Download Gonzaga university: Nursing 600/601 questions with correct answers and more Exams Nursing in PDF only on Docsity!
Gonzaga university: Nursing 600/601 questions with
correct answers
1.The nurse is preparing to perform a physical assessment. Which statement is true about the inspection phase of the physical assessment? a. Inspection usually yields little information. b. Inspection takes time and reveals a surprising amount of information. c. Inspection may be somewhat uncomfortable for the expert practitioner. d. Inspection requires a quick glance at the patient's body systems before proceeding on with palpation. Correct Answer-B A focused inspection takes time and yields a surprising amount of information. Initially, the examiner may feel uncomfortable "staring" at the person without also "doing something." A focused assessment is much more than a "quick glance." The nurse would use bimanual palpation technique in which situation? a. Palpating the thorax of an infant b. Palpating the kidneys and uterus c. Assessing pulsations and vibrations
d. Assessing the presence of tenderness and pain Correct Answer-B Bimanual palpation requires the use of both hands to envelop or capture certain body parts or organs such as the kidneys, uterus, or adnexa. The other situations are not appropriate for bimanual palpation. The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the underlying tissue: a. turgor. b. texture. c. density. d. consistency. Correct Answer-C Percussion yields a sound that depicts the location, size, and density of the underlying organ. Turgor and texture are assessed with palpation The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by the new nurse, indicates that more review is needed? The nurse: a. percusses once over each area. b. lifts the striking finger off quickly after each stroke. c. strikes with the finger tip, not the finger pad. d. uses the wrist to make the strikes, not the arm. Correct Answer-A For percussion, the nurse should percuss two times over each location. The striking finger should be lifted off quickly because a resting finger
Percussion notes that are louder in amplitude, lower in pitch, of a booming quality, and longer in duration are normal over a child's lung. A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After putting a call in to the physician and placing the patient on oxygen, which of these is the best action for the nurse to take when assessing the patient further? a. Count the patient's respirations. b. Percuss the thorax bilaterally, noting any differences in percussion tones. c. Call for a chest x-ray and wait for the results before beginning an assessment. d. Inspect the thorax for any new masses and bleeding associated with respirations. Correct Answer-B Percussion is always available, portable, and gives instant feedback regarding changes in underlying tissue density, which may yield clues of the patient's physical status. The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: a. is used to listen for high-pitched sounds. b. is used to listen for low-pitched sounds. c. should be held lightly against the person's skin to block out low- pitched sounds.
d. should be held lightly against the person's skin to listen for extra heart sounds and murmurs. Correct Answer-A The diaphragm of the stethoscope is best for listening to high-pitched sounds such as breath, bowel, and normal heart sounds. It should be held firmly against the person's skin, firmly enough to leave a ring. The bell of the stethoscope is best for soft, low-pitched sounds such as extra heart sounds or murmurs. The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations? a. Palpation b. Inspection c. Percussion d. Auscultation Correct Answer-A Palpation applies the sense of touch to assess these factors: texture, temperature, moisture, organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or pain. An examiner is using an ophthalmoscope to examine a patient's eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being performed correctly? a. Using the large full circle of light when assessing pupils that are not dilated
During the examination, it is often appropriate to offer some brief teaching about the patient's body or the examiner's findings. Which of these statements by the nurse is most appropriate? a. "Your atrial dysrhythmias are under control." b. "You have pitting edema and mild varicosities." c. "Your pulse is 80 beats per minute. This is within the normal range." d. "I'm using my stethoscope to listen for any crackles, wheezes, or rubs." Correct Answer-C Sharing of some information builds rapport as long as the patient is able to understand the terminology. The nurse keeps in mind that the most important reason to share information and offer brief teaching while performing the physical examination is to help: a. the examiner feel more comfortable and gain control of the situation. b. build rapport and increase the patient's confidence in the examiner. c. the patient understand his or her disease process and treatment modalities. d. the patient identify questions about his or her disease and potential areas of patient education. Correct Answer-B Sharing of information builds rapport and increases the patient's confidence in the examiner. It also gives the patient a little more control in a situation in which it is easy to feel completely helpless.
The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination? a. When the infant is sleeping b. At the end of the examination c. Before auscultation of the thorax d. Halfway through the examination Correct Answer-B Elicit the Moro or "startle" reflex at the end of the examination because it may cause the infant to cry. A 2-year-old child has been brought to the clinic for a well-child check- up. The best way for the nurse to begin the assessment is reflected by which statement? a. Ask the parent to place the child on the examining table. b. Have the parent remove all of the child's clothing before the examination. c. Allow the child to keep a security object such as a toy or blanket during the examination. d. Initially focus interactions on the child, essentially "ignoring" the parent, until the child's trust has been obtained. Correct Answer-C The best place to examine the toddler is on the parent's lap. Toddlers understand symbols, so a security object is helpful. Initially, focus more on the parent. This allows the child to gradually adjust and become familiar with you. A 2-year-old child does not like to take off his or her clothes. Have the parent undress one body part at a time.
awareness of body image and often compares himself or herself to peers. Apprise the adolescent of the wide variation among teenagers on the rate of growth and development. The most important step that the nurse can take to prevent transmission of microorganisms in the hospital setting is to: a. wear protective eye wear at all times. b. wear gloves during any and all contact with patients. c. wash hands before and after contact with each patient. d. clean the stethoscope with an alcohol swab between patients. Correct Answer-C The most important step to decrease the risk of microorganism transmission is to wash hands promptly and thoroughly before and after physical contact with each patient. Stethoscopes should also be cleansed with an alcohol swab before and after each patient contact. The best routine is to combine stethoscope rubbing with hand hygiene each time hand hygiene is performed. When examining an infant, the nurse should examine which area first? a. Ear b. Nose c. Throat d. Abdomen Correct Answer-D
Perform the least distressing steps first. Save the invasive steps of examination of the eye, ear, nose, and throat until last. 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 drum-like quality of the sound across the quadrants. This type of sound indicates: a. constipation. b. air-filled areas. c. the presence of a tumor. d. the presence of dense organs. Correct Answer-B A musical or drum-like sound (tympany) is the sound heard when percussion occurs over an air-filled viscus, such as the stomach or intestines. When examining the eye, the nurse notices that the patient's eyelid margins approximate completely. The nurse recognizes that this assessment finding: a. is expected. b. may indicate a problem with extraocular muscles. c. may result in problems with tearing. d. indicates increased intraocular pressure. Correct Answer-A The palpebral fissure is the elliptical open space between the eyelids, and, when closed, the lid margins approximate completely, which is a normal finding.
b. Posterior chamber as it accommodates an increase in fluid c. Contraction of the ciliary body in response to the aqueous within the eye d. Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber Correct Answer-D Intraocular pressure is determined by a balance between the amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber. The other responses are incorrect. The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true? a. The right side of the brain interprets vision for the right eye. b. The image formed on the retina is upside down and reversed from its actual appearance in the outside world. c. Light rays are refracted through the transparent media of the eye before striking the pupil. d. The light impulses are conducted through the optic nerve to the temporal lobes of the brain. Correct Answer-B The image formed on the retina is upside down and reversed from its actual appearance in the outside world. The light rays are refracted through the transparent media of the eye before striking the retina, and the nerve impulses are conducted through the optic nerve tract to the visual cortex of the occipital lobe of the brain. The left side of the brain interprets vision for the right eye. The nurse is testing a patient's visual accommodation, which refers to which action?
a. Pupillary constriction when looking at a near object b. Pupillary dilation when looking at a far object c. Changes in peripheral vision in response to light d. Involuntary blinking in the presence of bright light Correct Answer-A The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision, which also results in pupil constriction. The other responses are not correct. A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that: a. the eyes converge to focus on the light. b. light is reflected at the same spot in both eyes. c. the eye focuses the image in the center of the pupil. d. constriction of both pupils occurs in response to bright light. Correct Answer-D The pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina. The other responses are not correct. A mother asks when her newborn infant's eyesight will be developed. The nurse should reply: a. "Vision is not totally developed until 2 years of age." b. "Infants develop the ability to focus on an object at around 8 months." c. "By about 3 months, infants develop more coordinated eye movements and can fixate on an object."
A 52-year-old patient describes the presence of occasional "floaters" or "spots" moving in front of his eyes. The nurse should: a. examine the retina to determine the number of floaters. b. presume the patient has glaucoma and refer him for further testing. c. consider this an abnormal finding and refer him to an ophthalmologist. d. know that floaters are usually not significant and are caused by condensed vitreous fibers. Correct Answer-D Floaters are a common sensation with myopia or after middle age owing to condensed vitreous fibers. Usually they are not significant, but acute onset of floaters may occur with retinal de-tachment. The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed? a. Perform the confrontation test. b. Ask the patient to read the print on a handheld Jaeger card. c. Use the Snellen chart positioned 20 feet away from the patient. d. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches. Correct Answer-C The Snellen alphabet chart is the most commonly used and most accurate measure of visual acuity. The confrontation test is a gross measure of peripheral vision. The Jaeger card or newspaper tests are used to test near vision. A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next?
a. Refer the patient to an ophthalmologist or optometrist for further evaluation. b. Assess whether the patient can count the nurse's fingers when they are placed in front of his or her eyes. c. Ask the patient to put on his or her reading glasses and attempt to read the Snellen chart again. d. Shorten the distance between the patient and the chart until it is seen and record that distance. Correct Answer-D If the person is unable to see even the largest letters, then the nurse should shorten the distance to the chart until it is seen and should record that distance (e.g., "10/200"). If visual acuity is even lower, then the nurse should assess whether the person can count fingers when they are spread in front of the eyes or can distinguish light perception from a penlight. If vision is poorer than 20/30, then a referral to an ophthalmologist or optometrist is necessary, but first the nurse must assess the visual acuity. When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should: a. consider this a normal finding. b. refer the individual for further evaluation. c. document this as an asymmetric light reflex. d. perform the confrontation test to validate the findings. Correct Answer-A Reflection of the light on the corneas should be in exactly the same spot on each eye, or sym-metric. If asymmetry is noted, then the nurse should administer the cover test.
b. A blocked nasolacrimal duct in a newborn infant c. A slight swelling over the upper lid and along the bony orbit if the individual has a cold d. The absence of drainage from the puncta when pressing against the inner orbital rim Correct Answer-D There should be no swelling, redness, or drainage from the puncta when it is pressed. Regurgitation of fluid from the puncta, when pressed, indicates duct blockage. The lacrimal glands are not functional at birth. When assessing the pupillary light reflex, the nurse should use which technique? a. Shine a penlight from directly in front of the patient and inspect for pupillary constriction. b. Ask the patient to follow the penlight in eight directions and observe for bilateral pupil constriction. c. Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction. d. Ask the patient to focus on a distant object. Then ask the patient to follow the pen-light to about 7 cm from the nose. Correct Answer-C To test the pupillary light reflex, the nurse should advance a light in from the side and note the direct and consensual pupillary constriction. The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding? a. Dilation of the pupils b. A consensual light reflex
c. Conjugate movement of the eyes d. Convergence of the axes of the eyes Correct Answer-D The accommodation reaction includes pupillary constriction and convergence of the axes of the eyes. The other responses are not correct. In using the ophthalmoscope to assess a patient's eyes, the nurse notices a red glow in the patient's pupils. On the basis of this finding, the nurse would: a. suspect that there is an opacity in the lens or cornea. b. check the light source of the ophthalmoscope to verify that it is functioning. c. consider this a normal reflection of the ophthalmoscope light off the inner retina. d. continue with the ophthalmoscopic examination and refer the patient for further eval-uation. Correct Answer-C The red glow filling the person's pupil is the red reflex, and it is a normal finding caused by the reflection of the ophthalmoscope light off the inner retina. The other responses are not cor-rect. The nurse is examining a patient's retina with an ophthalmoscope. Which finding is considered normal? a. An optic disc that is a yellow-orange color b. Optic disc margins that are blurred around the edges c. The presence of pigmented crescents in the macular area d. The presence of the macula located on the nasal side of the retina Correct Answer-A
