Health Assessment (Final Exam Review; Jarvis 6th Ed.) 1. A 45-year-old mother of two children is seen at the clinic for complaints of "losing my urine when I sneeze." The nurse documents that she is experiencing: A. enuresis. B. stress incontinence. C. urinary frequency. D. urge incontinence. : B. stress incontinence. 2. A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says he "can't always tell where the sound is coming from" and the words often sound "mixed up." What might the nurse suspect as the cause for this change? A. Cilia becoming coarse and stiff B. Nerve degeneration in the inner ear C. Scarring of the tympanic membrane D. Atrophy of the apocrine glands : B. Nerve degeneration in the inner ear 3. A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting she gets "really dizzy" and feels like she is going to fall over. The nurse's best response would be: A. "I'll refer you for a complete neurologic examination." B. "Have you been extremely tired lately?" C. "You need to get up slowly when you've been lying or sitting." D. "You probably just need to drink more liquids." : C. "You need to get up slowly when you've been lying or sitting" 4. A nurse notices that a patient has ascites, which indicates the presence of: A. flatus. referred. : C. C. B. A patient has been admitted to the hospital with vertebral fractures related to osteoporosis. The nurse would record this information as gravida _____. 8.B. 2. 2. 5. A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. Increased blood pressure and pulse B. fluid. 2. She is in extreme pain. fibroid tumors. 2. A. para _____. 2. deep somatic. B. scleroderma. 1 C. visceral. C. 3. : A. The nurse suspects: A. fluid. Which of these assessment findings indicates an acute pain response to poorly controlled pain? A. damage to the trigeminal nerve. 3. C. D. frostbite with resultant paresthesia to the cheeks. D. D. 0 D. A patient states that the pain medication is "not working" and rates his postoperative pain at a 10 on a 1 to 10 scale. A patient has had three pregnancies and two live births. Bell's palsy. : D. This type of pain would be classified as: A. Confusion . 1 B. 3. damage to the trigeminal nerve. deep somatic. AB _____. cutaneous. 3. 6. feces. 1 7. 3. 1 : A. A. arms. increase amplitude of sound for the inner ear to function. There is a problem with the sensory cortex and its ability to discriminate the location. A woman states that 2 weeks ago she had a urinary tract infection that was treated with an antibiotic. "What does the middle ear do?" The nurse responds by telling the patient that the middle ear functions to: A. so the pain is felt elsewhere. : B. parathyroid D. : C. A patient with lack of oxygen to his heart will have pain in his chest and possibly the shoulder. conduct vibrations of sounds to the inner ear. conduct vibrations of sounds to the inner ear. The nurse knows that the statement that best explains why this occurs is which of these? A. B. D. the nurse should ask. 11. The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing pain. or jaw. Depression : A. A patient's laboratory data reveal an elevated thyroxine level. interpret sounds as they enter the ear. D. C. so the pain is felt elsewhere. There is a lesion in the dorsal root that is preventing the sensation from being transmitted normally. adrenal B. thyroid 12. The sensory cortex does not have the ability to localize pain in the heart. "Have you noticed: . parotid C. Increased blood pressure and pulse 9. Hyperventilation D. The nurse would proceed with an examination of the _____ gland. B. maintain balance. As a part of the interview. C. 10.C. A patient with a middle ear infection asks the nurse. The sensory cortex does not have the ability to localize pain in the heart. thyroid : D. D." D. An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages. D.A. breast cancer is not painful. "I would like some more information about the pain in your left breast. a patient states that she has noticed pain in her left breast. any unusual vaginal discharge or itching?" : D. colonoscopy every 10 years. of the shortening of the vertebral column. I had pain like that after my son was born. After completing an assessment of a 60-year-old man with a family history of colon cancer. colonoscopy every 10 years 14. "Oh. "Don't worry about the pain. digital rectal examinations every 2 years. there is a thickening of the intervertebral disks. During a breast health interview." ." : A. The nurse should explain that decreased height occurs with aging because: A. The nurse's most appropriate response to this would be: A. "Breast pain is almost always the result of benign breast disease. fecal test for blood every 6 months. the nurse discusses with him early detection measures for colon cancer. The nurse should mention the need for a(n): A. C. "I would like some more information about the pain in your left breast. : C." C. it turned out to be a blocked milk duct. C. annual proctoscopy." B. any excessive vaginal bleeding?" D. B. long bones tend to shorten with age. : B. 15. a change in your urination patterns?" B. of the shortening of the vertebral column. any changes in your desire for intercourse?" C. any unusual vaginal discharge or itching?" 13. B. there is a significant loss of subcutaneous fat. B. 19. : B. granular in appearance. stimulated by cranial nerves I and II. In assessing the tonsils of a 30 year old. Nothing. and VI. cartilage. urethral meatus and vaginal orifice. B. C. stimulated by cranial nerves III. D. tendons. Nothing. Refer the patient to a throat specialist. the nurse keeps in mind that movement of the extraocular muscles is: A. urethral meatus and paraurethral (Skene) glands. stimulated by cranial nerves III. D. the nurse notices that they are involuted. because this is the appearance of normal tonsils. 17. D. During ocular examinations. B. C. C. ligaments. because this is the appearance of normal tonsils. ligaments. bursa. During an examination the nurse observes a female patient's vestibule and expects to see the: A. Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called: A. IV. : A. and appear to have deep crypts. What is correct response to these findings? A. IV. Obtain a throat culture on the patient for possible strep infection. C. : C. urethral meatus and vaginal orifice. paraurethral (Skene) and vestibular (Bartholin) glands. decreased in the elderly. Continue with assessment looking for any other abnormal findings. B. vaginal orifice and vestibular (Bartholin) glands. D. : B. and VI. . 18. impaired in a patient with cataracts.16. C. pectoral. the largest quadrant of the breast. anterior. and suprascapular nodes B. B. lax. lateral. In performing an assessment of a woman's axillary lymph system. In performing a breast examination. intervertebral foramen. lateral. the nurse should assess which of these nodes? A. The nurse is bathing an 80-year-old man and notices that his skin is wrinkled. An increased loss of elastin and a decrease in subcutaneous fat in the elderly B. D. : D. more prone to injury and calcifications than other locations in the breast. the location of most breast tumors. This finding would be related to which factor? A. lateral. Central. Central. pectoral. : C. zygomatic arch of the temporal bone. Pectoral. An increased loss of elastin and a decrease in subcutaneous fat in the elderly .20. lateral. Increased vascularity of the skin in the elderly : A. and sternal nodes : B. axillary. condyle of the mandible. axillary. temporomandibular joint. thin. D. The reason for this is that the upper outer quadrant is: A. C. and subscapular nodes 22. B. An increase in elastin and a decrease in subcutaneous fat in the elderly C. Increased numbers of sweat and sebaceous glands in the elderly D. the nurse knows that it is especially important to examine the upper outer quadrant of the breast. and sternal nodes D. pectoral. where most of the suspensory ligaments attach. Central. The articulation of the mandible and the temporal bone is known as the: A. Lateral. and subscapular nodes C. and dry. temporomandibular joint 23. 21. the location of most breast tumors. especially on my face and feet but it doesn't have an odor. a disorder of the stratum corneum : B. Suspect that the patient has a venous insufficiency problem. C. 26. Which of these statements is correct and important to remember during this examination? A." The nurse knows that this could be related to: A. the eccrine glands. B. . The nurse is performing an assessment on an adult. C. 27. Exercise C. "I sure sweat a lot." Which is a mechanism of heat loss in the body? A. There are no sensory nerves in the anal canal or rectum. D. a disorder of the stratum germinativum. C.24. The nurse is examining a patient who is complaining of "feeling cold. Above the anal canal. Consider this a delayed capillary refill time and investigate further. Food digestion D. The rectum is about 8 cm long. : B. Consider this a delayed capillary refill time and investigate further. What should the nurse do next? A. Metabolism : A. Radiation B. B. the rectum turns anteriorly. D. Ask the patient about a past history of frostbite. Consider this a normal capillary refill time that requires no further assessment. B. The nurse is examining a patient who tells the nurse. The adult's vital signs are normal and capillary refill time is 5 seconds. Radiation 25. The nurse is performing an examination of the anus and rectum. the apocrine glands. the eccrine glands. C. broad speculum to help visualize the ear. C. The anorectal junction cannot be palpated. Which statement is true about the inspection phase of the physical assessment? A. is used to examine the structures of the internal ear. The nurse is preparing to perform a physical assessment. directs light into the ear canal and onto the tympanic membrane. The nurse is preparing to assess a patient's abdomen by palpation. : D. Inspection takes time and reveals a surprising amount of information. directs light into the ear canal and onto the tympanic membrane. B. encouraging the patient to relax and take deep breaths. The nurse is reviewing statistics regarding breast cancer. uses a short. has the highest risk for development of breast cancer? A. : D. Which statement is true regarding the otoscope? The otoscope: A. D. The nurse is preparing to use an otoscope for an examination. D. Start with light palpation to detect surface characteristics and to accustom the patient to being touched. 28. 30. Avoid palpation of reported "tender" areas because this may cause the patient pain. Start with light palpation to detect surface characteristics and to accustom the patient to being touched.D. : B. 29. Inspection requires a quick glance at the patient's body systems before proceeding on with palpation. C. The anorectal junction cannot be palpated. How should the nurse proceed? A. Which woman. Begin the assessment with deep palpation. B. is often used to direct light onto the sinuses. Inspection may be somewhat uncomfortable for the expert practitioner. Inspection usually yields little information. African-American . D. Inspection takes time and reveals a surprising amount of information. Quickly palpate a tender area to avoid any discomfort that the patient may experience. 31. B. : B. aged 40 years in the United States. brachial D. C. The nurse is teaching a pregnant woman about breast milk. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart. "Breast milk is rich in protein and sugars (lactose) but has very little fat. African-American 32. ulnar B." : C." B. Asian C. : A. Intraluminal valves ensure unidirectional flow toward the heart. 34. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart? A. Intraluminal valves ensure unidirectional flow toward the heart.B. brachial 33. The nurse is reviewing the blood supply to the arm. "You may notice a thick. deep palmar C. does not contain the same nutrition as breast milk does. A. B. "The colostrum. yellow fluid expressed from your breasts as early as the fourth month of pregnancy. The high-pressure system of the heart helps to facilitate venous return. Which statement by the nurse is correct? A." 35. "You may notice a thick." D. "Your breast milk is present immediately after delivery of the baby. which is present right after birth. which refers to which action? . American Indian : A. Contracting skeletal muscles milk blood distally toward the veins. yellow fluid expressed from your breasts as early as the fourth month of pregnancy." C. White D. radial : C. The nurse is reviewing venous blood flow patterns. D. The major artery supplying the arm is the _____ artery. The nurse is testing a patient's visual accommodation. " C.A." D." 38. Pupillary dilation when looking at a far object D. The nurse is using an otoscope to assess the nasal cavity. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? A. "It prevents distortion of bowel sounds that might occur after percussion and palpation. Insert the speculum at least 3 cm into the vestibule. D. "This prevents distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation. Changes in peripheral vision in response to light C. Gently displace the nose to the side that is being examined. "It prevents distortion of bowel sounds that might occur after percussion and palpation. "It allows the patient more time to relax and therefore be more comfortable with the physical examination. Involuntary blinking in the presence of bright light B. psychological wellness. : A. Which of these techniques is correct? A. B. . support systems. circulatory status. The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person's: A. Avoid touching the nasal septum with the speculum. socioeconomic status. Pupillary constriction when looking at a near object 36. circulatory status." B. D. : B. "We need to determine areas of tenderness before using percussion and palpation. Avoid touching the nasal septum with the speculum. B. Keep the speculum tip medial to avoid touching the floor of the nares. Pupillary constriction when looking at a near object : D. C. C. The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen." : A. 37. B.39. assume that the patient is having difficulty breathing and assist him to a supine position. filter coarse particles from inhaled air. VIII. On the basis of this observation. D. filter out dust and bacteria. C. C. the nurse may find that there has been damage to cranial nerve: A. : B. When assessing a 75-year-old patient who has asthma. This portion of the ear is called the: A. auricle. The nurse notices that a patient's palpebral fissures are not symmetrical. the nurse should: A. On examination. B. assume that the patient is eager and interested in participating in the interview. D. III. filter out dust and bacteria. 42. The primary purpose of the ciliated mucous membrane in the nose is to: A. . mastoid process. 41. VII. C. recognize that a tripod position is often used when a patient is having respiratory difficulties. D. auricle. : C. B. VII. leaning forward with arms braced on the chair. B. facilitate movement of air through the nares. warm the inhaled air. C. V. The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. : C. concha. the nurse notes that he assumes a tripod position. outer meatus. 40. the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system: A. "Is the pain a stabbing pain?" : C. of a pulse. "Do you believe in God?" B. When examining a patient's eyes. "How does your spirituality relate to your health care decisions?" 46. "When did the pain start?" C. which question by the nurse would be most appropriate? A. or strength. reflects the blood volume in the arteries during diastole. When beginning to assess a person's spirituality. is usually recorded on a 0. "What does your pain feel like?" 45.to 2-point scale. C. which may be exacerbated in the sitting position. "Do you believe in the power of prayer?" D. is a reflection of the heart's stroke volume. 44. When assessing the force.D. recognize that a tripod position is often used when a patient is having respiratory difficulties. demonstrates elasticity of the vessel wall. "What does your pain feel like?" D. D. . "How does your spirituality relate to your health care decisions?" C. B. : A. "Is it a sharp pain or dull pain?" B. evaluate the patient for abdominal pain. is a reflection of the heart's stroke volume. causes contraction of the ciliary body. When assessing the quality of a patient's pain. 43. the nurse should ask which question? A. "What religious faith do you follow?" : B. : C. the nurse recalls that it: A. composed mostly of milk ducts. D.B. D. and adipose tissue. The cerebellum is the center for speech and emotions. composed of fibrous. elevates the eyelid and dilates the pupil. Which of the following statements is true regarding the internal structures of the breast? The breast is: A. The nurse would suspect that these are: . with very little fibrous tissue. 47. composed of glandular tissue. glandular. The penis is composed of two cylindrical columns of erectile tissue. C. Which of these statements concerning areas of the brain is true? A. 48. The basal ganglia are responsible for controlling voluntary movements. the nurse observes abdominal pulsations between the xiphoid and umbilicus. C. : C. mainly muscle. which supports the breast by attaching to the chest wall. elevates the eyelid and dilates the pupil. : D. The corpus spongiosum expands into a cone of erectile tissue called the glans. : B. While examining a patient. adjusts the eye for near vision. glandular. B. composed of fibrous. known as lactiferous ducts. D. The hypothalamus controls temperature and regulates sleep. 50. The urethral meatus is located on the ventral side of the penis. : C. The hypothalamus controls temperature and regulates sleep. 49. B. C. The corpus spongiosum expands into a cone of erectile tissue called the glans. The prepuce is the fold of foreskin covering the shaft of the penis. Which of these statements is true regarding the penis? A. C. causes pupillary constriction. Motor pathways of the spinal cord and brainstem synapse in the thalamus. B. and adipose tissue. D. : D. increased peristalsis from a bowel obstruction. D.)Study online at quizlet.A. C. pulsations of the inferior vena cava. B. Health Assessment (Final Exam Review. normal abdominal aortic pulsations. normal abdominal aortic pulsations. pulsations of the renal arteries.com/_cb1m4 . Jarvis 6th Ed.