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168.123 Assessment and clinical decision making > All questions > Flashcards

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1

1. When performing the physical assessment the examiner should:
a) examine tender or painful areas first to help relieve the patient's anxiety
.b) follow the same examination sequence regardless of the patient's age or condition.
c) organize the steps of the assessment so that the patient does not change positions too often.
d) perform the examination from the left side of the bed.

c) organize the steps of the assessment so that the patient does not change positions too often.

2

2. The tympanic membrane should appear:
a) whitish with a small fleck of light in superior portion.
b) pearly grey and slightly concave.
c) pulled in at the base of the cone of light.
d) light pink with a slight bulge.

b) pearly grey and slightly concave.

3

3. While counting the apical pulse on a 16-year-old patient, you note an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be your response?
a) refer the patient to a cardiologist for further testing.
b) no further response needed as this is a normal finding.
c) talk with patient about his intake of caffeine.
d) do an electrocardiogram following the exam.

d) do an electrocardiogram following the exam.a) refer the patient to a cardiologist for further testing.

4

4. You notice that your client’s pupils are not equal. Normal pupillary light reflex would show:
a) pupillary dilation when looking at far objects.
b) eyes converging and pupils constricting when looking at a near object.
c) constriction of both pupils occurs in response to bright light.
d) both eyes converge to focus on the light.

c) constriction of both pupils occurs in response to bright light.Weber & Kelly Pg 272

5

5. When you ask your 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet furtherapart. You would document this as a:
a) negative Homan's sign.
b) positive Romberg's sign.
c) ataxia.
d) negative Romberg's sign.

b) positive Romberg's sign.Doesn't appear to be anything in Weber and Kelly on how to record this but found on internet

6

6. It is normal to palpate a few lymph nodes in the neck of a healthy person.What are the characteristics of these nodes?
a) mobile, soft, non-tender.
b) large, clumped, tender.
c) matted, fixed, tender, hard.
d) soft , fixed, non-tender.

a) mobile, soft, non-tender.Page 261 Weber and Kelly

7

7. Select the sequence of techniques used during an examination of the abdomen.
a) percussion, inspection, palpation, auscultation
.b) inspection, palpation, percussion, auscultation.
c) inspection, auscultation, percussion, palpation.
d) auscultation, inspection, palpation, percussion

c) inspection, auscultation, percussion, palpation.

8

8. In examining Mr. P., 70, you notice that he has bilateral gynaecomastia. Which of the following describes your best course of action?
a) ignore it, it is not unusual for men to have benign breast enlargement.
b) recommend that Mr. P. see his doctor for a mammogram.
c) explain that this condition may be the result of hormonal changes and recommend that he see his doctor.
d) tell Mr. P. that gynaecomastia in the male is usually associated with prostate enlargement and recommend that he be screened thoroughly.

c) explain that this condition may be the result of hormonal changes and recommend that he see his doctor.

Pg 381 Weber and KellyNot a normal finding - Gynaecomastia, a smooth, firm, moveable disc of glandular tissue may be seen in one breast in males for a temporary time. However it may also be seen in in hormonal imbalances, drug abuse, cirrhosis, leukaemia, and thyrotoxicosis. Irregular shaped, hard nodules occur in breast cancer.

9

9. Auscultation is the term used for?
a) Listening to the sounds produced by the body.
b) Listening to the sounds produced by palpation
.c) The sounds heard on percussion.
d) All of the above.

a) Listening to the sounds produced by the body.

10

10. Objective data in the assessment is obtained:
a) By what the patient says about themselves during the history.
b) During the initial interview.
c) From the nursing diagnosis.
d) By the nurse during the physical assessment

d) By the nurse during the physical assessment

11

11.When assessing an individual for their mental health status, there are four main headings of assessment. What are these?
a) Mood, affect, consciousness and orientation
b) Memory, attention, thought content and perception
c) Language, orientation, attention and abstract reasoning
d) Appearance, behaviour, cognition and thought process.

d) Appearance, behaviour, cognition and thought process.Info from the forum from the Jarvis textbookWeber & Kelly Pg 59 - Mental status refers to a persons level of cognitive and emotional functioning and stability

12

12. At the conclusion of the examination, the examiner should:
a) document findings before leaving the examination room.
b) have findings confirmed by another practitioner.
c) relate objective findings to the subjective findings for accuracy.
d) summarise findings to the patient.

d) summarise findings to the patient.

13

13. The purpose of percussion is to:
a) assess underlying tissue consistency.
b) assess underlying tissue texture.
c) assess underlying structures.
d) assess underlying tissue turgor

c) assess underlying structures.

Weber & Kelly Pg 37 Sounds and vibrations allow you to assess underlying structures. Percussion has several different assessment uses including:Elicit painDetermine location, size and shapeDetermine densityDetect abnormal massesElicit reflexes

14

14. The Glasgow Coma Scale is divided into three areas. They include:
a) pupillary response, a reflex test and assessing pain.
b) eye opening, motor response to stimuli and verbal response.
c) response to fine touch, stereognosis and sense of position.
d) orientation, rapid alternating movements and Romberg test.

b) eye opening, motor response to stimuli and verbal response.

15

15. When assessing the spine you would ask the patient to:
a) Adduct and extend
b) Supinate evert and retract
c) Extend adduct invert and rotate
d) Flex, extend, rotate

d) Flex, extend, rotateAlso need to add lateral bends (side to side)

From Marlas Notes

16

16. Examination of the shoulder includes:
a) Forward flexion, internal rotation, abduction and external rotation
b) Abduction ,adduction ,pronation and supination
c) Circumduction, inversion, eversion and rotation
d) Eversion, retraction, protraction, and circumduction

a) Forward flexion, internal rotation, abduction and external rotationFrom Marlas NotesAlso includes Hyperextension and adduction

17

17.When examining the apical pulse, the normal size of the impulse is?
a) < 1cm
b) about 2cm
c) 3cms
d) varies depending on the size of the person

b) about 2cm

Normally 1 to 2cm but in patients with large breasts or who are obese apical pulse may not be palpable
Pg 405 Weber and Kelly

18

18. The absence of bowel sounds is established after listening for
a) 1 full minute
b) 3 full minutes
c) 5 full minutes
d) None of the above

c) 5 full minutes

19

19. Auscultation of the abdomen may reveal bruits of which arteries
a) Aortic, renal iliac and femoral
b) Jugular, aortic, carotid and femoral
c) Pulmonic, aortic and portal
d) Renal iliac internal jugular and femoral

a) Aortic, renal iliac and femoral

20

20. The largest salivary gland is located
a) Within the cheeks in front of the ear
b) Beneath the mandible at the angle of the jaw
c) Within the floor of the mouth under the tongue
d) As the base of the tongue

a) Within the cheeks in front of the ear

Three pairs of salivary glands are:Parotid - below and in front of ears, empty through stensons ducts located in the cheek Submandibular - in lower jaw, open under the tongue on either side of frenulum through Whartons ductsSublingual - under the tongue, open through several ducts located on the floor of the mouthPage 313 Weber and Kelly

21

21. A common cause of conductive hearing loss is
a) Impacted cerumen
b) Acute rheumatic fever
c) A CVA
d) Otitis externa

a) Impacted cerumen

22

22. When auscultating the lungs of an adult patient, you note that over the posterior lower lobes you hear low pitched, soft breath sounds with inspirationbeing longer than expiration. You know that these are:
a) bronchial breath sounds and are normal in that location.
b) bronchovesicular breath sounds and are normal in that location.
c) vesicular breath sounds and are normal in that location
.d) sounds normally auscultated over the trachea.

c) vesicular breath sounds and are normal in that location.

Bronchial - Trachea/Thorax; High pitch, Short inspiration & long expiration
Bronchiovesicular - Over sternum and between scapulae; Moderate pitch, Same length during inspiration and expiration
Vesicular - Peripheral lung fields; Low pitch; Long inspiration and short expirationPage 355 Weber & Kelly

23

23. The first heart sound (S1) is the result of:
a) aortic and pulmonic valve closure.
b) aortic and mitral valve closure.
c) mitral and tricuspid valve closure.
d) tricuspid and pulmonic valve closure.

c) mitral and tricuspid valve closure.

S1 is lub and first sound of heart beat, S1 Starts systole - where blood is ejected from the ventricles (ventricular contraction)

24

24. The most important technique when progressing from one auscultatory site onthe thorax to another is:
a) top to bottom comparison.
b) side to side comparison.
c) posterior to anterior comparison.
d) interspace by interspace comparison.

b) side to side comparison.

25

25. Positive consensual light reflex is when
a) The convergence of the axes of the eyeballs
b) The simultaneous constriction of the other pupil when one eye is exposed to bright light
c) A reflex direction of the eye towards an object attracting a person’s attention
d) The adaptation of the eye to near vision

b) The simultaneous constriction of the other pupil when one eye is exposed to bright light

26

26. Bradycardia is the term given for?
a) a heart rate above 60 beats per minute (b.p.m)
b) a heart rate below 60 bpm
c) an irregular heart rate
d) the normal variation of heart rate related to inspiration and expiration

b) a heart rate below 60 bpm

27

27. To assess the dorsalis pedis artery, you would palpate:
a) in the groove behind the medial malleolus.
b) lateral to the extensor tendon of the great toe.
c) over the lateral malleolus.
d) behind the knee.

b) lateral to the extensor tendon of the great toe.

28

28. Tenderness on light palpation in the right lower quadrant could indicate a disorder of the:
a) spleen.
b) sigmoid.
c) gallbladder.
d) appendix.

d) appendix.

29

29. Upon percussion you note a dull sound at the midline in the pelvic region. You might suspect:
a) appendicitis.
b) distended bladder.
c) impaction.
d) renal calculi.

b) distended bladder.

If there is dull percussion on the flanks this may a dull percussion tone on the flanksPage 472 Weber and Kelly

30

30. The most reliable indicator of pain in an adult is?
a. degree of physical functioning.
b. non verbal behaviours.
c. the family’s comments.
d. the client’s self report.

d. the client’s self report.

31

1. Your patient tells you he is allergic to penicillin. What would be your next response?
a) "Are you allergic to any other drugs?"
b) "I'll write your allergy on your medication chart so you won't receive any."
c) "Would you describe what happens to you when you take penicillin?"
d) "How often have you received penicillin?"

c) "Would you describe what happens to you when you take penicillin?"

32

2. The force or strength of the pulse:
a) is a reflection of the heart's stroke volume.
b) reflects the blood volume in the arteries during diastole.
c) demonstrates elasticity of the vessel wall.
d) is usually recorded on a 0-2 scale.

a) is a reflection of the heart's stroke volume.From lecture notes

33

3. What should the examiner palpate for tenderness prior to examining the ear with the otoscope?
a) helix, external auditory meatus and lobule.
b) mastoid process, tympanic membrane and malleus.
c) pinna, pars flaccida and antitragus.
d) pinna, tragus and mastoid process.

d) pinna, tragus and mastoid process.Refer to lecture notes for this information

34

4. In the Rinne test, the 2 to 1 ratio refers to:
a) the loudness of the tone heard by the two ears.
b) the length of time until the patient stops hearing the tone by air conduction and by bone conduction.
c) the length of time until the patient no longer hears the tone and the examiner no longer hears the tone.
d) the examiner hearing the tone twice as long as the patient hears it.

b) the length of time until the patient stops hearing the tone by air conduction and by bone conduction.

Using the tuning forks to test air and bone conduction for sounds. Air conduction is twice as long as bone conduction for a normal. In sensorineural loss air conduction is longer than bone conduction but NOT twice as longPage 308 Weber and Kelly

35

5. The left lung:a) is shorter than the right because of the underlying stomach.b) consists of two lobes.c) consists primarily of an upper lobe on the posterior chest.d) is divided by the percardial fissure.

b) consists of two lobes.

36

6. The first heart sound (S1) is the result of
:a) aortic and pulmonic valve closure.
b) aortic and mitral valve closure.
c) mitral and tricuspid valve closure.
d) tricuspid and pulmonic valve closure.

c) mitral and tricuspid valve closure.

S1 is lub and first sound of heart beat, S1 Starts systole - where blood is ejected from the ventricles (ventricular contraction)

37

7. The valve closures that can BEST be heard at the base of the heart are:
a) aortic, pulmonic
b) mitral, tricuspid
c) mitral, pulmonic
d) tricuspid, aortic

a) aortic, pulmonic

Aortic area - 2nd intercostal at right sternal border (base of the heart)Pulmonic area - 2nd intercostal at the left sternal border (base of the heart)Erbs point - 3rd to 5th intercostal space at the left sternal borderMitral (apical) - 5th intercostal space near the midclavicular line (the apex of the heart)Tricuspid area - 4th or 5th intercostal space at the lower left sternal borderPage 396 Weber & Kelly

38

8. To assess the dorsalis pedis artery, you would palpate:
a) in the groove behind the medial malleolus.
b) lateral to the extensor tendon of the great toe.
c) over the lateral malleolus.
d) behind the knee.

b) lateral to the extensor tendon of the great toe.

Dorsiflex the patients foot and apply light pressure lateral to and along the side of the extensor tendon of the big toe. Assess amplitude bilaterallyPage 437 Weber and Kelly

39

9. Joe is being assessed for range of joint movement. You ask him to move his arm in towards the center of his body. This movement is called:a) flexion.b) extension.c) adduction.d) abduction.

c) adduction.

40

10. In assessing the tonsils of a 30-year-old, you note they are involuted, granular in appearance, and appear to have deep crypts. What would be your response to these findings?a) Nothing, this is the appearance of normal tonsils.b) Obtain a throat culture on the patient for possible strep infection.c) Refer patient to a throat specialist.d) Continue with assessment looking for any other abnormal findings.

a) Nothing, this is the appearance of normal tonsils.Check this answer? from quizletTonsilitis (detecting and grading) 1+ Tonsils are visible2+ Tonsils are midway between tonsillar pillars and uvula3+ Tonsils touch the uvula4+ Tonsils touch each other

41

11. Select the sequence of techniques used during an examination of the abdomen.a) Percussion, inspection, palpation, auscultation.b) Inspection, palpation, percussion, auscultation.c) Inspection, auscultation, percussion, palpation.d) Auscultation, inspection, palpation, percussion.

c) Inspection, auscultation, percussion, palpation.

42

12. You are obtaining a history from a 30-year-old male and are concerned about health promotion activities. Which of the following questions would you ask?a) "Have you ever noticed any pain in your testicles?"b) "Do you perform testicular self exams?"c) "Do you have any history of sexually transmitted infections?"d) "Have you had any problems with passing your urine?"

b) "Do you perform testicular self exams?"

43

13. Which of the following statements is true regarding the diaphragm of the stethoscope?a) Use the diaphragm to listen for high-pitched sounds.b) Use the diaphragm to listen for low-pitched sounds.c) Hold the diaphragm lightly against the person's skin to listen for extra heart sounds and murmurs.d) Hold the diaphragm lightly against the person's skin to block out the low-pitched sounds.

a) Use the diaphragm to listen for high-pitched sounds.

44

14. During the examination, it is often appropriate to offer some brief teaching about the patient's body or your findings. Which of the following statements is most appropriate?a) "You have pitting oedema and mild varicosities."b) "Your hypertension is under control."c) "I'm using my stethoscope to listen for any adventitious sounds."d) "Your pulse is 80 beats per minute; this is within the normal range."

d) "Your pulse is 80 beats per minute; this is within the normal range."

45

15. In assessing the radial pulse of a patient, you would:a) count the pulse for 15 seconds and multiply by 4, if the rhythm is regular.b) count the pulse for 1 minute if the rhythm is irregular.c) count the initial pulse for a full 2 minutes to detect any variation in amplitude.d) count the pulse for 10 seconds and multiply by 6, if the patient has no history of cardiac abnormalities.

b) count the pulse for 1 minute if the rhythm is irregular.

46

16. During an initial interview, the nurse asks, “Mrs. J., tell me what you do when your headaches occur.” With this question, the nurse is seeking informationabout:a) the client’s perception of the problem.b) aggravating or relieving factors.c) the frequency of the problem.d) the severity of the problem.

a) the client’s perception of the problem.

47

17. At the conclusion of the examination, the examiner should:
a) document findings before leaving the examination room.
b) have findings confirmed by another practitioner.
c) relate objective findings to the subjective findings for accuracy.
d) summarise findings to the patient.

d) summarise findings to the patient.

48

18. The purpose of percussion is to:
a) assess underlying tissue consistency.
b) assess underlying tissue texture.
c) assess underlying structures.
d) assess underlying tissue turgor.

c) assess underlying structures.

Percussion - Elicits pain; Determines location, size and shape ; Determines density ; Detects abnormal masses and Elicits reflexes (tendon hammer)Three types - direct (onto patient) , indirect (through finger) and blunt (fist through hand)Page 37 Weber & Kelly

49

19. The nurse must ensure that the earpieces of the stethoscope are placed so that the alignment fits the contour of the ear canal. In which direction should they be placed?
a) pointing upward.
b) pointing downward.
c) pointing forward.
d) pointing backward.

c) pointing forward

50

20. You are measuring the initial blood pressure on a 72 year-old client is being admitted for hypertension. How would you proceed?
a) Place the cuff on the client’s arm and inflate it 30 mmHg above the client’s pulse rate.
b) Inflate the cuff to 200 mmHg in an attempt to obtain the most accurate systolic reading.
c) Inflate the blood pressure cuff 30 mmHg above the point at which the palpated pulse disappeared.
d) Look at the client’s past blood pressure readings, and inflate the cuff 30 mmHg above the highest systolic reading recorded.

c) Inflate the blood pressure cuff 30 mmHg above the point at which the palpated pulse disappeared.

51

21. The capillary bed should refill after being depressed in
a) less than 1 second.
b) more than 2 seconds.
c) 1 – 2 seconds.
d) time is not significant as long as colour returns.

c) 1 – 2 seconds.

52

22. Which of the following is an expected normal finding when performing the diagnostic positions test?
a) Nystagmus in extreme superior gaze.
b) A slight amount of lid lag when moving the eyes from a superior to inferior position.
c) Parallel tracking of object with both eyes.
d) Convergence and accommodation of the eyes.

c) Parallel tracking of object with both eyes.

53

23. A patient has a normal pupillary light reflex. What does this mean?
a) The eye focuses the image in the centre of the pupil.
b) Constriction of both pupils occurs in response to bright light.
c) The eyes converge to focus on the light.
d) Light is reflected at the same spot in both eyes.

b) Constriction of both pupils occurs in response to bright light.

Pupillary light reflex causes pupils to immediately constrict when exposed to light.Direct reflex - only eye exposed to light constricts ORIndirect/Consensual reflex - opposite eye exposed to light constricts.Page 272 Weber and Kelly

54

24. The tympanic membrane should appear:
a) whitish with a small fleck of light in superior portion.
b) pearly grey and slightly concave.
c) pulled in at the base of the cone of light.
d) light pink with a slight bulge.

b) pearly grey and slightly concave.

55

25. The most important technique when progressing from one auscultatory site on the thorax to another is:a) top to bottom comparison.b) side to side comparison.c) posterior to anterior comparison.d) interspace by interspace comparison.

b) side to side comparison.

56

26. In your assessment of a healthy adult, where would you expect to palpate the apical impulse?
a) third left intercostal space at the midclavicular line.
b) fifth left intercostal space at the midclavicular line.
c) fourth left intercostal space at the sternal border.
d) fourth left intercostal space at the anterior axillary line.

b) fifth left intercostal space at the midclavicular line.

Use palmer of hand to palpate intercostal spaces and will find the apical pulse in the mitral area. Use one finger pad for more accurate palpation.Not always possible to palpate, consider patient sitting upright and leaning forward or on their lateral left sidePage 405 Weber and Kelly

57

27. Bradycardia is the term given for?
a) a heart rate above 60 beats per minute (b.p.m)
b) a heart rate below 60 bpm
c) an irregular heart rate
d) the normal variation of heart rate related to inspiration and expiration

b) a heart rate below 60 bpm

58

28. In the patient’s medical record their tonsils are graded as 3+. On assessment the tonsils would be?
a) visible.
b) half way between the tonsilar pillars and uvula.
c) touching the uvula.
d) touching each other.

c) touching the uvula.

Tonsilitis (detecting and grading)
1+ Tonsils are visible
2+ Tonsils are midway between tonsillar pillars and uvula
3+ Tonsils touch the uvula
4+ Tonsils touch each other

59

29. The sinuses that are accessible to examination are the
:a) ethmoid and sphenoid.
b) frontal and ethhmoid.
c) maxillary and sphenoid.
d) frontal and maxillary .

d) frontal and maxillary

Frontal sinus - above the eyesMaxillary - in the jawEthmoid and Sphenoid sinuses are deeper in the skull.

60

30. Visual acuity is assessed with:
a) the Snellen Eye Chart.
b) an ophthalmoscope.
c) the Confrontation Test.
d) the Hirschberg Test.

a) the Snellen Eye Chart.

Used for distant (6 metres) and close (35cm handheld) testing Patient stands 6 metres from the chart, covers one eye with a card and reads each letter.Recorded as a fraction. Top number is always 6 (distance from chart) and bottom number refers to the last full line patient could read. Last line on chart (smallest letters is usually 6/6). If any letters are missed record and then deduct number of letters eg 6/9 - 2Page 278 Weber & Kelly

61

1. Your patient tells you he is allergic to penicillin. What would be your next response?
a) "Are you allergic to any other drugs?"
b) "I'll write your allergy on your medication chart so you won't receive any."
c) "Would you describe what happens to you when you take penicillin?"
d) "How often have you received penicillin?"

c) "Would you describe what happens to you when you take penicillin?"

62

2. Which of the following statements is true regarding the assessment of mental status?
a) Mental status can be assessed directly, just like other systems of the body, e.g., cardiac and breath sounds.
b) Mental disorders occur in response to everyday life stressors.
c) Mental status functioning is inferred through assessment of an individual's behaviours.
d) Mental status assessment diagnoses specific psychiatric disorders.

b) Mental disorders occur in response to everyday life stressors.

Not sure

63

3. When percussing over the ribs of your patient you note a flat sound. You would:
a) consider this an abnormal finding and refer the patient for additional treatment.
b) reposition your hands and attempt to percuss in this area again.
c) consider this a normal finding.
d) palpate this area for an underlying mass.

c) consider this a normal finding.

64

4. The force or strength of the pulse:
a) is a reflection of the heart's stroke volume.
b) reflects the blood volume in the arteries during diastole.
c) demonstrates elasticity of the vessel wall.
d) is usually recorded on a 0-2 scale.

a) is a reflection of the heart's stroke volume.

From lecture notes

65

5. When auscultating the blood pressure of a 25-year old, you hear the Phase I Korotkoff sounds begin at 200 mm Hg; at 100 mm Hg the Korotkoff sounds muffle; at 92 mm Hg the Korotkoff sounds disappear. How should you record this patient's blood pressure?
a) 200/100/92
b) 200/100
c) 200/92
d) 100/200/92

a) 200/100/92

Weber and Kelly - Page 93 - Note that the American Heart Association recommends that values in phase IV and V be recorded when both a change in the sounds and a cessation in the sounds occur.

66

6. Erik comes to your clinic complaining of neck and shoulder pain, and is unable to turn his head. You suspect damage to the _____ cranial nerve, and proceed with your examination by:
a) 12th; percussing the sternocleidomastoid and submandibular neck muscles.
b) 11th: palpating the anterior and posterior triangles.
c) 12th; assessing for a positive Romberg.
d) 11th; asking the patient to shrug his shoulders against resistance.

d) 11th; asking the patient to shrug his shoulders against resistance.

From lecture notes

67

7. Movement of the extraocular muscles is:a) stimulated by cranial nerves III, IV and VI.b) impaired in a patient with cataracts.c) stimulated by cranial nerves II, III and V.d) decreased in the elderly.

a) stimulated by cranial nerves III, IV and VI.

68

8. Stimulation of the sympathetic branch of the autonomic nervous system:
a) causes pupillary constriction.
b) elevates the eyelid and dilates the pupil.
c) causes contraction of the ciliary body.
d) adjusts the eye for near vision.

b) elevates the eyelid and dilates the pupil.

Fight or flight - also decreased GI, bronchioles dilation, increased HR pupil dilation

69

9. A patient's vision is recorded as 6/9 (20/30) using the Snellen eye chart. What does this mean?
a) The patient can read from 9 metres (30 feet) what a person with normal vision can read from 6 metres (20 feet).
b) The patient can read the chart from 6 metres (20 feet) in the left eye and 9 metres (30 feet) in the right eye.
c) At 9 metres (30 feet) the patient can read the entire chart.
d) The patient can read at 6 metres (20 feet) what a person with normal vision can read at 9 metres (30 feet).

d) The patient can read at 6 metres (20 feet) what a person with normal vision can read at 9 metres (30 feet)

It's answer d). Let's disassemble it. There is a certain font size a person with normal visual acuity can distinguish at a distance of 6 metres or 20 feet. That's know as 6/6 or 20/20 vision. They can also distinguish larger font sizes at larger distances. So for example, at 9m or 30ft. That would be expressed as 9/9 or 30/30 vision.But if you have someone who can only distinguish patterns at 6m a person with normal visual acuity can distinguish 9m, then they have 6/9 or 20/30 vision. So first number is always 6 or 20 and the second is at what distance they can see that normed sizes clearly. On the other hand, some people may have better than average visual acuity and may be able to distinguish patterns most people will only be able to see at 3m or 10ft. These guys have 6/3 or 20/10. Hope that makes sense!Jana

70

10. What should the examiner palpate for tenderness prior to examining the ear with the otoscope?
a) helix, external auditory meatus and lobule.
b) mastoid process, tympanic membrane and malleus.
c) pinna, pars flaccida and antitragus.
d) pinna, tragus and mastoid process.

d) pinna, tragus and mastoid process.

71

11. In the Rinne test, the 2 to 1 ratio refers to:
a) the loudness of the tone heard by the two ears.
b) the length of time until the patient stops hearing the tone by air conduction and by bone conduction.
c) the length of time until the patient no longer hears the tone and the examiner no longer hears the tone.
d) the examiner hearing the tone twice as long as the patient hears it.

b) the length of time until the patient stops hearing the tone by air conduction and by bone conduction.

72

12. A normal finding on inspection of the thorax would be documented as follows:
a) anteroposterior diameter less than transverse.
b) barrel chest appearance of the thorax.
c) transverse and anteroposterior diameter equal.
d) transverse diameter less than anteroposterior

d) transverse diameter less than anteroposterior

73

13. Adventitious lung sounds are:
a) bronchial breath sounds heard over the trachea.
b) added sounds not normally heard in the lungs.
c) sounds normally auscultated over the lung fields
d) sounds normally auscultated over the adventitious.

b) added sounds not normally heard in the lungs.

74

14. The trachea bifurcates anteriorly at the:
a) costal angle.
b) xiphoid process.
c) suprasternal notch.
d) manubriosternal angle.

d) manubriosternal angle.Weber and Kelly p 340 says sternal angle. The costal angle is below the xiphoid process and suprasternal notch is too high

75

15. Over which of the following locations would it be normal to feel tactile fremitus most intensely?
a) 2nd right intercostal space (RICS) @ sternal border (SB)b) 3rd right intercostal space (RICS) @ mid axillary line (MAL)
c) 5th left intercostal space (LICS) @ midcl0avicular line (MCL)
d) 7th right intercostal space (RICS) @ anterior axillary line (AAL)

a) 2nd right intercostal space (RICS) @ sternal border (SB)

Normally, fremitus is most prominent between the scapulae and around the sternum. These are sites where the major bronchi are closest to the chest wall. Fremitus normally decreases as one progress down the chest because more tissue impedes sound transmission.From google

76

16. When auscultating the lungs of an adult patient, you note that over the posterior lower lobes you hear low pitched, soft breath sounds with inspiration being longer than expiration. You know that these are:
a) bronchial breath sounds and are normal in that location.
b) bronchovesicular breath sounds and are normal in that location.
c) vesicular breath sounds and are normal in that location.
d) sounds normally auscultated over the trachea.

c) vesicular breath sounds and are normal in that location.

Weber and Kelly pg 355

77

17. The left lung
:a) is shorter than the right because of the underlying stomach.
b) consists of two lobes.
c) consists primarily of an upper lobe on the posterior chest.
d) is divided by the percardial fissure.

b) consists of two lobes.

78

18. Identify the blood vessel that runs diagonally across the sternomastoid muscle.
a) Temporal artery.
b) Carotid artery.
c) External jugular vein.
d) Internal Jugular vein.

c) External jugular vein.

79

19. The first heart sound (S1) is the result of:
a) aortic and pulmonic valve closure.
b) aortic and mitral valve closure.
c) mitral and tricuspid valve closure.
d) tricuspid and pulmonic valve closure.

c) mitral and tricuspid valve closure.S1 is lub and first sound of heart beat, S1 Starts systole - where blood is ejected from the ventricles (ventricular contraction)

80

20. In your assessment of a healthy adult, where would you expect to palpate the apical impulse?
a) third left intercostal space at the midclavicular line.
b) fifth left intercostal space at the midclavicular line.
c) fourth left intercostal space at the sternal border.
d) fourth left intercostal space at the anterior axillary line.

b) fifth left intercostal space at the midclavicular line.Use palmer of hand to palpate intercostal spaces and will find the apical pulse in the mitral area. Use one finger pad for more accurate palpation.Not always possible to palpate, consider patient sitting upright and leaning forward or on their lateral left sidePage 405 Weber and Kelly

81

21. While counting the apical pulse on a 16-year-old patient, you note an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be your response?
a) Refer the patient to a cardiologist for further testing.
b) No further response needed as this is a normal finding.
c) Talk with patient about his intake of caffeine.
d) Do an electrocardiogram following the exam.

d) Do an electrocardiogram following the exam.

82

22. The valve closures that can BEST be heard at the base of the heart are:
a) aortic, pulmonic
b) mitral, tricuspid
c) mitral, pulmonic
d) tricuspid, aortic

a) aortic, pulmonic

Aortic area - 2nd intercostal at right sternal border (base of the heart)
Pulmonic area - 2nd intercostal at the left sternal border (base of the heart)Erbs point - 3rd to 5th intercostal space at the left sternal borderMitral (apical) - 5th intercostal space near the midclavicular line (the apex of the heart)Tricuspid area - 4th or 5th intercostal space at the lower left sternal borderPage 396 Weber & Kelly

83

23. To assess the dorsalis pedis artery, you would palpate:
a) in the groove behind the medial malleolus.
b) lateral to the extensor tendon of the great toe.
c) over the lateral malleolus.
d) behind the knee.

b) lateral to the extensor tendon of the great toe.

Dorsiflex the patients foot and apply light pressure lateral to and along the side of the extensor tendon of the big toe. Assess amplitude bilaterallyPage 437 Weber and Kelly

84

24. When testing the triceps reflex, what is the expected response?
a) Flexion of the hand.
b) Extension of the forearm.
c) Flexion and supination of the forearm.
d) Pronation of the hand.

b) Extension of the forearm.

Pg 614 Weber and KellyElbow extends, tricep contracts.

85

25. Joe is being assessed for range of joint movement. You ask him to move his arm in towards the center of his body. This movement is called:
a) flexion.
b) extension.
c) adduction.
d) abduction.

c) adduction.

86

26. In assessing the tonsils of a 30-year-old, you note they are involuted, granular in appearance, and appear to have deep crypts. What would be your response to these findings?
a) Nothing, this is the appearance of normal tonsils.
b) Obtain a throat culture on the patient for possible strep infection.
c) Refer patient to a throat specialistd) Continue with assessment looking for any other abnormal findings.

a) Nothing, this is the appearance of normal tonsils.

Check this answer? from quizlet

Tonsilitis (detecting and grading)
1+ Tonsils are visible
2+ Tonsils are midway between tonsillar pillars and uvula
3+ Tonsils touch the uvula
4+ Tonsils touch each other

87

27. The salivary gland that is located in the cheek in front of the ear is the:
a) Submandibular gland.
b) Sublingual gland.
c) Stenson’s gland.
d) Parotid gland.

d) Parotid gland.

88

28. Select the sequence of techniques used during an examination of the abdomen.
a) Percussion, inspection, palpation, auscultation.
b) Inspection, palpation, percussion, auscultation.
c) Inspection, auscultation, percussion, palpation.
d) Auscultation, inspection, palpation, percussion.

c) Inspection, auscultation, percussion, palpation.

89

29. Borborygmi could best be described as:
a) a loud continuous hum.
b) a peritoneal friction rub.
c) hyperactive bowel sounds.
d) hypoactive bowel sounds.

c) hyperactive bowel sounds.

90

30. A woman complains of a thick, white vaginal discharge with intense itching. These symptoms are suggestive of:
a) vaginitis
b) trichomoniasis
c) chlamydia
d) candidiasis

d) candidiasis

91

Explain the significance of phase V, of Korotokoff's sounds during blood pressure measurement

Silence. Decreased velocity of blood flow. Streamlined blood flow is silent. The last audible sound is diastolic pressure

92

Explain the significance of phase IV, of Korotokoff's sounds during blood pressure measurement

Phase IV, abrupt muffling. Sound mutes to a low pitched, cushioned murmur, blowing quality. Artery no longer closes in any part of cardiac cycle. Chang in quality, not intensity

93

Explain the significance of phase I, of Korotokoff's sounds during blood pressure measurement

Phase I-Soft, clear tapping, increasing in intensity. Systolic pressure-as the cuff pressure lowers to reach intrluminal systolic pressure, the artery opens, and blood first sputs into the brachial artery. Blood is at a very high velocity because of small opening of artery and large pressure difference across opening. This creates turbulent flow, which is audible

94

Relate the use of an improperly sized blood pressure cuff to the possible findings that might be obtained

Wider cuffs deliver false low reading and narrow cuffs give a false high reading (because it takes extra pressure to compress the artery

95

List factors that affect blood pressure and define why this occurs

Age-normally a gradual rise occurs through childhood to adult years. Gender-After puberty, females usually have a lower BP reading than males. After menopause females have higher BP. Diurnal rhythm-high in late afternoon and declines to an early morning low. Weight-higher in obese persons. Exercise. Emotions-Momentarily rises with fear, anger and pain as a result of stimulation of the sympathetic nervous system. Stress-BP is elevated

96

Mean arterial pressure

pressure-forcing blood into the tissues, averaged over the cardiac cycle. Close to diastolic pressure plus one-third of pulse pressure

97

Pulse pressure

difference between the systolic and diastolic and reflects the stroke volume

98

Diastolic pressure

Teh elastic recoil, or resting pressure that the blood exerts constantly between each contraction

99

Systolic pressure

Maximum pressure felt on the artery during left ventricular contraction, or systole

100

Blood Pressure

Force of blood pushing against the side of the vessel wall

101

Relate the qualities of normal respirations to the appropriate approach to counting them

Relaxed, Regular, Automatic, Silent, Count without the patient being aware.

102

Describe 4 qualities to consider when assessing the pulse

Rate, Rhythm, Strength, Elasticity

103

Tympanic membrane thermometer

Noninvasive, nontraumatic device that is extremely quick and efficient. Sense infrared emissions of the tympanic membrane (eardrum)

104

What changes in height and weight distribution would you expect from an adult in his or her 70s or 80s

Weight-Body weight decreases. Muscles shrinkage. Sucutaneous fat is lost from face and periphery. Additional fat deposited on abdomen and hips. Height-Shorter. Shorter trunk with longer extremities

105

For serial weight measurement, what time of the day would you instruct the person to have weight measured?

At the same time each day

106

List the significant information considered in each of the 4 areas of general survey.
Physical appearance
Body structure
Mobility
Behaviour

Physical Appearance
-Age
-Sex
-Level of consciousness
-Skin
-Facial features
Body Structure
-Stature
-Nutrition
-Symmetry
-Posture
-Position
-Body build, contour
Mobility
-Gait
-Range of motion
Behaviour
-Facial expression
-Mood and affect
-Speech
-Dress
-Personal Hygiene

107

Mean arterial pressure is:

diastolic pressure plus one third pulse pressure

108

Pulse pressure is:

the difference between the systolic and diastolic pressure

109

After assessing the patient's pulse, the practitioner determines it to be 'normal'. This would be recorded as:

2+

110

During the general survey part of the examination, gait is assessed. When walking, the base is usually:

as wide as the shoulder width

111

Blood pressure cuff

Use a cuff with a bladder length equaling 80% of the client's arm circumference

112

Accurate assessment of respirations:

Count for 30 seconds after completing a pulse assessment

113

Endogenous obesity is

-due to excess cortisol secretion by adrenals
-endogenous or exogenous ACTH stimulates the adrenals to release cortisol
-It is characterised by central trunk and cervical obesity

114

Tympanic membrane thermometer

-provides an accurate reflection of core temperature
-Senses the infrared emissions of the tympani member, which is perfused by the same blood supply as the hypothalamus
-Is quick and efficient device that is non traumatic and noninvasive

115

The doppler technique is used to:

-locate peripheral pulses
-Identify korotkoff's sounds
-measure blood pressure at the radial pulse

116

Common errors in taking blood pressure measurement include:

waiting <1 to 2 minutes before repeating the blood pressure reading on the same arm

117

A general survey consists of:

-Physical appearance
-body structure
-mobility
-behaviour

118

An area of the body that is supplied mainly from one spinal segment through a particular spinal nerve is identified as a:
A. dermatome.
B. dermatomee.
C. dermatophyte.
D. dermoblast.

A. dermatome.

119

The two parts of the nervous system are the: 1. motor and sensory.
2. central and peripheral.
3. peripheral and autonomic.
4. hypothalamus and cerebral.

2. central and peripheral. The nervous system can be divided into two parts central and peripheral. The central nervous system includes the brain and spinal cord. The peripheral nervous system includes the 12 pairs of cranial nerves, the 31 pairs of spinal nerves, and all their branches.

120

The area of the nervous system that is responsible for mediating reflexes is the:
1. medulla.
2. cerebellum.
3. spinal cord.
4. cerebral cortex.

3. spinal cord. The spinal cord is the main highway for ascending and descending fiber tracts that connect the brain to the spinal nerves, and it mediates reflexes.

121

A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient s deep tendon reflexes?
1. Reflexes will be normal.
2. Reflexes will not be able to be elicited.
3. All reflexes would be diminished but present.
4. Some would be present depending on the area of injury.

1. Reflexes will be normal. A reflex is a defense mechanism of the nervous system. It operates below the level of conscious control and permits a quick reaction to potentially painful or damaging situations.

122

During the history, a patient tells the nurse that it feels like the room is spinning around me. The nurse would document this as: 1. vertigo. 2. syncope. 3. dizziness. 4. seizure activity.

1. vertigo. True vertigo is rotational spinning caused by neurologic dysfunction or a problem in the vestibular apparatus or the vestibular nuclei in the brainstem.

123

A 50-year-old woman is in the clinic for weakness in my left arm and leg for the past week. The nurse will perform which type of neurologic examination?
1. Glasgow Coma Scale
2. Neurologic recheck examination
3. Screening neurologic examination
4. Complete neurologic examination

4. Complete neurologic examination

Perform a complete neurologic examination on persons who have neurologic concerns (e.g., headache, weakness, loss of coordination) or who have shown signs of neurologic dysfunction.

124

During an assessment of the cranial nerves, the nurse finds the following: lack of blink in right eye with corneal reflex; intact ability to sense light touch on face; loss of movement with facial features on right side. This would indicate dysfunction of which of the following cranial nerves?
1. Motor component of IV
2. Motor component of VII
3. Motor and sensory components of XI
4. Motor component of X and sensory component of VII

2. Motor component of VII The findings listed reflect a dysfunction of the motor component of cranial nerve VII as well as the sensory afferent in cranial nerve V.

125

The nurse is testing the function of cranial nerve XI. Which of the following best describes the response the nurse would expect if the nerve is intact?
1. Demonstrates full range of motion of the neck
2. Sticks tongue out midline without tremors or deviation 3. Follows an object with eyes without nystagmus or strabismus
4. Moves the head and shoulders against resistance with equal strength

4. Moves the head and shoulders against resistance with equal strength Examine the sternomastoid and trapezius muscles for equal size. Check equal strength by asking the person to rotate the head forcibly against resistance applied to the side of the chin. Then ask the person to shrug the shoulders against resistance. These movements should feel equally strong on both sides.

126

When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet further apart. The nurse would document this finding as a(n):
1. ataxia.
2. lack of coordination.
3. negative Homan s sign.
4. positive Romberg s sign.

4. positive Romberg s sign.

Abnormal findings for Romberg s test: patient sways; falls; widens base of feet to avoid falling. Positive Romberg s sign is loss of balance that is increased by closing of the eyes

127

The nurse is doing an assessment on a 29-year-old woman who visits the clinic complaining of always dropping things and falling down. While testing rapid alternating movements, the nurse notices that the woman is unable to pat both her knees. Her response is very slow and she misses frequently. What might the nurse suspect?
1. Vestibular disease
2. Lesion of cranial nerve IX
3. Dysfunction of the cerebellum
4. Inability to understand directions

3. Dysfunction of the cerebellum

In rapid, alternating movements, slow, clumsy, and sloppy response occurs with cerebellar disease.

128

The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notes the following: unable to feel vibrations on the great toe or ankle bilaterally; is able to feel vibrations on both patellae. Given this information, what would the nurse suspect?
1. Hyperalgesia
2. Hyperesthesia
3. Peripheral neuropathy
4. Lesion of sensory cortex

3. Peripheral neuropathy Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism). Peripheral neuropathy is worse at the feet and gradually improves as you move up leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome.

129

The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles and quadriceps, the nurse is unable to elicit a reflex. The nurse s next response should be to:
1. ask the patient to lock her fingers and pull.
2. complete the examination and then test these reflexes again.
3. refer the patient to a specialist for further testing.
4. document these reflexes as 0 on a scale of 0 to 4+.

1. ask the patient to lock her fingers and pull. Sometimes the reflex response fails to appear. Try further encouragement of relaxation, varying the person s position or increasing the strength of the blow. Reinforcement is another technique to relax the muscles and enhance the response. Ask the person to perform an isometric exercise in a muscle group somewhat away from the one being tested. For example, to enhance a patellar reflex, ask the person to lock the fingers together and pull.

130

The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How would the nurse document this finding?
1. Positive Babinski sign
2. Plantar reflex abnormal
3. Plantar reflex present
4. Plantar reflex 2+ on a scale from 0 to 4+

3. Plantar reflex present With the same instrument, draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot, like an upside-down J. The normal response is plantar flexion of the toes and sometimes of the whole foot.

131

The nurse knows that which of the following scores would indicate that a patient is in a coma on the basis of the criteria of the Glasgow Coma Scale? 1. 6 2. 12 3. 15 4. 24

1. 6 A fully alert, normal person has a score of 15, whereas a score of 7 or less reflects coma on the Glasgow Coma Scale.

132

To test for stereognosis, you would:
a. have the person close his or her eyes, then raise the person's arm and ask the person to describe its location
b. touch the person with a tuning fork
c. place a coin in the person's hand and ask him or her to identify it
d. touch the person with a cold object

c. place a coin in the person's hand and ask him or her to identify it

133

cerebellar function is assessed by which of the following tests?
a. muscle size and strength
b. cranial nerve examination
c. coordination-hop on one foot
d. spinothalamic test

c. coordination-hop on one foot

134

8A positive babinski sign is:
a. dorsiflexion of the big toe and fanning of all toes
b. plantar flexion of the big toe with a fanning of all toes c. the expected response in healthy adults
d. withdrawal of the stimulated extremity from the stimulus

a. dorsiflexion of the big toe and fanning of all toes

135

The complex motor system that coordinates movement, maintains equilibrium, and helps maintain posture is identified as the:
A. extrapyramidal system.
B. cerebellum.
C. upper and lower motor neurons.
D. basal ganglia.

B. cerebellum.

136

Outline some guidelines for distinguishing S1 from S2

S1 is when the tricuspid and mitral valves are closing
S1 associated with beginning of systole (ventricular contraction). Blood prevented from going back into atria.
S2 is when the Aortic and pulmonic valves close.
S2 associated with diastole, as blood is pushed from the ventricles, pressure falls and the aortic and pulmonary valves close which results in the end of systole.

137

List the areas to address during the health history of the cardiovascular system?

Chest pain
Palpitations
Dyspnoea
Orthopnoea
Paroxysmal nocturnal dyspnoea
Cough
Fatigue
Cyanosis or pallor
Oedema
Nocturia
Past Cardiac hx
Fam Cardiac hx
Personal habits - risk

138

What information can be gained from checking (measuring) the R. jugular vein pressure/volume? Total 3 points

For determining haemodynamics of the right side of the heart.
Reflects right atrial pressure (also known as central venous pressure CVP). The CVP reflects the bodys fluid status as well as degree of cardiac failure in a patient with right sided heart failure.
JVP starts to get backed up with blood if right sided hart failure is severe.
Decreased JVP occurs with reduced blood volume and left ventricular output.

139

List the key questions used to obtain subjective data on a clients neurological state.

Numbness/Tingling?
Seizures?
Headaches?
Dizziness?
Senses – smell, taste, ringing in ears, vision?
Speech?
Swallowing?
Muscle Control?

140

List pertinent health history information to be obtained from both male and female clients as part of the genitalia examination

Current Hx
Past Hx
Family Hx
Lifestyle

141

When comparing the anteroposterior diameter of the chest to the transverse diameter, what is the expected ratio? What is the significance of this?

1:2 to 5:7. Anteroposterior = Transverse diameter or barrel chest. Ribs are horizontal, occurs in chronic emphysema from hyperinflation of the lungs

142

List teaching points to include when teaching a client testicular self examination

T = Timing, Once a month
S = Shower. Warm water/room relaxes scrotal sac
E= Examine. Check both testes. One at a time. Report changes immediately
Perform exam standing
Feel testicle between thumb and fingers – feeling for firm lump or nodule
Compare each teste for size and tenderness

143

Identify appropriate history questions regarding a breast assessment

Cuurent - Pain ,Lump, Discharge ,Rash ,Swelling, Trauma,
History of breast disease, Surgery
Self-care behaviors- “Breast Aware” - Mammogram
Relevant Medical History - Mammography, Menstrual, Pregnancy
Relevant Past History – Lactation, number of children breast-fed; duration of breast-feeding; date of last breast-feeding; medications to suppress lactation,
Menopause: onset, course, associated problems, residual problems
Use of hormonal medications: name and dosage, reason for use, length of time on hormones, date of termination
Other nonprescription or prescription medications: tamoxifen, raloxifene

144

List the recommended order for the examination of a joint

Inspect size, shape, colour and symmetry – note any deformities, muscle atrophy
Palpate for oedema, heat, tenderness, pain, nodules or Crepitus ¬ - compare bilaterally
ROM

145

List the types of subjective data that should be obtained during the abdominal health history

Abdominal pain – PQRSTU
Indigestion, Nausea, Vomiting (Contents or blood)
Loss of appetite, early satiety
Dysphagia and/or ordynophagia
Food intolerances
Change in bowel function, constipation, diarrhea
Medications
Suprapubic pain
Dysuria, urgency, frequency
Hesitancy, decreased stream
Polyuria nocturia
Urinary incontinence
Haematuria
Kidney or Flank pain

146

List the three (3) areas of assessment on the Glasgow Coma Scale (GCS)

Eyes =4
Voice = 5
Motor = 6

147

Describe two (2) tests which can assesses cerebellar function

Rapid Alternating Movements (RAM) – where the patient is seated and places the palms of their hands on the knees then raises them and turns them over to place on knees, then raises turns them over etc increasing speed
Romberg test – pt stands with arms at side, then closes eyes. Watch for any swaying or stumbling.

148

List the common factors that can cause extraneous noise during auscultation

-Examiners breathing on stethoscope tubing
-Stethoscope tubing bumping together
-Patient shivers
-Patients hairy chest
-Rustling of paper gown or paper drapes

149

Describe the tripod position and when is it utilised?

Leaning forward with arms branded against their knees, chair or bed. Gives them leverage to aid in expiration

150

Name and describe the three (3) types of normal breath sounds

Bronchial (tracheal) - high pitch, loud, harsh, hollow and tubular (trachea and larynx)
Bonchovesicular - moderate pitch, moderate, mixed quality (scapulae, upper sternum in 1st and 2nd intercostal spaces)
Vesicular - low pitch, soft, rustling (over peripheral lung fields)

151

List four (4) examples of key questions to ask during the health history for the respiratory system.

Present Hx– cough? Difficulty breating? Chest pain? GI symptoms?
Past Hx – resp problems? Allergies? Surgeries? Travelled?

152

List the areas of questioning to address during the health history of the cardiovascular system

Current Hx
Past Hx
FHx
Lifestyle

153

Relate the use of an improper size blood pressure cuff to the possible findings that may be obtained

Wider cuffs deliver false low reading and narrow cuffs give a false high reading (because it takes extra pressure to compress the artery.

154

What is ascites?

Fluid in the abdomen

155

Define bruit and discuss what it indicates?

Abnormal sound; blowing, swishing or murmuring. Caused by turbulent blood flow and could indicate artheriosclerosis

156

Discuss the inspection of the abdomen, including findings that should be noted

Inspect for:
Symmetry
Contour – flat, scaphoid, rounded, distended
Umbilicus
Condition of skin – vascualrity, striae, scars, lesions, rashes
Hair distribution
Presence/absence of pulsations/movement

157

Define and describe the technique of the 4 physical examination techniques?

Inspection – use senses of vision, smell and hearing. Comfy room, good lighting, look, listen, smell and observe, expose body. Note colour, patterns, size, location, consistency, symmetry, movement, behaviour, odours, sounds. Compare.
Palpation – using parts of the hand to touch and feel for texture, temperature, moisture, mobility, consistency, strength and rhythm, size, shape, and tenderness, Use fingerpads, ulnar/palmer and dorsal (light, moderate, deep and bimanual)
Percussion – involves tapping on body parts to produce sound waves. Assess by elicit pain, determine location, size, shape, Determine density, determine mass, elicit reflex.
(direct, blunt and indirect)
Auscultation – stethoscope to listen for heart, blood, bowel, air sounds.
Diaphragm – high pitched
Bell – low pitched
(measured by intensity, pitch, length, quality)

158

Explain the statement that normal visual acuity is 6/6 (20/20)

This means the patient can distinguish what the person with normal vision can distinguish from 6 metres away.

159

List the components of the neurological examination that are performed routinely on hospitalised persons being monitored for neurological deficit?

LOC (GCS or AVPU)
Pupillary response to light
Movement and strength of arms and legs
Sensation in the extremities
Vital signs

160

Brudzinski reflex:

With one hand under the neck and other hand on person's chest, sharply flex chin on chest, watch hips and knees. Abnormal: Resistance and pain in neck, flexion of hips and knees. Indicates meningeal irritation.

161

How many pairs of spinal nerves are there?

31

162

What are bursae?

Pouches of synovial fluid that cushions movement of tendons and muscles over bone and other structures.

163

The Cerebral Cortex (gray matter) is the center for:

Human's highest functions, governing thought, memory, reasoning, sensation, and voluntary movement.

164

1) The Frontal lobe is the center for:
2) It contains the _____ gyrus which controls:
3) Also contains ___ area which controls:

1) Personality, behavior, emotions, and intellectual function.
2) Precentral gyrus, initiates voluntary movement.
3) Broca's area, which control motor speech. Damage to this = expressive aphasia.

165

The Parietal lobe contains the ____ gyrus which controls:

Postcentral gyrus, controls sensation

166

1. The Temporal lobe is the center for:
2. Contains _____ areas which controls:

1. Auditory reception
2.Contains Wernicke's area which control language comprehension. Damage to this = receptive aphasia.

167

Paresis:

Partial or incomplete paralysis

168

Dysarthria:

Difficulty forming words

169

Positive Romberg sign:

loss of balance that occurs when closing the eyes.

170

Past-pointing:

Constant deviation to one side.

171

Hemiplegia:

Spastic or flaccid paralysis of one side (right or left) of body and extremities.

172

Paraplegia:

Symmetric paralysis of both lower extremities.

173

Quadriplegia:

Paralysis of all four extremities.

174

Graphesthesia:

The ability to "read" a number by having it traced on the skin.

175

Babinski reflex:

Stroke lateral aspect and across ball of foot. Abnormal: Extension of great toe, fanning of toes. Indicates corticospinal (pyramidal) tract disease.

176

Kernig reflex:

In flat-lying supine position, raise leg straight or flex thigh on abdomen, then extend knee. Abnormal: Resistance to straightening, pain down posterior thigh. Indicates meningeal irritation.

177

What are the 12 cranial nerves

Olfactory
Optic
Oculomotor
Trochlear
Trigeminal
Abducens
Facial
Vestibulocochlear
Glossopharyngeal
Vagus
Accessory
Hypoglossal

178

What five factors make up the Neuro structure?

CNS
PNS
Motor pathways
Sensory pathways
Spinal reflexes

179

What are the palpable arteries of the body?

Temporal
Carotid
Brachial
Adial
Ulnar
Femoral
Popliteal
Dorsalis pedis
Posterior tibial

180

What is the cause of murmurs?

Turbulent blood flow

181

What are murmurs?

Extra sounds often described as swooshing/blowing

182

What is the location of the precordium?

Between the 1st rib and 5th intercostal space (basically the space the heart fills)

183

Where is the costal angle located?

Below the xiphoid process of the sternum

184

What are the four landmarks of the anterior thoracic region for respiratory assessment?

Suprasternal notch
Sternum
Manubriosternal angle (angle of Louis)
Costal angle

185

Are vesicular sounds soft or loud?

Soft

186

What are adventitious sounds?

Added sounds

187

What do normal healthy lungs sound like?

Resonant

188

What is the symmetrical expansion test?

Using the hand/thumbs s to see if they expand/contract evenly with inhalation/exhalation

189

What is the line called in the lungs that separate the upper from lower lobes?

Oblique fissure

190

What are the four posterior thoracic landmarks?

Vertebra prominens
Spinous processes
Inferior border of the scapula
Twelfth rib

191

What happens to the pupils if they focus on near vision?

They constrict

192

What does PERRLA mean?

Pupils Equal Round and React to Light and Accommodation

193

What is the Hirschberg test?

Corneal light reflex

194

What is the Rinne test?

Air and bone conduction test with tuning forks

195

What is the Weber test?

Putting tuning forks on top of head when 'twanged"

196

When holding the otoscope and inspecting the ears what is an important thing to do for safety?

Make sure that your hand is resting on the face so that the otoscope wont damage ears if patient suddenly moves

197

What do you palpate on the ear for tenderness?

Pinna Tragus (little bit at front near face)
Mastoid Process

198

What can cause conductive hearing loss?

Impacted cerumen

199

What are three forms of hearing loss?

Conductive
Sensorineural (perceptive)
Equilibrium

200

What are the three levels of the auditory system?

Peripheral
Brain stem
Cerebral cortex

201

What is the average length of the adult ear canal?

2.5cm

202

What are you feeling for when you palpate the lymph glands

Size
Shape
Delimitation
Mobility
Tenderness

203

What sinuses are not able to be palpated?

Ethmoid and sphenoid

204

How do you palpate the sinuses for tenderness?

Frontal sinuses - press up from under the bony brows
Maxillary sinuses - press up on the front of the cheeks on the bone near the nose

205

Name the three pairs of salivary glands?

Parotid
Submandibular
Sublingual

206

What do you inspect of the nose?

Nares
Nasal mucosa
Nasal septum

207

What is epistaxis?

Nose bleed

208

What are you assessing in the mouth?

Oral/buccal mucosa
Hard palate
Lips
Gums
Gum margins
Teeth
Tongue

209

What is the waist to hip ratio for measuring for obesity?

WHR = waist circum/hip circum.Ratio of 1 or greater in men OR 0.8 or greater in women = upper body obesity

210

What is the formula to calculate BMI?

BMI = weight(kg) / height (m's)

211

What are the five sounds you will hear with percussion ?

Resonant (chest/lung)
Hyper resonant (indicates extra air) (abnormal)
Tympany (air filled viscus)
Dull (over dense/solid organs)
Flat (over bone)

212

What is the purpose of percussion - 4 things

Determine:
Painful areas
Location, size and shape
Density
Abnormal mass detection

213

What side of the bell listens for low frequency sounds?

Bell

214

What are you assessing when you inspect?

Colour
Patterns
Size
Location
Symmetry
Movement
Behaiour
Sounds
Odours

215

Name the nine basic lesion patterns

Annular (circular)
Confluent (splotchy - like ink in water)
Discrete ( like pimple dots)
Grouped (lots of small ones in a group - like bacterium)
Gyrate (squiggles - like ebola)
Target (looks like a shooting target)
Linear (line)
Polycyclic ( groups of dots)
Zosteriform (groupings together like a raised rash)

216

What are you assessing when you examine nails?

Colour
Texture
Shape
Cap refill

217

What do you describe when assessing recording information about hair?

Colour
Texture
Distribution
Lesions

218

What is the ABCDE assessment of pigmented lesions

Asymmetry (round/oval/diff shape)
Border (clear/poorly defined)
Colour (variations)
Diameter (>6mm)
Elevation/Enlargement (changes/itching/burning/bleed)

219

What are the 4 point scales of oedema?

1+ Mild oedema/no visble swelling
2+ Moderate oedema/indentation subsides quickly
3+ Deep pitting oedema/ area looks swollen
4+ very deep pitting/lasts long time

220

What are you assessing for when you palpate skin?

Moisture/dryness
Temperature
Texture (rough/smooth)
Thickness
Oedema
Mobility and turgor
Vascularity
Lesions

221

How many layers to the skin and name them?

Epidermis, Dermis and Subcutaneous layer

222

What does the acronym SOAPIE (R) stand for?

Subjective data
Objective data
Assessment findings
Plan of action
Intervention
Evaluation
Revision

223

What are the 5 essential elements to focus charting?

Date & Time
Focus column
Progress notes - data or assessment
Progress notes - action or intervention
Progress notes - response or evaluation

224

What is the principle of focus charting?

Describes patient perspective and focuses on patients current status

225

What are two forms of charting?

Focus chartings
SOAPIE (R)

226

What do you do if you make a mistake in documentation?

Draw a line through it

227

What are the 8 principles of charting?

Factual
Signed & dated
Written ASAP
Objective
Done by person who did care
Completed before leaving work
Conforms to requirements
Confidential

228

What is the purpose of charting?

Communicate information:
Legal record
Information for health team
Record of services
Mandated
Effective patient care

229

Is pain subjective or objective?

Subjective

230

When assessing a radial pulse you should include the assessment of which four criteria?

Rate – 30 seconds x 2 for normal rhythm or 1 full minute and if irregular 1 full minute
Rhythm – regular/irregular or regular irregular
Strength – 0 absent, 1+ weak, 2+ normal, 3+ bounding
Elasticity – normal, springy, straight, rigid
From lecture notes

231

List what you are assessing for when palpating the skin of an adult?

Moisture – sweaty, dehydration
Mobility & turgor
Temperature – hypothermia, hyperthermia
Texture – rough, smooth
Thickness
Tone
Oedema
Lumps & Lesions for size, soft, hard, movement, ooze
From lecture notes

232

State the purpose of the health history?

Groundwork for possible nursing problems
Info on pt strength and limitations
Current health status
Ques to health problems
8 sections: ( Bio, Reason, Pres concern, Past Hx, Family Hx, ROS (review of body systems), Lifestyle, Dev level)

233

Define the terms blood pressure, systolic pressure, diastolic pressure and pulse pressure?

Blood pressure is the force of the blood pushing against the sides of the blood vessels
Systolic pressure is the maximum pressure on the arterial walls during ventricular contraction
Diastolic pressure is the elastic recoil or resting pressure that the blood within the vessels exerts between cardiac contractions
Pulse pressure is the difference between systolic and diastolic.

Mean arterial pressure is the pressure forcing blood into the tissues
Factors affecting blood pressure Age, sex, body position, weight, exercise/activity, stress, emotions, diurnal ryhtms (waking, getting up etc)

234

What same subjective data would you collect for both male and female clients undergoing an assessment of their genitals?

Present health concerns (pain, lesions, discharge, lumps, swelling, masses, urination – difficulty, pain, colour, odour, blood, Sexual dysfunction
Past health history – previous problems STD’s, fertility, examinations,
Family history – reproductive of genital cancer
Lifestyle and health practices – sexual partners, contraceptive/protection, genital problems affecting function, self exams, fears/concerns, previous STD tests, HIV, sexual education

235

What is the rationale for performing auscultation of the abdomen before palpation or percussion?

Because palpation and percussion could disrupt the normal bowel sounds – you will be listening for bruits or lack of sounds. Also helps to ensure that your patient is comfortable and relaxed.

236

Several frameworks have been developed to guide assessments and are used to explore each symptom the client identifies. List eight symptom characteristics that can be found using PQRSTU or COLDSPA

Sharp stabbing pain
8am this morning
Lower left abdomen
Comes and goes
5/10
Comes when I move
Nausea, vomiting

C = Character
O = Onset
L = Location
D = Duration
S = Severity
P = Pattern
A = Associated symptoms

237

List the significant information considered in each of the four areas of a general survey – physical appearance, body structure, molbility and behaviour?

Physical appearance - Age, Sex, LOC, facial appearance, Skin,
Body structure – stature, height, nutrition, symmetry, posture, position, body build, deformities
Gait – gait and range of motion
Behaviour – expression, mood, speech, grooming, hygiene

238

Relate the use of an improper size blood pressure cuff to possible findings that might be obtained.

The ideal size cuff to use on a patient is the widhth being 40% of the arm circumference and the length being 80% of the arm circumference for the bladder.
Inaccurate cuff sizes no matter what size the patient is will give in accurate blood pressure readings which is a misdiagnosis of a patients ocniditon.

239

List what needs to be done when assessing a skin lesion.

Pigmented Lesion
• A for Asymmetry (round, irregular)
• B for Border – defined/irregular/blended
• C for Colour variations and changes
• D for Diameter: is it >6 mm?
• E for Elevation and Enlargement and any changes in appearance, itching, burning or bleeding

Morphology , Colour, Pattern, Organization, Location

240

Name the four areas of the general survey and list the significant information considered in each of these areas.

Physical appearance - Age, Sex, LOC, facial appearance, Skin,
Body structure – stature, height, nutrition, symmetry, posture, position, body build, deformities
Gait – gait and range of motion
Behaviour – expression, mood, speech, grooming, hygiene

241

List four areas that you would pay attention to when assessing the mental health status.Total 4 points

Appearance
Behaviour
Cognition
Thought process

242

Before commencing a physical health assessment, examiners conduct a ‘general survey’. List the four (4) main areas of a general survey. Total 4 points

Physical Appearance
Body structure
Mobility
Behavior
From class lecture notes

243

How do you assess mood and affect and what questions can you ask?Total 3

pointsMood and affect assessed by:
AFFECT: clinical observation of range and appropriateness of patients emotions.
Range = flat/blunt/ normal/restricted/labile, Appropriateness = with regards to speech or ideation
MOOD: describe how patient perceives their own mood; use pt words; descriptors include, depressed, euphoric, anxious, irritable, angry,normal

Questions to ask: can you describe how you feel today? What are your plans for the future? Explain more please about what you just said?

244

How would you introduce your intention to use the Abuse Assessment Screen on your female client, what would you say? Total 2 points

Is partner present? Perform an initial interview with questions such as; has anyone been hurt in your home?
has anyone made you do anything you don't want to?
ever been touched when you don't want to be?
threatened?
Would advise patient is routine to screen for intimate partner violence as it affects so many people. Pg 126
Then ask patient to fill out form or help her do so.
Be supportive, acknowledge the abuse, and acknowledge patients rights to autonomy.

Screening test is on page 127 of Weber and Kelly

245

To encourage patients to describe their symptoms several frameworks have been developed, one of which is PQRSTU. What does this mnemonic stand for and provide a sample question related to each concept Total 6 points

Provokes
Quality/Quantity
Region/Radiation
Severity
Timing
Understanding patients perception of problem

246

What is a nosocomial infection and how can it be prevented? Total 1 point

Hospital acquired infection.
Prevented through breaking the chain of infection by:
- immunisation
- hand hygiene
- transmission based precautions(Sterilisation/disposable)
- dry dressings
- cover nose/mouth if sneezing
- gloves, masks

247

List a minimum of 5 interventions that are part of Standard Precautions. Total 5 points

Hand hygiene
PPE
Gloves
Gowns/plastic aprons
Mouth, nose, eye protection
Patient placement
Textiles/Laundry
Equipment care
Cough/respiration care

248

Percussion is the tapping of a client’s skin with short sharp strokes. Please list the uses for percussion. Total 5 points

Elicit pain - detect inflamed underlying structures
Determine location, size and shape
Determine density
Detect abnormal masses
Elicit reflexes

249

The pulse is assessed on the following qualities: Total 2 points

Rate
Rhythm
Strength
Elasticity

250

List four (4) factors that determine the level of the blood pressure Total 2 points ½ point each answer

Cardiac output
Distensibility of the arteries - stiff or elastic
Blood volume
Blood viscosity
Blood velocity

251

What questions do you ask in the initial pain assessment? Total 4 points

Are you experiencing any pain? and then OPQRST
When did it come on?
What makes it better/worse?
Describe the pain? sharp/dull/heavy/knifelike
Does it radiate anywhere?
Whats is on a scale of 1 - 10
Timing - come on etc?

252

What is the pupillary light reflex? Total 2 points

The pupillary light reflex causes the pupils to immediately constrict when exposed to bright light.
Direct reflex is constriction in the eye exposed to light
Consensual reflex is constriction in the opposite eye.
Protective reflexes mediated by oculomotor nerve to prevent damage to photoreceptors

Pg 272 Weber and Kelly

253

What is the ‘Hirschberg Test’? Total 2 points

corneal reflex test, is a screening test that can be used to assess whether a person has strabismus (ocular misalignment).

Shine a light in persons eye and see where reflects off corneas.
Normal - light reflex lies slightly nasal from cornea centre - simetrical results in both eyes
Abnormal - depends where light falls to decide if there is:
Exotropia (abnormal eye is turned out)
Esotropia (abnormal eye is turned in)
Hypertropia (abnormal eye higher than the normal one) Hypotropia (abnormal eye is lower than the normal one).

254

List six (6) areas of questioning to address during the health history of the auditory system. Total 3 points ½ point each answer

1. Earaches/Ear pain
2. Infections
3. Discharge
4. Hearing loss
5. Environmental noise
6. Tinnitus
7. Vertigo
8. Surgeries/implants
9. Self care
From lecture notes getting subjective info

255

List six (6) areas of questioning to address during the health history of the respiratory system. Total 3 point ½ point each answer

1. SOB
2. Hx of cough/ infections
3. Chest Pain
4. Environmental factors
5. Self care
6. Smoking
From lecture notes getting subjective info

256

What do you note when inspecting the anterior chest? Total 5 points

Landmarks
Facial expressions
Deformities
Asymmetry
Accessory muscle use
Impairment
Skin (ABCDE)
- Asymmetry (round/oval/diff shape)
- Border (clear/poorly defined)
- Colour (variations)
- Diameter (>6mm)
- Elevation/Enlargement (changes/itching/burning/bleed)

257

List the measures you can take to enhance abdominal wall relaxation Total 5 points

1. Place pillow under knees as patient lying supine
2. Get patient to breathe through mouth and take slow deep breaths
3. Explain each aspect of the examination, answer questions and cover private parts
4. Use a controlled hands technique - patients hand under your own before beginning palpation
5. Warm hands
Pg 457 Weber and Kelly

258

Describe 2 tests, which can assess cerebellar function. Total 2 points

Romberg Test - for balance
Pt stand erect with arms at side and feet together. Ask pt close eyes and stand for 20 seconds. Note imbalance or swaying

Rapid Alternating Movements (RAM) test - Have patient sit down, touch fingers to thumbs rapidly increasing
Can also sit with palms of both hands on both legs, then turn the palms up, then turn the palms down again rapidly increasing. look for uncoordinated movements

Stand on one foot, bend knee of leg standing on and hop & Finger to Nose test - for coordination

259

What is a nursing assessment?

"a process of systematically collecting and analysing data to make judgements about the health and life processes of individuals, families and communities"

260

What are the 4 types of health assessment?

Comprehensive
Focused/problem orientated
Follow up/on going/episodic or partial
Emergency

261

What is the focus of nursing?

Human response to actual and potential health problems

262

What are the nurses responsibilities when abnormalities are detected?

Assess (collect data)
Diagnose (interpret, validate, compare clusters, identify related factors and document)
Outcome identification (realistic, individualised and timeframed)
Implement (review, collaborate, counselling, document)
Evaluate (summarise, identify success/failure, correct where can)

263

What are 5 perceived barriers to health assessment skills?

Lack of:
Resources
Equipment
Time
Patient acceptance
Poor equipment

264

What are the key skills when attaining a health history - hint have to do with communication.

Facilitation - active listening
Silence – patience
Reflection Empathy - be accepting
Clarification - don't assume-clarify and confirm

265

What are some traps nurses fall into with patients when discussing health histories?

False assurance
Unwanted advice
Using authority
Using professional jargon
Interrupting

266

What four things are the focus of the Complete Health History?

Biographical data (name, DOB, gender etc)
Source of history ( reliable source)
Reason for seeking care (annual exam, acute)
Present and past health history (overall health)

267

What does the acronym COLDSPA mean?

Character
Onset
Ocation
DurationS
Everity
Pattern
Associated factors/how it affects the client

268

What systems are reviewed in a complete health history?

General appearance
SkinHEENT (Head, Eyes, Ears, Nose, Throat)
Respiratory
Cardiovascular
Gastro
Intestinal
Genital urinarySexual Neurological
Musculoskeletal
Gynaecological
Endocrine
Haematological
Lymphatic
Mental

269

What are the five Vital signs?

Temperature
Blood
Pressure
Heart Rate
Respiratory rate
Pain

270

Why do we monitor vital signs?

To see if there is any change in a physical condition

271

When would we monitor vital signs?

Pre and/or Post and or During;
Operations
Transfusions
Medications
Patient reports of nonspecific complaints
Frequency

272

What is the normal body temperature range?

35.8-37.5 degrees Celsius

273

What can you expect from a rectal temperature

Can be 0.4 to 0.5 degrees higher

274

At what temperature do we call a patient with mild hypothermia?

< 35 degrees Celsius

275

What temperature is moderate hypothermia?

28 - 32.2 degrees Celsius

276

What temperature is a patient with severe hypothermia?

< 28 degrees Celsius

277

What is an elevated temperature range?

37.5 - 38 degrees Celsius

278

AT what temperature does a patient have hyperpyrexia?

> 40 degrees Celsius

279

Where do you place an oral thermometer and for how long?

In the sublingual pocket for 2 minutes

280

How long is a rectal thermometer kept in place?

3 minutes

281

Where does a tympanic thermometer get placed?

In the ear

282

How long do you measure a pulse if it is a regular heart beat?

30 seconds and x 2

283

How long do you take a pulse if the heart beat is irregular?

1 full minute

284

What are the 4 things you ascertain with regards to respiration?

Rate
Rhythm (regular/irregular)
Quality (deep, effortless)
Ratio (pulse/resp approx. 4.1)

285

Where would you located the apical pulse?

4-5 intercostal space, left midclavicular

286

Where would you locate the carotid pulse?

groove between the trachea and sternogleidomastoi muscle

287

Where is the brachial pulse located

Antecubital fossa (anterior elbow)

288

What is the normal rate of respiration for an adult?

12-20 breaths per minutes

289

What are the 4 things you ascertain with regards to respiration?

Rate
Rhythm (regular/irregular)
Quality (deep, effortless)
Ratio (pulse/resp approx. 4.1)

290

What influences the blood pressure?

Blood
Volume
Blood Viscosity
Vascular Elasticity
Vascular Resistance
Cardiac output

291

What is the systolic value of blood pressure measuring?

The maximum pressure on the arterial walls during left ventricular contraction

292

What is the diastolic value of blood pressure measuring?

The resting pressure of blood in the vessels between contractions

293

What is the pulse pressure?

The difference between systolic and diastolic

294

What is the normal blood pressure?

120/80 mmHg

295

What is hypertensive?

140/90 mmHg

296

What is hypotensive?

95/60

297

What do you need to ensure about the cuff length and width to get an accurate blood pressure reading?

Width should be 40% of circumference of upper arm length (bladder) should be 80% circumference