SU NSG3012 Week 5 Final Exam Latest 2022

NSG3012 Principles of Assessment for RN

Final Exam

Question 1 The nurse is comparing the concepts of religion and spirituality. Which of the following is an appropriate component of one's spirituality?

Belief in and the worship of God or gods

 Attendance at a specific church or place of worship

 Personal effort made to find purpose and meaning in life

 Being closely tied to one's ethnic background

Question 2 The nurse is conducting an interview. Which of these statements is true regarding open-ended questions? Select all that apply.

Open-ended questions elicit cold facts.

 They allow for self-expression.

 Open-ended questions build and enhance rapport.

 They leave interactions neutral.

 

Open-ended questions call for short one- to two-word answers.

 They are used when narrative information is needed.

Question 3 The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient:

Demonstrates the ability to hear normal conversation.

 Sticks out the tongue midline without tremors or deviation.

 Follows an object with his or her eyes without nystagmus or strabismus.

 Moves the head and shoulders against resistance with equal strength.

Question 4 In a patient who has anisocoria, the nurse would expect to observe:

Dilated pupils.

 Excessive tearing.

 Pupils of unequal size.

 Uneven curvature of the lens.

Question 5 During an assessment of a 26 year old at the clinic for "a spot on my lip I think is cancer," the nurse notices a group of clear vesicles with an erythematous base around them located at the lip-skin border. The patient mentions that she just returned from Hawaii. What would be the most appropriate response by the nurse?

Tell the patient she needs to see a skin specialist.

 Discuss the benefits of having a biopsy performed on any unusual lesion.

 Tell the patient that these vesicles are indicative of herpes simplex I or cold sores and that they will heal in 4 to 10 days.

 Tell the patient that these vesicles are most likely the result of a riboflavin deficiency and discuss nutrition.

Question 6 During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the:

Costal angle.

 Sternal angle.

 Xiphoid process.

 Suprasternal notch.

Question 7 The nurse is assessing a patient's skin during an office visit. What part of the hand and technique should be used to best assess the patient's skin temperature?

Fingertips; they are more sensitive to small changes in temperature.

 Dorsal surface of the hand; the skin is thinner on this surface than on the palms.

 Ulnar portion of the hand; increased blood supply in this area enhances temperature sensitivity.

 Palmar surface of the hand; this surface is the most sensitive to temperature variations because of its increased nerve supply in this area.

Question 8 The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm:

Is used to listen for high-pitched sounds.

 Is used to listen for low-pitched sounds.

 Should be lightly held against the person's skin to block out low-pitched sounds.

 Should be lightly held against the person's skin to listen for extra heart sounds and murmurs.

Question 9 During an abdominal assessment, the nurse would consider which of these findings as normal?

Presence of a bruit in the femoral area

 Tympanic percussion note in the umbilical region

 Palpable spleen between the ninth and eleventh ribs in the left midaxillary line

 Dull percussion note in the left upper quadrant at the midclavicular line

Question 10 During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his son's treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This changed posture would suggest that the parent is:

Simply changing positions.

 More comfortable in this position.

 Tired and needs a break from the interview.

 Uncomfortable talking about his son's treatment.

Question 11 A woman has come to the clinic to seek help with a substance abuse problem. She admits to using cocaine just before arriving. Which of these assessment findings would the nurse expect to find when examining this woman?

Dilated pupils, pacing, and psychomotor agitation

 Dilated pupils, unsteady gait, and aggressiveness

 Pupil constriction, lethargy, apathy, and dysphoria

 Constricted pupils, euphoria, and decreased temperature

Question 12 For the first time, the nurse is seeing a patient who has no history of nutrition-related problems. The initial nutritional screening should include which activity?

Calorie count of nutrients

 Anthropometric measures

 Complete physical examination

 Measurement of weight and weight history

Question 13 During the examination, offering some brief teaching about the patient's body or the examiner's findings is often appropriate. Which one of these statements by the nurse is most appropriate?

"Your atrial dysrhythmias are under control."

 "You have pitting edema and mild varicosities."

 "Your pulse is 80 beats per minute, which is within the normal range."

 "I'm using my stethoscope to listen for any crackles, wheezes, or rubs."

Question 14 A patient reports excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice each day. The nurse should suspect:

Hypertension.

 Cluster headaches.

 Tension headaches.

 Migraine headaches.

Question 15 A nurse notices that a patient has ascites, which indicates the presence of:

Fluid.

 Feces.

 Flatus.

 Fibroid tumors.

Question 16 The nurse is examining a 62-year-old man and notes that he has bilateral gynecomastia. The nurse should explore his health history for which related conditions? Select all that apply.

Malnutrition

 Hyperthyroidism

 Type 2 diabetes mellitus

 Liver disease

 History of alcohol abuse

Question 17 A patient is visiting the clinic for an evaluation of a swollen, painful knuckle. The nurse notices that the knuckle above his ring on the left hand is swollen and that he is unable to remove his wedding ring. This joint is called the _________ joint.

Interphalangeal

 Tarsometatarsal

 Metacarpophalangeal

 Tibiotalar

Question 18 During a routine office visit, a patient takes off his shoes and shows the nurse "this awful sore that won't heal." On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well-defined edges, and no drainage. The nurse should assess for other signs and symptoms of:

Varicosities.

 Venous stasis ulcer.

 Arterial ischemic ulcer.

 Deep-vein thrombophlebitis.

Question 19 During an examination, the nurse can assess mental status by which activity?

Examining the patient's electroencephalogram

 Observing the patient as he or she performs an intelligence quotient (IQ) test

 Observing the patient and inferring health or dysfunction

 Examining the patient's response to a specific set of questions

Question 20 The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?

Percuss and palpate in the lumbar region.

 Inspect and palpate in the epigastric region.

 Auscultate and percuss in the inguinal region.

 Percuss and palpate the midline area above the suprapubic bone.

Question 21 A 70-year-old patient with a history of hypertension has a blood pressure of 180/100 mm Hg and a heart rate of 90 beats per minute. The nurse hears an extra heart sound at the apex immediately before the S1. The sound is heard only with the bell of the stethoscope while the patient is in the left lateral position. With these findings and the patient's history, the nurse knows that this extra heart sound is most likely a(n):

Split S1.

 Atrial gallop.

 Diastolic murmur.

 Summation sound.

Question 22 The nurse is examining a patient's retina with an ophthalmoscope. Which finding is considered normal?

Optic disc that is a yellow-orange color

 Optic disc margins that are blurred around the edges

 Presence of pigmented crescents in the macular area

 Presence of the macula located on the nasal side of the retina

Question 23 During an interview, a patient reveals that she is pregnant. She states that she is not sure whether she will breastfeed her baby and asks for some information about this. Which of these statements by the nurse is accurate?

"Breastfed babies tend to be more colicky."

 "Breastfeeding provides the perfect food and antibodies for your baby."

 "Breastfed babies eat more often than infants on formula."

 "Breastfeeding is second nature, and every woman can do it."

Question 24 During an examination, the nurse finds that a patient's left temporal artery is tortuous and feels hardened and tender, compared with the right temporal artery. The nurse suspects which condition?

Crepitation

 Mastoiditis

 Temporal arteritis

 Bell palsy

Question 25 When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are:

Mitral and tricuspid.

 Tricuspid and aortic.

 Aortic and pulmonic.

 Mitral and pulmonic.

Question 26 A 2-year-old child has been brought to the clinic for a well-child checkup. The best way for the nurse to begin the assessment is to:

Ask the parent to place the child on the examining table.

 Have the parent remove all of the child's clothing before the examination.

 Allow the child to keep a security object such as a toy or blanket during the examination.

 Initially focus the interactions on the child, essentially ignoring the parent until the child's trust has been obtained.

Question 27 When checking for proper blood pressure cuff size, which guideline is correct?

The standard cuff size is appropriate for all sizes.

 The length of the rubber bladder should equal 80% of the arm circumference.

 The width of the rubber bladder should equal 80% of the arm circumference.

 The width of the rubber bladder should equal 40% of the arm circumference.

Question 28 A 22-year-old woman comes to the clinic because of severe sunburn and states, "I was out in the sun for just a couple of minutes." The nurse begins a medication review with her, paying special attention to which medication class?

Nonsteroidal antiinflammatory drugs for pain

 Tetracyclines for acne

 Proton pump inhibitors for heartburn

 Thyroid replacement hormone for hypothyroidism

Question 29 The most important step that the nurse can take to prevent the transmission of microorganisms in the hospital setting is to:

Wear protective eye wear at all times.

 Wear gloves during any and all contact with patients.

 Wash hands before and after contact with each patient.

 Clean the stethoscope with an alcohol swab between patients.

Question 30 The nurse is assessing the joints of a woman who has stated, "I have a long family history of arthritis, and my joints hurt." The nurse suspects that she has osteoarthritis. Which of these are symptoms of osteoarthritis? Select all that apply.

Symmetric joint involvement

 Asymmetric joint involvement

 Pain with motion of affected joints

 Affected joints are swollen with hard, bony protuberances

 Affected joints may have heat, redness, and swelling

Question 31 The nurse is reviewing aspects of cultural care. Which statements illustrate proper cultural care? Select all that apply.

Examine the patient within the context of one's own cultural health and illness practices.

 Select questions that are not complex.

 Ask questions rapidly.

 Touch patients within the cultural boundaries of their heritage.

 Pace questions throughout the physical examination.

Question 32 The uterus is usually positioned tilting forward and superior to the bladder. This position is known as:

Anteverted and anteflexed.

 Retroverted and anteflexed.

 Retroverted and retroflexed.

 Superiorverted and anteflexed.

Question 33 During a follow-up visit, the nurse discovers that a patient has not been taking his insulin on a regular basis. The nurse asks, "Why haven't you taken your insulin?" Which statement is an appropriate evaluation of this question?

This question may place the patient on the defensive.

 This question is an innocent search for information.

 Discussing his behavior with his wife would have been better.

 A direct question is the best way to discover the reasons for his behavior.

Question 34 Which of these statements is most appropriate when the nurse is obtaining a genitourinary history from an older man?

"Do you need to get up at night to urinate?"

 "Do you experience nocturnal emissions, or 'wet dreams'?"

 "Do you know how to perform a testicular self-examination?"

 "Has anyone ever touched your genitals when you did not want them to?"

Question 35 A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handle bars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation?

The spleen can be enlarged as a result of trauma.

 The spleen is normally felt on routine palpation.

 If an enlarged spleen is noted, then the nurse should thoroughly palpate to determine its size.

 An enlarged spleen should not be palpated because it can easily rupture.

Question 36 The nurse is examining a 2-month-old infant and notices asymmetry of the infant's gluteal folds. The nurse should assess for other signs of what disorder?

Question 36 options:

 Fractured clavicle

 Down syndrome

 Spina bifida

 Hip dislocation

Question 37 During an examination of a patient's abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drumlike quality of the sounds across the quadrants. This type of sound indicates:

Constipation.

 Air-filled areas.

 Presence of a tumor.

 Presence of dense organs.

Question 38 The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase:

Question 38 options:

 Usually yields little information.

 Takes time and reveals a surprising amount of information.

 May be somewhat uncomfortable for the expert practitioner.

 Requires a quick glance at the patient's body systems before proceeding with palpation.

Question 39 The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure?

Thickness or bulging of the lens

 Posterior chamber as it accommodates increased fluid

 Contraction of the ciliary body in response to the aqueous within the eye

 Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber

Question 40 The nurse is assessing the abilities of an older adult. Which activities are considered IADLs? Select all that apply.

Question 40 options:

 Feeding oneself

 Preparing a meal

 Balancing a checkbook

 Walking

 Toileting

 Grocery shopping

Question 41 A 55-year-old man is experiencing severe pain of sudden onset in the scrotal area. It is somewhat relieved by elevation. On examination the nurse notices an enlarged, red scrotum that is very tender to palpation. Distinguishing the epididymis from the testis is difficult, and the scrotal skin is thick and edematous. This description is consistent with which of these?

Varicocele

 Epididymitis

 Spermatocele

 Testicular torsion

Question 42 During a group prenatal teaching session, the nurse teaches Kegel exercises. Which statements would be appropriate for this teaching session? Select all that apply.

"Kegel exercises help keep your uterus strong during the pregnancy."

 "Kegel exercises should be performed twice a day."

 "Kegel exercises should be performed 50 to 100 times a day."

 "To perform Kegel exercises, slowly squeeze to a peak at the count of eight, and then slowly release to a count of eight."

 "To perform Kegel exercises, rapidly perform alternating squeeze-release exercises up to the count of eight."

Question 43 In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the:

Bell of the stethoscope at the base with the patient leaning forward.

 Bell of the stethoscope at the apex with the patient in the left lateral position.

 Diaphragm of the stethoscope in the aortic area with the patient sitting.

 Diaphragm of the stethoscope in the pulmonic area with the patient supine.

Question 44 A black patient is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patient's skin?

Ruddy blue.

 Generalized pallor.

 Ashen, gray, or dull.

 Patchy areas of pallor.

Question 45 A mother of a 1-month-old infant asks the nurse why it takes so long for infants to learn to roll over. The nurse knows that the reason for this is:

A demyelinating process must be occurring with her infant.

 Myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated.

 The cerebral cortex is not fully developed; therefore, control over motor function gradually occurs.

 The spinal cord is controlling the movement because the cerebellum is not yet fully developed.

Question 46 A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his health assessment is important to:

Identify the cause of his illness.

 Make accurate disease diagnoses.

 Provide cultural health rights for the individual.

 Provide culturally sensitive and appropriate care

Question 47 The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply.

Test for the Murphy sign

 Test for the Blumberg sign

 Test for shifting dullness

 Perform the iliopsoas muscle test

 Test for fluid wave

Question 48 An 85-year-old patient comments during his annual physical examination that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because:

Long bones tend to shorten with age.

 The vertebral column shortens.

 A significant loss of subcutaneous fat occurs.

 A thickening of the intervertebral disks develops.

Question 49 The functional units of the musculoskeletal system are the:

Question 49 options:

 Joints.

 Bones.

 Muscles.

 Tendons.

Question 50 The nurse is examining the hip area of a patient and palpates a flat depression on the upper, lateral side of the thigh when the patient is standing. The nurse interprets this finding as the:

Ischial tuberosity.

 Greater trochanter.

 Iliac crest.

 Gluteus maximus muscle.

Question 51 The nurse is assessing the IV infusion at the beginning of the shift. Which factors should be included in the assessment of the infusion? Select all that apply.

Proper IV solution is infusing, according to the physician's orders.

 The IV solution is infusing at the proper rate, according to physician's orders.

 The infusion is proper, according to the nurse's assessment of the patient's needs.

 Capillary refill in the fingers is checked and noted.

The IV site date is noted.

 Whether the patient is sufficiently voiding is noted.

Question 52 When examining children affected with Down syndrome (trisomy 21), the nurse looks for the possible presence of:

Ear dysplasia.

 Long, thin neck.

 Protruding thin tongue.

 Narrow and raised nasal bridge.