ANS: C
NURSINGTB.COM
Products containing lindane, a toxic ingredient, often cause adverse reactions and neurotoxic effects. Patients who have head lice are instructed to shampoo thoroughly with pediculicide (shampoo available at drugstores) in cold water, comb thoroughly with a fine-toothed comb, and discard the comb. A dilute solution of vinegar and water helps loosen nits.
DIF: Apply REF: 629, Box 32-10
OBJ: Describe physical measurements made in assessing each body system.
TOP: Implementation MSC: CPNRE: Foundations of Practice
8. A parent calls the school nurse with questions regarding the recent school vision screening. Snellen chart examination revealed 20/60 for both eyes in the child. Considering the visual acuity results, what does the nurse informs the parent?
a. That the child should have an optometric examination.
b. That the child is suffering from strabismus.
c. That the child may have presbyopia.
d. That the child has vision issues probably because of cataracts.
ANS: A
Normal vision is 20/20. The larger the denominator, the poorer the patient’s visual acuity. For example, a value of 20/60 means that the patient, when standing 20 feet away, can read a line that a person with normal vision can read from 60 feet away. Strabismus is a (congenital) condition in which both eyes do not focus on an object simultaneously: these eyes appear crossed. Acuity may not be affected. Presbyopia is impaired near vision that occurs in
middle-aged and older persons and is caused by loss of elasticity of the lens. Cataracts develop slowly and progressively after age 35 or suddenly after trauma.
DIF: Apply REF: 634
OBJ: Identify preventive screenings and the appropriate age(s) for each screening to occur. TOP: Implementation MSC: CPNRE: Foundations of Practice
9. During a routine pediatric history documentation and physical examination, the parents report that their child was a premature infant and was so small that he had to stay in the neonatal intensive care unit longer than usual. They state that the infant was yellow when born, and that he developed an infection that required “every antibiotic under the sun” to cure him. Considering the neonatal history, the nurse determines that it is especially important to perform which type of a focused examination?
a. Cardiac.
b. Respiratory.
c. Ophthalmic.
d. Hearing acuity.
ANS: D
Risk factors for hearing problems include low birth weight, nonbacterial intrauterine infection, and excessively high bilirubin levels. Hearing loss caused by ototoxicity (injury to auditory nerves) can result from high maintenance doses of antibiotics. Cardiac, respiratory, and eye
examinations are important assUessmSenNts bTut are nOot relevant to this child’s condition.
DIF: Apply REF: 636, Table 32-13
OBJ: Identify data to collect from the nursing history before an examination.
TOP: Implementation MSC: CPNRE: Foundations of Practice
10. During a presentation about sexually transmitted infections to high school students, the nurse recommends the human papillomavirus (HPV) vaccine series to prevent which of the following?
a. Cervical cancer.
b. Genital lesions.
c. Vaginal discharge.
d. Swollen perianal tissues.
ANS: A
HPV infection increases the risk for cervical cancer. HPV vaccine is recommended by the Public Health Agency of Canada for female patients aged 9 to 26 years. Vaginal discharge, painful or swollen perianal tissues, and genital lesions are signs and symptoms that may indicate a sexually transmitted infection.
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