An 85-year-old man has come in for a physical examination, and the nurse observes that he uses a cane. When documenting general appearance, the nurse should document this information under the section that covers:
c. Mood and affect
d. Physical deformity
Use of assistive devices would be documented under the mobility section. The other responses are all other categories of the general appearance section of the health history
The nurse is performing a vision examination. Which of these charts is most widely used for vision examinations?
The Snellen eye chart is most widely used for vision examinations. The other options are not tests for vision examinations
After the health history has been obtained and before beginning the physical examination, the nurse should first ask the patient to:
a. Empty the bladder
b. Completely disrobe
c. Lie on the examination table
d. Walk around the room
Before beginning the examination, the nurse should ask the person to empty the bladder (save the specimen, if needed), disrobe except for underpants, put on a gown, and sit with the legs dangling off side of the bed or table
During a complete health assessment, how would the nurse test the patient’s hearing?
a. Observing how the patient participates in normal conversation
b. Using the whispered voice test
c. Using the Weber and Rinne tests
d. Testing with an audiometer
During the complete health assessment, the nurse should test hearing with the whispered voice test. The other options are not correct
A patient states, “Whenever I open my mouth real wide, I feel this popping sensation in front of my ears.” To further examine this, the nurse would:
a. Place the stethoscope over the temporomandibular joint and listen for bruits
b. Place the hands over his ears and ask him to open his mouth “really wide”
c. Place one hand on his forehead and the other on his jaw and ask him to try to open his mouth
d. Place a finger on his temporomandibular joint and ask him to open and close his mouth
The nurse should palpate the temporomandibular joint by placing the fingers over the joint as the person opens and closes the mouth
Which statement regarding the complete physical assessment is true?
a. The male genitalia should be examined with the patient in the supine position.
b. The patient should be in the sitting position for examination of the head and neck.
c. The vital signs, height, and weight should be obtained at the end of the examination.
d. To promote consistency among patients, the examiner should not vary the order of the assessment
The head and neck should be examined with the patient in the sitting position to best palpate the thyroid and lymph nodes. The male patient should stand during an examination of the genitalia. Vital signs are measured early in the assessment. The sequence of the assessment may need to vary according to different patient situations.
Which of these is included when the nurses assesses the general appearance of the patient?
c. Skin colour
d. Vital signs
General appearance includes items such as level of consciousness, skin colour, nutritional status, posture, mobility, facial expression, mood and affect, speech, hearing, and personal hygiene. Height, weight, and vital signs are considered measurements
A patient tells the nurse, “Sometimes I wake up at night and I have real trouble breathing. I have to sit up in bed to get a good breath.” When documenting this information, the nurse would note:
b. Acute emphysema
c. Paroxysmal nocturnal dyspnea
d. Acute shortness of breath episode
Paroxysmal nocturnal dyspnea occurs when the patient awakens from sleep with shortness of breath and needs to be upright to achieve comfort
The nurse has just recorded a positive iliopsoas test on a patient who has abdominal pain. This test is used to confirm a(n):
a. Inflamed liver
b. Perforated spleen
c. Perforated appendix
d. Enlarged gallbladder
An inflamed or perforated appendix irritates the iliopsoas muscle, producing pain in the right lower quadrant
After the examination of an infant, the nurse documents opisthotonos. The nurse recognizes that this finding often occurs with:
a. Cerebral palsy
b. Meningeal irritation
c. Lower motor neuron lesion
d. Upper motor neuron lesion
Opisthotonos is a form of spasm in which the head is arched back, and a stiffness of the neck and an extension of the arms and legs are observed. Opisthotonus occurs with meningeal or brainstem irritation
After assessing a female patient, the nurse notices flesh-coloured, soft, pointed, moist, papules in a cauliflowerlike patch around her introitus. This finding is most likely:
a. Urethral caruncle
b. Syphilitic chancre
c. Herpes simplex virus
d. Human papillomavirus
Human papillomavirus appears in a flesh-coloured, soft, moist, cauliflowerlike patch of papules
While reviewing a patient’s medical record, the nurse notices that a patient’s Hematest results are positive. This finding indicates that there is (are):
a. Crystals in his urine
b. Parasites in his stool
c. Occult blood in his stool
d. Bacteria in his sputum
If a stool specimen is Hematest positive, then it indicates the presence of occult blood
A 5-year-old child is in the clinic for a checkup. The nurse would expect him to:
a. Need to be held on his mother’s lap.
b. Be able to sit on the examination table.
c. Be able to stand on the floor for the examination.
d. Be able to remain alone in the examination room
At 4 or 5 years of age, a child usually feels comfortable on the examination table. Older infants and young children ages 6 months to 2 or 3 years should be positioned in the parent’s lap
When assessing the neonate, the nurse should test for hip stability with which method?
a. Eliciting the Moro reflex
b. Checking the Romberg test
c. Performing the Ortolani manoeuvre
d. Assessing the stepping reflex
The nurse should test for hip stability in the neonate by performing the Ortolani manoeuvre. The other tests are not appropriate for testing hip stability
The nurse is documenting the assessment of an infant. During the abdominal assessment, the nurse noticed a very loud splash auscultated over the upper abdomen when the nurse rocked her from side to side. This finding would indicate:
a. Epigastric hernia
b. Pyloric obstruction
c. Hypoactive bowel sounds
d. Hyperactive bowel sounds
A succussion splash, which is unrelated to peristalsis, is a very loud splash auscultated over the upper abdomen when the infant is rocked side to side. It indicates increased air and fluid in the stomach as observed with pyloric obstruction or large hiatus hernia
Which of these actions is most appropriate to perform on a 9-month-old infant at a well-child checkup?
a. Performing the Ortolani manoeuvre
b. Assessment for stereognosis
c. Blood pressure measurement
d. Assessment for the presence of the startle reflex
Until age 12 months, the infant should be assessed by using the Ortolani manoeuvre. If the Ortolani sign is present, then it could indicate the presence of a dislocated hip. The other tests are not appropriate for a 9-month-old child
The nurse is conducting an abdominal assessment on a 52-year-old patient with ascites and a history of extensive alcohol use. During inspection what should the nurse expect to observe?
a. Scaphoid abdomen with visible fine veins
b. Abdominal distension with visible dilated abdominal veins
c. Flat abdomen with bulging hernia
d. Abdominal contraction with sunken umbilicus
Veins may become prominent and dilated with portal hypertension, cirrhosis, ascites, or vena caval obstruction. With ascites there is an increase in abdominal girth presenting in distension of the abdomen
During assessment, the nurse notes an old vertical scar across the patient’s lower abdomen. How should the nurse best document this finding?
a. With a full-scale drawing of patient and location of the scar
b. By using a comprehensive drawing to detail the type of scar
c. By using a line drawing of the abdomen with the location and length of the scar
d. With a detailed narrative description of how the scar was acquired
Simple line drawings should be used to describe the findings. A simple sketch of a tympanic membrane, breast, abdomen, or cervix should be drawn and the findings marked on it. The record should be kept complete but succinct by using short, clear phrases