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Week 2 Ch 3,4,5,6
Health Assessment Week 2 Ch.3,4,5,& 6 Quiz
| Question | Answer |
|---|---|
| What is the first step for the nurse preparing to assess a patient in a hospital setting? Wear a mask Don gloves Don goggles Wash hands | Wash hands |
| Which part of the hand does a nurse use to palpate a patient’s superficial mass in the skin? The ulnar surface of the hand The heel of the hand The dorsal surface of the hand The fingertips | The fingertips |
| The nurse should use a(n) _________ to auscultate the chest and abdomen. transilluminator audiometer stethoscope Doppler | stethoscope |
| The nurse is percussing the liver of an obese patient. Which percussion finding would be expected? Tones with a booming quality An enhanced tone quality A reduced intensity of tone A higher pitch tone than in patients of a normal weight | A reduced intensity of tone |
| The nurse is palpating the abdomen of a patient. How deep should the hands press while performing deep palpation? 2 cm 4 cm 8 cm 1 cm | 4 cm |
| The nurse is assessing a patient who does not speak English. Which chart does the nurse use to check this patient’s visual acuity? Pupil gauge chart Snellen chart Snellen E chart Rosenbaum pocket screener | Snellen E chart |
| The nurse suspects that a patient has a fungal infection of the skin. Which instrument helps confirm this suspicion? Transilluminator Monofilament Slit lamp Wood’s lamp | Wood’s lamp |
| The nurse is percussing a patient’s abdomen. What sound will the nurse most likely percuss? Resonance Tympany Dullness Flatness | Tympany |
| Pulse oximetry is used to determine hemoglobin percentages of the blood. estimate the oxygen saturation of arterial blood. estimate the saturation of oxygen in the alveoli. estimate the pulse rate. detect pulsation in the veins. | estimate the oxygen saturation of arterial blood. estimate the pulse rate. |
| Which are considered basic techniques for physical assessment? Percussion History of present illness Palpation Inspection Medication reconciliation Auscultation | Palpation Inspection Auscultation |
| Where does the nurse place the oral thermometer in a patient’s mouth? Under the tongue in the posterior sublingual pocket Along the outer aspect of the lower molars and against the cheek Between the tongue and the hard palate Under the tongue next to the frenulum of the lower lip | Under the tongue in the posterior sublingual pocket |
| Which technique does the nurse use to count respirations? Use a stethoscope to listen to the breath sounds. Watch the abdomen for movement. Watch the chest rise and fall. Place a hand across the patient’s chest. | Watch the chest rise and fall. |
| The nurse is auscultating the lungs for breath sounds. What sounds indicate the expected breath sounds? The nurse will hear the diffusion of air and carbon dioxide. The nurse will hear gurgling noises. The nurse will hear the air move in and out of the lungs. The nurse will hear a lub/dub sound. | The nurse will hear the air move in and out of the lungs. |
| Which artery is used to assess an adult’s blood pressure? Brachial artery Carotid artery Radial artery Humeral artery | Brachial artery |
| The nurse suspects an irregular rhythm of a patient’s radial pulse. What is the most appropriate action for the nurse to take to assess the pulse rate? Count the patient’s apical rate for one full minute. Document this rhythm as normal for this patient. Count the brachial rate for 30 seconds and multiply by 2. Use a pulse oximeter to determine the pulse rate. | Count the patient’s apical rate for one full minute. |
| A temperature of 99.8°F taken in the axilla is equivalent to which temperature value taken orally? 99.8°F 100.8°F 97.8°F 98.8°F | 100.8°F |
| Why is the weight of an adult patient measured routinely during a physical assessment? Weight identifies patients who exercise and those who do not exercise. Fat deposits in specific locations can be identified. A change in body weight can be indicative of health problems. Measurement allows assessment of body fat content. | A change in body weight can be indicative of health problems. |
| What factors could cause a false-high blood pressure reading? Having the nurse’s eyes looking down at the meniscus Positioning patient’s arm below the level of the heart Using a cuff that is too narrow Deflating the cuff too rapidly | Using a cuff that is too narrow |
| What is the most common procedure for determining a patient’s radial pulse? Palpate the radial artery pulse for 15 seconds and multiply by 4. Use the automatic blood pressure cuff to count the rate. Use the pulse oximeter to obtain the heart rate and multiply by 4. Palpate the carotid artery for 1 full minute. | Palpate the radial artery pulse for 15 seconds and multiply by 4. |
| What factors can affect blood pressure? (Select all that apply.) Select all that apply. Pain Weight Gender Smoking Mobility Race What the person ate | Pain Weight Gender Smoking Race What the person ate |
| An elderly African-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally sensitive nurse should apply statistical trends of various ethnic and cultural groups. take a history and perform a physical examination. recognize and accept different beliefs about health. identify high-risk patients for various diseases. | recognize and accept different beliefs about health. |
| The nurse states, “All homosexuals have HIV infection.” This statement is an example of prejudice. racism. sexism. stereotyping. | stereotyping |
| Which is a common mistake made by health care professionals when collecting data about ethnic and cultural considerations of a patient? Acknowledging the practice of folk or herbal remedies Assuming data about the patient based on skin color or ethnic group Overestimating the ability of individuals from diverse cultures to understand health care concepts Adapting health care concepts to meet the needs of individuals of other cultures | Assuming data about the patient based on skin color or ethnic group |
| The nurse is performing a cultural assessment for an immigrant from Mexico. The patient is having difficulty adapting to the American health system. What is the most likely explanation for this problem? Cultural unfamiliarity Cultural taboos Culture shock Culture disorientation | Culture shock |
| A patient has a belief in a divines to be obeyed and worshipped as the creator. This belief is known as ethnicity. spirituality. religion. culture. | religion |
| What standards or guidelines exist to help eliminate racial and ethnic health disparities and to improve the health of all people who live in the United States? The American Society of Cultural Competence has guidelines containing the health beliefs and practices of major cultural groups. The US Office of Minority Health published standards to ensure culturally appropriate health care services. Each ethnic group has its own written standards for competent cultural care. | The US Office of Minority Health published standards to ensure culturally appropriate health care services. |
| __________ refers to differences in gender, age, culture, race, ethnicity, religion, sexual orientation, physical or mental disabilities, and social and economic status. Diversity Discrimination Spirituality Culture sensitivity | Diversity |
| Which example below best characterizes a patient’s race? The language spoken in the patient’s home is Tagalog. The patient and his family have blonde hair and fair skin. The patient’s family follows a kosher diet. The patient’s grandparents came to the United States from Germany. | The patient and his family have blonde hair and fair skin. |
| Examples of providing culturally competent care are (Select all that apply.) Select all that apply. seeking knowledge of the health beliefs and practice of all the cultures. speaking at least one foreign language. understanding people from cultures other than his or her own. allowing for complementary interventions for pain relief. visiting a foreign country. incorporating foods from home into the diet. | seeking knowledge of the health beliefs and practice of all the cultures. understanding people from cultures other than his or her own. allowing for complementary interventions for pain relief. incorporating foods from home into the diet. |
| The nurse is assessing a patient’s spiritual beliefs and practices. Which questions should be considered part of the assessment? (Select all that apply.) Select all that apply. What does dying mean to you? What are your educational goals? Do you use prayer in your life? What is the name of your clergy, ministers, chaplains, pastor, or rabbi? What type of spiritual/religious support do you desire? What does pain mean to you? | What does dying mean to you? Do you use prayer in your life? What is the name of your clergy, ministers, chaplains, pastor, or rabbi? What type of spiritual/religious support do you desire? |
| How do nurses assess a patient’s pain? By asking the patient to rate the pain being experienced By understanding the sensory experience related to the amount of tissue damage By assessing physiologic changes of the patient By the patient’s medical diagnosis or surgical procedure | By asking the patient to rate the pain being experienced |
| Which findings by the nurse would produce the most accurate assessment of the severity level of a patient’s pain? The cause of the pain The patient’s subjective data The nurse’s experience The patient’s objective findings | The patient’s subjective data |
| The nurse is assessing a patient who has pain with a sudden onset and a limited duration and that subsides as healing occurs. Which type of pain would this be considered? Nonmalignant pain Cancer pain Acute pain Chronic pain | Acute pain |
| When assessing the quality of a patient’s pain, the nurse should ask which of the following question? “When did the pain start?” “What does your pain feel like?” “Is it a sharp pain or dull pain?” “Is the pain a stabbing pain?” | “What does your pain feel like?” |
| The nurse is reviewing the physiology of pain. Where does the perception of pain actually occur? The visceral and somatic free nerve endings (nociceptors) The parietal lobe of the cerebral cortex The dorsal horn of the spinal cord The afferent (sensory) nerves | The parietal lobe of the cerebral cortex |
| _________ pain is associated with feeling pain when a limb has been amputated. Phantom Acute Persistent Chronic | Phantom |
| The nurse notices 2 women who are in labor, but they're responding differently to their contractions. The 1st woman, who is having her 1st baby, has rated her pain as a “7,” seems agitated, and has asked for pain medications. The 2nd woman, who is having her third baby, has also rated her pain as a “7,” but is calmer and says she does not need anything for pain at this time. What explains the differences in the outward responses to pain between these women? Pain threshold Pain tolerance Nociception | Pain tolerance |
| Nurses must trust the patient’s self-report of pain even when it differs from the nurse’s beliefs or the patient’s non-verbal behavior. How does the nurse assess pain in a patient who is alert, but unable to communicate? Check the medication record for the last time pain medication can be given. Talk to the patient about the pain and observe the patient’s non-verbal behavior. Give a pain med for the estimated intensity of pain and observe changes in the patient. | Give a pain med for the estimated intensity of pain and observe changes in the patient. |
| The nurse is attending an in-service on pain management for postoperative patients. Which statements regarding pain are true? (Select all that apply.) Select all that apply. An individual’s pain response is predictable based on his or her culture or ethnicity. The pain response may be influenced by one’s culture. Individuals from all cultures respond to pain similarly. Pain management may vary depending on the source of pain. Individuals may express pain differently. | The pain response may be influenced by one’s culture. Individuals may express pain differently. |
| The nurse is assessing for objective findings that may be associated with the patient’s acute pain level. Which findings might be associated with acute pain? (Select all that apply.) Select all that apply. An elevated blood pressure The patient is crying. Diaphoresis An elevated heart rate The patient states a pain level of 8 out of 10 on pain scale. Vital signs stable | An elevated blood pressure Diaphoresis An elevated heart rate |
Created by:
PRO Teacher
garrisonjr84