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NUR 120 Exam
When percussing the liver, what should you hear? ANS: Dullness QUIZ: What is a Health assessment? ANS: a comprehensive assessment of the physical, mental, spiritual, socioeconomic, and cultural status of an individual, group, or community. QUIZ: What are the purposes of health assessment? ANS: Health history & physical assessment (and lab work) QUIZ: What is a health history? ANS: a collection of subjective data that provide info abt the pt's health status. QUIZ: What is a physical assessment.(aka physical examination)? ANS: a collection of objective data that provides info abt changes in the pt's body systems QUIZ: What is a nursing assessment? ANS: Focus on the patient's functional abilities and physical responses to illness and other stressors. QUIZ: What are the different types of nursing physical examination? ANS: -Focused -Comprehensive -Ongoing partial -System-specific -Emergency QUIZ: What is a focused examination? ANS: -to assess a presenting problem -ex. the ER RN assesses the pt complaining of (c/o) chest pain (CP) QUIZ: What is a comprehensive examination? ANS: -pt interview plus complete head- to-toe examination -ex.the cardiac RN performs an admission history and physical (H&P) on a newly admitted pt to the telemetry unit QUIZ: What is an ongoing partial examination? ANS: -conducted at regular intervals -ex. the cardiac RN continues to monitor the newly admitted pt on the telemetry unit every 4 hrs QUIZ: What is a system-specific examination? ANS: -to assess one body problem -ex. the newly admitted pt now c/o abdominal pain and heartburn, so the cardiac RN performs a GI examination on the telemetry unit. QUIZ: What is an emergency examination? ANS: -to determine life-threatening or unstable conditions
-ex. the hospital ER trauma team is working on a pt who is in cardiac arrest after being brought in by an ambulance following a car crash QUIZ: What do you include when documenting health history? ANS: -Biographical data (i.e. name, DOB, gender, race) -Chief complaint -History of present illness (HPI) -Past medical history (PMH) -Past surgical history (PSH) -Family history (FH) -ROS -Functional health patterns -Psychosocial and lifestyle factors QUIZ: What are you assessing for when auscultating? ANS: -assessing the four characteristics of sound, that is, pitch, loudness, quality, and duration -ex. heart sounds, lung sounds, and abdomen. -Pitch: ranging from high to low. -Loudness: ranging from soft to loud. -Quality: i.e. gurgling or swishing. -Duration: short, medium, or long. QUIZ: What are you assessing for when inspecting? ANS: -assessing size, color, shape, position, and symmetry -ex. compares bilateral body parts QUIZ: What are you assessing for when palpating? ANS: -assessing mobility, moisture, pulsation, shape, size, skin turgor, temperature, texture, tenderness, and vibrations. QUIZ: What are you assessing for when percussion? ANS: -assessing location, shape, size, and density of tissues. QUIZ: The nurse would be able to gather the most complete data about a patient's pedal edema using the assessment skill of: a. inspection. b. palpation. c. percussion. d. auscultation. ANS: B QUIZ: An emaciated patient complains of thirst and headache. Upon physical examination, the nurse finds that the skin does not return to normal shape; thus, consistent with: a. pallor.
QUIZ: What is the correct order of assessing for an abdominal exam? ANS: 1. Inspection
- Auscultation
- Palpation
- Percussion QUIZ: When preparing a patient for a physical assessment, what should you do? ANS: -consider the patient's need (physiological and psychological) -explain the physical assessment process -explain what you're doing in detail as conducting your assessment -provide the patient with a gown and ask if they need to use the bathroom QUIZ: What are some tips for the physical assessment? ANS: -compare both sides for symmetry -if the patient is seriously ill, first assess the body system that is most critically ill -if the patient is easily fatigued, allow rest periods in between assessments -leave the most painful assessments for last -record quick notes during the exam, and larger notes at the end of the exam QUIZ: What are some considerations to take into account when conducting a physical assessment on the cardio system of a geriatric patient? ANS: -difficulty palpating apical pulse -difficulty palpating distal arteries -dilated proximal arteries -increased BP -varicose veins QUIZ: What are some considerations you should be thinking of when conducting a physical assessment on the lungs/ thorax of a geriatric patient? ANS: -decreased thoracic expansion -increased anteposterior chest diameter -increased dorsal spine curve -using accessory muscles to exhale QUIZ: What are some considerations you should be thinking of when conducting a physical assessment on the GI system of a geriatric patient? ANS: -decreased abdominal tone -decreased bowel sounds -fat accumulation of the abdomen and hips QUIZ: When auscultating the abdomen, how long should the nurse listen before concluding the bowel sounds are absent? a. 1 minute. b. 5 minutes. c. 10 minutes.
d. 15 minutes. ANS: B QUIZ: At what age should you start mammograms? ANS: 40 QUIZ: When is the best time to start a breast exam? ANS: When menstruation starts QUIZ: What musculoskeletal changes is seen in pregnant women during the last trimester? a. Kyphosis. b. Lordosis. c. Scoliosis. d. No Change. ANS: B QUIZ: Use which part of the stethoscope to assess for potential abdominal bruits: aorta, iliac arteries, renal arteries, and femoral arteries. ANS: Bell QUIZ: At what age does BP screening start? ANS: 18 QUIZ: If you have normal cholesterol, how often should you check it? ANS: every 5 yrs QUIZ: At what age should you screen for colon cancer? ANS: 50+ yrs men & women QUIZ: What does each # of the muscle strength grading represent? ANS: - 0: no contraction
- 1: flicker of contraction
- 2: active movement; cant resist gravity
- 3: active movement against gravity
- 4: active movement against resistance
- 5: normal strength QUIZ: What is scoliosis? ANS: lateral S deviation of the spine QUIZ: What is kyphosis? ANS: accentuated thoracic curve, hunchback QUIZ: What is lordosis? ANS: accentuated lumbar curve, swayback (the butt sticks out) QUIZ: What is the Rhomberg test? ANS: Patient stand with arms straight out to each side with feet together and instructed to close both eyes while standing in that position. Observe for steadiness QUIZ: During the Rhomberg test, if the hands (palms facing up) drifted that would indicate what? ANS: a stroke QUIZ: For a Rhomberg test, what is considered normal? ANS: a negative test
QUIZ: What is the goal of using a client history assessment tool to gather data about nutrition, exercise, leisure activities, spirituality, and home environment? a. To gather data required by insurers and regulatory agencies b. To assist the physician in developing a medical diagnosis c. To gather data about the causes of the client's illness d. To increase the client's awareness of lifestyle choices and his or her role in wellness ANS: D QUIZ: The client has received a prescription for a metered-dose inhaler from the care provider. Before the client leaves the clinic, the nurse instructs the client on how to use the inhaler. The nurse is tending to the client's need in which stage of illness behavior? a. Dependence on others b. Sick role behavior c. Seeking professional care d. Recovery ANS: A QUIZ: A nurse is using a caring approach with a client to influence healthy lifestyle changes. The best statement by the nurse is: a. "I would like you to perform this exercise once a day." b. "Your physician has left orders for you to follow." c. "The laboratory tests reveal the need to reduce your daily percentage of fat grams." d. "Adapting your diet and activity will lower your blood glucose levels." ANS: D QUIZ: What does each # of the deep tendon reflexes grading scale represent? ANS: - 0: no response, absent
- 1: somewhat diminished, low normal
- 2: average, expected response; normal
- 3: brisker than average, slightly hyperreflexic
- 4: very brisk, hyperactive, with clonus QUIZ: What is a normal grade on the deep tendon reflexes grading? ANS: 2+ QUIZ: What is organs are found in the RUQ? ANS: -Pylorous -Duodenum -Liver -Right kidney and adrenal gland -Hepatic flexure of colon -Head of pancreas QUIZ: What organs are found in the RLQ? ANS: -Cecum -Appendix -Right ovary and fallopian tube -Right ureter and lower kidney pole
-Right spermatic cord QUIZ: What organs are found in the LUQ? ANS: -Stomach -Spleen -Left kidney and adrenal gland -Splenic flexure of colon -Body of pancreas QUIZ: What organs are found in the LLQ? ANS: -Sigmoid colon -Left ovary and fallopian tube -Left ureter and lower kidney pole -Left spermatic cord QUIZ: What organs are found midline? ANS: -Urinary bladder -Urethra QUIZ: S1 is when the __________ & __________ valve close ANS: -Mitral -Tricuspid QUIZ: S2 is when the ___________ & ___________ valve close ANS: -Aortic -Pulmonic QUIZ: Which descriptions are advantages of healthcare info technology (IT)? SELECT ALL THAT APPLY a. Increases healthcare delivery costs b. Improves communication among providers c. Improves administration functions d. Increases time necessary to document care e. Decreases the safety of providing care ANS: B,C QUIZ: Which description is an example of data? a. A printout of a pt's history and physical examination b. A pt's blood pressure and pulse rate c. The nurse's knowledge of a disease d. A nurse's interpretation of a change in the pt's condition ANS: B QUIZ: Which items are supported by point of care use of info technology? SELECT ALL THAT APPLY a. More accurate documentation b. Direct access to diagnostic results c. confidentiality d. Direct access to records by pts e. Access to med profiles ANS: A, B, C, E
a. Ignore. This staff member has a hospital ID badge. b. Tell the patient that someone from off the unit was reading his record. c. Ask the attending physician if this person is allowed to read the record. d. Inform this staff person that the medical record is only available for staff involved in the patient's care with a legitimate need for information. ANS: D QUIZ: You find a pt on the floor beside his bed. After doing an assessment and ensuring that the pt is safe and not injured, the next thing you do is a. Complete an incident report b. Determine that since no injury occurred no further documentation is necessary c. Ask your nursing assistant to complete an incident report d. Call the risk manager ANS: A QUIZ: Your experience with an EHR has shown that the outcomes of its use include: a. Decreased communication between health care providers b. The potential for greater numbers of medication errors c. Decreased productivity d. A decreased in the duplication of diagnostic tests ANS: D QUIZ: The impact of computerized provider order entry (CPOE) on the medical record has been: a. Increased legibility of orders b. The need for unit secretaries to transcribe orders c. An increase in medication errors d. Better billing practices ANS: A QUIZ: Charting by exception (CBE) means a. All normal pt activities are documented b. Standardized terminologies are not used in documentation c. Abnormal pt responses are highlighted d. All pt care is considered "normal" ANS: C QUIZ: The basic guideline used for nursing documentation is a. HIPPA d. Code of Ethics c. The nursing process d. The pt's diagnosis ANS: C QUIZ: Legal issues related to medical records include SELECT ALL THAT APPLY
a. The medical record is the legal documentation of care provider to a pt b. In the event of litigation, the medical record is often the only available evidence of an event in question c. Medical record documentation should be based strictly on facts, not opinions d. Medical record entries can be altered or erased to increase accuracy ANS: A, B, C QUIZ: Medical record documentation is important because SELECT ALL THAT APPLY a. It improves communication between providers b. It is the record of care provided c. The record becomes a legal document d. It is where the nurse records his or her thoughts and feelings about the pt. ANS: A, B, C QUIZ: When examining a pt's hearing using the Weber Test, the nurse would expect which of the following results if the pt had an obstruction in the right ear? a. The tone from a tuning fork is louder in the right ear b. The tone from a tuning fork is louder in the left ear c. The tone from a tuning fork is absent bilaterally d. The tone from a tuning fork is present equally in both ears ANS: A QUIZ: When inspecting a pt with suspected nasal rhinitis, physical assessment of the nares would most likely reveal a. Pt nares with pink, moist membranes and clear discharge b. Bright red, swollen mucosa and an upper respiratory infection c. Pain with nasal breathing and nasal flaring when breathing cool air d. A lower respiratory infection and difficulty swallowing liquids ANS: B QUIZ: When examining a pt's cornea, which of the following physical assessment findings is a normal occurrence? a. The cornea is tested for visual acuity b. Corneal sensitivity is controlled by cranial nerve 6 c. No blood vessels should be present d. Absence of a blink response with stimulation ANS: C QUIZ: Which type of lung sounds does the nurse expect to auscultate over most of the lung fields? a. Vesicular b. Resonance c. Dull d. Flat ANS: A
QUIZ: Name at least 3 health promotion and screenings for middle adult ANS: Health promotion -Obesity -Sexuality -Update of immunizations Health screening -Mammograms -Bone density -DRE (digital rectal exam) QUIZ: Name at least 3 health promotion and screenings for older adult ANS: Health promotion -Nutrition -Oral health -Update of immunizations Health screening -Falls risk -Hearing -Eye exam/glaucoma QUIZ: What is health promotion vs health protection? ANS: Health promotion is motivated by the desire to increase well-being, while health protection is motivated by a desire to avoid illness QUIZ: What is the appropriate age group and gender for a lipid panel screening (at least every 5 yr if no risk factors)? ANS: -20yrs + (young, middle, old) -both genders QUIZ: What is the appropriate age group and gender for a dental assessments (every 6 months)? ANS: - all age groups
- both genders QUIZ: What is the appropriate age group and gender for a mammogram (yearly)? ANS:
- 40-45 yrs (middle adult) -female QUIZ: What is the appropriate age group and gender for an initial pap smear? ANS: - 20yrs+ (young adult) -female
QUIZ: What is the appropriate age group and gender for an initial fecal occult blood test? ANS: -50yrs + (middle adult) -both genders QUIZ: What is the appropriate age group and gender for an initial colonoscopy if no family history of colon cancer/disease? ANS: - 50yrs + (middle adult) -both genders QUIZ: What is the appropriate age group and gender for a body mass index? ANS: -all age groups -both genders QUIZ: Define the cognitive domain of learning ANS: -Storage and recall of info -ex. facts abt a disease QUIZ: Define the psychomotor domain of learning ANS: - "hands" on skill
- requires thinking and doing
- ex. self administration of insulin QUIZ: Define the affective domain of learning ANS: - changing feelings, beliefs, attitudes, and values
- ex. changing a belief abt diet QUIZ: Which of the following are accurate principles for client teaching? SELECT ALL THAT APPLY a. Teaching multiple concepts all at once b. Keeping sessions short c. Continuing if the client becomes fatigued d. Providing positive feedback to the client e. Starting with familiar material and progressing to new info f. Reviewing key points at the end of the session ANS: B, D, E, F QUIZ: Which of the following examples is an evaluation of a psychomotor skill? a. Client is able to discuss side effects of meds b. Client maintains eye contact with the nurse c. Client has planned menu within therapeutic diet d. Client uses walker correctly ANS: D QUIZ: When teaching an older adult client, the nurse incorporates which teaching strategy into the plan? a. Keep teaching sessions short
a. Sharing personal info with the client b. Posting photos of the client on social media site c. Refusing to provide health info on a client to a caller from a newspaper d. Meeting with a client for a social event after his or her hospitalization e. Speaking with other members of the health care team abt the client's status f. Telling the client's roommate abt the outcome of the client's surgical procedure ANS: C, E QUIZ: Which of the following statements made by the nurse are therapeutic? SELECT ALL THAT APPLY a. "Everything will be okay" b. "I don't agree with what u want to do" c. "It's for ur own good" d. "Have u made a decision abt accepting the treament" e. "U seem happy abt being discharged today" f. "So, there are 2 areas that u want more info abt- ur diet and meds ANS: D, E, F QUIZ: A nurse is immunizing children against measles. This is an example of what level of preventive care? ANS: Primary QUIZ: A nurse refers an HIV-positive client to a local support group. This is an example of what level of preventive care? ANS: Tertiary QUIZ: A nurse is caring for a client who has COPD, a chronic illness of the lungs. The client is in remission. Which statement best describes a period of remission in a client with a chronic illness? a. The symptoms of the illness reappear b. The disease is no longer present c. New symptoms occur at this time d. Symptoms are not experienced ANS: D QUIZ: A nurse is performing health promotion activities for clients at a local health care clinic. Which nursing actions show the focus of secondary preventative care? SELECT ALL THAT APPLY a. Scheduling a series of immunizations for a child b. Teaching parents abt child safety in the home c. Performing ROM exercises d. Screening for HTN e. Scheduling a mammogram for a client f. Referring a client to outpatient mental health counseling for chronic depression ANS: D, E QUIZ: Which of the following is an ex. of tertiary prevention?
a. Providing info on immunizations b. Screening a family for hereditary disease c. Presenting a class on hand hygiene to an elementary school class d. Working with a pt who is paraplegic to prevent musculoskeletal complications ANS: D QUIZ: Assessment for the client reveals some negative health behaviors. Which of the following indicates a lifestyle risk factor? a. Tanning bed b. 9 hr work day c. FH of breast cancer d. Manufacturing based occupations ANS: A QUIZ: The nurse is working with a client to modify his risk factors. Which one fo the following areas can be addressed by the nurse? a. Diet b. Family history c. Developmental level d. Gender ANS: A QUIZ: A nurse at the provider's office is talking abt routine screenings with a 45 yr old female client who has no specific FH of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed? a. "So I don't need the colon cancer procedure for another 2-3 yrs" b. "For now, I should continue to have a mammogram each yr" c. "Because the doctor just did a pap smear, Ill come back nxt yr for another one" d. "So I don't need a blood glucose test until Im 55" ANS: B QUIZ: The nurse sits at the unit computer to begin her shift documentation for her patient. She notes the previous user of the computer, the physical therapist, did not log off appropriately. The nurse should: a. Call the physical therapist and have her come back and log off. b. Complete the log off for the physical therapist before beginning her documentation. c. Proceed with her documentation because it will be in a different screen. d. Report the physical therapist to the unit manager. ANS: B QUIZ: What is nursing informatics? ANS: Managing and processing information applying to nursing education, practice, and research. QUIZ: The basic guideline used for nursing documentation is the ____________________ ANS: Nursing process
c. Lengthy entry using lay terminology. d. Objective data that are observed. ANS: D QUIZ: How does MD SBAR report differ from the RN hand-off report? ANS: MD SBAR- For a patient's critical condition RN hand off report SBAR- change-of-shift QUIZ: What is health literacy? ANS: the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions QUIZ: A nurse has taught a diabetic patient how to administer his daily insulin. The nurse should evaluate the teaching-learning process by: a. Determining the patient's motivation to learn b. Deciding if the learning outcomes have been met c. Allowing the patient to practice the skill he has just learned d. Documenting the teaching session in the patient's medical record ANS: C QUIZ: The client needs to be taught how to find and check his own radial pulse. The nurse will complete this teaching: a. Only if the client asks her to do so, to avoid causing stress. b. When the client recognizes the need to learn the skill. c. Before pain medication is administered when the client is alert. d. Right before the client is discharged so he can remember the skill. ANS: B QUIZ: The client is given a pamphlet to read about how to manage his newly inserted central venous access device at home. It will be most important for the nurse to assess the client's a. Health beliefs b. Literacy level c. Fine motor abilities d. Ability to see ANS: D QUIZ: What is health? ANS: -Ideal state of physical wellness and mental well-being -A positive concept emphasizing social and personal resources, as well as physical capacities -Power of the soul to cope with varying conditions of the body QUIZ: What is the transferring/discharging process? ANS: -On the day and time of transfer confirm that the receiving facility or unit is expecting with the client and that room or bed is available -Community the time the client will transfer to the receiving facility or unit
-Complete documentation (medical records, transfer form) -Give a verbal transfer report in person or via telephone -Confirm the mode of transportation the client will use to complete the transfer or discharge (car, wheelchair, ambulance) -Make sure the client was dressed appropriately if going outside the facility -Account for all the clients valuables QUIZ: What are the discharge instructions? ANS: -Written instructions in the clients language -Diet at home -Step-by-step instructions for procedures at home -Precautions to take when performing procedures or administrating medications -Manifestations of complications to report -Names and numbers of providers and community services to contact -Plans for follow-up care in therapies QUIZ:
