Health assesment exam 3

Question 1

What should a nurse prioritize when receiving change of shift report?

Answer 1

The client who has been admitted for chest pain and reporting a new onset of indigestion.

Question 2

What is an appropriate action for a cardiovascular assessment?

Answer 2

Auscultate the apical pulse.

Question 3

Why is asking the client about shortness of breath important in a cardiovascular assessment?

Answer 3

It can indicate alterations in the cardiovascular system that result in fluid accumulation in the lungs.

Question 4

What skin colors should a nurse inspect during a cardiovascular assessment?

Answer 4

Pallor, cyanosis, or grey color.

Question 5

What action is NOT included in a cardiovascular assessment?

Answer 5

Auscultate bowel motility.

Question 6

What should a nurse instruct a patient with a BMI over 32?

Answer 6

Limit sodium intake.

Question 7

What family history can indicate cardiovascular disease?

Answer 7

A sibling or parent with hypertension.

Question 8

What is the electrical conduction of the heart called?

Answer 8

Sanode.

Question 9

Where are the auscultatory sites for heart valves located?

Answer 9

In the intercostal spaces.

Question 10

What is palpable vibration in the cardiovascular assessment?

Answer 10

An unexpected finding that can accompany murmurs or cardiac malformation called thrill.

Question 11

How long should a nurse count the apical pulse?

Answer 11

60 seconds.

Question 12

Where should the stethoscope be placed to assess the aortic valve?

Answer 12

Right second intercostal space.

Question 13

What are the signs and symptoms of left-sided heart failure?

Answer 13

Paroxysmal nocturnal dyspnea, congestion, cough, crackles, wheezing, tachypnea, blood in sputum, orthopnea, tachycardia, fatigue, cyanosis, confusion.

Question 14

What are the signs and symptoms of right-sided heart failure?

Answer 14

Fatigue, ascites, hepatomegaly, JVD, anorexia, GI distress, weight gain, dependent edema.

Question 15

What is the pericardium?

Answer 15

A tough, fibrous, double-walled sac that surrounds and protects the heart.

Question 16

What is the myocardium?

Answer 16

The muscular wall of the heart responsible for pumping.

Question 17

What is the endocardium?

Answer 17

A thin layer of endothelial tissue that lines the inner surface of heart chambers and valves.

Question 18

What is hypercarbia?

Answer 18

Increased levels of carbon dioxide in the blood.

Question 19

What does S1 represent in heart sounds?

Answer 19

Closure of the mitral and tricuspid valves.

Question 20

What does S2 represent in heart sounds?

Answer 20

Closure of the aortic and pulmonic valves.

Question 21

What is an S3 heart sound?

Answer 21

A ventricular gallop that can occur after S2 due to heart failure.

Question 22

What is an S4 heart sound?

Answer 22

An atrial gallop that can occur before S1 due to heart failure.

Question 23

What do veins carry?

Answer 23

De-oxygenated blood to the heart.

Question 24

What do arteries transport?

Answer 24

Oxygenated blood from the ventricles to the body’s tissues.

Question 25

What is the purpose of the lymphatic system?

Answer 25

To detect and eliminate foreign substances from the body.

Question 26

What are common causes of swollen lymph nodes?

Answer 26

Infection, common cold, flu, strep throat, HIV, mono, cytomegalovirus, tonsillitis.

Question 27

What should a client with a peripheral venous ulcer avoid?

Answer 27

Crossing their legs when sitting.

Question 28

What is abduction in gait movements?

Answer 28

Movement away from the body midline.

Question 29

What is adduction in gait movements?

Answer 29

Movement towards the body midline.

Question 30

What is the definition of dorsiflexion?

Answer 30

Toes pointing upward in flexion.

Question 31

What is plantar flexion?

Answer 31

Planting feet/hand down.

Question 32

What is ataxia?

Answer 32

Unsteady gait of movement of the muscles, usually from injury or pain in the extremities.

Question 33

What is osteoporosis?

Answer 33

A progressive disease where the bone matrix is not replaced, leading to decreased bone mass and density.

Question 34

What are interventions for preventing osteoporosis?

Answer 34

No smoking, limit alcohol, increase exercise, strength training, increase calcium/vitamin D.

Question 35

What is kyphosis?

Answer 35

A curvature in the spine associated with osteoporosis, leading to a hunched back.

Question 36

What is scoliosis?

Answer 36

An abnormal lateral curvature of the spine, which can be C or S shaped.

Question 37

What is lordosis?

Answer 37

A curvature of the lower lumbar spine that looks like an arched back.

Question 38

What are expected findings in assessing upper extremities?

Answer 38

Symmetrical, equal length, no tenderness, depressions, bulges, changes in temperature.

Question 39

What are unexpected findings in assessing lower extremities?

Answer 39

Unable to bear weight equally, shortened/missing extremity, generalized edema.

Question 40

What is a transient stroke?

Answer 40

A stroke that comes and goes.

Question 41

What is an ischemic stroke?

Answer 41

Obstruction that blocks blood flow to the part of the brain.

Question 42

What is a hemorrhagic stroke?

Answer 42

A weakened vessel wall that ruptures, causing bleeding in the brain.

Question 43

What is bradykinesia?

Answer 43

Slowness of movement.

Question 44

What are the two main types of strokes?

Answer 44

Ischemic strokes and hemorrhage strokes

Question 45

Define Ischemic Stroke.

Answer 45

Obstruction blocks blood flow to the part of the brain, causing deprivation of blood

Question 46

Define Hemorrhage Stroke.

Answer 46

Weakened vessel wall ruptures, causing bleeding in the brain

Question 47

What is a Transient Stroke?

Answer 47

A stroke that comes and goes

Question 48

List four symptoms of Parkinson’s disease.

Answer 48

* Tremor of the hands, arms, legs, jaw, and face * Bradykinesia (slowness of movement) * Rigidity or stiffness of the limbs and trunk * Postural instability or impaired balance and coordination

Question 49

What does the grading of Deep Tendon Reflexes (DTR) indicate?

Answer 49

The intactness of the reflex arc at specific spinal levels

Question 50

What is the grading scale for DTR?

Answer 50

* 4+ = Very brisk with clonus * 3+ = More brisk than average * 2+ = Expected * 1+ = Diminished * 0 = No response

Question 51

What does the Frontal lobe control?

Answer 51

* Broca’s area * Personality, behavior, emotion, and intellectual functions

Question 52

What are the functions of the Temporal lobe?

Answer 52

* Hearing * Taste * Smell * Temperature

Question 53

What is the role of the Cerebellum?

Answer 53

Motor coordination, equilibrium, and balance

Question 54

Name two coordination tests for cerebellar function.

Answer 54

* Finger to nose * Toe tapping/heel to shin

Question 55

What is the primary function of the Occipital lobe?

Answer 55

Visual reception

Question 56

What is assessed using the Glasgow Coma Scale (GCS)?

Answer 56

Level of consciousness (eye, verbal, and motor response)

Question 57

What is the highest and lowest value on the GCS?

Answer 57

Highest: 15 (full LOC), Lowest: 3

Question 58

What does Decorticate posturing indicate?

Answer 58

Brain injury

Question 59

Describe Decerebrate posturing.

Answer 59

Arms stiffly extended, adducted, and hyperpronated; legs stiffly extended

Question 60

What is the function of Cranial Nerve I (Olfactory)?

Answer 60

Sensory nerve for smell

Question 61

What is the purpose of the Snellen Chart in relation to Cranial Nerve II?

Answer 61

To assess the client’s vision

Question 62

What does Cranial Nerve III control?

Answer 62

Opening eyelids, moving eye, and constricting pupils

Question 63

What does PERRLA stand for?

Answer 63

Pupils Equal, Round, Reactive to Light and Accommodation

Question 64

What is tested with Cranial Nerve V?

Answer 64

Both sensory (light touch sensation) and motor (jaw clenching) functions

Question 65

What does Cranial Nerve VII assess?

Answer 65

Facial movements and taste on the anterior 2/3 of the tongue

Question 66

What test is used to assess Cranial Nerve VIII?

Answer 66

Whisper test for hearing

Question 67

What are the sensory and motor functions of Cranial Nerve IX?

Answer 67

* Sensory: Taste sour/bitter on posterior 1/3 of the tongue * Motor: Swallowing, speech sounds, gag reflex

Question 68

What does Cranial Nerve X control?

Answer 68

Muscles of the soft palate, larynx, pharynx, and gag reflex

Question 69

What is the function of Cranial Nerve XI?

Answer 69

Motor nerve for turning head and shrugging shoulders

Question 70

What does Cranial Nerve XII assess?

Answer 70

Tongue movement and position