Test Bank for Seidel's Guide to Physical Examination;An Interprofessional Approach 10E by Ball;Dains

TEST BANK

TEST BANK

Chapter 01: Cultural Competency Ball: Seidel’s Guide to Physical Examination, 10th Edition MULTIPLE CHOICE 1. Which statement is true regarding the relationship of physical characteristics and culture? a. Physical characteristics should be used to identify members of cultural groups. b. There is a difference between distinguishing cultural characteristics and

distinguishing physical characteristics. c. To be a member of a specific culture, an individual must have certain identifiable

physical characteristics. d. Gender and race are the two essential physical characteristics used to identify cultural groups.

ANS: B

Physical characteristics are not used to identify cultural groups; there is a difference between the two, and they are considered separately. Physical characteristics should not be used to identify members of cultural groups. To be a member of a specific culture, an individual does not need to have certain identifiable physical characteristics. You should not confuse physical characteristics with cultural characteristics. Gender and race are physical characteristics, not cultural characteristics, and are not used to identify cultural groups.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. An image of any group that rejects its potential for originality or individuality is known as

a(n) a. acculturation. b. norm. c. stereotype. d. ethnos.

ANS: C

A fixed image of any group that rejects its potential for originality or individuality is the definition of stereotype. Acculturation is the process of adopting another culture’s behaviors.

A norm is a standard of allowable behavior within a group. Ethnos implies the same race or nationality.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. Mr. L presents to the clinic with severe groin pain and a history of kidney stones. Mr. L’s son

tells you that for religious reasons, his father wishes to keep any stone that is passed into the urine filter that he has been using. What is your most appropriate response? a. ―With your father’s permission, we will examine the stone and request that it be

returned to him.‖ b. ―The stone must be sent to the lab for examination and therefore cannot be kept.‖ c. ―We cannot let him keep his stone because it violates our infection control policy.‖ d. ―We don’t know yet if your father has another kidney stone, so we must analyze

this one.‖ ANS: A

We should be willing to modify the delivery of health care in a manner that is respectful and

This document is available on the following link: https://drive.google.com/file/d/1p00fC2QJo2y0Cf4TzEDE9wn0_PhezdWv/view?usp=sharing Due to the website upload size restrictions some documents maybe incomplete.

We shall send you the document directly to your email in the next less than 2 hours. Once the document is purchased.

However, to speed things up, kindly send an email to: sturdydrone2707@gmail.com or kriswilliams2707@gmail.com

The title documents are also available in full on the following links. We respond to and resolve any queries within 2 hours.

Kindly contact us for the full document or visit: https://issuu.com/kriswilliams2707

in keeping with the patient’s cultural background. ―With your father’s permission, we will examine the stone and request that it be returned to him‖ is the most appropriate response. ―The stone must be sent to the lab for examination and therefore cannot be kept‖ and ―We don’t know yet if your father has another kidney stone, so we must analyze this one‖ do not support the patient’s request. ―We cannot let him keep his stone because it violates our infection control policy‖ does not provide a reason that it would violate an infection control policy.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 4. The motivation of the healthcare professional to ―want to‖ engage in the process of becoming

culturally competent, not ―have to,‖ is called a. cultural knowledge. b. cultural awareness. c. cultural desire. d. cultural skill.

ANS: C

Cultural encounters are the continuous process of interacting with patients from culturally diverse backgrounds to validate, refine, or modify existing values, beliefs, and practices about a cultural group and to develop cultural desire, cultural awareness, cultural skill, and cultural knowledge. Cultural awareness is deliberate self-examination and in-depth exploration of one’s biases, stereotypes, prejudices, assumptions, and ―-isms‖ that one holds about individuals and groups who are different from them. Cultural knowledge is the process of seeking and obtaining a sound educational base about culturally and ethnically diverse groups. Cultural skill is the ability to collect culturally relevant data regarding the patient’s presenting problem, as well as accurately performing a culturally based physical assessment in a culturally sensitive manner. Cultural desire is the motivation of the healthcare professional to want to engage in the process of becoming culturally competent, not have to.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 5. Mr. Marks is a 66-year-old patient who presents for a physical examination to the clinic.

Which question has the most potential for exploring a patient’s cultural beliefs related to a health problem? a. ―How often do you have medical examinations?‖ b. ―What is your age, race, and educational level?‖ c. ―What types of symptoms have you been having?‖ d. ―Why do you think you are having these symptoms?‖ ANS: D

―Why do you think you are having these symptoms?‖ is an open-ended question that avoids stereotyping, is sensitive and respectful toward the individual, and allows for cultural data to be exchanged. The other questions do not explore the patient’s cultural beliefs about health problems.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 6. The definition of ill or sick is based on a a. stereotype. b. cultural behavior. c. belief system.

d. cultural attitude.

ANS: C

The definition of ill or sick is based on the individual’s belief system and is determined in large part by his or her enculturation.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 7. A 22-year-old female nurse is interviewing an 86-year-old male patient. The patient avoids

eye contact and answers questions only by saying, ―Yeah,‖ ―No,‖ or ―I guess so.‖ Which of the following is appropriate for the interviewer to say or ask? a. ―We will be able to communicate better if you look at me.‖ b. ―It’s hard for me to gather useful information because your answers are so short.‖ c. ―Are you uncomfortable talking with me?‖ d. ―Does your religion make it hard for you to answer my questions?‖ ANS: C

It is all right to ask if the patient is uncomfortable with any aspect of your person and to talk about it; the other choices are less respectful.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 8. As you explain your patient’s condition to her husband, you notice that he is leaning toward

you and pointedly blinking his eyes. Knowing that he is from England, your most appropriate response to this behavior is to a. tell him that you understand his need to be alone. b. ask whether he has any questions. c. ask whether he would prefer to speak to the clinician. d. tell him that it is all right to be angry.

ANS: B

The English worry about being overheard and tend to speak in modulated voices so, when they lean in toward you, they are probably poised to ask a question.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 9. An aspect of traditional Western medicine that may be troublesome to many Hispanics,

Native Americans, Asians, and Middle Eastern groups is Western medicine’s attempts to a. use a holistic approach that views a particular medical problem as part of a bigger picture. b. determine a specific cause for every problem in a precise way. c. establish harmony between a person and the entire cosmos. d. restore balance in an individual’s life.

ANS: B

A more scientific approach to healthcare problem solving, in which a cause can be determined for every problem in a precise way, is a Western approach. Hispanics, Native Americans, Asians, and Arabs embrace a more holistic approach. Using a holistic approach, establishing harmony between a person and the entire cosmos, and restoring balance in an individual’s life would not be troublesome to many Hispanics, Native Americans, Asians, and Arabs.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

10. The attitudes of the healthcare professional a. are largely irrelevant to the success of relationships with the patient. b. do not influence patient behavior. c. are difficult for the patient to sense. d. are culturally derived.

ANS: D

The attitudes of the healthcare provider are foundationally derived from his or her own culture; understanding this is relevant to the success of patient relationships. Attitudes of the healthcare professional are easily detected by others, and they influence patient behavior; they are not irrelevant to the success of relationships with the patient; they do influence patient behavior; and they are not difficult for the patient to sense.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 11. Mr. Sanchez is a 45-year-old gentleman who has presented to the office for a physical

examination to establish a new primary care healthcare provider. Which of the following describes a physical, not a cultural, differentiator? a. Race b. Rite c. Ritual d. Norm ANS: A

Race is a physical, not a cultural, differentiator. Rite is a prescribed, formal, customary observance. Ritual is a stereotypic behavior regulating religious, social, and professional behaviors. A norm is a prescribed standard of allowable behavior within a group.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 12. Mr. Abdul is a 40-year-old Middle Eastern man who presents to the office for a first visit with

the complaint of new abdominal pain. You are concerned about violating a cultural prohibition when you prepare to do his rectal examination. The best tactic would be to a. forego the examination for fear of violating cultural norms. b. ask a colleague from the same geographic area if this examination is acceptable. c. inform the patient of the reason for the examination and ask if it is acceptable to him. d. refer the patient to a provider more knowledgeable about cultural differences.

ANS: C

Asking, if you are not sure, is far better than making a damaging mistake. Not completing the examination could cause the patient further harm. Asking a colleague from the same geographic area if this examination is acceptable may not be appropriate. Referring the patient to a provider more knowledgeable about cultural differences at this point is unnecessary.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 13. Mr. Jones is a 45-year-old patient who presents to the office. A person’s definition of illness is

likely to be most influenced by a. race. b. socioeconomic class. c. enculturation.

d. age group.

ANS: C

The definition of illness is determined in large part by the individual’s enculturation (the process whereby an individual assumes the traits and behaviors of a given culture).

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 14. As the healthcare provider, you are informing a patient that he or she has a terminal illness.

This discussion is most likely to be discouraged in which cultural group? a. Navajo Native Americans b. Dominant Americans c. First-generation African descendants d. First-generation European descendants ANS: A

The Navajo culture believes that thought and language have the power to shape reality; the desire to avoid discussing negative information is particularly strong in this culture.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 15. Because of common cultural food preferences, avoidance of monosodium glutamate (MSG) is

likely to be most problematic for the hypertensive patient of which group? a. Native Americans b. Hispanics c. Chinese d. Italians ANS: C

The Chinese are most likely to use MSG and soy sauce in their diet.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 16. An example of a cold condition is a. b. c. d.

a fever. a rash. tuberculosis. an ulcer.

ANS: C

A cold condition in cultures with a holistic approach is tuberculosis.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation MULTIPLE RESPONSE 1. Which variables can intrude on successful communication? (Select all that apply.) a. Social class b. Gender c. Stereotype d. Phenotype

e. Age ANS: A, B, E

Social class, age, and gender are variables that characterize everyone; they can intrude on successful communication if there is no effort for mutual knowledge and understanding.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. Campinha-Bacote’s Process of Cultural Competence Model includes which cultural

constructs? (Select all that apply.) a. Desire b. Awareness c. Thought processes d. Skill e. Language ANS: A, B, D

Campinha-Bacote’s Process of Cultural Competence Model includes the cultural constructs encounters, desires, awareness, knowledge, and skill.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

Due to the website upload size restrictions some documents maybe incomplete. We shall send you the document directly to your email in the next less than 6 hours. If the document is purchased

However, to speed things up, kindly send an email to: sturdydrone2707@gmail.com or kriswilliams2707@gmail.com

The title documents are available in full on the following links. We respond and resolve to all queries within 2hours.

Test Bank for Seidel's Guide to Physical Examination;An Interprofessional Approach 10th Edition by Jane Ball , Joyce Dains , John Flynn, Barry Solomon, Rosalyn Stewart - Complete, Elaborated and Latest Test Bank. ALL Chapters[1-26] Included and Updated.

Link I: https://browsegrades.net/singlePaper/412327/test-bank-for-seidels-guide-to-physicalexamination-an-interprofessional-approach-10th-edition-by

Link II: https://browsegrades.net/singlePaper/412328/test-bank-for-seidels-guide-to-physicalexamination-an-interprofessional-approach-10th-edition-by

Similarly, should you face any challenges, or would like a document that is currently not updated on our profile, do not hesitate to send an email to: sturdydrone2707@gmail.com or kriswilliams2707@gmail.com

Chapter 02: The History and Interviewing Process Ball: Seidel’s Guide to Physical Examination, 10th Edition

MULTIPLE CHOICE 1. Which question would be considered a ―leading question?‖ a. ―What do you think is causing your headaches?‖ b. ―You don’t get headaches often, do you?‖ c. ―On a scale of 1 to 10, how would you rate the severity of your headaches?‖ d. ―At what time of the day are your headaches the most severe?‖ ANS: B

Stating to the patient that he or she does not get headaches would limit the information in the patient’s answer. Asking the patient what he or she thinks is causing the headaches is an open-ended question. Asking the patient how he or she would rate the severity of the headaches and asking what time of the day the headaches are the most severe are direct questions.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. When are open-ended questions generally most useful? a. During sensitive area part of the interview b. After several closed-ended questions have been asked c. While designing the genogram d. During the review of systems ANS: A

Asking open-ended questions during the sensitive part of the interview allows you to gather more information and establishes you as an empathic listener, which is the first step of effective communication. Asking closed-ended questions may stifle the patient’s desire to discuss the history of the illness. Interviewing for the purpose of designing a genogram or conducting a review of systems requires more focused data than can be more easily gathered with direct questioning.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. Periods of silence during the interview can serve important purposes, such as a. allowing the clinician to catch up on documentation. b. promoting calm. c. providing time for reflection. d. increasing the length of the visit.

ANS: C

Silence is a useful tool during interviews for the purposes of reflection, summoning courage, and displaying compassion. This is not a time to document in the chart, but rather to focus on the patient. Periods of silence may cause anxiety rather than promote calm. The length of the visit is less important than getting critical information.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

4. Mr. Franklin is speaking with you, the healthcare provider, about his respiratory problem. Mr.

Franklin says, ―I’ve had this cough for 3 days, and it’s getting worse.‖ You reply, ―Tell me more about your cough.‖ Mr. Franklin states, ―I wish I could tell you more. That’s why I’m here. You tell me what’s wrong!‖ Which caregiver response would be most appropriate for enhancing communication? a. ―After 3 days, you’re tired of coughing. Have you had a fever?‖ b. ―I’d like to hear more about your experiences. Where were you born?‖ c. ―I don’t know what’s wrong. You could have almost any disease.‖ d. ―I’ll examine you and figure out later what the problem is.‖ ANS: A

―After 3 days, you’re tired of coughing. Have you had a fever?‖ is the only response aimed at focusing on the chief compliant to gather more data and does not digress from the issue.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 5. After you ask a patient about her family history, she says, ―Tell me about your family now.‖

Which response is generally most appropriate? a. Ignore the patient’s comment and continue with the interview. b. Give a brief, undetailed answer. c. Ask the patient why she needs to know. d. Tell the patient that you do not discuss your family with patients.

ANS: B

Giving a brief, undetailed answer will satisfy the patient’s curiosity about yourself without invading your private life. Ignoring the patient’s comment, continuing with the interview, and telling the patient that you do not discuss your family with patients will potentially anger or frustrate her and keep her from sharing openly. Asking the patient why she needs to know will distract from the real reason she is seeking care and instead move the interview conversation away from the topics that should be discussed.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 6. A 36-year-old woman complains that she has had crushing chest pain for the past 2 days. She

seems nervous as she speaks to you. An appropriate response is to a. continue to collect information regarding the chief complaint in an unhurried manner. b. finish the interview as rapidly as possible. c. ask the patient to take a deep breath and calm down. d. ask the patient if she wants to wait until another day to talk to you.

ANS: A

With an anxious, vulnerable patient, it is best to not hurry; a calm demeanor will communicate caring to the patient. If you as a healthcare provider are hurried, the patient will be more anxious. The best way to assist an anxious patient is to not hurry and remain calm, because this will communicate caring to the patient. Asking the patient if she wants to wait until another day to talk to you delays the needed health care.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 7. Ms. A states, ―My life is just too painful. It isn’t worth it.‖ She appears depressed. Which one

of the following statements is the most appropriate caregiver response?

a. b. c. d.

―Try to think about the good things in life.‖ ―What in life is causing you pain?‖ ―You can’t mean what you’re saying.‖ ―If you think about it, nothing is worth getting this upset about.‖

ANS: B

Specific but open-ended questions are best used when the patient has feelings of loss of self-worth and depression. ―Try to think about the good things in life,‖ ―You can’t mean what you’re saying,‖ and ―If you think about it, nothing is worth getting this upset about‖ are statements that will hurry the patient and offer only superficial assurance.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 8. You are collecting a history from a 16-year-old girl. Her mother is sitting next to her in the

examination room. When collecting history from older children or adolescents, they should be a. given the opportunity to be interviewed without the parent at some point during the interview. b. mailed a questionnaire in advance to avoid the need for them to talk. c. ignored while you address all questions to the parent. d. allowed to direct the flow of the interview.

ANS: A

The adolescent should be given the opportunity to give information directly. This enhances the probability that the adolescent will follow your advice. Mailing a questionnaire in advance to avoid the need for her to talk does not assist the adolescent in learning to respond to answers regarding her health. The parent can help fill in gaps at the end. If she is ignored while you address all questions to the parent, the patient will feel as though she is just being discussed and is not part of the process for the health care. The healthcare provider should always direct the flow of the interview according to the patient’s responses.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 9. Information that is needed during the initial interview of a pregnant woman includes all the

following except a. the gender that the woman hopes the baby will be. b. past medical history. c. healthcare practices. d. the woman’s remembering (knowledge) about pregnancy.

ANS: A

The initial interview for the pregnant woman should include information about her past medical history, assessment of health practices, identification of potential risk factors, and assessment of remembering (knowledge) as it affects the pregnancy. The gender of the fetus is not as important as the information about her past medical history, healthcare practices, and the woman’s remembering (knowledge) about her pregnancy.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 10. When interviewing older adults, the examiner should a. speak extremely loudly, because most older adults have significant hearing

impairment. b. provide a written questionnaire in place of an interview.

c. position himself or herself facing the patient. d. dim the lights to decrease anxiety.

ANS: C

The healthcare provider should position himself or herself so that the older patient can see his or her face. Shouting distorts speech, dimming the lights impairs vision, and a written interview may be necessary if all else fails.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 11. To what extent should the patient with a physical disability or emotional disorder be involved

in providing health history information to the health professional? a. The patient should be present during information collection but should not be addressed directly. b. All information should be collected from past records and family members while the patient is in another room. c. The patient should be involved only when you sense that he or she may feel ignored. d. The patient should be fully involved to the limit of his or her ability.

ANS: D

Patients who are disabled may not give an effective history, but they must be respected, and the history must be obtained from them to the greatest extent possible. Patients should be addressed directly and participate in the interview to the extent of their ability.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 12. When taking a history, the nurse should a. ask the patient to give you any information he or she can recall about his or her

health. b. start the interview with the patient’s family history. c. use a chronologic and sequential framework. d. use a holistic and eclectic structure.

ANS: C

To give structure to the present problem or chief complaint, the provider should proceed in a chronologic and sequential framework. Asking patients to give any information they can recall about their health and using a holistic and electric structure do not provide structure to the history. Gathering the patient’s family history is only the first step.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 13. When questioning the patient regarding his or her sexual history, which question should be

asked initially? a. b. c. d.

―Do you have any particular sexual likes or dislikes?‖ ―Do you have any worries or concerns regarding your sexual life?‖ ―How often do you have intercourse and with whom?‖ ―Do you have any reason to think you may have been exposed to a sexually transmitted infection?‖

ANS: B

When approaching questioning about a sensitive area, it is recommended that the provider

first ask open-ended questions that explore the patient’s feelings about the issue. ―Do you have any particular sexual likes or dislikes?‖ is not a question that should be asked in an interview regarding sexual history. ―How often do you have intercourse and with whom?‖ and ―Do you have any reason to think you may have been exposed to a sexually transmitted infection?‖ are not questions that should be asked initially in an interview regarding the patient’s sexual history.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 14. A guideline for history taking is for caregivers to a. ask direct questions before open-ended questions so that data move from simple to

complex. b. ask for a complete history at once so that data are not forgotten between meetings. c. make notes sparingly so that the patient can be observed during the history taking. d. write detailed information as stated by patients so that their priorities are reflected.

ANS: C

During the interview, you should maintain eye contact with the patient, observing body language and proceeding from open-ended to direct questions. Asking direct questions first may upset the patient. During the interview you should gather as much information as you need for the current reason the patient is seeking health care. It is important to focus on the patient. Brief notes can be charted, but you should maintain eye contact with the patient, observing body language and proceeding from open-ended to direct questions.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 15. Mr. D complains of a headache. During the history, he mentions his use of alcohol and illicit

drugs. This information would most likely belong in the a. chief complaint. b. past medical history. c. personal and social history. d. review of systems.

ANS: C

Habits are included within the personal and social history. The chief complaint is the reason the patient is seeking health care. The past medical history is made up of the previous medical conditions that the patient has had. The review of systems is an overview of problems with other body systems.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

16. Direct questioning about domestic violence in the home should be a. a routine component of history taking with all patients. b. avoided for fear of offending the patient’s partner. c. conducted only in cases in which there is a history of abuse. d. used only when the patient is obviously being victimized.

ANS: A

The presence of domestic violence should be routinely queried, and the questioning should be direct for all patients. Direct questioning about domestic violence in the home should not be avoided for fear of offending the patient’s partner, should be part of a routine examination, and should not be used only when the patient is obviously being victimized.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 17. A tool used to screen adolescents for alcoholism is the a. CAGE. b. CRAFFT. c. PACES. d. HITS. ANS: B

The CRAFFT tool is used to screen for alcoholism in adolescents. The CAGE test is used to screen for alcoholism in adults. PACES is used to screen adolescents for important issues in their life. HITS is the screen for domestic violence.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 18. Tom is a 16-year-old diabetic who does not follow his diet. He enjoys his dirt bike and seems

unconcerned about any consequences of his activities. Which factor is typical of adolescence and pertinent to Tom’s health? a. Attachment to parents b. High self-esteem c. Low peer support needs d. Propensity for risk taking ANS: D

Adolescents tend to experiment with risky behaviors that can lead to a high incidence of morbidity and mortality.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 19. Mr. Mills is a 55-year-old patient who presents to the office for an initial visit for health

promotion. A survey of mobility and activities of daily living (ADL) is part of a(n) a. ethnic assessment. b. functional assessment. c. genetic examination. d. social history.

ANS: B

A functional assessment is an assessment of a patient’s mobility, upper extremity movement, household management, ADL, and instrumental activities of daily living (IADL).

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 20. Constitutional symptoms in the ROS refer to a. height, weight, and body mass index. b. fever, chills, fatigue, and malaise. c. hearing loss, tinnitus, and diplopia. d. rashes, skin turgor, and temperature.

ANS: B

General constitutional symptoms refer to pain, fever, chills, malaise, fatigue, night sweats, sleep patterns, and weight (average, preferred, present, change).

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 21. JM has been seen in your clinic for 5 years. She presents today with signs and symptoms of

acute sinusitis. The type of history that is warranted is a(n) a. complete b. inventory c. problem or focused d. interim

history.

ANS: C

If the patient is well known, or if you have been seeing the patient for the same problem over time, a focused history is appropriate. A complete history is only obtained during initial visits or during a complete history and physical examination (H&P). An inventory is related to but does not replace the complete history. It touches on the major points without going into detail.

This is useful when the entire history taking will be completed in more than one session. An interim history is only obtained during a return of the patient after several months of absence.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation MULTIPLE RESPONSE 1. Which are appropriate for the interview setting with a patient? (Select all that apply.) a. Playing music in the background b. Ensuring comfort for all involved c. Maintaining eye contact d. Using a conversational tone e. Keeping the door open f. Removing physical barriers ANS: B, C, D, F

The interview setting requires comfort for all involved, removal of physical barriers, unobtrusive access to a clock, maintaining eye contact, and using a conversational tone.

Playing music in the background may be distracting and keeping the door open does not provide for privacy.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 03: Examination Techniques and Equipment Ball: Seidel’s Guide to Physical Examination, 10th Edition MULTIPLE CHOICE 1. According to the guidelines for Standard Precautions, the caregiver’s hands should be washed a. only after touching body fluids with ungloved hands and between patient contacts. b. only after touching blood products with ungloved hands and after caring for

infectious patients. c. only after working with patients who are thought to be infectious. d. after touching any body fluids or contaminated items, regardless of whether gloves

are worn.

ANS: D

Handwashing is to be done after removal of gloves, between patient contacts, and after touching body fluids, regardless of whether gloves are used. The nurse should never touch body fluids or blood products with ungloved hands. The nurse should use hand hygiene regardless of a patient’s possible infection.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. Which patient is at the highest risk for developing latex allergy? a. The new patient who has no chronic illness and has never been hospitalized b. The patient who has had multiple procedures or surgeries c. The patient who is a vegetarian d. The patient who is allergic to contrast dye ANS: B

The patient who has had multiple procedures or surgeries has a higher rate of exposure to rubber gloves and to equipment and supplies that contain latex and therefore is at a higher risk for developing an allergic response.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. Which initial action, in a patient with autonomic dysreflexia, would aid in lowering blood

pressure? a. Have the patient lie on the left side. b. Assist the patient to remove any tight clothing. c. Recheck the blood pressure after 5 minutes. d. Perform an EKG. ANS: B

Autonomic dysreflexia occurs as a result of dysregulation of the autonomic nervous system.

Cutaneous or visceral stimulation below the level of the spinal cord injury initiates afferent impulses that elicit reflex sympathetic nervous system activity. This response leads to diffuse vasoconstriction, which causes a rise in blood pressure. Helping the patient remove any tight clothing can help lower blood pressure.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—application MSC: Physiologic Integrity: Physiologic Adaptation

4. The use of secondary, tangential lighting is most helpful in the detection of a. variations in skin color. b. enlarged tonsils. c. foreign objects in the nose or ear. d. variations in contour of the body surface.

ANS: D

Tangential lighting is used to cast shadows to observe contours and variations in body surfaces best.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 5. You are caring for a nonambulatory 80-year-old male patient and he tells you, a female nurse,

that he feels like he is having drainage from his rectum. Which initial nursing action is appropriate? a. Drape the patient and observe the rectal area. b. Tell the patient that his doctor will be notified of his problem. c. Tell the patient that you will ask the male nurse on the next shift to check on the problem. d. Give the patient an ice pack to apply to the area.

ANS: A

Necessary exposure for direct observation, while adjusting for modesty, is warranted. The complaint warrants validation before referral or delegation. Before you call the clinician, you need to assess the patient. The assessment should not wait for another shift. Before treatment, it is important to assess the complaint.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 6. You are planning to palpate the abdomen of your patient. Which part of the examiner’s hand

is best for palpating vibration? a. Dorsal surface b. Finger pads c. Fingertips d. Ulnar surface ANS: D

The ulnar surface of the hand and bases of the fingers can best feel vibratory sensations such as thrills and fremitus. The dorsal surface of the hand is best for assessing temperature. The finger pads and fingertips are best for palpating pulses.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 7. The dorsal surface of the hand is most often used for the assessment of a. crepitus. b. temperature. c. texture. d. vibration.

ANS: B

The dorsal surface, or back of the hand, is best for assessing warmth, or temperature. The palmar surface, rather than the dorsal surface, is best for assessing crepitus. The palmar surface, rather than the dorsal surface, is best for assessing texture. The ulnar surfaces of the hand and fingers, rather than the dorsal surface, are best for assessing vibration.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 8. Mrs. Berger is a 39-year-old woman who presents with a complaint of epigastric abdominal

pain. You have completed the inspection of the abdomen. What is your next step in the assessment process? a. Light palpation b. Deep palpation c. Percussion d. Auscultation ANS: D

Auscultation precedes palpation or percussion of the abdomen because these techniques can stimulate peristalsis, which may alter correct assessment of the abdominal sounds. Light palpation, deep palpation, and percussion should not be completed until auscultation is completed.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 9. The degree of percussion tone is determined by the density of the medium through which the

sound waves travel. Which statement is true regarding the relationship between density of the medium and percussion tone? a. The more dense the medium, the louder the percussion tone. b. The less dense the medium, the louder the percussion tone. c. The more hollow the area percussed, the quieter the percussion tone. d. Percussion over muscle areas produces the loudest percussion tones.

ANS: B

Percussion sounds vary according to the tissue being percussed. Less dense tissue (such as that over normal lungs) produces a loud tone, whereas more dense tissue (such as a muscle) produces a softer tone. The more dense the medium, the softer is the percussion tone. The more hollow the area, the louder is the percussion tone. Percussion tones over muscle are soft and flat.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 10. Expected normal percussion tones include a. b. c. d.

dullness over the lungs. hyperresonance over the lungs. tympany over an empty stomach. flatness over an empty stomach.

ANS: C

A normal lung produces resonance percussion tones, whereas an empty stomach is expected to produce tympany. Dullness indicates atelectasis of the lung. Hyperresonance over the lungs indicates emphysema. Flatness occurs over muscle.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

11. During percussion, a dull tone is expected to be heard over a. healthy lung tissue. b. emphysemic lungs. c. the liver. d. most of the abdomen.

ANS: C

Dull tones are expected over denser areas such as the liver. Healthy lung tissue is resonant.

Emphysemic lungs are hyperresonant. Tympany is heard over most of the abdomen.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 12. When using mediate or indirect percussion, which technique is appropriate? a. Place the palmar surface of the nondominant hand on the body surface, with the

fingers held together. b. Place the palmar surface of the nondominant hand on the body surface, with the

fingers slightly spread apart. c. Place the ulnar surface of the nondominant hand on the body surface, with the

fingers together. d. Place the ulnar surface of the nondominant hand on the body surface, with the

fingers slightly spread apart.

ANS: B

The palmar surface of the nondominant (stationary) hand should rest against the body surface, with the fingers spread slightly. A helpful tip to improve elicitation of correct tones is to hyperextend the middle finger of the stationary hand and place the distal interphalangeal joint firmly against the body surface. This lifting of the fingertip avoids dampening of the vibratory sounds.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 13. During percussion, the downward snap of the striking fingers should originate from the a. shoulder. b. forearm. c. wrist. d. interphalangeal joint.

ANS: C

The downward snap of the striking fingers should originate from the wrist.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 14. Which technique is commonly used to elicit tenderness arising from the liver, gallbladder, or

kidneys? a. Finger percussion b. Palmar percussion c. Fist percussion d. Forearm percussion ANS: C

Fist percussion is a direct percussion technique used to elicit tenderness over organs such as the liver, gallbladder, or kidneys.

DIF:Cognitive Level: Remembering (Knowledge)

OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

15. During auscultation, you can limit your perceptual field best by a. asking patients to describe their symptoms. b. closing your eyes. c. performing auscultation before percussion. d. using an aneroid manometer.

ANS: B

By closing your eyes, your sense of hearing becomes more acute, and it increases your ability to isolate sounds. Asking patients to describe their symptoms does not assist in the technique of auscultation. The only time that auscultation occurs before percussion is in examination of the abdomen. Using an aneroid manometer does not assist in the technique of auscultation.

During auscultation, the only equipment needed is the stethoscope.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 16. You are auscultating a patient’s chest. The sounds are not clear, and you are having difficulty

distinguishing between respirations and heartbeats. Which technique can you use to facilitate your assessment? a. Anticipate the next sounds. b. Isolate each cycle segment. c. Listen to all sounds together. d. Move the stethoscope clockwise.

ANS: B

If you are hearing everything at once, it is more difficult to distinguish different sounds. Try isolating each segment and listen to that segment intently; then move on to another segment.

For example, listen only to breath sounds, then only to inspiratory breath sounds, and then only to expiratory breath sounds. Anticipating the next sounds will not facilitate the assessment. Listening to all sounds together will not facilitate the assessment. One of the most difficult achievements in auscultation is learning to isolate sounds. Moving the stethoscope clockwise will not facilitate the assessment.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 17. Auscultation should be carried out last, except when examining the a. neck area. b. heart. c. lungs. d. abdomen.

ANS: D

Auscultation is the last examination technique used for all areas except the abdomen. In this case, it is performed after inspection.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

18. Tympanic thermometers measure body temperature when a probe is placed a. anterior to the ear. b. posterior to the ear. c. under the ear. d. in the auditory canal.

ANS: D

Tympanic thermometer probes are placed at the external opening of the auditory canal.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 19. A scale used to assess patients’ weight should be calibrated a. only by the manufacturer. b. by a qualified technician at regularly scheduled intervals. c. each time it is used. d. when necessary, with the patient standing on the scale.

ANS: C

Obtaining weight begins with a manual calibration of the scale before the patient stands on the scale. Electronic scales are automatically calibrated before each reading. The manufacturer does not calibrate the scale after it is sold. A qualified technician does not calibrate the scale at regularly scheduled intervals. Scales cannot be calibrated with the patient standing on the scale.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 20. The height-measuring attachment of the standing platform scale should be pulled up a. before the patient steps on the scale. b. before the scale is balanced. c. after the patient steps on the scale. d. only after weight has been assessed.

ANS: A

To ensure patient safety, the arm of the height-measuring attachment should be pulled up before the patient steps on the scale, after the scale is balanced, and before weight is assessed.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 21. The infant should be placed in which position to have his or her height or length measured? a. Vertically, with the examiner’s hands under the infant’s axillae b. Supine on a measuring board c. Prone on a measuring board d. In the lateral position, with the toes against a measuring board ANS: B

The infant should be placed supine on a measuring board to measure height or length.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 22. You are using an ophthalmoscope to examine a patient’s inner eye. You rotate the lens

selector clockwise and then counterclockwise to compensate for a. amblyopia.

b. astigmatism. c. myopia. d. strabismus.

ANS: C

Rotating the lens selector compensates for myopia (nearsightedness) or hyperopia (farsightedness) in the examiner and patient.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 23. The pneumatic attachment for the otoscope is used to evaluate a. ear canal patency. b. eardrum landmarks. c. hearing acuity. d. tympanic membrane movement.

ANS: D

The pneumatic attachment on the otoscope produces a puff of air directed to the tympanic membrane, resulting in its movement. The pneumatic attachment for the otoscope is not used to evaluate ear canal patency, eardrum landmarks, or hearing acuity. Ear canal patency is assessed by visually inspecting the ear. Hearing acuity is assessed by the whisper test.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 24. Mr. Walters, a 32-year-old patient, tells you that his ears are ―stopped up.‖ An objective

assessment of this complaint is achieved by using the a. tuning fork. b. reflex hammer. c. otoscope with pneumatic attachment. d. tympanometer.

ANS: D

This patient is describing eustachian tube dysfunction. The tympanometer measures compliance of the middle ear as air pressures are varied. It is an objective means of assessing the function of the ossicular chain, eustachian tube, and tympanic membrane. The tuning fork assesses vibration. The reflex hammer assesses tendon reflexes. The otoscope with pneumatic attachment assesses tympanic membrane movement.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 25. Tuning forks with a frequency of 500 to 1000 Hz are most commonly used to measure a. buzzing or tingling sensations. b. buzzing from bone conduction. c. hearing range of normal speech. d. noise above the threshold level.

ANS: C

Normal speech has a range of 300 to 3000 Hz; therefore the 500- to 1000-Hz fork is used most often because it can estimate hearing loss in the range of normal speech.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

26. To perform a deep tendon reflex measurement, you should a. briskly tap the tendon with the rubber end of the hammer. b. place the hammer firmly on the tendon for 3 to 5 seconds. c. tap the silver end of the hammer on the tendon. d. use the needle implement to determine sensory perception.

ANS: A

Deep tendon reflexes are measured by quickly and firmly tapping either end of the rubber hammer on the stretched tendon and then observing muscle movement.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 27. A variant of the percussion hammer is the neurologic hammer, which is equipped with which

of the following? a. Brush and needle b. Tuning fork and cotton swab c. Penlight and goniometer d. Ruler and bell ANS: A

The neurologic hammer unscrews at the handle to reveal a soft brush, and the knob on the head unscrews to reveal an attached sharp needle.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 28. Transillumination functions on the principle that a. air, fluid, and tissue transmit light differentially. b. black light causes certain substances to fluoresce. c. converging and diverging light brings structures into focus. d. tangential light casts shadows that illuminate contours.

ANS: A

Transillumination functions to differentiate between various media in a cavity. It can distinguish among air, fluid, and tissue.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation MULTIPLE RESPONSE 1. Which of the following are the causes of hyperreflexia? (Select all that apply.) a. Cold stirrups b. Standard scale c. Insertion of a speculum d. Fever e. Pressure during bimanual examination ANS: A, C, E

Hyperreflexia is often caused by a cold, hard, examination table, cold stirrups, insertion or manipulation of a speculum, or pressure during bimanual or rectal examinations.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 04: Taking the Next Steps: Clinical Reasoning Ball: Seidel’s Guide to Physical Examination, 10th Edition MULTIPLE CHOICE 1. After the subjective and objective data have been prioritized, the next step is to a. order laboratory tests. b. formulate a problem list. c. initiate appropriate referrals. d. initiate therapy.

ANS: B

After the data have been prioritized and a presumed diagnosis is made, the next step is to consider the appropriate laboratory tests, imaging studies, or specialty consultations.

DIF:Cognitive Level: Understanding (Comprehension) MSC: Safe and Effective Care: Management of Care

OBJ:Nursing process—evaluating

2. New findings of unknown causes are a. b. c. d.

problems to be noted on the problem list. deferred for subsequent visits. diagnosed before physical examination. reserved for specialists.

ANS: A

New findings of unknown causes are added to the problem list, but do not let them become a red herring that distracts your attention from the central issues.

DIF:Cognitive Level: Understanding (Comprehension) MSC: Safe and Effective Care: Management of Care

OBJ:Nursing process—diagnosis

3. Which is an accepted method of making a diagnosis? a. Relying on intuition b. Making maximal use of laboratory tests c. Using first assumptions d. Using algorithms ANS: D

Methods to make a diagnosis include recognizing patterns, sampling the universe, and using algorithms. Do not rely on intuition, extensive use of laboratory findings, or always going with your first assumptions.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—diagnosis MSC: Safe and Effective Care: Management of Care 4. The adage that ―common problems occur commonly‖ advises the practitioner to a. always diagnose the patient’s problem in terms of what their practice usually sees. b. refer any uncommon complaints to specialists as soon as possible. c. not consider more than one diagnosis unless necessary. d. examine uncommon problems critically before assuming that the issue is an

unusual presentation of a common problem.

ANS: C

This adage is to guide the practitioner to pay attention to unexpected or unusual findings but

not to consider more than one diagnosis unless necessary and to favor the simplest hypothesis when competing hypotheses exist.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—diagnosis MSC: Safe and Effective Care: Management of Care 5. The most important guide to sequencing actions should be a. probability and utility. b. assumption and intuition. c. costs and risks of procedures. d. reimbursement potential and patient acceptance.

ANS: A

Although all choices are relevant, the prioritized guide is to select actions based on an estimate of the probability of successfully achieving the patient’s goals and on the utility of implementation.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—diagnosis MSC: Safe and Effective Care: Management of Care 6. Utilitarianism can be described as a. balancing interests. b. preventing harm. c. choosing wisely. d. doing good.

ANS: C

Utilitarianism occurs when one considers appropriate use of resources with concern for the greater good of the larger community. It also means to ―choose wisely.‖ DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—diagnosis MSC: Safe and Effective Care: Management of Care 7. Positive outcomes depend on the a. number of laboratory tests ordered. b. quality of decisions made. c. use of pharmacologic modalities. d. time saved by the use of ancillary personnel.

ANS: B

Positive patient outcomes are dependent on your ability to arrive at accurate hypotheses that then direct quality patient care decisions.

DIF:Cognitive Level: Understanding (Comprehension) MSC: Safe and Effective Care: Management of Care

OBJ:Nursing process—diagnosis

8. Self-analysis assists providers in giving proper context to a. history and physical findings. b. therapeutic options. c. attitudes, values, and feelings. d. differential diagnoses.

ANS: C

Knowing the intensity of your personal attitudes, values, and emotional feelings about patient care situations helps prevent you from being overtaken by your own impaired or distorted viewpoints.

DIF:Cognitive Level: Understanding (Comprehension) MSC: Safe and Effective Care: Management of Care

OBJ:Nursing process—diagnosis

9. Medical decision making requires a balance between a. trust and suspicion. b. ethical and unethical behavior. c. remembering and superstition. d. mechanism and probabilism.

ANS: D

In making medical decisions, you cannot be too scientific or pursue every possible scenario.

DIF:Cognitive Level: Understanding (Comprehension)

OBJ:Nursing process—diagnosis

MSC: Safe and Effective Care: Management of Care 10. A valid history and physical examination can serve to a. create higher healthcare costs. b. limit the indiscriminate use of diagnostics. c. threaten patient satisfaction. d. increase the risk of liability.

ANS: B

A comprehensive history with a competent clinical examination can lead you to generate a more accurate problem list, and therefore increase the proper usage of diagnostic testing while limiting its indiscriminate use.

DIF:Cognitive Level: Understanding (Comprehension) MSC: Safe and Effective Care: Management of Care

OBJ:Nursing process—diagnosis

11. A specific test is one that has the ability to a. correctly identify those who have the disease. b. correctly identify those who do not have the disease. c. be exclusively used to make a diagnosis. d. exclude competing explanations for another test finding.

ANS: B

The specificity of a test is determined by its ability to identify those who do not have the disease for which the test has been designed. Negative results are more likely to be valid.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—diagnosis MSC: Safe and Effective Care: Management of Care 12. Mr. Johnson actually has streptococcal pharyngitis; however, the throat culture is initially read

as negative. This situation describes a test with a a. low sensitivity. b. high sensitivity. c. high specificity. d. low specificity.

ANS: A

This situation describes a test designed to test those who are positive for the disease. At this time, the test was not able to detect a true-positive; therefore, the test had a low sensitivity.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—diagnosis MSC: Safe and Effective Care: Management of Care

13. Which of the following is not a component of a management plan? a. Presumptive diagnosis b. Patient education c. Diet modification d. Physical therapy ANS: A

The management plan details what you are going to do about a patient problem such as education, diet modifications, and physical therapy referrals.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—implementing MSC: Safe and Effective Care: Management of Care 14. When determining actions for the management plan, the practitioner should first address a. b. c. d.

problems in the order of their chronologic development. the patient’s concern about a particular problem. the patient’s social and economic circumstances. the most urgent problem.

ANS: D

In developing patient care plans, priority should be given to the most life-threatening and urgent physical needs of the patient. Then focus on addressing the patient’s social and economic circumstances.

DIF:Cognitive Level: Understanding (Comprehension) MSC: Safe and Effective Care: Management of Care

OBJ:Nursing process—diagnosis

MULTIPLE RESPONSE 1. When utilizing a joint approach with the patient, which factors are likely to be considered?

(Select all that apply.) a. Consultations b. Laboratory studies c. Assistive technology d. Patient education e. Practitioner background ANS: A, B, C

A joint approach between the patient and practitioner should include laboratory and imaging studies, subspecialty consultation, medications, equipment, special care, diet and activity modification, follow-up visit, and patient education.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—evaluating MSC: Safe and Effective Care: Management of Care

Chapter 05: The Health Record Ball: Seidel’s Guide to Physical Examination, 10th Edition MULTIPLE CHOICE 1. Which part of the information contained in the patient’s record may be used in court? a. Subjective information only b. Objective information only c. Diagnostic information only d. All information ANS: D

Anything that is entered into a patient’s record, in paper or electronic form, is a legal document and can be used in court.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 2. Ms. S reports that she is concerned about her loss of appetite. During the history, you learn

that her last child recently moved out of her house to go to college. Rather than infer the cause of Ms. S’s loss of appetite, it would be better to a. defer or omit her comments. b. have her husband call you. c. quote her concerns verbatim. d. refer her for psychiatric treatment.

ANS: C

It is best to document what you observe and what is said by the patient rather than documenting your interpretation. Listening and quoting exactly what the patient says is the better rule to follow.

DIF:Cognitive Level: Applying (Application) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 3. Which is an effective adjunct to document the location of findings during the recording of the

physical examination? a. Relationship to anatomic landmarks b. Computer graphics c. Comparison with other patients of same gender and size d. Comparison to previous examinations using light pen markings ANS: A

Abnormal or normal findings are best described in relationship to universal topographic and anatomic landmarks.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 4. The position on a clock, topographic notations, and anatomic landmarks a. are methods for recording locations of findings. b. are used for noting disease progression. c. are ways for recording laboratory study results.

d. should not be used in the legal record.

ANS: A

Descriptions of the locations of findings are universally referenced by using positions on a clock, topographic notations, or anatomic landmarks.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 5. Regardless of the origin, discharge is described by noting a. a grading scale of 0 to 4. b. color and consistency. c. demographic data and risk factors. d. associated symptoms in alphabetic order.

ANS: B

Regardless of where the discharge originates, color and consistency determine whether it is an expected finding.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 6. Drawing of stick figures is most useful to a. compare findings in extremities. b. demonstrate radiation of pain. c. indicate consistency of lymph nodes. d. indicate mobility of masses.

ANS: A

Simple drawings, such as stick figures, are more practical illustrations for findings in extremities. Radiation of pain, consistency of lymph nodes, and mobility of masses would not be adequately described by such simple drawings.

DIF:Cognitive Level: Applying (Application) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 7. Which is an example of a problem that requires recording on the patient’s problem list? a. Common age variations b. Expected findings c. Problems needing further evaluation d. Minor variations ANS: C

Any problem is worth noting on the patient problem list, even if the cause or significance is unknown. Common age variations, expected findings, and minor variations within normal limits should not be classified as a problem.

DIF:Cognitive Level: Applying (Application) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 8. A problem may be defined as anything that will require a. evaluation. b. medication.

c. surgery. d. treatment.

ANS: A

The need for further evaluation or attention indicates a problem. If a problem is found, it does not necessarily warrant medication, surgery, or treatment.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 9. Differential diagnoses belong in the a. history. b. physical examination. c. assessment. d. plan.

ANS: C

Differential diagnoses for problems that have not been diagnosed are placed in the assessment category for each problem. The differentials are prioritized, and contributing factors are identified.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 10. Which of the following is not a component of the plan portion of the problem-oriented

medical record? a. Diagnostics ordered b. Therapeutics c. Patient education d. Differential diagnosis ANS: D

The differential diagnosis is part of the assessment phase.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 11. Your patient returns for a blood pressure check 2 weeks after a visit during which you

performed a complete history and physical examination. This visit would be documented by creating a(n) a. progress note. b. accident report. c. problem-oriented medical record. d. triage note.

ANS: A

A second visit with the clinician is always recorded on a progress note, noting any updates to the condition.

DIF:Cognitive Level: Applying (Application) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 12. A detailed description of the symptoms related to the chief complaint is presented in the

a. b. c. d.

history of present illness. differential diagnosis. assessment. general patient information section.

ANS: A

The signs and symptoms and historical data of the patient’s experience that led up to the chief complaint are placed in the history of present illness.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 13. The effect of the chief complaint on the patient’s lifestyle is recorded in which section of the

medical record? a. Chief complaint b. History of present illness c. Past medical history d. Social history ANS: B

The effect of the patient’s complaint on current everyday lifestyle or work performance is recorded in the history of present illness.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 14. The patient’s perceived disabilities and functional limitations are recorded in the a. problem list. b. general patient information. c. social history. d. history of present illness.

ANS: D

The history of present illness contains information about the patient’s lifestyle, as well as disabilities or functional limitations that alter activities of daily living.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 15. The review of systems is a component of the a. physical examination. b. health history. c. assessment. d. past medical-surgical history.

ANS: B

The review of systems relates health history according to physical systems and is presented just before the actual physical examination.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 16. Allergies to drugs and foods are generally listed in which section of the medical record?

a. History of present illness b. Past medical history c. Social history d. Problem list ANS: B

The past medical history section contains information such as allergies to drugs and foods and environmental allergies.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 17. Information recorded about an infant differs from that recorded about an adult, mainly

because of the infant’s a. attention span. b. developmental status. c. nutritional differences. d. source of information.

ANS: B

The organizational structure of an infant’s record is different because the infant’s current and future health is referenced in terms of developmental status.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 18. Which finding is unique to the documentation of a physical examination of an infant? a. Fontanel size b. Liver span c. Prostate size d. Thyroid position ANS: A

The size and characteristic of the fontanel are unique and important in the assessment of an infant.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 19. Data relevant to the social history of older adults includes information on a. family support systems. b. previous healthcare visits. c. over-the-counter medication intake. d. date of last cancer screening.

ANS: A

The social history of older adults includes community and family support systems.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 20. A SOAP note is used in which type of recording system?

a. b. c. d.

Preventive care Problem oriented Systems review Traditional treatment

ANS: B

A SOAP note—subjective problem data, objective problem data, assessment, and plan—is a type of recording system that has a problem-oriented style.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 21. The examiner’s evaluation of a patient’s mental status belongs in the a. history of present illness. b. review of systems. c. physical examination. d. patient education.

ANS: C

Mental status assessment, including cognitive and emotional stability and speech and language, is part of the physical examination.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 22. Which format would be used for visits that address problems not yet identified in the

problem-oriented medical record (POMR)? a. Brief SOAP note b. Comprehensive health history c. Progress note d. Referral note ANS: A

Follow-up visits for problems identified in the POMR are recorded in the progress notes.

Those visits not identified as problems are recorded using the SOAP format. Careful review of all SOAP notes on a regular basis will detect the emergence of a condition that explains the patient’s complaints; at that point, SOAP documentation is stopped.

DIF:Cognitive Level: Applying (Application) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort 23. George Michaels, a 22-year-old patient, tells the nurse that he is here today to ―check his

allergies.‖ He has been having ―green nasal discharge‖ for the last 72 hours. How would the nurse document his reason for seeking care? a. GM is a 22-year-old male here for ―allergies.‖ b. GM came into the clinic complaining of green discharge for the past 72 hours. c. GM, a 22-year-old male, states that he has allergies and wants them checked. d. GM is a 22-year-old male here for having ―green nasal discharge‖ for the past 72

hours.

ANS: D

Documentation of the chief complaint should always be done by using the patient’s own

words in quotation marks.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Integrated process—communication and documentation MSC: Physiologic Integrity: Basic Care and Comfort

Chapter 06: Vital Signs and Pain Assessment Ball: Seidel’s Guide to Physical Examination, 10th Edition MULTIPLE CHOICE 1. The pyrexia response is triggered by the production and release of a. prostaglandins. b. endogenous pyrogens. c. hypothalamic enzymes. d. thyroid hormones.

ANS: A

When microorganisms invade the body, pyrogens are released and travel to the hypothalamus.

The pyrexia response is then triggered by the production and release of prostaglandins.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. During expiration, the internal intercostals a. increase the force of muscular contraction. b. decrease the lateral diameter during expiration. c. decrease the intrathoracic space. d. increase elastic recoil during expiration.

ANS: B

The diaphragm is the dominant muscle during respiration. It contracts and pushes downward during inspiration to increase the intrathoracic space. The external intercostal muscles increase the AP diameter during inspiration and the internal intercostals decrease the lateral diameter during expiration.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. The fifth vital sign is a. pain. b. orientation. c. waist-to-hip ratio. d. body mass index (BMI).

ANS: A

Pain, the universal distress signal, is now recognized as the fifth vital sign.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 4. The Joint Commission (TJC) requires that a. pain be assessed on all discharges. b. repeated assessment of pain be limited to those patients who complain of pain. c. repeated intensity documentation be made of the course of pain relief for all

patients. d. pain be assessed on surgical patients.

ANS: C

TJC requires pain assessment on all admissions, repeated assessments for pain regardless of

the initial complaint or surgical experience, and repeated intensity documentation of the course of pain relief for all patients.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 5. The perception of pain a. is the same across cultures. b. can be easily assessed in neonates. c. is predictable with the same circumstances. d. is affected by emotions and quality of sleep.

ANS: D

The perception of pain is variable and is affected by emotions, cultural background, sleep deprivation, previous pain experience, and age. Perception of pain is different among different cultures. Neonates do feel pain, but perception of pain cannot be assessed in neonates. Each circumstance will provide different pain perception.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 6. The most frequent cause of serious hypertension in children is a. heart disease. b. liver failure. c. renal disease. d. rheumatic fever.

ANS: C

If the systolic blood pressure is elevated and the diastolic blood pressure is not, anxiety may be responsible. Blood pressure in children varies by gender and height at any age.

Hypertension in children is becoming more common because of the increased prevalence of overweight children. Usually, hypertension is caused by kidney disease, renal arterial disease, coarctation of the aorta, and pheochromocytoma, not heart disease, liver failure, or rheumatic fever.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 7. Underestimation of blood pressure will occur if the cuff’s width covers a. b. c. d.

less than half of the upper arm. less than 5 inches of the lower arm. more than two-thirds of the upper arm. more than 4 inches of the lower arm.

ANS: C

Cuffs that are too wide will underestimate blood pressure, which would occur with a cuff that covers more than two-thirds of the upper arm.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 8. Which pulse characteristic in the neonate may indicate infection? a. Bounding pulse rate b. Regular pulse rate c. Sustained high pulse rate

d. Intermittent slow pulse rate ANS: C

Sustained tachycardia in a neonate may be the first indication of infection.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 9. Infants delivered by Cesarean section demonstrate which respiratory characteristic in

comparison to infants delivered vaginally? a. Slower respiratory rate b. Faster respiratory rate c. Shallower respirations d. Deeper respirations ANS: B

Infants delivered by Cesarean section may have a more rapid respiratory rate than babies delivered vaginally.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation MULTIPLE RESPONSE 1. Which occurs with malignant hypertension? (Select all that apply.) a. Blurred vision b. Sleep disturbance c. Tachycardia d. Dyspnea e. Encephalopathy ANS: A, D, E

Signs of malignant hypertension include headache, blurred vision, dyspnea, and encephalopathy.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

2. In a syndrome in which regional pain extends beyond this specific peripheral nerve injury,

you would notice which of the following? (Select all that apply.) a. Allodynia b. Sleep disturbance c. Blood flow changes d. Numbness e. Edema ANS: A, C, D, E

Complex regional pain syndrome includes the following symptoms: burning shooting pain with aching character, exaggerated sensitivity to cold, allodynia, numbness, edema, blood flow changes, and temperature changes.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 07: Mental Status Ball: Seidel’s Guide to Physical Examination, 10th Edition MULTIPLE CHOICE 1. When is the mental status portion of the neurologic system examination performed? a. During the history-taking process b. During assessment of cranial nerves and deep tendon reflexes c. During the time when questions related to memory are asked d. Continually, throughout the entire interaction with a patient ANS: D

A mental status evaluation should be continually performed throughout the patient encounter.

Assessing and validating clues to determine the individual’s ability to interact within the environment is a priority of the mental status evaluation.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. A 69-year-old truck driver presents with a sudden loss of the ability to understand spoken

language. This indicates a lesion in the a. temporal lobe. b. Broca area. c. frontal cortex. d. cerebellum.

ANS: A

The temporal lobe, specifically in the Wernicke speech area, is responsible for the comprehension of spoken and written language.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. The ability for abstract thinking normally develops during a. b. c. d.

infancy. early childhood. adolescence. adulthood.

ANS: C

Abstract thinking is an intellectual maturation that develops during adolescence.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

4. The Mini-Mental State Examination (MMSE) may be used to a. estimate cognitive changes quantitatively. b. estimate personality disorders qualitatively. c. diagnose neurologic disorders. d. determine the cause of memory loss.

e.

ANS: A The MMSE is a standard tool that functions to estimate cognitive function quantitatively or to document cognitive changes serially.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

5. Assessing orientation to person, place, and time helps determine a. ability to understand analogies. b. abstract reasoning. c. attention span. d. state of consciousness.

ANS: D Orientation to person, place, and time are measures of states of consciousness and awareness.

DIF:Cognitive Level: Understanding (Comprehension)

OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

6. When you ask the patient to tell you the meaning of a proverb or metaphor, you are assessing which of the following? a. Level of consciousness b. Abstract reasoning c. Emotional stability d. Memory e.

ANS: B Asking the patient to tell you the meaning of a proverb, metaphor, or fable assesses the patient’s ability to reason abstractly. Asking the patient to tell you the meaning of a proverb or metaphor does not assess level of consciousness, emotional stability, or memory. The Mini-Mental State Examination tests memory.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

7. Impairment of arithmetic skills is often the result of a. impaired execution of motor skills.

b. impaired judgment. c. perceptual distortions. d. depression. e.

ANS: D The patient with depression can display difficulty with simple arithmetic calculations.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

8. Peripheral neuropathy is most likely to be manifested by a. impaired memory. b. impaired abstract reasoning. c. impaired writing ability. d. hallucinations. e.

ANS: C Uncoordinated writing or drawing may indicate peripheral neuropathy, dementia, parietal lobe damage, or a cerebellar lesion.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

9. Recent memory may be tested by a. asking the patient to name the past four presidents. b. asking the patient to listen to and repeat a series of numbers. c. showing the patient four items and asking him or her to list the items about 10 minutes later. d. asking the patient about verifiable information, such as his or her mother’s maiden name. e.

ANS: C Showing the patient four or five objects, saying you will ask about them in a few minutes, and then 10 minutes later asking the patient to list the objects is a technique to measure recent memory.

DIF:Cognitive Level: Understanding (Comprehension)

OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

10. Loss of immediate and recent memory with retention of remote memory suggests a. attention-deficit/hyperactivity disorder (ADHD). b. impaired judgment. c. stupor. d. dementia. e.

ANS: D Dementia is the loss of both immediate and recent memory while retaining remote memories.

ADHD is associated with recent and remote memory impairment. Impaired judgment is a thought process dysfunction. Stupor is impaired consciousness.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

11. You ask the patient to follow a series of short commands to assess a. judgment. b. attention span. c. arithmetic calculations. d. abstract reasoning. e.

ANS: B Asking the patient to follow a series of short commands will test attention span.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

12. Which observation would be most significant when assessing the condition of a patient who has judgment impairment? a. Repeated failure to fulfill family obligations b. Forgetting family members’ birth dates c. Going to church three times a week d. Planning for retirement in 20 years ANS: A Inadequately dealing with family and social affairs indicates impaired judgment, whereas the

other choices do not.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

13. Appropriateness of logic, sequence, cohesion, and relevance to topics are markers for the assessment of a. mood and feelings. b. attention span. c. thought process and content. d. abstract reasoning. e.

ANS: C Thought process and content are examined while observing the patient’s patterns of thinking, especially appropriateness of sequence, logic, coherence, and relevance to the topics discussed.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

14. Which type of hallucination is most commonly associated with alcohol withdrawal? a. Olfactory b. Visual c. Auditory d. Tactile

ANS: D Tactile hallucinations are most commonly associated with alcohol withdrawal.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

15. Flight of ideas or loosening of associations is associated with a. aphasia. b. dysphonia. c. multiple sclerosis. d. psychiatric disorders.

e.

ANS: D Flight of ideas, loosening of associations, word salads, neologisms, clang associations, echolalia, and utterances of unusual sounds are all associated with psychiatric disorders.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

16. The Glasgow Coma Scale is used to a. determine the cause of decreased consciousness. b. diagnose disorders that alter level of consciousness. c. quantify consciousness. d. predict response to stimulant medications. e.

ANS: C The Glasgow Coma Scale is used when a patient has an altered level of consciousness and is used to quantify consciousness.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

17. Which condition is considered progressive rather than reversible? a. Delirium b. Dementia c. Depression d. Anxiety e.

ANS: B Dementia is considered progressive and irreversible. Delirium has the potential for reversal.

Depression and anxiety are reversible.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

18. A clinical syndrome of failing memory and impairment of other intellectual functions, usually related to obvious structural diseases of the brain, describes a. delirium.

b. dementia. c. depression. d. anxiety. e.

ANS: B Dementia results from a chronic progressive deterioration of the brain that results in failing memory and impairment of other intellectual functioning.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

19. Mrs. Griffiths, a 28-year-old patient, presents to your office to discuss her attention-deficit/hyperactivity disorder (ADHD). Which statement is true in regard to ADHD? a. It occurs before 7 years of age. b. It is usually related to mental retardation. c. It is usually related to dementia. d. It is manifested by prolonged periods of catatonic behavior.

ANS: A ADHD occurs before 7 years of age. ADHD is not related to mental retardation, dementia, or prolonged periods of catatonic behavior.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

20. An aversion to touch or being held, along with delayed or absent language development, is characteristic of a. attention-deficit/hyperactivity disorder. b. autism. c. dementia. d. mental retardation. e.

ANS: B Autistic disorder involves a combination of behavioral traits (lack of awareness of others, aversion to touch or being held, odd or repetitive behaviors, or preoccupation with parts of objects) and communication deficits (usually echolalia [parrot speech]).

DIF:Cognitive Level: Understanding (Comprehension)

OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

21. You are interviewing a 20-year-old patient with a new-onset psychotic disorder. The patient is apathetic and has disturbed thoughts and language patterns. The nurse recognizes this behavior pattern as consistent with a diagnosis of a. depression. b. autistic disorder. c. mania. d. schizophrenia.

ANS: D Schizophrenia manifests as a psychotic disorder of early adult onset, with disturbances in language and speech, emotions and social withdrawal, and apathy. Depression and mania do not have the language or speech component. Autistic disorders are not psychotic disorders, and they usually begin before 3 years of age.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

22. While interviewing a patient, you ask him to explain the ―Lion and the Mouse‖ to assess a. reading comprehension. b. attention span. c. mood and feeling. d. reasoning skills. e.

ANS: D Having the patient explain fables or metaphors determines abstract reasoning skills.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

23. The Mini-Mental State Examination (MMSE) should be administered for the patient who a. gets lost in her neighborhood. b. sleeps an excessive amount of time. c. has repetitive ritualistic behaviors. d. uses illegal hallucinogenic drugs.

ANS: A

The MMSE is a tool used to quantitatively estimate cognitive function or to serially document cognitive changes. Getting lost in a familiar territory is a sign of possible cognitive impairment.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

MULTIPLE RESPONSE

1. Which clinical assessments test attention span? (Select all that apply.) a. Spell WORLD backward. b. Draw a clock. c. Say the days of the week. d. Do arithmetic calculations. e. Explain ―a stitch in time saves nine.‖ f.

ANS: A, C, D Clinical assessments to test attention span include spell WORLD backward, say the days of the week, and do arithmetic calculations. Drawing a clock tests writing ability, and explaining a ―stitch in time saves nine‖ tests abstract reasoning.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

2. Which are signs and symptoms of dementia? (Select all that apply.) a. Aphasia b. Apathy c. Odd behaviors d. Disintegration of personality e. Lack of awareness of others ANS: A, B, D Aphasia, apathy, and disintegration of personality are all characteristics of dementia. Odd behaviors and lack of awareness of others are characteristics of autism.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

COMPLETION

1. Under most conditions, adult patients should be able to repeat forward a series of numbers.

ANS: five to eight (or) 5 to 8 five to eight 5 to 8 Most adults should be able to immediately recall a series of five to eight numbers forward and a series of four to six numbers backward.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

2. The examiner should be concerned about neurologic competence if a social smile cannot be elicited by the time a child is

old.

ANS: 2 to 3 months two to three months 2- to 3-months A social smile is expected in the 2- to 3-month-old infant. If it is difficult or impossible to elicit a social smile by 3 months, the infant may not be neurologically intact.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 08: Growth and Nutrition Ball: Seidel’s Guide to Physical Examination, 10th Edition

MULTIPLE CHOICE 1. The gonads begin to secrete estrogen and testosterone during a. infancy. b. puberty. c. pregnancy. d. early adulthood. e.

ANS: B At puberty, the gonads secrete testosterone and estrogen. As a result, secondary sex characteristics (e.g., genitalia growth) begin to appear. Maturation occurs at a mean age of 11.5 years in females and 13.5 years in males.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

2. Developmental changes of puberty are caused mainly by the interaction of the pituitary gland, gonads, and a. hypothalamus. b. islet cells. c. thalamus. d. thymus.

ANS: A Under the influence of the hypothalamus, pituitary gland, and gonads, developmental changes of puberty are established.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

3. After 50 years of age, stature a. becomes fixed. b. begins a barely perceptible secondary increase. c. increases at a rate of 0.5 cm/year. d. declines.

e.

ANS: D As the individual reaches 50 years of age, the intervertebral disk begins to thin and become more compressed, which leads to a decline in stature.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

4. By 10 to 12 years of age, lymphatic tissues are about a. 25% of adult size. b. 50% of adult size. c. the same as adult size. d. twice the size of those in the adult. e.

ANS: D Lymphatic tissues are small compared with total body size, but they are almost fully developed at birth. They grow fast and are about twice the adult size by age 10 to 12 years.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

5. During adolescence, the head size normally increases as a result of a. sinus development. b. brain mass increase. c. evolution of lymphatic tissue. d. hypertrophy of myelin. e.

ANS: A As the facial sinuses grow, the head size enlarges its surface area to accommodate their growth.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

6. Gender-specific skeletal differences first occur during a. the second stage of fetal development. b. late infancy.

c. early childhood. d. adolescence. e.

ANS: D During adolescence, females develop a wider pelvis and males develop broad shoulders; males transition from a slight increase in body fat to more lean muscle mass in later puberty, whereas females maintain an increase in adipose tissue throughout adolescence.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

7. Mrs. Layton is a 33-year-old patient who is obese. Most adult obesity begins a. in adolescence. b. in childhood. c. after the skeletal growth is completed. d. once sexual maturation is complete.

ANS: A Most adult obesity begins in adolescence.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

8. The legs are the fastest growing body part during a. early infancy. b. late infancy. c. childhood. d. early adulthood. e.

ANS: C Legs grow the fastest during childhood, whereas the trunk grows fastest in infancy, and the skeletal muscles and organs grow fastest in early adulthood.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

9. Skeletal mass and organ systems double in size during a. infancy.

b. early childhood. c. adolescence. d. early adulthood. e.

ANS: C During puberty, sex steroids stimulate secretion of growth hormone, causing the organs and skeletal mass to double in size.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

10. Optimal infant birth weight is difficult for pregnant adolescents to obtain because a. they have not completed their own growth spurt. b. there are insufficient uterine supporting structures. c. the amniotic fluid is variable in pregnant adolescents. d. blood volume has not reached adult proportions. e.

ANS: A Pregnant adolescents younger than 16 years, or less than 2 years from menarche, may still be in their growth spurt. They may require higher weight gains during pregnancy to achieve an optimal infant birth weight. There are sufficient uterine supporting structures in the pregnant adolescent. The amnionic fluid is not variable in pregnant adolescents. Blood volume has reached adult proportions in the pregnant adolescent.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

11. How much of the weight gained during a normal pregnancy is accounted for by the fetus? a. Less than 5 pounds b. 6 to 8 pounds c. 9 to 12 pounds d. 13 to 30 pounds e.

ANS: B The growing fetus accounts for only 6 to 8 pounds of the total weight gained. The remainder results from an increase in maternal tissues (e.g., placenta, amniotic fluid, uterus, blood and fluid volume, breasts, and fat reserves).

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

12. The rate of weight gain during pregnancy is expected to be a. greatest in the first trimester. b. greatest in the second trimester. c. greatest in the third trimester. d. about the same in each trimester. e.

ANS: B The rate of weight gain is slow during the first trimester, rapid during the second trimester, and less rapid during the third trimester. Maternal tissue growth accounts for most of the weight gained in the first and second trimesters, whereas fetal growth accounts for weight gained during the third trimester.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

13. During a preventive healthcare visit, Ms. G, an older patient, states that she is getting shorter.

She says that her son mentioned that her change in stature became noticeable to him during his last visit with her. Her posture appears straight and aligned. When addressing Ms. G.’s present concerns, it is most important to inquire about a. the number of pregnancies. b. her parents’ heights. c. a history of scoliosis. d. her usual height and weight. e.

ANS: D Stature declines after 50 years of age because of progressive thinning of the intervertebral disks, so it is important to determine the patient’s height and weight at this age as a baseline for future trending.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

14. Over the past 2 decades, there has been a trend toward a. increased osteoporosis.

b. preservation of height. c. obesity in older adults. d. preservation of muscle mass. e.

ANS: C An increase in overweight and obese older adults has been documented over the past 15 to 20 years. A decrease in weight for height and body mass index has been found with increasing age in patients between 70 and 89 years of age.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

15. Milestone achievements are data most likely to appear in the history of a. adolescents. b. infants. c. school-age children. d. young adults. e.

ANS: B As part of developmental assessment in infants, milestone achievements at certain ages, such as crawling, laughing, picking up their head, and turning over, are recorded.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

16. To estimate an individual’s frame size, the examiner should measure a. skull circumference. b. the length from the olecranon process to the acromion process. c. elbow breadth. d. hip circumference. e.

ANS: C With the patient’s right arm extended and the elbow flexed to 90 degrees, measure the elbow breadth using a measuring device or skinfold calipers, held on the same plane as the upper arm, on the two most prominent bones of the elbow.

DIF:Cognitive Level: Applying (Application)

OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

17. Healthy term babies generally double their birth weight by what age? a. 3 months b. 5 months c. 9 months d. 12 months e.

ANS: B In general, healthy infants double their birth weight by 4 to 5 months of age and triple their birth weight by 12 months of age. Formula-fed infants are heavier after the first 6 months of life than breast-fed infants; they grow faster in the first 6 months of life and experience slower growth in the second 6 months of the first year.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

18. Infants born to the same parents are normally within which range of weight of each other? a. 6 ounces b. 12 ounces c. 1 pound d. 2 pounds e.

ANS: A Siblings born at term to the same parents usually weigh within 6 ounces of each other.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

19. To measure head circumference, the tape is wrapped snugly around the child’s head at the occipital protuberance and the a. supraorbital prominence. b. brow line. c. nasal bridge. d. chin. e.

ANS: A The measuring tape should be snugly wrapped around the child’s head at the occipital

protuberance and supraorbital prominence, thereby documenting the largest circumference.

Care should be taken to ensure that the tape does not cut the skin. Make the reading to the nearest 0.5 cm or inch, and remember to remeasure the head circumference at least once to check the accuracy of your measurement.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

20. Between 5 and 24 months of life, the infant’s chest circumference is normally a. about equal to the head circumference. b. greater than head circumference by 2 inches. c. smaller than head circumference by about 4 inches. d. at least 2 inches smaller than head circumference.

ANS: A Between the ages of 5 months and 2 years, the infant’s chest circumference should closely approximate the head circumference; the ratio should be monitored so that possible microcephaly can be identified.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

21. In clinical practice, the Ballard Assessment Tool is used to assess a newborn’s a. length. b. weight. c. lung maturity. d. gestational age. e.

ANS: D The Ballard Assessment Tool assesses six physical and six neuromuscular characteristics and is administered within 36 hours of birth to confirm the newborn’s gestational age.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

22. Which situation poses the most concern? a. The child whose weight and height ratios have remained at the 50th percentile b. The child whose weight and height ratios have stayed between the 90th and 95th

percentiles c. The child whose weight and height ratios have never been above the 50th percentile d. The child whose weight and height ratios have dropped 15 percentiles since the last visit ANS: D Over time, interval measurements should demonstrate that the child has established a growth pattern, indicated by consistently following a percentile curve on the growth chart. Greatest concern is for the child who is trending down in a more dramatic fashion. Children who suddenly fall below or rise above their established percentile growth curve should be examined more closely to determine the cause.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

23. The upper-to-lower segment ratio should be calculated a. bimonthly for the first year of life. b. annually for the first 5 years. c. only when a child is suspected of having a growth problem or unusual body proportions. d. in children of first-generation immigrants. e.

ANS: C The upper-to-lower segment ratio is calculated when a child is suspected of having a growth problem or unusual body proportions.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

24. Which statement regarding female pubertal changes is true? a. Most adolescent girls will develop breasts before they develop pubic hair. b. Peak height velocity should occur after menarche. c. Breast asymmetry is an abnormal finding. d. Menarche should occur by Tanner breast stage 2. e.

ANS: A

In two-thirds of the population of girls, breasts begin to develop before pubic hair. Peak height velocity actually occurs about 1 year before menarche, breast asymmetry is common, and menarche occurs after Tanner breast stage 2. Peak height velocity will not occur after menarche. Breast asymmetry is not an abnormal finding. Menarche does not generally occur

by Tanner breast stage 2.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

25. What is the youngest age at which pubic hair growth in the male may be considered normal? a. 7 years b. 8 years c. 9 years d. 10 years e.

ANS: C In males, sexual development before 9 years of age is precocious puberty and is considered an abnormal finding; sexual development after 9 years of age is considered normal puberty.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

26. A pregnant woman of normal prepregnancy weight should be expected to gain how much weight per week during the second and third trimesters of pregnancy? a. 1 pound b. 3 pounds c. 2 pounds d. 4 pounds

ANS: A Expected weight gain in the first trimester is variable, between 1 and 2 kg (2 to 4 pounds); however, in the second and third trimesters, weekly weight gain should be around 0.45 kg (1 pound) per week.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

27. A prominent forehead, large nose, large jaw, and elongation of the facial bones and extremities are signs of a. infantile hydrocephalus. b. acromegaly. c. Cushing syndrome. d. achondroplasia. e.

ANS: B A prominent forehead, large nose, large jaw, and elongation of the facial bones and extremities are all prominent characteristics of acromegaly; a prominent forehead can also occur with achondroplasia, but hypoplasia of the midface differentiates the two.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

28. Round face, preauricular fat, hyperpigmentation, and ―buffalo hump‖ in the posterior cervical area are associated with a. infantile hydrocephalus. b. acromegaly. c. Cushing syndrome. d. achondroplasia.

ANS: C Round face, preauricular fat, hyperpigmentation, and a buffalo hump in the posterior cervical area are all commonly associated with Cushing syndrome; the buffalo hump distinguishes Cushing syndrome from the other choices.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

29. Mrs. Raymonds is a 24-year-old patient who has presented for a routine concern over her current weight. In your patient teaching with her, you explain the importance of macronutrients. Which of the following is a macronutrient? a. Iron b. Thiamin c. Calcium

d. Fat e.

ANS: D Carbohydrates, protein, and fat are referred to as macronutrients because they are required in large amounts. Iron, thiamin, and calcium are minerals.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

30. Which is the most vital nutrient? a. Protein b. Carbohydrate c. Fat d. Water

ANS: D Water is the most vital nutrient. A person can exist without food for several weeks but without water for only a few days.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

31. Which of the following is the most accurate reflection of an individual’s food intake? a. 24-hour diet recall b. Food diary c. Computerized nutrient analysis d. Serum protein assay e.

ANS: B The food diary is a record of intake as it happens, making this method the most accurate reflection of an individual’s food intake.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

32. Mrs. Hartzell is a 34-year-old patient who has presented for nutritional counseling because she is a vegetarian. Deficiency of which of the following is a concern in the vegetarian diet? a. Ascorbic acid

b. Vitamin B12 c. Folate d. Fiber e.

ANS: B The nutrients that may be deficient in a vegetarian diet, if not carefully planned, include proteins, calcium, iron, vitamin B12, and vitamin D. DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

33. Ms. Otten is a 45-year-old patient who presents with a complaint of weight gain. Which medication is frequently associated with weight gain? a. Diuretics b. Oral hypoglycemics c. Laxatives d. Steroids e.

ANS: D Medications that contribute to weight gain include steroids, oral contraceptives, antidepressants, and insulin.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

34. Ms. Davis is a 27-year-old patient with a BMI of 33. Based on her BMI, your diagnosis would be a. normal body weight. b. overweight. c. obese. d. extremely obese. e.

ANS: C An obese BMI is 30 to 39.9. A normal BMI is less than 24. An overweight BMI is 25 to 29.9.

An extremely obese BMI is greater than 40.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

35. A 17-year-old girl presents to the clinic for a sports physical. Physical examination findings reveal bradycardia, multiple erosions of tooth enamel, and scars on her knuckles. She appears healthy otherwise. You should ask her if she a. binges and vomits. b. has regular menstrual periods. c. has constipation frequently. d. is cold intolerant. e.

ANS: A In young adults, usually female, bradycardia, knuckle scars, and tooth decay are signs of chronic, self-induced vomiting characteristic of bulimia. Amenorrhea can occur from increased physical activity or anorexia. Constipation and cold intolerance are usually symptoms of anorexia nervosa.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

MULTIPLE RESPONSE 1. Which are signs and symptoms of hydrocephalus? (Select all that apply.) a. Early closed suture lines b. Hyperreflexia Y c. Irritable, poor feeding Y d. Does not meet expected height and weight e. Difficulty holding head up Y f. Rapidly increasing head circumference Y g.

ANS: B, C, E, F Signs and symptoms of hydrocephalus include hyperreflexia, difficulty holding head up, irritability, lack of energy, rapidly increasing head circumference, and poor feeding. Early closed suture lines and inability to meet expected height and weight do not indicate hydrocephalus.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

COMPLETION 1. An 11-year-old boy is brought in for an annual physical examination by his mother. The boy’s height is 60 inches. You suspect Marfan syndrome because the boy’s arm span is greater than inches.

ANS: 60 sixty Arm span that is greater than a child’s height is associated with Marfan syndrome. Children with Marfan syndrome can have cardiovascular problems and should be thoroughly evaluated.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

2. Infants normally increase their birth length by 3.

ANS:

_% during the first year of life.

50

Infant length generally increases by 50% in the first year of life.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

4. The term large for gestational age (LGA) indicates that an infant is larger than

% of

infants born at the same number of weeks’ gestation.

ANS: 90 LGA corresponds to an infant whose weight is classified as greater than the 90th percentile.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 09: Skin, Hair, and Nails Ball: Seidel’s Guide to Physical Examination, 10th Edition

MULTIPLE CHOICE

1. The skin repairs surface wounds by a. exaggerating cell replacement. b. excreting lactic acid. c. producing vitamins. d. providing a mechanical barrier. e.

ANS: A The skin’s tissue cells have a rapid rate of turnover and constant renewal, thereby enabling the skin to repair damaged surfaces.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

2. The adipose tissue in the hypodermis serves to a. provide sensory input. b. generate heat and insulate. c. create tensile strength. d. secrete collagen.

ANS: B The hypodermis layer consists of adipose tissue that serves to generate heat and provide insulation, shock absorption, and a reserve of calories.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

3. The secretory activity of the sebaceous glands is stimulated by a. body heat. b. ambient temperature. c. sex hormones. d. dietary protein.

e.

ANS: C The sebaceous glands, when stimulated by the sex hormones, produce a lipid-rich substance that keeps the skin moist.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

4. Mrs. Tuber is a 36-year-old patient who comes into the health center with complaints that her fingernails are not growing. Which structure is the site of new nail growth? a. Cuticle b. Perionychium c. Matrix d. Nail bed e.

ANS: C The white crescent-shaped area beyond the proximal nail fold is called the matrix, which is the site of new nail growth.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

5. Mrs. Leonard brings her newborn infant into the pediatrician’s office for a first well-baby visit. As the healthcare provider, you teach her that newborns are more vulnerable to hypothermia because of a. the presence of coarse terminal hair. b. desquamation of the stratum corneum. c. their covering of vernix caseosa. d. a poorly developed subcutaneous fat layer. e.

ANS: D Newborns have a poorly developed subcutaneous fat layer and therefore have a reduced ability to generate heat.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

6. Mrs. Mulligan brings her 16-year-old son into the office for a sports physical examination. As

the healthcare provider, you explain that normal hormone-related changes of adolescence include a. increased oil production. b. slowed hair growth. c. depleted apocrine glands. d. decreased sebaceous gland activity. e.

ANS: A During adolescence, the sebaceous glands increase sebum production, which causes the skin to have an oily appearance and predisposes the individual to acne.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

7. Expected hair distribution changes in older adults include a. increased terminal hair follicles on the scalp. b. more prominent axillary and pubic hair production. c. increased terminal hair follicles to the tragus of men’s ears. d. more prominent peripheral extremity hair production. e.

ANS: C The transition from a vellus to terminal hair pattern occurs in older men at the nares and tragus.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

8. Brittle nails are typical findings in a. adolescents. b. infants. c. pregnant women. d. older adults. e.

ANS: D Older adults typically have decreased peripheral circulation to the nails, causing the nails to develop longitudinal ridges that are more brittle and susceptible to splitting into layers.

DIF:Cognitive Level: Remembering (Knowledge)

OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

9. Mrs. Franklin is a 68-year-old patient who presents to the office with a complaint that her nails do not seem to be growing. As the healthcare provider, you explain to her that the nails of older adults grow slowly because of a. decreased circulation. b. dietary deficiencies. c. fungal infections. d. low hormone levels. e.

ANS: A Decreased circulation to the nails of older adults causes nail growth retardation.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

10. As part of your health promotion education for a new patient, you explain that the risk factors for skin cancer include a. an olive complexion. b. repeated trauma or irritation to skin. c. history of allergic reactions to sunscreen. d. dark eyes and hair. e.

ANS: B Fair-skinned persons with light eyes with repeated trauma or skin irritation have higher risk factors for skin cancer development.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

11. The type and brand of grooming products used are important to the health history of a. adolescents. b. everyone. c. older adults. d. persons with rashes.

ANS: B

Knowledge of exposure to environmental chemicals is valid health history data for all age groups, not just adolescents, older adults, or persons with rashes.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

12. Mr. Donalds is a 45-year-old roofer. Your inspection to determine color variations of the skin is best conducted a. using an episcope. b. under fluorescent lighting. c. with illumination provided by daylight. d. using a Wood’s light. e.

ANS: C Daylight provides the best illumination source for determining color variations of the skin.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

13. Tangential lighting is best used for inspecting skin a. color. b. contour. c. exudates. d. symmetry. e.

ANS: B Tangential lighting—light shined laterally to the surface—is best for inspecting skin contour.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

14. Unusual white areas on the skin may be caused by a. adrenal disease. b. polycythemia. c. vitiligo. d. Down syndrome. e.

ANS: C

The absence of melanin produces unpigmented white areas known as vitiligo.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

15. Which cultural group has the lowest incidence of nevi? a. Native Americans b. African Americans c. Mexican Americans d. Asians e.

ANS: B Nevi are more common in persons who burn, rather than tan; therefore, African Americans have the lowest rates of nevi.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

16. You are inspecting the lower extremities of a patient and have noted pale, shiny skin of the lower extremities. This may reflect a. systemic disease. b. a history of vigorous exercise. c. peptic ulcer disease. d. mental retardation. e.

ANS: A Pale, shiny skin of the lower extremities may reflect peripheral changes that occur with systemic disorders, such as diabetes mellitus and cardiovascular disease.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

17. A 29-year-old white woman appears jaundiced. Liver disease as a cause has been excluded.

What history questions should the nurse ask? a. Whether she had unprotected sex b. Whether she has a history of diabetes mellitus c. Whether she had unusual bleeding problems d. Whether she eats a lot of yellow and orange vegetables

e.

ANS: D In the absence of liver disease, another cause of jaundice is increased carotene pigmentation.

Diets high in carrots, sweet potatoes, and squash are high in carotene and can make the skin appear to be jaundiced. Whether she had unprotected sex, a history of diabetes mellitus, or unusual bleeding problems would not be relevant when assessing the jaundiced skin.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

18. Mrs. Bower is a 39-year-old patient who has come to the office for a routine physical examination. As a healthcare provider, you know that the skin temperature is best assessed with the a. dorsal surface of the examiner’s hand. b. palmar surface of the examiner’s hand. c. ulnar surface of the examiner’s hand. d. pads of the examiner’s fingers. e.

ANS: A The dorsal surface of the hand is best for estimating temperature variations.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

19. You are examining a pregnant patient and have noted a vascular lesion. When you blanch over the vascular lesion, the site blanches and refills evenly from the center outward. The nurse documents this lesion as a a. telangiectasia. b. spider angioma. c. petechiae. d. purpura. e.

ANS: B Spider angiomas are dilated arterioles. A network of dilated capillaries radiate from the center arteriole, outward like a spider’s legs. Spider angiomas are often associated with high estrogen levels, as occur in pregnancy. Blanching over the center is followed by a rapid return of redness from the center outward. Telangiectasias refill erratically. Petechiae and purpura do

not blanch.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

20. Small, minute bruises are called a. ecchymoses. b. petechiae. c. spider veins. d. telangiectasias.

ANS: B Petechiae are smaller than 0.5 cm in diameter. Ecchymoses are larger than 0.5 cm in diameter.

Spider veins and telangiectasias are vascular lesions.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

21. A flat, nonpalpable lesion is described as a macule if the diameter is a. larger than 1 cm. b. smaller than 1 cm. c. 3 cm exactly. d. too irregular to measure. e.

ANS: B A macule, by definition, is a flat, circumscribed area smaller than 1 cm in diameter and is measurable. An example of a macular rash is measles.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

22. Mrs. Britton is a 34-year-old patient who presents to the office with complaints of skin rashes.

You have noted a 4.3-cm, rough, elevated area of psoriasis. This is an example of a a. plaque. b. patch. c. macule. d. papule.

ANS: A A plaque, by definition, is an elevated, firm, rough lesion with a flat top surface larger than 1 cm in diameter, as seen in someone with, for example, psoriasis.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

23. Skin turgor checks are performed to determine the a. temperature of the skin. b. hydration status. c. actual age. d. extent of an ecchymosis. e.

ANS: B Skin will remain tented if the patient is dehydrated or will not tent if edema is present.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

24. You have just completed a skin assessment on Mr. Baker. During your assessment, you have transilluminated a skin lesion. During the physical examination, you know that skin lesions are transilluminated to distinguish a. vascular from nonvascular lesions. b. furuncles from folliculitis lesions. c. fluid-filled lesions from solid cysts or masses. d. herpes zoster from varicella. e.

ANS: C Transillumination is used to determine the presence of fluid in cysts and masses. Fluid-filled lesions will transilluminate with a red glow, and solid masses will not transilluminate.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

25. Fluorescing lesions are best distinguished using a(n) a. incandescent lamp. b. magnifying glass.

c. transilluminator. d. Wood’s lamp. e.

ANS: D Fluorescing lesions (e.g., some tinea lesions) show a characteristic yellow-green color under a Wood’s lamp.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

26. Women with terminal hair growth in a male distribution pattern should receive further evaluation for a(n) a. circulation condition. b. endocrine disorder. c. inflammatory state. d. nutritional deficit. e.

ANS: B Hirsutism in women (growth of terminal hair in a male distribution) can be a clinical sign of an endocrine disorder. Hair loss can be associated with poor circulation, inflammation, or nutritional deficits.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

27. Which nail change found on examination would be most alarming? a. Dark bands seen on all fingernails of a dark-skinned person b. Yellow discoloration of the great toe of an older adult c. Single dark band in a white adult d. Pits in both index fingernails of an adult e.

ANS: C Dark bands in a dark-skinned person are normal; yellow in the toe of an older adult can represent a nail disease or a chronic respiratory condition; and pits are related to psoriasis. A single dark band in a white adult indicates a more serious condition—melanoma.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

28. Transient mottling of the patient’s skin in a cool room is a common finding in a. menopausal women. b. newborn infants. c. pregnant women. d. sedentary adults. e.

ANS: B Cutis marmorata, a mottled appearance, is part of the newborn’s response to changes in temperature.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

29. A single transverse line seen in the palm of a small child may imply a. Down syndrome. b. Turner syndrome. c. systemic sclerosis. d. profound dehydration.

ANS: A The simian line, a single transverse crease, is seen on the palm of children with Down syndrome.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

30. Cafe au lait patches are numbered with each assessment of infants and young children because a. the numbers are expected to increase each year. b. coalescent lesions are a more serious finding. c. the presence of six or more patches suggests neurofibromatosis. d. decreasing numbers are expected with growth. e.

ANS: C The presence of six or more patches with diameters larger than 1 cm in children younger than 5 years of age suggests neurofibromatosis. Fewer than five patches is usually considered harmless. The numbers of cafe au lait patches are not expected to increase each year.

Coalescent lesions are not a more serious finding. Decreasing numbers are not expected with

growth.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

31. A Dennie-Morgan fold is probably caused by a. birth trauma. b. high fever. c. excess adipose tissue. d. chronic rubbing.

ANS: D Persons with chronic atopic or allergic conditions tend to rub the eyes sufficiently to cause an extra crease or pleat of skin below the eye, called the Dennie-Morgan fold.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

32. Linea nigra is commonly found on the abdomens of a. infants and children. b. adolescents. c. pregnant patients. d. older adults. e.

ANS: C Pregnant patients commonly develop pigmentation of the abdomen from the symphysis pubis to the top of the fundus in the midline.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

33. Cherry angiomas are a common finding in a. adults older than 30 years. b. newborns. c. pregnant women. d. sunbathers. e.

ANS: A

Cherry angiomas occur in almost everyone older than 30 years and increase numerically with age.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

34. Pigmented, raised, warty lesions over the face and trunk should be assessed by an experienced practitioner who can distinguish a. cutaneous tags from lentigines. b. furuncles from folliculitis. c. sebaceous hyperplasia from eczema. d. seborrheic keratoses from actinic keratoses. e.

ANS: D Actinic keratoses have malignant potential, and seborrheic keratoses do not. Because they can look similar, an experienced practitioner should make the determination.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

35. Age spots are also called a. seborrheic keratoses. b. solar lentigines. c. cutaneous horns. d. acrochordon. e.

ANS: B Solar lentigines are irregular, round, gray-brown lesions with a rough surface that occur in sun-exposed areas and are referred to as age spots.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

36. The most common inflammatory skin condition is a. cutis marmorata. b. eczematous dermatitis. c. intradermal nevus.

d. pityriasis rosea. e.

ANS: B The most common inflammatory skin disorder is eczematous dermatitis.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

37. Which is a noncandidal fungal infection? a. Pityriasis rosea b. Psoriasis c. Tinea corporis d. Rosacea e.

ANS: C Tinea corporis is the only listed fungal infection (noncandidal); the others are not fungal in origin.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

38. The characteristic that best differentiates psoriasis from other skin abnormalities is the a. color of the scales. b. formation of tiny papules. c. general distribution over the body. d. recurrence. e.

ANS: A Unlike other skin conditions, silvery papules and plaques characterize psoriasis.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment 39. Painful vesicles are associated with a. psoriasis. b. pityriasis rosea. c. paronychia. d. herpes zoster.

MSC: Physiologic Integrity: Physiologic Adaptation

e.

ANS: D Herpes zoster (shingles) produces painful itching or burning of the dermatome area.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

40. A 17-year-old student complains of a ―rash for 3 days.‖ You note pale, erythematous oval plaques over the trunk. They have fine scales and are arranged in a fernlike pattern, with parallel alignment. What is the nurse’s next action? a. Teach infectious control measures. b. Inquire about another recent skin lesion. c. Inspect the palms and the soles. d. Inform the patient that this will resolve within a week. e.

ANS: B The described rash is the typical presentation of pityriasis rosea. The rash is not infectious or contagious, does not involve the palms and soles, and usually lasts for several weeks.

Pityriasis rosea begins with a sudden primary (herald) patch, with generalized eruption to the trunk and extremities following 1 to 3 weeks later.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

41. Which of the following is an ABCDE characteristic of malignant melanoma? a. Asymmetric borders b. Borders well demarcated c. Color of lesion is uniform d. Diameter less than 6 mm e.

ANS: A ABCDE melanoma mnemonic includes asymmetry, borders that are irregular, color that is not the same all over, diameter larger than 6 mm and growing, and evolution.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

42. The most common cutaneous neoplasm is

a. basal cell carcinoma. b. compound nevus. c. seborrheic keratosis. d. senile actinic keratosis. e.

ANS: A Basal cell carcinoma is the most common form of skin cancer. It occurs more frequently on sun-exposed parts of the body.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

43. Soft, painless, bluish papules in persons who are HIV-positive are most likely a. Kaposi sarcoma. b. malignant melanoma. c. molluscum contagiosum. d. pityriasis rosea. e.

ANS: A Kaposi sarcoma is the more common malignant skin lesion of HIV-infected persons. The lesions are soft, painless, bluish purple macules or papules.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

44. A 5-year-old child presents with discrete vesicles on an erythematous base that began near her scalp and are spreading to the trunk. The child has a low-grade fever and feels tired. What is the nurse’s next action? a. Teach infectious control measures. b. Inquire about other patterns of physical abuse. c. Inspect the buccal mucosa for Koplik spots. d. Inform the parent that this will resolve within a couple of days. e.

ANS: A The description of this child’s complaint is a varicella rash, not physical abuse or rubeola.

Chickenpox is a highly communicable disease and can be prevented by immunization. The period of communicability lasts from 1 or 2 days before onset of the rash until all the vesicles

have crusted over, which usually takes about 1 week. This is not physical abuse. Inspecting the buccal mucosa for Koplik spots will not diagnose the problem. This will not resolve within a couple of days.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

45. During history taking, a mother states that her son awoke in the middle of the night complaining of intense itching to his legs. Today, your inspection reveals a honey-colored exudate from the vesicular rash on his legs. Which condition is consistent with these findings? a. Exanthem b. Impetigo c. Solar keratoses d. Trichotillomania e.

ANS: B Impetigo causes intense pruritus, regional lymphadenopathy, and honey-colored exudative crusting as the vesicles or bullae rupture and dry.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

46. You are conducting a preschool examination on a 5-year-old child. Which injury would most likely raise your suspicion that the child is being abused? a. Recent bruising over both knees b. A healed laceration under the chin c. A bruise on the right shin with associated abrasion of tissue d. Bruises in various stages of resolution over body soft tissues e.

ANS: D Toddlers and older children who bruise themselves accidentally do so over bony prominences, like the knees, chin, and shin. Bruises over soft tissues are more consistent with abuse.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

47. Assessment of poor hygiene, healed fractures with deformity, or unexplained trauma in older adults indicates

a. sexual abuse. b. physical neglect. c. psychological abuse. d. violated rights. e.

ANS: B Physical neglect is described as the most common form of elder abuse.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

48. The nurse assesses the nail base angle using the Schamroth technique. Which nail bed shape indicates a normal expected examination finding? a. Flat b. Convex c. Concave d. Bowed e.

ANS: C The normal nail base angle should be 160 degrees, which results in a concave nail base that produces a diamond-shaped window with the Schamroth technique.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

MULTIPLE RESPONSE 1. Which identify the signs and symptoms of basal cell cancer? (Select all that apply.) a. Itching b. Reddish patch c. Starts from a nevi d. Various clinical forms—cystic, nodular, pigmented e. Macule type f.

ANS: A, B, D Common signs and symptoms of basal cell carcinoma include a, pink, red, tan, white, black, or brown shiny nodule, in a variety of clinical forms, which may be crusted and itching.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 10: Lymphatic System Ball: Seidel’s Guide to Physical Examination, 10th Edition

MULTIPLE CHOICE

1. Which organ does not have lymphatic vessels? a. Brain b. Kidneys c. Liver d. Lungs e.

ANS: A Lymphatic tissues are found abundantly throughout the body except in two places, the placenta and the brain (central nervous system). Lymphatic tissues are found abundantly in the kidneys, liver, and lungs.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

2. Cells that line the lymph node sinuses perform the specific function of a. fat absorption. b. fetal immunization. c. hematopoiesis. d. phagocytosis. e.

ANS: D Lymph nodes defend against the invasion of microorganisms by phagocytosis.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

3. Lymph flows faster in response to a. increased metabolic activity. b. decreased blood volume. c. decreased metabolic rate. d. decreased permeability of the capillary walls.

e.

ANS: A Lymph flow increases with mounting capillary pressure, greater permeability of the capillary walls, or increased metabolic rate.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

4. An organ that is essential to the development of protective immune function in the infant but has little or no demonstrated function in the adult is the a. spleen. b. liver. c. thymus. d. pancreas.

ANS: C In the adult, the thymus atrophies and, in the older adult, is replaced by fat and connective tissue.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

5. Mr. Shea is a 45-year-old patient who presents to the office for multiple complaints. The examination of the upper left quadrant of the abdominal cavity is essential to the evaluation of the immune system because of the location of which organ? a. Spleen b. Liver c. Stomach d. Pancreas e.

ANS: A The spleen is the largest of the lymphatic organs. It is located in the upper left portion of the abdomen.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

6. Mrs. Farrel brings in her 6-year-old son with complaints of a sore throat and fever. As the

healthcare provider, you are concerned about his tonsils and adenoids. Enlarged tonsils and adenoids may obstruct the a. thoracic duct. b. esophagus. c. nasopharyngeal passageway. d. external auditory meatus. e.

ANS: C The palatine tonsils are located on either side of the pharynx; the adenoids (pharyngeal tonsils) are found on the posterior wall of the pharynx and superior to the soft palate. If these structures become enlarged, they block the passage between the pharynx and nasal cavity.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

7. Mrs. Sing is a 44-year-old patient who presents to the office with a complaint of enlarged lymph nodes. When enlarged, which lymph nodes are most likely to be a sign of pathology (e.g., malignancy)? a. Occipital b. Anterior cervical c. Supraclavicular d. Femoral e.

ANS: C Supraclavicular nodal enlargement is of special concern because it suggests a malignancy, even in children; an enlarged supraclavicular lymph node may be the sentinel node of Hodgkin disease.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

8. As adults age, their ability to resist infection is reduced because of the lymphatic nodes becoming more a. fibrotic. b. mucoid. c. porous.

d. profuse. e.

ANS: A Older adults’ lymph nodes diminish in both number and size and are replaced with more fibrotic and fatty tissues.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

9. Equipment for examining the lymphatic system includes a a. caliper. b. centimeter ruler. c. goniometer. d. syringe and needle. e.

ANS: B The centimeter ruler and marking pencil are the only equipment needed for examination of the lymphatic system. They are used to measure and outline the borders of the nodes.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

10. Which nodes are most often associated with inflammation? a. Shotty b. Movable c. Fixed d. Tender e.

ANS: D Tenderness is almost always indicative of inflammation. Shotty nodes (feel like the tip of an eraser) that are fixed are of greater concern. Shotty, movable, or fixed nodes are not usually associated with inflammation.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

11. Which nodes are also called Virchow nodes?

a. Internal mammary b. Anterior axillary c. Deep cervical d. Supraclavicular e.

ANS: D The supraclavicular nodes are also referred to as Virchow nodes.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

12. The harder and more discrete a node, the more likely that there is a(n) a. innocent cause. b. infection. c. malignancy. d. metabolic disease. e.

ANS: C Tender nodes almost always indicate the presence of an infection, whereas a hard, discrete, and nontender node is more likely to represent a malignancy.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

13. Which finding indicates that the examiner is assessing a blood vessel rather than a lymph node? a. A bruit b. Inflammation c. Tenderness d. Redness e.

ANS: A Pulsations and auscultation of bruits indicate a blood vessel and not a lymph node.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

14. When examining lymph nodes near a joint in the arm or leg, which of the following maneuvers is likely to facilitate the examination?

a. Extension of the extremity b. Circumduction of the extremity c. Flexion of the extremity d. Rotation of the extremity e.

ANS: C Bending joint areas will ease taut tissues and allow for better accessibility to palpation.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

15. To palpate the inguinal nodes, you should have the patient a. bend over a table and cough. b. lie supine with knees slightly flexed. c. lie supine with legs extended. d. stand and cough vigorously.

ANS: B To palpate the inguinal nodes, you should have the patient lie supine and slightly flex her or his knees.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

16. The most important clue to the diagnosis of immunodeficiency disease in a child is a. family history. b. illness in siblings. c. previous hospitalizations. d. serious recurring infections. e.

ANS: D Although family history, illness in siblings, and previous hospitalizations are helpful clues to discover an immunodeficiency in a child, it is most important to review the occurrence of serious, uncommon infections, such as Pneumocystis jirovecii, or other fungal infections that do not respond as expected to therapy.

DIF:Cognitive Level: Analyzing (Analysis)

OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

17. A red streak that follows the course of the lymphatic collecting duct is a finding associated with a. Hodgkin disease. b. lymphangitis. c. lymphedema. d. lymphoma.

ANS: B Lymphangitis—inflammation of the lymphatic vessels—is evident by a red streak that follows the course of the inflamed lymphatic duct. Hodgkin disease and lymphoma refer to malignancies manifested primarily by nodal enlargements; lymphedema is lymph swelling that distinguishes itself from interstitial edema because it does not pit.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

18. Which disorder is characterized by a single node that is chronically enlarged and nontender in a patient with no other symptoms? a. Retropharyngeal abscess b. Streptococcal pharyngitis c. Mononucleosis d. Toxoplasmosis e.

ANS: D Toxoplasmosis is characterized by a chronically enlarged, nontender, single node—usually in the posterior cervical chain.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

19. Initial signs and symptoms of Epstein-Barr virus mononucleosis usually include a. pharyngitis, fever, and malaise. b. bleeding gums and spontaneous nosebleeds. c. headache, visual disturbance, and rash. d. inguinal adenopathy and painful urination.

ANS: A Presenting signs and symptoms of Epstein-Barr virus mononucleosis are pharyngitis, fever, fatigue, malaise, often splenomegaly, and occasionally hepatomegaly and/or rash.

OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

20. Tender nodes associated with cat scratch disease are usually found in which area? a. Epitrochlear area b. Popliteal area c. Axilla d. Inguinal area e.

ANS: C Cat scratch disease usually results in enlargement of nodes in the head, neck, and axillae.

Although epitrochlear enlargement occurs most exclusively in cat scratch fever, its occurrence is less common.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

21. Serum sickness is usually characterized first by the appearance of a. lymph node enlargement. b. joint pain. c. urticaria. d. fever. e.

ANS: C Urticaria is the first sign of serum sickness, followed by lymphadenopathy, joint pain, fever, and facial edema.

OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

MULTIPLE RESPONSE

1. Which condition stimulates lymph node enlargement? (Select all that apply.) a. Graves disease b. Lymphangioma c. Esophageal reflux

d. Parotid swelling e.

ANS: A, B, D Lymph node enlargement is stimulated by Graves disease, lymphangioma, and parotid swelling.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 11: Head and Neck Ball: Seidel’s Guide to Physical Examination, 10th Edition

MULTIPLE CHOICE

1. Which cranial nerves innervate the face? a. II and V b. III and VI c. V and VII d. VIII and IX e.

ANS: C Facial nerves are controlled by cranial nerves V and VII; cranial nerves II, III, and VI control the eyes, cranial nerve VIII deals with hearing, and cranial nerve IX deals with swallowing.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

2. Mrs. Britton brings her 16-year-old son in with a complaint that he is not developing correctly into adolescence. Which structures disproportionately enlarge in the male during adolescence? a. Coronal sutures b. Hyoid and cricoid cartilages c. Mandible and maxilla bones d. Nose and thyroid cartilages e.

ANS: D In adolescent males, the nose enlarges and the thyroid cartilage becomes the largest component of the anterior larynx, known as the Adam’s apple.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

3. Which of the following is an expected change in the assessment of the thyroid during pregnancy? a. Palpation of the gland becomes difficult. b. A bruit is auscultated.

c. Inspection reveals a goiter. d. The gland is tender on palpation. e.

ANS: B During pregnancy, the thyroid gland hypertrophies (not to the point of a goiter), palpation is easier and, because the gland also has increased vascularity, bruits are common. It is an abnormal finding for the thyroid to feel fibrotic, tender, or smaller.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

4. Mr. Mathews is a 47-year-old patient who presents for a routine physical examination. On examination, you noted a bruit heard over the thyroid. This is suggestive of a. hypothyroidism. b. hyperthyroidism. c. thyroid cancer. d. thyroid cyst. e.

ANS: B Because of hypermetabolic states such as hyperthyroidism, a bruit may be heard as a result of the increased blood flow to the area. Auscultating a bruit is not symptomatic of hypothyroidism, cancer, or a cyst. A nodule is more indicative of cancer.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

5. Ms. Galvan is a 22-year-old secretary who comes to the clinic with headaches of 6 weeks’ duration. She tells the office assistant about her heavy schedule, including part-time work and evening classes. Her vital signs are normal. Which information is most appropriate to Ms. Galvan’s history? a. Current medications b. Elimination patterns c. Immunization status d. Previous pregnancies e.

ANS: A Some current medications, such as birth control pills, nitroglycerin, antihypertensives, antiseizure drugs, and some diabetic drugs, can be headache triggers. Withdrawal of headache

medication can also trigger headaches.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

6. Observation during history taking is the best way to examine for a. head position. b. scalp lice. c. thyroid size. d. tracheal alignment. e.

ANS: A Head position as well as facial features is best observed when talking to the patient during the history. Scalp lice, thyroid size, and tracheal alignment are best assessed by palpation and closer physical observation.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

7. During a head and neck assessment of a neonate, it is important to screen for a. the presence of torticollis. b. signs and symptoms of cerebral palsy. c. uneven movement of the eyes. d. unilateral movement of the tongue. e.

ANS: A Torticollis is usually caused by constraint of the newborn in utero or injury during vaginal delivery. The other symptoms may be difficult to discern because of the infant’s lack of fine motor skills and control of voluntary muscle groups. During a head and neck assessment of a neonate, it is not important to screen for signs and symptoms of cerebral palsy, uneven movement of the eyes, or unilateral movement of the tongue.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

8. During a physical examination of a 30-year-old Chinese man, you notice a slight asymmetry of his face. The cranial nerve examination is normal. Your best action is to a. ask the patient if this characteristic runs in his family. b. perform monofilament testing on the face.

c. consult with the clinician regarding the laboratory tests needed. d. record the finding in the patient’s chart. e.

ANS: D It is not abnormal to have some slight asymmetry of the face that does not require further questioning, tests, or unnecessary laboratory work, but it does require a notation in the chart that could be referenced for future concerns.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

9. Which is the best way to position a patient’s neck for palpation of the thyroid? a. Flexed away from the side being examined b. Flexed directly forward c. Flexed toward the side being examined d. Hyperextended directly backward e.

ANS: C The patient should be positioned so that the sternocleidomastoid muscle is relaxed and the thyroid is easier to palpate. This is done by having the patient flex the neck slightly forward and laterally toward the side being examined.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

10. The thyroid gland should a. be slightly left of midline. b. have a clear vascular sound. c. move when the patient swallows. d. tug with each heartbeat. e.

ANS: C It is a normal finding for the thyroid gland to move with swallowing; however, being off center may indicate a nodular growth or enlargement. The thyroid gland should not be slightly left of midline. Vascular sounds indicate hypermetabolic states such as hyperthyroidism, and a tug with each heartbeat is a sign of an aortic aneurysm.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

11. You are palpating a patient’s thyroid and find that its broadest dimension measures 4 cm. The right lobe is 25% larger than the left. These data would indicate a. a congenital anomaly. b. a multinodular goiter. c. a normal thyroid gland. d. thyroiditis. e.

ANS: C The situation described is most likely a normal finding; the right lobe of the thyroid gland is typically 25% larger than the left and measures 4 cm. The other choices produce enlargements beyond these normal findings.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

12. The correct way to transilluminate an infant’s skull is to a. hold the light 18 inches from the skull. b. move the light toward and then away from the head. c. place the light firmly against the skull. d. shine the light inside the infant’s mouth. e.

ANS: C The correct technique for transillumination of the infant’s skull is to place the light source tightly against the skull so that no light escapes.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

13. Which of the following is true regarding a cephalohematoma? a. It is bound by suture lines. b. The affected part feels soft. c. It is obvious at birth. d. The margins are poorly defined. e.

ANS: A The condition is subperiosteal, under the bone, and contained by the margins of the suture lines; it does not cross the suture line. It is often unnoticed at birth and typically feels firm, with its edges well defined.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

14. Nuchal rigidity is most commonly associated with a. thyroiditis. b. meningeal irritation. c. Down syndrome. d. cranial nerve V damage.

ANS: B Stiffness and inability to flex the neck, or nuchal rigidity, constitute a classic symptom of meningeal irritation.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

15. When noting a bulging fontanel with marked pulsations in a 6-month-old, you suspect a. normal development. b. congenital anomaly. c. increased intracranial pressure. d. fever response to a viral infection. e.

ANS: C A bulging fontanel with pulsations suggests increased intracranial pressure. A normal fontanel feels slightly depressed, with mild pulsations.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

16. Which type of headache usually occurs at night, is precipitated by alcohol consumption, and occurs more often in men than in women? a. Classic migraine b. Temporal arteritis

c. Cluster d. Hypertensive ANS: C Cluster headaches usually occur at night; they are associated with alcohol consumption and occur more often in men.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

17. Mr. Johnson presents with a freely movable cystic mass in the midline of the high neck region, at the base of the tongue. This is most likely a a. parotid gland tumor. b. branchial cleft cyst. c. Stensen duct stone. d. thyroglossal duct cyst. e.

ANS: D A thyroglossal duct cyst presents as a freely movable mass at the base of the tongue. A parotid gland tumor occurs in the ear and cheek bone area. A branchial cleft cyst occurs in the lateral neck area. A Stensen duct stone occurs in the parotid duct.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

18. The premature union of cranial sutures that involves the shape of the head without mental retardation is a. craniosynostosis. b. encephalocele. c. microcephaly. d. myxedema. e.

ANS: A In patients with craniosynostosis, the cranial sutures fuse prematurely, causing a misshapen head, but mental retardation is not involved. Encephalocele and microcephaly involve mental retardation. Myxedema is a condition of hyperthyroidism.

DIF:Cognitive Level: Understanding (Comprehension)

OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

19. Mr. Donaldson is a 64-year-old patient with complaints of headaches. As the examiner, you are palpating his head during your physical examination. Which of the following would be your first step? a. Palpate the patient’s hair, noting texture, color, and distribution. b. Palpate the temporomandibular joint. c. Palpate the skull from front to back. d. Palpate the temporal artery. e.

ANS: C Palpate the skull in a gentle rotary movement first, progressing systematically from front to back.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 12: Eyes Ball: Seidel’s Guide to Physical Examination, 10th Edition

MULTIPLE CHOICE

1. Mrs. Alden is a 29-year-old pregnant patient in her third trimester. She tells you that her vision has been a little blurred, and she thinks she needs to get new contact lenses. You should advise her to a. get new lenses as soon as possible to avoid complications. b. wait until several weeks after delivery to get new lenses. c. go to the nearest emergency department for evaluation. d. change her diet to include more yellow vegetables.

ANS: B Because of the increased level of lysozyme in the tears during pregnancy, a blurred sensation may occur but will subside several weeks after pregnancy. The blurred vision is a normal occurrence during pregnancy. It is not an emergency, nor is it diet-dependent.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

2. A condition that typically develops by the age of 45 years is a. presbyopia. b. hyperopia. c. myopia. d. astigmatism. e.

ANS: A By 45 years of age, a condition known as presbyopia develops; presbyopia involves a weakening of accommodation. Hyperopia occurs in early infancy. Myopia and astigmatism can occur at any time.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

3. Which finding, when seen in the infant, is ominous? a. Difficulty tracking objects with the eyes

b. Appearing to have better peripheral than central vision c. Blinking when bright light is directed at the face d. White pupils on photographs ANS: D

The absence of a red reflex, determined by physical examination or the appearance of white pupils on a photograph, is indicative of retinoblastoma, a serious retinal tumor.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 4. Mr. C’s visual acuity is 20/50. This means that he a. can see 50% of what the average person sees at 20 feet. b. has perfect vision when tested at 50 feet. c. can see 20% of the letters on the chart’s 20/50 line. d. can read letters while standing 20 feet from the chart that the average person could

read at 50 feet.

ANS: D

Visual acuity is measured as a fraction, in which the top number is the distance that the patient is standing from the chart; the bottom number is the distance that an average person can stand and still read the line.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 5. The criterion for determining the adequacy of a patient’s visual field is a. the ability to discriminate primary colors. b. the ability to discriminate details. c. correspondence with the visual field of the examiner. d. distance vision equal to that of an average person.

ANS: C

The examiner compares his or her own peripheral vision to that of the patient while performing the confrontation test, so unless the examiner is aware of a problem with his or her own vision, the examiner could assume that the fields are full if they match.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 6. Mrs. S. is a 69-year-old woman who presents for a physical examination. On inspection of her

eyes, you note that the left upper eyelid droops, covering more of the iris than does the right.

This is recorded as a. exophthalmos on the right. b. ptosis on the left. c. nystagmus on the left. d. astigmatism on the right.

ANS: B

Ptosis is when one of the upper eyelids covers more of the iris than the other lid, possibly extending over the pupil.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 7. A condition in which the eyelids do not completely meet to cover the globe is called

a. b. c. d.

glaucoma. lagophthalmos. exophthalmos. hordeolum.

ANS: B

Lagophthalmos is a term used to describe the condition in which eyelids do not completely meet when closing. Glaucoma involves elevated pressure in the eye. Exophthalmus involves bulging eyes. A hordeolum is better known as a stye.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 8. Mr. Morris is a 38-year-old patient who presents to the clinic with complaints of allergies. An

allergy can cause the conjunctiva to have a a. cobblestone pattern. b. dry surface. c. subconjunctival hemorrhage. d. rust-colored pigment.

ANS: A

A red or cobblestone pattern, especially to the upper conjunctiva, indicates allergic conjunctivitis. Allergies also cause itchy, watery eyes rather than dry surfaces, hemorrhage, or rust-colored pigment.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 9. A pterygium is more common in people heavily exposed to a. high altitudes. b. tuberculosis. c. ultraviolet light. d. cigarette smoke.

ANS: C

Persons heavily exposed to ultraviolet light are more susceptible to the development of a pterygium.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 10. Mr. Brown was admitted from the emergency department, and you are completing his

physical examination. His pupils are 2 mm bilaterally, and you notice that they fail to dilate when the penlight is moved away. This is characteristic in patients who are or have been a. in a coma. b. taking sympathomimetic drugs (cocaine). c. taking opioid drugs (morphine). d. treated for head trauma.

ANS: C

Pupil constriction to less than 2 mm is called miosis. With miosis, the pupils fail to dilate in the dark, a common result of opioid ingestion or the use of drops for glaucoma. Pupils are usually dilated greater than 6 mm in a patient described in the other choices.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

11. When testing corneal sensitivity controlled by cranial nerve V, you should expect the patient

to respond with a. brisk blinking. b. copious tearing. c. pupil dilation. d. reflex smiling.

ANS: A

Brisk blinking is an expected response to corneal sensitivity testing, which involves gently touching the cornea with a piece of cotton.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 12. You observe pupillary response as the patient looks at a distant object and then at an object

held 10 cm from the bridge of the nose. You are assessing for a. confrontation reaction. b. accommodation. c. pupillary light reflex. d. nystagmus.

ANS: B

Testing for accommodation involves asking the patient to look at an object at a distance (pupils dilate) and then to look at another, much closer object (pupils constrict).

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 13. When inspecting the region of the lacrimal gland, palpate a. the lower orbital rim, near the inner canthus. b. in the area between the arch of the eyebrow and upper lid. c. beneath the lower lid, adjacent to the inner canthus. d. adjacent to the lateral aspect of the eye, just beneath the upper lid.

ANS: A

The lacrimal gland is located at the lower orbital rim near the inner canthus of the eye.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 14. Examination to assess for extraocular muscle imbalance is conducted by a. comparing pupillary responses to different shapes. b. having the patient follow your finger through planes. c. inspecting slightly closed lids for fasciculations. d. transilluminating the cornea with tangential light.

ANS: B

The test for extraocular muscle function is to have the patient follow an object as you move it through planes of vision while observing for nystagmus.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

15. Mr. Older is a 40-year-old patient who presents to the office for a follow-up eye examination

after the diagnosis of myopia. To see retinal details in a myopic patient, you will need to

a. adjust your ophthalmoscope into the plus lens. b. move your ophthalmoscope backward. c. move your hand farther forward. d. turn your ophthalmoscope to a minus lens.

ANS: D

The myopic patient (nearsighted) has longer eyeballs, so that light rays focus in front of the retina. To see the retina, use the minus (red) numbers by moving the diopter wheel counterclockwise; to assess a hyperopic patient, use a plus lens.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 16. Ask the patient to look directly at the light of the ophthalmoscope when you are ready to

examine the a. retina. b. optic disc. c. retinal vessels. d. macula.

ANS: D

The macula is the site of central vision and is observed when the patient looks directly at the ophthalmoscope light.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 17. Opacities of the red reflex may indicate the presence of a. hypertension. b. hydrocephalus. c. cataracts. d. myopia.

ANS: C

Opacities or dark spots of the red reflex may indicate the presence of congenital cataracts in the newborn.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 18. If a patient has early papilledema, using an ophthalmoscope, the examiner will be able to

detect a. dilated retinal veins. b. retinal vein pulsations. c. sharply defined optic discs. d. visual defects.

ANS: A

Papilledema is caused by increased intracranial pressure along the optic nerve, pushing the vessels forward (cup protrudes forward) and dilating the retinal veins. Retinal vein pulsations and visual defects are not visible with an ophthalmoscope. On examination, papilledema is characterized by loss of definition of the optic disc.

DIF:Cognitive Level: Applying (Application)

OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

19. Cupping of the optic disc may be a result of a. migraine headaches. b. diabetes. c. glaucoma. d. dehydration.

ANS: C

Cupping is seen with causes of increased intraocular pressure, such as glaucoma. Migraine headaches, diabetes, and dehydration do not cause cupping of the optic disc. Diabetes results in cotton wool patches and hemorrhages.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 20. When drusen bodies are noted to be increasing in number or in intensity of color, the patient

should be further evaluated with a(n) a. Amsler grid. b. Snellen E chart. c. litmus test. d. confrontation test.

ANS: A

Drusen bodies, when they increase in number or intensity of color, may indicate a precursor state of macular degeneration. When this happens, the patient’s central vision should be assessed using the Amsler grid. The Snellen E chart measures visual acuity, the litmus test is used for testing pH, and a confrontation test examines peripheral vision.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 21. Cotton wool spots are most closely associated with a. glaucoma. b. normal aging processes. c. hypertension. d. eye trauma.

ANS: C

Cotton wool spots actually represent infarcts of the retina and are associated with hypertension or diabetes.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 22. Which may be suggestive of Down syndrome? a. b. c. d.

Drusen bodies Papilledema Narrow palpebral fissures Prominent epicanthal folds

ANS: D

Prominent epicanthal folds, or slanting of the eyes, may be normal in Asian infants, but in other ethnic groups it may indicate Down syndrome.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 23. To differentiate between infants who have strabismus and those who have pseudostrabismus,

use the a. confrontation test. b. corneal light reflex. c. E chart. d. Amsler grid.

ANS: B

The corneal light reflex is used with infants to differentiate between strabismus and pseudostrabismus by noting an asymmetric versus symmetric light reflex.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 24. You are attempting to examine the eyes of a newborn. To facilitate eye opening, you would

first a. dim the room lights. b. elicit pain. c. place him in the supine position. d. shine the penlight in his or her eyes.

ANS: A

The best way to assess the eyes of a newborn is to start by dimming the lights because it encourages infants to open their eyes.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 25. Dot hemorrhages, or microaneurysms, in the retina and the presence of hard and soft exudates

are most commonly seen in those with a. Down syndrome. b. diabetic retinopathy. c. systemic lupus. d. glaucoma.

ANS: B

Dot hemorrhages or tiny aneurysms are characteristics of background retinopathy. A trapping of lipids within incompetent capillaries causes the hemorrhages.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

26. Which maneuver can be done to reduce the systemic absorption of cycloplegic and mydriatic

agents when examining a pregnant woman if the examination is mandatory? a. Have the woman keep her eyes closed for several minutes. b. Instill half the usual dosage. c. Keep the patient supine, with her head turned and flexed. d. Use nasolacrimal occlusion after instillation.

ANS: D

To reduce absorption systemically, the examiner may use nasolacrimal occlusion after applying, which involves pinching the upper bridge of the nose.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 27. Changes seen in proliferative diabetic retinopathy are the result of a. anoxic stimulation. b. macular damage. c. papilledema. d. minute hemorrhages.

ANS: A

New vessels are a characteristic seen in proliferative retinopathy resulting from anoxic stimulation. An insufficient blood supply from failing capillaries causes new vessel growth.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation MULTIPLE RESPONSE 1. Which are the signs and symptoms of infant retinoblastoma? (Select all that apply.) a. White reflex b. Red reflex c. Corneal light reflex d. Absence of a blink reflex e. Autosomal dominant trait f. Drainage from the affected eye g. Visual acuity of 20/500 ANS: A, E

Retinoblastoma in an infant is marked by a characteristic white reflex, also called cat’s eye reflex or leukocoria. Red reflex and corneal light reflex are expected findings. Absence of the blink reflex is not associated with retinoblastoma.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 13: Ears, Nose, and Throat Ball: Seidel’s Guide to Physical Examination, 10th Edition MULTIPLE CHOICE 1. Mr. Sprat is a 21-year-old patient who complains of nasal congestion. He admits to using

recreational drugs. On examination, you have noted a septal perforation. Which of the following recreational drugs is commonly associated with nasal septum perforation? a. Heroin b. Cocaine c. PCP d. Ecstasy ANS: B

Long-term cocaine snorting causes ischemic necrosis of the septal cartilage and leads to perforation of the nasal septum.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. A 5-year-old child presents with nasal congestion and a headache. To assess for sinus

tenderness, you should palpate over the a. sphenoid and frontal sinuses. b. maxillary and frontal sinuses. c. maxillary sinuses only. d. sphenoid sinuses only.

ANS: C

Only the maxillary and the frontal sinuses are accessible for physical examination; however, the young child does not develop frontal sinuses until 7 to 8 years of age.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. Mr. and Mrs. Johnson have presented to the office with their infant son with complaints of ear

drainage. When examining an infant’s middle ear, the nurse should use one hand to stabilize the otoscope against the head while using the other hand to a. pull the auricle down and back. b. hold the speculum in the canal. c. distract the infant. d. stabilize the chest.

ANS: A

The nurse should use the other hand to pull the auricle down and back in an effort to straighten the upward curvature of the canal.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 4. Mrs. Donaldson is a 31-year-old patient who is pregnant. In providing Mrs. Donaldson with

healthcare information, you will explain that she can expect to experience a. more nasal stuffiness. b. a sensitive sense of smell. c. drooling.

d. enhanced hearing.

ANS: A

Physiologic changes of pregnancy include nasal stuffiness, a decreased sense of smell, impaired hearing, epistaxis, and a sense of fullness in the ears.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

5. You are performing hearing screening tests. Who would be expected to find difficulty in

hearing the highest frequencies? a. A 7-year-old b. An 18-year-old c. A 30-year-old d. A 50-year-old ANS: D

Sensorineural hearing loss begins after 50 years of age, initially with losses of high-frequency sounds and then progressing to tones of lower frequency.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 6. Mr. Spencer presents with the complaint of hearing loss. You specifically inquire about

current medications. Which medications, if listed, are likely to contribute to his hearing loss? a. Chlorothiazide b. Acetaminophen c. Salicylates d. Cephalosporins ANS: C

Ototoxic medications include aminoglycoside, salicylates, furosemide, streptomycin, quinine, ethacrynic acid, and cisplatin.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 7. To approximate vocal frequencies, which tuning fork should be used to assess hearing? a. 100 to 300 Hz b. 200 to 400 Hz c. 500 to 1000 Hz d. 1500 to 2000 Hz ANS: C

Use of a 500- to 1000-Hz tuning fork approximates vocal frequencies.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 8. You are using a pneumatic attachment on the otoscope while assessing tympanic membrane

movement. You gently squeeze the bulb but see no movement of the membrane. Your next action should be to a. remove all cerumen from the canal. b. change to a larger speculum. c. squeeze the bulb with more force.

d. insert the speculum to a depth of 2 cm.

ANS: B

To see tympanic movement when using the pneumatic attachment, there should be a seal around the speculum to block outside air. In this manner, the normal tympanic membrane moves as a result of pressure changes from the insufflator bulb. A soft rubber speculum is recommended to establish the seal.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 9. When conducting an adult otoscopic examination, you should a. position the patient’s head leaning toward you. b. grasp the handle of the otoscope as you would a baseball bat. c. select the largest speculum that will fit in the canal. d. ask the patient to keep his or her eyes closed.

ANS: C

When conducting an adult otoscopic examination, select the largest speculum that will comfortably fit in the patient’s ear. When you are conducting an adult otoscopic examination, the patient’s head should be positioned toward the opposite shoulder. Hold the handle of the otoscope between the thumb and index finger, supporting it on the middle finger. There is no reason for the patient to keep her or his eyes shut.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 10. Bulging of an amber tympanic membrane without mobility is usually associated with a. middle ear effusion. b. healed tympanic membrane perforation. c. impacted cerumen in the canal. d. repeated and prolonged crying cycles.

ANS: A

An amber color, with bulging of the tympanic membrane and without mobility or redness, usually indicates the presence of fluid in the middle ear.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 11. When hearing is evaluated, which cranial nerve is being tested? a. III b. IV c. VIII d. XII ANS: C

Cranial nerve VIII, the vestibulocochlear nerve, is associated with hearing.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 12. Speech with a monotonous tone and erratic volume may indicate a. otitis externa. b. hearing loss.

c. serous otitis media. d. sinusitis.

ANS: B

Speech with a monotonous tone and erratic volume may indicate hearing loss.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 13. You are performing Weber and Rinne hearing tests. For the Weber test, the sound lateralized

to the unaffected ear; for the Rinne test, air conduction-to-bone conduction ratio is less than 2:1. You interpret these findings as suggestive of a. a defect in the inner ear. b. a defect in the middle ear. c. otitis externa. d. impacted cerumen.

ANS: A

These results are consistent with a sensorineural hearing loss, a defect in the inner ear. Otitis externa and impacted cerumen are conditions of the external ear that can cause conductive hearing problems.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 14. Nasal symptoms that imply an allergic response include a. purulent nasal drainage. b. bluish gray turbinates. c. small, atrophied nasal membranes. d. firm consistency of turbinates.

ANS: B

Nasal symptoms that imply an allergic response include bluish gray or pale pink nasal turbinates that are swollen and boggy and a transverse crease at the junction between the cartilage and bone of the nose.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 15. You are interviewing a parent whose child has a fever, is pulling at her right ear, and is

irritable. You ask the parent about the child’s appetite and find that the child has a decreased appetite. This additional finding is more suggestive of a. acute otitis media. b. otitis externa. c. serous otitis media. d. middle ear effusion.

ANS: A

Anorexia is an initial symptom of acute otitis media.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 16. A hairy tongue with yellowish brown to black elongated papillae on the dorsum a. is indicative of oral cancer. b. is sometimes seen following antibiotic therapy. c. usually indicates vitamin deficiency.

d. usually indicates anemia.

ANS: B

Recent antibiotic use can turn the tongue yellow-brown to black and make it appear hairy.

Oral cancer involves lesions. A smooth red tongue with a slick appearance may indicate a niacin or vitamin B12 deficiency. Pallor usually indicates anemia.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 17. To inspect the lateral borders of the tongue, you should a. ask the patient to extend the tongue outward. b. insert the tongue blade obliquely against the tongue. c. lift the tongue upward with gloved fingers. d. pull the gauze-wrapped tongue to each side.

ANS: D

To inspect the lateral borders of the tongue, you should wrap the tongue with a piece of gauze and then pull the tongue to each side for inspection.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 18. For best results, an otoscopic and oral examination in a child should be a. conducted at the beginning of the assessment. b. done after inspection. c. performed at the end of the examination. d. performed before palpation.

ANS: C

Because young children often resist an otoscopic and oral examination, it may be wise to postpone these procedures until the end, after you have gained some trust.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation MULTIPLE RESPONSE 1. Mr. Akins is a 78-year-old patient who presents to the clinic with complaints of hearing loss.

Which are changes in hearing that occur in older adults? (Select all that apply.) a. Results from cranial nerve VII b. Slow progression c. d. e. f.

Loss of high frequency Bone conduction heard longer than air conduction Sounds may be garbled, difficult to localize Unable to hear in a crowded room

ANS: C, E, F

Age-related hearing loss is associated with degeneration of hair cells in the organ of Corti, loss of cortical and organ of Corti auditory neurons, degeneration of the cochlear conductive membrane, and decreased vascularity in the cochlea. Sensorineural hearing loss first occurs with high-frequency sounds and then progresses to tones of lower frequency. Loss of high-frequency sounds usually interferes with the understanding of speech and localization of sound. Conductive hearing loss may result from an excess deposition of bone cells along the ossicle chain, causing fixation of the stapes in the oval window, cerumen impaction, or a

sclerotic tympanic membrane.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. Which signs and symptoms occur with a sensorineural hearing loss? (Select all that apply.) a. Air conduction shorter than bone conduction b. Lateralization to the affected ear c. Loss of high-frequency sounds d. Speaks more loudly e. Disorder of the inner ear f. Air conduction longer than bone conduction ANS: C, D, E, F

The signs and symptoms of sensorineural hearing loss include loss of high-frequency sounds, speaks more loudly, disorder of the inner ear, air conduction longer than bone conduction, and lateralization to the unaffected ear.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation COMPLETION 1. When you ask the patient to identify smells, you are assessing cranial nerve

.

ANS:

I The first cranial nerve, the olfactory nerve, is tested when you ask a patient to identify different smells.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 14: Chest and Lungs Ball: Seidel’s Guide to Physical Examination, 10th Edition MULTIPLE CHOICE 1. A 44-year-old male patient who complains of a cough has presented to the emergency

department. He admits to smoking one pack per day. During your inspection of his chest, the most appropriate lighting source to highlight chest movement is a. b. c. d.

bright tangential lighting. daylight from a window. flashlight in a dark room. fluorescent ceiling lights.

ANS: A

Bright tangential light is best for visualizing chest movements.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. When auscultating the apex of the lung, you should listen at a point a. even with the second rib. b. 4 cm above the first rib. c. higher on the right side. d. on the convex diaphragm surface.

ANS: B

The apex of the lung is 4 cm above the first rib.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. To count the ribs and the intercostal spaces, you begin by palpating the reference point of the a. distal point of the xiphoid. b. manubriosternal junction. c. suprasternal notch. d. acromion process.

ANS: B

The angle of Louis, the junction of the manubrium and the sternum, corresponds to the second rib, the reference point for counting ribs and intercostal spaces.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 4. Mr. Curtis is a 44-year-old patient who has presented to the emergency department with

shortness of breath. During the history, the patient describes shortness of breath that gets worse when he sits up. To document this, you will use the term a. platypnea. b. orthopnea. c. tachypnea. d. bradypnea.

ANS: A

Dyspnea that increases in the upright posture is called platypnea. Orthopnea is dyspnea that

worsens when the person lies down. Tachypnea is an increased respiratory rate. Bradypnea is a decreased respiratory rate.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 5. Which finding suggests a minor structural variation? a. Barrel chest b. Clubbed fingers c. Pectus carinatum d. Chest wall retractions ANS: C

Pectus carinatum (pigeon chest) is a minor structural variation. Barrel chest, clubbing of the fingers, and chest wall retractions result from compromised respirations.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 6. Ms. Rudman, age 74 years, has no known health problems or diseases. You are doing a

preventive healthcare history and examination. Which symptom is associated with intrathoracic infection? a. Barrel chest b. Cor pulmonale c. Funnel chest d. Malodorous breath ANS: D

Intrathoracic infections may make the breath malodorous.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 7. The best time to observe and count respirations is while a. the patient is answering questions. b. weighing the patient. c. palpating the pulse. d. the patient is sleeping.

ANS: C

Counting respirations while you palpate the pulse does not make the patient self-conscious because the patient expects you to be counting the pulse. Respiratory patterns change as the patient speaks. Attempting to count during weighing would make the patient self-conscious and affect the respiratory rate. Respiratory patterns change as the patient sleeps.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 8. As you take vital signs on Mr. Barrow, age 78 years, you note that his respirations are 40

breaths/min. He has been resting, and his mucosa is pink. In regard to Mr. Barrow’s respirations, you would a. document his rate as normal. b. do nothing because his color is pink. c. note that his rate is below normal. d. report that he has an above-average rate.

ANS: D

The normal adult respiratory rate is 12 to 20 breaths/min, and the ratio of breaths to heartbeats is 1:4. A respiratory rate of 40 breaths/min is not within the normal range and should be documented as above average.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 9. In which patient situation would you expect to assess tachypnea? a. Patient who is depressed b. Patient who abuses narcotics c. Patient with metabolic acidosis d. Patient with myasthenia gravis ANS: C

In metabolic acidosis, the body compensates by increasing the respiratory rate to blow off the excess carbon dioxide. A patient who is depressed, abuses narcotics, or has myasthenia gravis would have respiratory depression.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 10. Which site of chest wall retractions indicates a more severe obstruction in the asthmatic

patient? a. Lower chest b. Along the anterior axillary line c. Above the clavicles d. At the nipple line ANS: C

Asthma usually causes retractions of the lower chest. The more severe the obstruction, the greater the negative pressure produced in the chest during inspiration, and retractions are manifested in the upper thorax.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 11. You would expect to document the presence of a pleural friction rub for a patient being treated

for a. b. c. d.

pneumonia. atelectasis. pleurisy. emphysema.

ANS: C

A pleural friction rub is caused by inflammation of the pleural surfaces and would be expected to be auscultated with pleurisy.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 12. Which type of apnea requires immediate action? a. Primary apnea b. Secondary apnea

c. Sleep apnea d. Periodic apnea of the newborn ANS: B

Secondary apnea is a grave condition, and unless resuscitative measures are instituted immediately, breathing will not resume spontaneously. Primary apnea is self-limiting. Sleep apnea should be evaluated but does not require immediate action. Periodic apnea of the newborn is a normal condition.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 13. With consolidation in the lung tissue, the breath sounds are louder and easier to hear, whereas

healthy lung tissue produces softer sounds. This is because a. consolidation echoes in the chest. b. consolidation is a poor conductor of sound. c. air-filled lung sounds are from smaller spaces. d. air-filled lung tissue is an insulator of sound.

ANS: D

Air is a poor conductor of sound. Denser consolidation promotes louder sounds and is a better conductor of sound. Consolidation is a better conductor of sound than air. Breath sounds are easier to hear when the lungs are consolidated; the mass surrounding the tube of the respiratory tree promotes sound transmission better than air-filled alveoli.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation MULTIPLE RESPONSE 1. Which lung sounds are associated with atelectasis? (Select all that apply.) a. Wheezes b. Ronchi c. Crackles d. Crepitus e. Rales ANS: A, B, C

Wheezes, rhonchi, and crackles in varying amounts are associated with atelectasis.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation COMPLETION 1. An Apgar score of

is given to the infant who demonstrates irregular respiratory

effort.

ANS:

1 The Apgar score of 1 in an infant reflects slow or irregular breathing.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 15: Heart Ball: Seidel’s Guide to Physical Examination, 10th Edition MULTIPLE CHOICE 1. Mr. O, age 50 years, comes for his annual health assessment, which is provided by his

employer. During your initial history-taking interview, Mr. O mentions that he routinely engages in light exercise. At this time, you should a. ask if he makes his own bed daily. b. have the patient describe his exercise. c. make a note that he walks each day. d. record ―light exercise‖ in the history.

ANS: B

When Mr. O says that he engages in light exercise, have him describe his exercise. To qualify his use of the term light, ask him the type, length of time, frequency, and intensity of his activities.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. Which of the following information belongs in the past medical history section related to heart

and blood vessel assessment? a. Adolescent inguinal hernia b. Childhood mumps c. History of bee stings d. Previous unexplained fever ANS: D

Previous unexplained fever should be included in the past medical history of a heart and blood vessel assessment. This incidence may be related to acute rheumatic fever, with potential heart valve damage.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. A patient you are seeing in the emergency department for chest pain is believed to be having a

myocardial infarction. During the health history interview of his family history, he relates that his father had died of ―heart trouble.‖ The most important follow-up question you should pose is which of the following? a. b. c. d.

―Did your father have coronary bypass surgery?‖ ―Did your father’s father have heart trouble also?‖ ―What were your father’s usual dietary habits?‖ ―What age was your father at the time of his death?‖

ANS: D

A family history of sudden death, particularly in young and middle-aged relatives, significantly increases one’s chance of a similar occurrence.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 4. Which one of the following is a common symptom of cardiovascular disorders in the older

adult?

a. b. c. d.

Fatigue Joint pain Poor night vision Weight gain

ANS: A

Common symptoms of cardiovascular disorders in older adults include confusion, dizziness, blackouts, syncope, palpitations, coughs and wheezes, hemoptysis, shortness of breath, chest pains or tightness, impotence, fatigue, and leg edema.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 5. In the adult, the apical impulse should be most visible when the patient is in what position? a. Supine b. Upright c. Lithotomy d. Right lateral recumbent ANS: B

In most adults, the apical impulse should be visible at about the midclavicular line in the fifth left intercostal space, but it is easily obscured by obesity, large breasts, or muscularity. The apical impulse may become visible only when the patient sits upright and the heart is brought closer to the anterior wall. A visible and palpable impulse when the patient is supine suggests an intensity that may be the result of a problem. In most adults, the apical impulse will not be visible in the upright, lithotomy, or right lateral recumbent positions.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 6. If the apical impulse is more vigorous than expected, it is called a a. lift. b. thrill. c. bruit. d. murmur.

ANS: A

If the apical impulse is more vigorous than expected, it is referred to as a lift or heave. A thrill is a palpable murmur. A bruit is an auscultated arterial murmur. A murmur is an auscultated sound caused by turbulent blood flow into, through, or out of the heart.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 7. A palpable rushing vibration over the base of the heart at the second intercostal space is called

a a. b. c. d.

heave. lift. thrill. thrust.

ANS: C

A thrill is a fine, palpable, rushing vibration—a palpable murmur. Cardiac thrills generally indicate a disruption of the expected blood flow related to some defect in the closure of one of the semilunar valves (generally aortic or pulmonic stenosis), pulmonary hypertension, or atrial septal defect. A heave or lift is a more vigorous apical impulse. A lift is another term for a

heave, which is a more vigorous apical impulse. A thrust is sudden, forcible forward movement.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 8. An apical PMI palpated beyond the fifth intercostal space may indicate a. decreased cardiac output. b. obesity. c. left ventricular hypertrophy. d. hyperventilation.

ANS: C

An apical impulse that is more forceful and widely distributed, fills systole, or is displaced laterally and downward may be indicative of left ventricular hypertrophy. Obesity, large breasts, and muscularity can obscure the visibility of the apical impulse.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 9. A lift along the left sternal border is most likely the result of a. aortic stenosis. b. atrial septal defect. c. pulmonary hypertension. d. right ventricular hypertrophy.

ANS: D

A lift along the left sternal border may be caused by right ventricular hypertrophy. A thrill indicates a disruption of the expected blood flow related to a defect in the closure of one of the semilunar valves, which is seen in aortic or pulmonic stenosis, pulmonary hypertension, or atrial septal defect.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

10. To estimate heart size by percussion, you should begin tapping at the a. anterior axillary line. b. left sternal border. c. midclavicular line. d. midsternal line.

ANS: A

Estimating the size of the heart can be done by percussion. Begin tapping at the anterior axillary line, moving medially along the intercostal spaces toward the sternal border. The change from a resonant to a dull note marks the cardiac border.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 11. To hear diastolic heart sounds, you should ask patients to a. lie on their back. b. lie on their left side. c. lie on their right side. d. sit up and lean forward.

ANS: B

Left lateral recumbent is the best position to hear the low-pitched filling sounds in diastole with the bell of the stethoscope. Sitting up and leaning forward is the best position in which to hear relatively high-pitched murmurs with the diaphragm of the stethoscope. The right lateral recumbent position is the best position for evaluating the right rotated heart of dextrocardia.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 12. You are listening to a patient’s heart sounds in the aortic and pulmonic areas. The sound

becomes asynchronous during inspiration. The prevalent heart sound in this area is most likely a. S1. b. S2. c. S3. d. S4.

ANS: B

S2 marks the closure of the semilunar valves, which indicates the end of systole; it is best heard in the aortic and pulmonic areas. It is higher pitched and shorter than S1. S2 typically splits during inspiration.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 13. Chest pain with an organic cause in a child is most likely the result of a. cardiac disease. b. asthma. c. esophageal reflux. d. arthritis.

ANS: B

Unlike chest pain in adults, chest pain in children and adolescents is seldom caused by a cardiac problem. More likely, the case is related to trauma, exercise-induced asthma, or cocaine use.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 14. A condition that is likely to present with dizziness and syncope is a. bacterial endocarditis. b. hypertension. c. sick sinus syndrome. d. pericarditis.

ANS: C

Sick sinus syndrome (SSS) is a sinoatrial dysfunction that occurs secondary to hypertension, arteriosclerotic heart disease, or rheumatic heart disease. SSS causes dysrhythmia with subsequent syncope, transient dizzy spells, light-headedness, seizures, palpitations, angina, or congestive heart failure (CHF). Bacterial endocarditis presents with prolonged fever, signs of neurologic dysfunction, and sudden onset of CHF. Chest pain is an initial symptom in acute pericarditis, along with a triphasic friction rub.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 15. Your patient, who abuses intravenous (IV) drugs, has a sudden onset of fever and symptoms

of congestive heart failure. Inspection of the skin reveals nontender erythematic lesions to the

palms. These findings are consistent with the development of a. rheumatic fever. b. cor pulmonale. c. pericarditis. d. endocarditis.

ANS: D

Endocarditis is a bacterial infection of the endothelial layer of the heart. It should be suspected with at-risk patients (e.g., IV drug abusers) who present with fever and sudden onset of congestive heart symptoms. The lesions described are Janeway lesions.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 16. The most helpful finding in determining left-sided heart failure is a. dyspnea. b. orthopnea. c. jugular vein distention. d. an S3 heart sound.

ANS: C

Evidence-based research has shown that the most helpful clinical examination finding supportive of left-sided heart failure is jugular vein distention.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation MULTIPLE RESPONSE 1. Your patient has been diagnosed with pericarditis. Which are signs and symptoms, or a

precipitating factor? (Select all that apply.) a. b. c. d. e. f. g.

Sharp pain Pain relieved by sitting up Pain relieved by resting Friction rub heard to right of sternum History of kidney failure Result of viral infection Result of medications such as procainamide

ANS: A, B, E, F, G

Pericarditis may be seen with a viral infection, kidney failure, or medications such as procainamide. Symptoms include pain relieved by sitting up or leaning forward. A friction rub is heard at the left of the sternum, at the third or fourth intercostal space.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 16: Blood Vessels Ball: Seidel’s Guide to Physical Examination, 10th Edition MULTIPLE CHOICE 1. Induration, edema, and hyperpigmentation are common associated findings with which of the

following? a. Peripheral arterial disease b. Venous ulcer c. Arterial embolic disease d. Venous thrombus ANS: B

A venous ulcer also results from chronic venous insufficiency and demonstrates induration edema and hyperpigmentation. Peripheral arterial edema results in ischemia, in which the foot or leg is painful and cold; nonulceration is common as the muscles atrophy. Arterial embolic disease includes occlusion of the small arteries, resulting in blue toe syndrome and splinter hemorrhages in the nail bed. A venous thrombus presents with minimal ankle edema, low-grade fever, tachycardia, and possibly a positive Homan sign.

DIF:Cognitive Level: Applying (Application) MSC: Physiologic Integrity: Reduction of Risk Potential

OBJ:Nursing process—diagnosis

2. The most prominent component of the jugular venous pulse is the a. a wave. b. c wave. c. v wave. d. x slope.

ANS: A

The a wave is the first and most prominent component of the jugular venous pulse. The a wave represents a brief backflow of blood into the vena cava during right atrial contraction.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 3. During a routine prenatal visit, Ms. T was noted as having dependent edema, varicosities of

the legs, and hemorrhoids. She expressed concern about these symptoms. You explain to Ms. T that her enlarged uterus is compressing her pelvic veins and her inferior vena cava. You would further explain that these findings a. are usual conditions during pregnancy. b. indicate a need for hospitalization. c. indicate the need for amniocentesis. d. suggest that she is having twins.

ANS: A

Explain to the patient that these are usual conditions during pregnancy. Blood in the lower extremities tends to pool in later pregnancy because of the occlusion of the pelvic veins and inferior vena cava from pressure created by the enlarged uterus. This occlusion results in an increase in dependent edema, varicosities of the legs and vulva, and hemorrhoids.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 4. Vascular changes expected in the older adult include

a. b. c. d.

loss of vessel elasticity. decreased peripheral resistance. decreased pulse pressure. constriction of the aorta and major bronchi.

ANS: A

With age, the walls of the arteries become calcified and they lose their elasticity and vasomotor tone; therefore, they lose their ability to respond appropriately to changing body needs. Increased peripheral vascular resistance occurs, causing an increase in blood pressure.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 5. You are examining Mr. S, a 79-year-old diabetic man complaining of claudication. Which of

the following physical findings is consistent with the diagnosis of peripheral arterial disease? a. Thick, calloused skin b. Ruddy, thin skin c. Warmer temperature of extremity in contrast to other body parts d. Loss of hair over the extremities ANS: D

An individual with peripheral artery disease or claudication will have thin skin with localized pallor and cyanosis, a loss of body warmth in the affected area, and loss of hair over the extremities.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential

6. You are performing a physical examination on a 46-year-old male patient. His examination

findings include the following: positive peripheral edema, holosystolic murmur in the tricuspid region, and a pulsatile liver. His diagnosis is a. an aortic aneurysm. b. an arteriovenous fistula. c. tricuspid stenosis. d. tricuspid regurgitation.

ANS: D

An aneurysm is a localized isolation that results in a pulsatile swelling and a thrill or bruit. An arteriovenous fistula is a pathologic communication between an artery and vein resulting in a thrill or bruit and edema or ischemia in the involved extremity. Tricuspid regurgitation results in a holosystolic murmur in the tricuspid region, a pulsatile liver, and peripheral edema.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—diagnosis MSC: Physiologic Integrity: Reduction of Risk Potential 7. A characteristic distinguishing primary Raynaud phenomenon from secondary Raynaud

phenomenon includes which of the following? a. Vasospasm b. Digital ischemia with pain c. Triphasic demarcated skin d. Cold and achy improving with warming ANS: B

In primary Raynaud phenomenon, there is triphasic demarcation of the skin—white, cyanotic, and reperfused—and vasospasm that lasts a minutes to less than an hour, areas of cold, and an

achy feeling that improves with rewarming. In secondary Raynaud phenomenon, there is intense pain from digital ischemia.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 8. In children, coarctation of the aorta should be suspected if you detect a. a delay between the radial and femoral pulses. b. a simultaneous radial and femoral pulse. c. an absent femoral pulse on the left. d. bilateral absence of femoral pulses.

ANS: A

Coarctation of the aorta is a congenital stenosis or narrowing seen most commonly in the descending aortic arch, near the origin of the left subclavian artery and ligamentum arteriosum. Ordinarily, the radial and femoral pulses are palpated simultaneously. When there is a delay and/or a palpable diminution of amplitude of the femoral pulse, coarctation must be suspected. Differences in blood pressure taken in the arms and legs should confirm the suspicion. Coarctation of the aorta should not be suspected if the radial and femoral pulses are palpated simultaneously, if the femoral pulse on the left is absent, or if there is bilateral absence of femoral pulses.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 9. Which of the following statements is true regarding the development of venous ulcers in older

adults? a. The major symptom is severe leg pain, especially when walking. b. The affected leg is commonly pale and hairless, and pulses are difficult to palpate. c. Diabetes, peripheral neuropathy, and nutritional deficiencies are causative factors. d. The ulcers are generally located on the tips of toes.

ANS: C

Venous ulcers are generally found on the medial or lateral aspects of the lower limbs, most often in older adults. Induration, edema, and hyperpigmentation are common. Heart failure, hypoalbuminemia, peripheral neuropathy, diabetes mellitus, nutritional deficiencies, and arterial disease cause the venous ulcers to develop. The major symptom of venous ulcers is not severe leg pain. In patients with venous ulcers, the affected leg is not commonly pale and hairless, and pulses are not difficult to palpate. Venous ulcers are not generally located on the tips of toes.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 10. When examining arterial pulses, the thumb may be used a. especially if vessels have a tendency to move. b. never for palpating pulses. c. checking the jugular venous pressure. d. during the Allen test.

ANS: A

The thumb may be used, especially if the vessels have a tendency to move when probed by the fingers. The thumb is particularly useful in fixing the brachial and even the femoral pulses.

You cannot palpate for jugular venous pressure waves. The Allen test is used to ensure ulnar patency prior to radial artery puncture.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 11. To assess a patient’s jugular veins, the patient should first be placed in which position? a. Supine b. Semi-Fowler c. Upright d. Left lateral recumbent ANS: A

To assess jugular veins, place the patient in the supine position. This causes engorgement of the jugular veins. Then gradually raise the head of the bed until the pulsations of the jugular vein become visible between the angle of the jaw and the clavicle. Jugular veins cannot be palpated.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 12. Observation of hand veins can facilitate the assessment of a. mitral valve competency. b. a heart murmur. c. right heart pressure. d. left heart pressure.

ANS: C

Hand veins can be used as an auxiliary manometer of right heart pressure. Assess the hand veins while the hand is at the patient’s side. Then raise the hand until the veins collapse, and use a ruler to measure the vertical distance between the midaxillary line (level of the heart) and the level of the collapsed hand veins.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 13. You are assessing Mr. Z’s fluid volume status as a result of heart failure. If your finger

depresses a patient’s edematous ankle to a depth of 6 mm, you should record this pitting as a. 1+. b. 2+. c. 3+. d. 4+.

ANS: C

Pitting edema to 6 mm represents a 3+ rating. This edema is noticeably deep and may last more longer a minute; the dependent extremity looks fuller and swollen. Edema is graded on a scale of mild (1+) through worse (4+).

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 14. A bounding pulse in an infant may be associated with a. patent ductus arteriosus. b. coarctation of the aorta. c. decreased cardiac output. d. peripheral vaso-occlusion.

ANS: A

A bounding pulse is associated with a large left-to-right shunt produced by a patent ductus arteriosus. A weaker or thinner pulse represents diminished cardiac output or peripheral vasoconstriction. A difference in pulse amplitude between the upper extremities or between the femoral and radial pulses, and absence of the femoral pulse, suggests a coarctation of the aorta.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 15. In infants or small children, a capillary refill time of 4 seconds a. is normal. b. indicates hypervolemia. c. indicates dehydration or hypovolemic shock. d. indicates renal artery stenosis.

ANS: C

Capillary refill time represents the time it takes the capillary bed to refill after being occluded by pressure to the nail bed for several seconds. Observe the time it takes for the nail to regain its full color, which should be less than 2 seconds for an intact system. The capillary refill time will be longer than 2 seconds during arterial occlusion, hypovolemic shock, hypothermia, and dehydration.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 16. A venous hum heard over the internal jugular vein of a child a. usually signifies untreatable illness. b. usually has no pathologic significance. c. usually requires surgical intervention. d. must be monitored until the child is grown.

ANS: B

A venous hum is caused by the turbulence of blood flow in the internal jugular veins. It is common in children and usually has no pathologic significance. To detect a venous hum, auscultate over the right supraclavicular space at the medial end of the clavicle and along the anterior border of the sternocleidomastoid muscle. It is louder during diastole.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 17. You are palpating bilateral pedal pulses and cannot feel one of the pulses. The feet are equally

warm. You find that both great toes are pink, with a capillary refill within 2 seconds. Which of the following statements is correct? a. Immediate emergency surgery is indicated. b. Pedal pulses are not always palpable. c. Unilateral pulses are never normal. d. Venogram studies will be needed.

ANS: B

Dorsalis pedis and posterior tibia pulses may be difficult to palpate or may not be palpable in some well persons. The feet are warm and capillary refill is less than 2 seconds; there is adequate circulation to the feet. Immediate emergency surgery is not indicated. Unilateral pulses may be normal. Venogram studies will not be needed.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE 1. When palpating the carotid artery, which of the following is most important? (Select all that

apply.) a. Rotate the patient’s head to the side being examined to relax the sternocleidomastoid. b. Excessive carotid sinus massage can compromise blood flow to the brain. c. Excessive carotid sinus massage can cause slowing of the pulse. d. Palpate both sides simultaneously.

ANS: A, B, C

When palpating the carotid arteries, never palpate both sides simultaneously. Excessive carotid sinus massage can cause slowing of the pulse and a drop in blood pressure and can compromise blood flow to the brain, leading to syncope. If you have difficulty feeling the pulse, rotate the patient’s head to the side being examined to relax the sternocleidomastoid muscle.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 2. Which are risk factors for varicose veins? (Select all that apply.) a. Gender b. Alcohol use c. Lower extremity trauma d. Increased body mass e. Hypertension f. Diabetes ANS: A, C, D

Gender (women are four times more likely than men to have varicose veins—genetic predisposition), tobacco use, increased body mass, age, and history of lower extremity trauma are all risk factors for varicose veins.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential

Chapter 17: Breasts and Axillae Ball: Seidel’s Guide to Physical Examination, 10th Edition MULTIPLE CHOICE 1. Montgomery tubercles are most prominent in the breasts of a. adult males. b. patients with lung disease. c. pregnant women. d. pubertal females.

ANS: C

Montgomery tubercles undergo hypertrophy and become more prominent in the breasts of pregnant and lactating women.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 2. Most women with breast cancer a. lack the BRCA1 or BRCA2 gene. b. risk increases with aging. c. have a aunt who had breast cancer. d. continue to menstruate after age 52.

ANS: B

Risk of breast cancer increases with aging. Female patient’s with inherited BRCA1 or BRCA2 mutation have a 45% to 80% chance of developing breast cancer during their lifetime. Having a first-degree relative with breast cancer doubles the risk. Menopause after the age of 55 slightly increases the risk.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. A 50-year-old woman presents as a new patient. Which finding in her personal and social

history would increase her risk profile for developing breast cancer? a. Drinking three glasses of wine per week b. Early menopause c. Nulliparity d. Late menarche ANS: C

Nulliparity, or late age at the birth of the first child (after 30 years old), is a risk factor for breast cancer. Other risk factors include late menopause, early menarche, and drinking more than one alcoholic drink daily.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 4. If your patient has nipple discharge, you will most likely need a a. Vacutainer tube. b. glass slide and fixative. c. specimen jar with formaldehyde. d. tape strip to test pH. ANS: B

A glass slide and fixative are used for microscopic examination of the discharge to identify its cellular makeup.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 5. While examining a 30-year-old woman, you note that one breast is slightly larger than the

other. In response to this finding, you should a. note the finding in the patient’s record. b. ask the patient if she has ever had breast cancer. c. tell the patient to get a mammogram as soon as possible. d. tell the patient to get a mammary sonogram as soon as possible.

ANS: A

Often one breast is slightly larger than the other. This is a normal variation and no further intervention is required.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 6. A 23-year-old white woman has come to the clinic because she has missed two menstrual

periods. She states that her breasts have enlarged and that her nipples have turned a darker color. Your response to this finding is to a. instruct her that this is a side effect of birth control injection therapy. b. suggest pregnancy testing. c. question her use of tanning beds. d. schedule an appointment with a surgeon.

ANS: B

In light-skinned women, pregnancy produces enlarged breasts with a darker areola. Neither hormonal injections nor the use of tanning beds will change the color of the areola as does pregnancy. Surgical consultation is not necessary.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 7. In patients with breast cancer, peau d’orange skin is often first evident a. in the axilla. b. in the upper inner quadrant. c. on or around the nipple. d. at the inframammary ridge.

ANS: C

The areola is the most common initial site for visualization of peau d’orange skin.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 8. A firm, transverse ridge of compressed tissue is felt bilaterally along the lower edge of a

40-year-old patient’s breast. You should a. ask the patient if she has a history of breast cancer. b. refer the patient to a surgeon. c. ask the patient to have a mammogram as soon as possible. d. record the finding in the patient’s record.

ANS: D

The inframammary ridge thickens and can be felt more easily with age. It is an expected, normal finding, without indications for further action.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 9. When examining axillary lymph nodes, the patient’s arm is a. raised fully above the head. b. extended at the side. c. flexed at the elbow. d. crossed over the chest.

ANS: C

To examine the axilla, support the patient’s lower arm with the elbow flexed with one of your hands and use your other hand to palpate the axilla.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 10. Male gynecomastia associated with illicit or prescription drug use can be expected to a. lessen when the body becomes accustomed to the drug. b. resolve after the drug is discontinued. c. leave permanent breast enlargement when the drug is discontinued. d. cause purulent drainage if left untreated.

ANS: B

Gynecomastia associated with illicit or prescription drug use (e.g., antihypertensive drugs, estrogens, steroids) usually resolves after the offending drug is discontinued and does not require further intervention.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 11. A nursing mother complains that her breasts are tender. You assess hard, shiny, and erythemic

breasts bilaterally. You should advise the patient to a. massage gently and continue nursing. b. apply warm compresses and stop nursing. c. monitor her temperature and restrict fluids. d. sleep wearing a bra and wash her breasts with antibacterial soap.

ANS: A

This patient has mastitis. The aim of treatment is to promote breast drainage. You should not advise the patient to apply warm compresses and stop nursing. Applying warm compresses will not encourage breast milk flow, and stopping nursing will increase the risk of a breast infection turning into a breast abscess. Monitoring her temperature and restricting fluids do not encourage breast milk flow. Sleeping with a bra and washing the breasts with antibacterial soap do not encourage breast milk flow. Only mild soaps are advised; harsh soaps can dry and crack the nipple and compound infection.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 12. You are conducting a clinical breast examination for your 30-year-old patient. Her breasts are

symmetric, with bilateral, multiple tender masses that are freely movable and with well-defined borders. You recognize that these symptoms and assessment findings are consistent with

a. b. c. d.

fibroadenoma.

Paget disease. cancer. fibrocystic changes.

ANS: D

Fibrocystic changes are tender masses, usually bilateral, with multiple round, mobile, well-delineated borders. A fibroadenoma is usually nontender. Paget disease is an eczema-like condition of the nipple that signals an underlying cancer. Cancer is usually nontender.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Health Promotion and Maintenance 13. Your patient is a nursing mother who asks you to look at a mole she has under her left breast

at the inframammary fold. The mole is nontender and soft and has grown in size since she started nursing. There are no other changes to the mole. This mole probably represents an undiagnosed a. Montgomery tubercle. b. case of Paget disease. c. supernumerary nipple. d. fat necrosis.

ANS: C

Supernumerary nipples usually resemble moles and occur, as in this example, along the milk line. Those that have glandular tissue may enlarge under hormonal influences. They may not be recognized as extra nipples in infants because they are usually small and not well formed.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 14. When conducting a clinical breast examination, the examiner should a. forgo the examination if the patient has had a recent mammogram. b. keep the patient’s breasts completely covered to respect modesty. c. dim the lights to minimize anxiety. d. inspect both breasts simultaneously.

ANS: D

Simultaneous observation of both breasts is essential to detect differences between breast size, symmetry, contour, and skin color.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential MULTIPLE RESPONSE 1. Mrs. Weber is a 65-year-old patient who has presented at the clinic with a complaint of a

tender breast mass that she discovered during breast self-examination. You have completed a physical examination on Mrs. Weber and have palpated a mass of the right breast in the lower outer quadrant. When providing patient education to Mrs. Weber regarding the breast mass, you will explain that the characteristics of a cancerous mass would be which of the following?

(Select all that apply.) a. Immobile and firm b. Pain on palpation c. Irregular border edges

d. Mobile and rubbery e. Nontender ANS: A, C, E

Characteristics of cancerous breast masses are irregular or stellate, hard, fixed, nontender, and poorly delineated.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential 2. Ms. Lawson is a 41-year-old patient who presents for a routine annual examination. During

her breast examination, you are also completing a lymphatic examination. Which of the following lymph nodes are examined during a breast examination? (Select all that apply.) a. Supraclavicular b. Lateral axillary nodes c. Anterior cervical nodes d. Anterior axillary nodes e. Posterior cervical nodes ANS: A, B, D

During a routine breast examination it is common practice to examine lymph nodes. When enlarged and fixed, lymph nodes can indicate the presence of cancer. Common lymph nodes included in this examination are the supraclavicular, lateral axillary, and posterior cervical lymph nodes.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Reduction of Risk Potential

Chapter 18: Abdomen Ball: Seidel’s Guide to Physical Examination, 10th Edition MULTIPLE CHOICE 1. Mrs. James is 7 months’ pregnant and states that she has developed a problem with

constipation. She eats a well-balanced diet and is usually regular. You should explain that constipation is common during pregnancy because of changes in the colorectal areas, such as a. decreased movement through the colon and increased water absorption from the stool. b. increased movement through the colon and increased salt taken from foods. c. looser anal sphincter and fewer nutrients taken from foods. d. tighter anal sphincter and less iron eliminated in the stool.

ANS: A

Constipation and flatus are more common during pregnancy because the colon is displaced, peristalsis is decreased, and water absorption is increased. Movement through the colon is decreased during pregnancy. The colon does not absorb nutrients. A tighter sphincter tone is not related to pregnancy.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. The family history of a patient with diarrhea and abdominal pain should include inquiry about

cystic fibrosis because it is a. a common genetic disorder. b. one cause of malabsorption syndrome. c. a curable condition with medical intervention. d. the most frequent cause of diarrhea in general practice.

ANS: B

Cystic fibrosis is an uncommon, chronic genetic disorder affecting multiple systems. In the gastrointestinal tract, it causes malabsorption syndrome because of pancreatic lipase deficiency. Steatorrhea and abdominal pain from increased gas production are frequent complaints.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. When assessing abdominal pain in a college-age woman, one must include a. history of interstate travel. b. food likes and dislikes. c. age at completion of toilet training. d. the first day of the last menstrual period.

ANS: D

Exploring abdominal pain complaints in a young woman can reveal multiple causes related to the menstrual cycle, including menstrual pain, ovulation discomfort, and abnormal menses.

Asking the patient to tell you the first day of her last menstrual period can help discriminate among these factors. History of international travel and traveler’s diarrhea can be related to abdominal pain, but interstate travel usually does not. Food preferences and age at completion of toilet training are not relevant.

DIF:Cognitive Level: Applying (Application)

OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

4. Infants born weighing less than 1500 g are at higher risk for a. hepatitis A. b. necrotizing enterocolitis. c. urinary urgency. d. pancreatitis.

ANS: B

Necrotizing enterocolitis is a gastrointestinal disease that mostly affects premature infants. It involves infection and inflammation that cause destruction of the bowel, and it becomes more apparent after feedings.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 5. You are completing a general physical examination on Mr. Rock, a 39-year-old man with

complaints of constipation. When examining a patient with tense abdominal musculature, a helpful technique is to have the patient a. hold his or her breath. b. sit upright. c. flex his or her knees. d. raise his or her head off the pillow.

ANS: C

To help relax the abdominal musculature, it is helpful to place a small pillow under the patient’s head and under slightly flexed knees. The other techniques are not helpful because they increase muscle flexion.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 6. Mrs. Little is a 44-year-old patient who presents to the office with abdominal pain and fever.

During your examination, you ask the patient to raise her head and shoulders while she lies in a supine position. A midline abdominal ridge rises. You document this observation as a(n) a. small inguinal hernia. b. large epigastric hernia. c. abdominal lipoma. d. diastasis recti.

ANS: D

A diastasis recti occurs when the abdominal contents bulge between two abdominal muscles to form a midline ridge as the head is lifted. It has little clinical significance and usually occurs in women who have had repeated pregnancies and in obese patients.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Integrated Process: Communication and Documentation 7. Mr. Robins is a 45-year-old man who presents to the emergency department with a complaint

of constipation. During auscultation, you note borborygmi sounds. This is associated with a. gastroenteritis. b. peritonitis. c. satiety. d. paralytic ileus.

ANS: A

Borborygmi are prolonged loud gurgles that occur with gastroenteritis, early intestinal obstruction, or hunger. Peritonitis and paralytic ileus result in hypoactive bowel sounds. Food satiety does not stimulate growling sounds as does hunger.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 8. To document absent bowel sounds correctly, one must listen continuously for a. 30 seconds. b. 1 minute. c. 3 minutes. d. 5 minutes.

ANS: D

Absent bowel sounds are confirmed after listening to each quadrant for 5 minutes.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 9. Percussion of the abdomen begins with establishing a. liver dullness. b. spleen dullness. c. gastric bubble tympany. d. overall dullness and tympany in all quadrants.

ANS: D

Percussion begins with a general establishment over all quadrants for areas of dullness and tympany and then proceeds to specific target organs.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 10. When percussing a spleen, Traube space is a a. semilunar region. b. splenic percussion sign. c. left-sided pleural effusion. d. solid mass.

ANS: A

Percussion of the spleen is more difficult because percussion tones elicited may be caused by other conditions. Traube space is a semilunar region defined by the sixth ribs superiorly, the midaxillary line laterally, and the left costal margin inferiorly.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 11. Your patient is complaining of acute, intense, sharp epigastric pain that radiates to the back

and left scapula, with nausea and vomiting. Based on this history, your prioritized physical examination should be to a. percuss for ascites. b. assess for rebound tenderness. c. inspect for ecchymosis of the flank. d. auscultate for abdominal bruits.

ANS: C

Abdominal pain that radiates to the back could be caused by pancreatitis or a gastric ulcer,

gallbladder pain usually radiates to the right or left scapula but not to the back, pancreatitis pain can radiate to the left shoulder or scapula, and nausea and vomiting usually occur with gallbladder, pancreas, or appendix conditions. Pancreatitis is a differential diagnosis for all these symptoms, so begin the examination by inspecting the flanks for the Grey Turner sign, an indication of pancreatitis.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 12. To assess for liver enlargement in the obese person, you should a. use the hook method. b. have the patient lean over at the waist. c. auscultate using the scratch technique. d. attempt palpation during deep exhalation.

ANS: C

If the abdomen is obese or distended, or if the abdominal muscles are tight, you should plan on auscultating the liver using the scratch method to estimate the lower border of the liver.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 13. An umbilical assessment in the newborn that is of concern is a. a thick cord. b. umbilical hernia. c. one umbilical artery and two veins. d. pulsations superior to the umbilicus.

ANS: C

Expect two arteries and one vein. A single umbilical artery indicates the possibility of congenital anomalies. A thick cord suggests a well-nourished fetus, an umbilical hernia will generally close spontaneously by 2 years, and pulsations to the abdomen in the epigastric area are common.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 14. Your patient presents with symptoms that lead you to suspect acute appendicitis. Which

assessment finding is least likely to be associated with this condition? a. Positive psoas sign b. Positive McBurney sign c. Consistent right lower quadrant (RLQ) pain d. Rebound tenderness ANS: C

A positive psoas sign, McBurney point pain, rebound tenderness, and periumbilical pain that migrates to the RLQ are signs of appendicitis. The absence of pain migration makes appendicitis less likely.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 15. When using the bimanual technique for palpating the abdomen, you should a. push down with the bottom hand and the other hand on top. b. push down with the top hand and concentrate on sensation with the bottom hand.

c. place the hands side by side and push equally. d. place one hand anteriorly and the other hand posteriorly, squeezing the hands

together.

ANS: B

The bimanual technique uses one hand on top of the other. Exert pressure with the top hand while concentrating on sensation with the other hand.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 16. Flatulence, diarrhea, dysuria, and tenderness with abdominal palpation are findings usually

associated with a. diverticulitis. b. pancreatitis. c. ruptured ovarian cyst. d. splenic rupture.

ANS: A

Only diverticulitis has all these presenting symptoms.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 17. A 51-year-old woman calls with complaints of weight loss and constipation. She reports

enlarged hemorrhoids and rectal bleeding. You advise her to a. b. c. d.

use a topical, over-the-counter hemorrhoid treatment for 1 week. exercise and eat more fiber. come to the laboratory for a stool guaiac test. eat six small meals a day.

ANS: C

Blood in the stool is an abnormal finding that should never be ignored, even if it can be explained by conditions other than colon cancer. She should have her stool checked for blood now as well as annually because she is older than 50 years.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 18. Costovertebral angle tenderness should be assessed whenever you suspect that the patient may

have a. cholecystitis. b. pancreatitis. c. pyelonephritis. d. ulcerative colitis.

ANS: C

Pyelonephritis is characterized by flank pain and costovertebral angle tenderness.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 19. A mother brings her 2-year-old child for you to assess. The mother feels a lump whenever she

fastens the child’s diaper. Nephroblastoma is a likely diagnosis for this child when your physical examination of the abdomen reveals a(n) a. fixed mass palpated in the hypogastric area.

b. tender, midline abdominal mass. c. olive-sized mass of the right upper quadrant. d. nontender, slightly movable, flank mass.

ANS: D

A Wilms tumor (nephroblastoma) is the most common intraabdominal tumor of childhood. It presents with hypertension, fever, malaise, and a firm nontender mass deep within the flank that is only slightly movable and is usually unilateral.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 20. In older adults, overflow fecal incontinence is commonly caused by a. malabsorption. b. parasitic diarrhea. c. fecal impaction. d. fistula formation.

ANS: C

Constipation with overflow occurs when the rectum contains hard stool and soft feces above a leak around the mass of stool.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation MULTIPLE RESPONSE 1. Your patient is a 48-year-old woman with complaints of severe cramping pain in the abdomen

and right flank. Her past medical history includes a history of bladder calculi. You diagnose her with renal calculi at this time. Which of the following symptoms would you expect with her diagnosis? (Select all that apply.) a. Abdominal pain on palpation b. Blumberg sign c. Cullen sign d. CVA tenderness e. Fever f. Grey Turner sign g. Hematuria h. Nausea ANS: A, D, E, G

Abdominal pain on palpation, CVA tenderness, fever, hematuria, and nausea are all signs and symptoms of renal calculi. The Cullen sign is ecchymosis around the umbilicus, the Blumberg sign is rebound tenderness for appendicitis, the Grey Turner sign is ecchymosis in the flanks, and the McBurney sign is rebound tenderness at McBurney’s point.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—diagnosis MSC: Physiologic Integrity: Reduction of Risk Potential 2. Your patient returns to the office with multiple complaints regarding her abdomen. Which of

the following are objective findings? (Select all that apply.) a. Nausea b. Dullness on percussion c. Rebound tenderness d. Vomiting

e. Diarrhea f. Burning pain in epigastrium ANS: B, C, E, F

Nausea, vomiting and diarrhea, and burning pain in epigastrium are subjective signs. Dullness on percussion and rebound tenderness are objective findings.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—diagnosis MSC: Physiologic Integrity: Reduction of Risk Potential

Chapter 19: Female Genitalia Ball: Seidel’s Guide to Physical Examination, 10th Edition

MULTIPLE CHOICE 1. Posteriorly, the labia minora meet as two ridges that fuse to form the a. fourchette. b. vulva. c. clitoris. d. perineum.

ANS: A

The labia minora join posteriorly to form the fourchette.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. A cervical polyp usually appears as a a. grainy area at the ectocervical junction. b. bright red, soft protrusion from the endocervical canal. c. transverse or stellate scar. d. hard granular surface at or near the os.

ANS: B

Cervical polyps are bright red, soft, and fragile. They usually protrude from the endocervical canal.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. Which structure is located posteriorly on each side of the vaginal orifice? a. Skene glands b. Clitoris c. Perineum d. Bartholin glands ANS: D

Bartholin glands are found posteriorly on each side of the vaginal orifice.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 4. During sexual excitement, how is the vaginal introitus lubricated? a. The Bartholin glands secrete mucus. b. The clitoris produces moisture. c. The Skene glands drain fluid. d. The urethral surfaces secrete water.

ANS: A

The Bartholin glands secrete mucus into the introitus for lubrication during sexual stimulation.

DIF:Cognitive Level: Remembering (Knowledge)

OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

5. The vaginal mucosa of a woman of childbearing years should appear a. b. c. d.

smooth and pink. moist and excoriated. dry and papular. transversely rugated.

ANS: D

Between puberty and menopause, the vagina is transversely rugated; after menopause, it loses its rugation.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 6. The adnexa of the uterus are composed of the a. corpus and cervix. b. fallopian tubes and ovaries. c. uterosacral and broad ligaments. d. vagina and fundus.

ANS: B

The fallopian tubes and ovaries are collectively referred to as the adnexa of the uterus.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 7. A bluish color to the cervix during pregnancy is called (the) a. McDonald sign. b. Spinnbarkeit. c. Goodell sign. d. Chadwick sign.

ANS: D

The Chadwick sign is a bluish color to the cervix during pregnancy. The Goodell sign is an increase in vascularity and softening of the cervix. Spinnbarkeit refers to the quality of elastic mucus during mittelschmerz, and the McDonald sign is fundal flexing on the cervix.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 8. The pelvic joint that separates most appreciably during late pregnancy is the a. sacroiliac. b. symphysis. c. sacrococcygeal. d. iliofemoral.

ANS: B

Of the four pelvic joints, the one that moves appreciably later in pregnancy is the symphysis pubis.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 9. Pregnancy-related cervical changes include

a. b. c. d.

flattening and lengthening. thinning and reddening. hardening and pallor. softening and bluish coloring.

ANS: D

During pregnancy, the cervix softens (Goodell sign) and then appears bluish (Chadwick sign).

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 10. Mrs. Robinson, a 49-year-old patient, presents to the office complaining of missing her

menstrual period. She asks about menopause. You explain to her that the conventional definition of menopause is a. the first day of the last menstrual period. b. 1 year with no menses. c. the last day of the last menstrual period. d. the cessation of ovulation.

ANS: B

Menopause is defined as 1 year without menses.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 11. Which systemic feature is related to the effects of menopause? a. Increased abdominal fat distribution b. Decreased LDL levels c. Cold intolerance d. Decreased cholesterol levels ANS: A

Systemic effects of menopause include increased intraabdominal body fat, increased LDL and cholesterol levels, and hot flashes.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 12. Ms. A, age 32, states that she has a recent history of itchy vaginal discharge. Ms. A has never

been pregnant. Her partner uses condoms and she uses spermicide for birth control. Which of the following data are most relevant to Ms. A’s problem? a. Bowel habits b. Douching routines c. Menstrual flow d. Nutritional factors ANS: B

When obtaining history of present illness information for the woman with a vaginal discharge, you should inquire about her douching habits. Douching is not only medically unnecessary but it can also mask, or even worsen, conditions such as bacterial vaginosis or a yeast infection.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 13. Which risk factor is associated with cervical cancer?

a. Endometriosis b. Low parity c. Multiple sex partners d. Obesity ANS: C

Cervical cancer is associated with certain HPV strains. Multiple sex partners increase the risk of HPV infection.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 14. The risk of ovarian cancer is increased by a. the use of oral contraceptives. b. cigarette smoking. c. age between 35 and 50 years. d. early age at first intercourse.

ANS: A

There is a relationship between the number of menstrual cycles and risk of ovarian cancer.

Early menarche and menopause after 50 years of age increase the risk.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 15. The form of gynecologic cancer that is increased in obese women is a. vaginal. b. cervical. c. ovarian. d. endometrial.

ANS: D

Obesity increases a woman’s chance of developing endometrial cancer by twofold to fivefold.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 16. The mother of an 8-year-old child reports that she has recently noticed a discharge stain on her

daughter’s underwear. Both the mother and daughter appear nervous and concerned. You would need to ask questions to assess the child’s a. drug ingestion. b. fluid intake. c. risk for sexual abuse. d. hormone responsiveness.

ANS: C

Vaginal discharge in a child could be related to a chemical irritation from soaps, lotions, or powders or to urinary tract infections. Concerned parents and children should be assessed for the risk of sexual abuse.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 17. The female patient should ideally be in which position for the pelvic examination?

a. b. c. d.

Fowler Prone Lateral supine Lithotomy

ANS: D

Ideally, the woman should be in a lithotomy position for a pelvic examination.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 18. When you plan to obtain cytologic studies, speculum introduction may be facilitated by a. lubrication with gel. b. lubrication with warm water. c. use of a plastic speculum. d. opening the blades completely.

ANS: B

It is generally thought that gel lubrication may interfere with cytologic studies; therefore, most clinicians lubricate the speculum with warm water. Although gel lubrication would facilitate speculum introduction, the gel could interfere with cytologic studies. Use of a plastic speculum or opening the blades completely would not facilitate speculum introduction.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 19. Which one of the following is a proper technique for the use of a speculum during a vaginal

examination? a. Allow the labia to spread, and insert the speculum slightly open. b. Insert one finger, and insert the opened speculum. c. Press the introitus downward, and insert the closed speculum obliquely. d. Spread the labia, and insert the closed speculum horizontally.

ANS: C

Use two fingers of one hand to push the introitus down to relax the pubococcygeal muscle.

Then hold the closed speculum with the other hand, and insert the speculum past your fingers obliquely.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 20. When collecting specimens, which sample should be obtained first? a. Chlamydial swab b. Gonococcal culture c. Pap smear d. Wet mount ANS: C

A Pap smear is obtained first and then other samples to test for gonorrhea, chlamydia, Trichomonas, bacterial vaginosis, or candidiasis are obtained. Pap smear results are affected by the presence of blood, and vaginal infections result in more friable tissues; therefore, the Pap smear should be obtained first.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 21. The presence of a fishy odor after adding potassium hydroxide to a wet mount slide

containing vaginal mucus suggests a. bacterial vaginosis. b. yeast infection. c. chlamydial infection. d. pregnancy.

ANS: A

A positive whiff test suggests bacterial vaginosis.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 22. The assessment of which structure is not part of the bimanual examination? a. Cervix b. Bladder c. Uterus d. Ovaries ANS: B

The bimanual examination consists of assessing the cervix, uterus, adnexa, and ovaries.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 23. Mrs. Reilly brings her 6-year-old daughter in with complaints of a foul vaginal discharge

noted in her underpants. The most common cause of a foul vaginal discharge in children is a(n) a. accident. b. foreign body. c. infection. d. ruptured hymen.

ANS: B

A foul vaginal discharge in the preschool-age girl is most likely indicative of the presence of a foreign body.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 24. A 3-year-old girl is being seen because of a foul vaginal odor. To inspect the vaginal vault,

you should first a. insert a pediatric vaginal speculum. b. place the child prone and in the fetal position. c. insert a cotton-tipped applicator and press down. d. pull the labia forward and slightly to the side.

ANS: D

Applying anterior labial traction allows the hymenal opening and the interior of the vagina to become visible, almost to the cervix. The presence of a foreign body will be visible with this maneuver.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 25. A mother brings her 8-year-old daughter to the clinic because the child says it hurts to urinate

after she fell while riding her bicycle. On inspection, you find posterior vulvar and gross perineum bruising. These findings are consistent with a. chronic masturbation. b. congenital defects. c. acute urinary tract infection. d. sexual abuse.

ANS: D

A straddle injury from a bicycle seat is usually evident over the symphysis pubis; injuries resulting from sexual molestation are generally more posterior and may involve the perineum grossly.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 26. What accommodations should be used for the position of a hearing-impaired woman for a

pelvic examination? a. The patient should assume the M or V position. b. Her legs should be farther apart. c. The head of the table should be elevated. d. The lithotomy position with obstetric stirrups should be used.

ANS: C

The woman with a hearing impairment will need to see the clinician and/or an interpreter during the examination; therefore, her head should be elevated.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 27. Asking the woman to close the introitus during a pelvic examination is a test for a. endometriosis. b. rectocele. c. cervical polyps. d. sphincter tone.

ANS: D

The test for sphincter tone is to have the woman squeeze the vaginal opening around your finger. A rectocele can be seen as a bulge on the posterior wall. Endometriosis is suggested with tender nodules along the uterosacral ligaments. Cervical polyps can be inspected without squeezing.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 28. Itchy, painful, small red vesicles are typical of a. condyloma acuminatum. b. condyloma latum. c. herpes simplex lesions. d. syphilitic chancre.

ANS: C

Herpetic lesions are painful, itchy red vesicles; condyloma acuminatum are warty lesions on the genitalia; condyloma latum are secondary syphilis lesions that appear as flat, round, or oval papules covered by a gray exudate; and a chancre is a painless ulcer.

DIF:Cognitive Level: Understanding (Comprehension)

OBJ:Nursing process—diagnosis

MSC: Physiologic Integrity: Physiologic Adaptation 29. A young, sexually active woman comes to the urgent care clinic complaining of suprapubic

abdominal pain. She is afebrile with rebound tenderness to the right side. There is no dysuria and no vaginal discharge or odor. A pelvic examination is done. She has pain with cervical motion, and you palpate a painful mass over the left adnexal area. Your prioritized action is to a. swab for gonococcal infection and then dip her urine. b. obtain a surgical consult immediately. c. remove the foreign body. d. dip her urine and then swab for Chlamydia.

ANS: B

The presenting symptoms of a tubal pregnancy are a surgical emergency. The only diagnostic test should be a pregnancy test.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 20: Male Genitalia Ball: Seidel’s Guide to Physical Examination, 10th Edition MULTIPLE CHOICE 1. While examining an 18-year-old man, you note that his penis and testicles are more darkly

pigmented than the body skin. You should consider this finding to be a. within normal limits. b. suggestive of a skin fungus. c. suggestive of psoriasis. d. caused by excessive progesterone.

ANS: A

Darker pigmentation on the penis and testicles, as compared with other body skin, is a normal finding and is not suggestive of a skin fungus, psoriasis, or excessive progesterone.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. In an uncircumcised male, retraction of the foreskin may reveal a cheesy white substance.

This is usually a. evidence of a fungal infection. b. a collection of sebaceous material. c. indicative of penile carcinoma. d. suggestive of diabetes.

ANS: B

In the uncircumcised male, smegma is formed by the secretion of sebaceous material by the glans and the desquamation of epithelial cells from the prepuce. It appears as a cheesy white substance on the glans and in the fornix of the foreskin. Smegma lubricates the cavity between the foreskin of the penis and the glans, allowing smooth movement between them during intercourse. It is not usually evidence of a fungal infection, penile carcinoma, or diabetes.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. Inspection of the scrotum should reveal a. lightly pigmented skin. b. two testes per sac. c. smooth scrotal sacs. d. the left scrotal sac lower than the right.

ANS: D

The left cord is longer than the right; consequently, the left testis hangs somewhat lower. The skin of the scrotum is more darkly pigmented. The scrotum has one testis per sac. The scrotum has small epidermoid cysts that give it a lumpy appearance.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 4. Expected genitalia changes that occur as men age include that a. the ejaculatory volume decreases with age. b. erections develop more quickly. c. the viability of sperm increases.

d. the scrotum becomes more pendulous.

ANS: D

Ejaculatory volume increases with age, erections develop more slowly, sperm viability decreases, and the scrotum becomes more pendulous with age.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 5. Inspection of the male urethral orifice requires the examiner to a. ask the patient to bear down. b. insert a small urethral speculum. c. press the glans between the thumb and forefinger. d. transilluminate the penile shaft.

ANS: C

Inspection of the urethral orifice is accomplished by pressing the glans between the examiner’s thumb and forefinger. This maneuver opens the slitlike orifice for further inspection.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 6. You are inspecting the genitalia of an uncircumcised adult male. The foreskin is tight and

cannot be easily retracted. You should a. chart the finding as paraphimosis. b. inquire about previous penile infections. c. retract the foreskin firmly. d. transilluminate the glans.

ANS: B

This condition is phimosis and is usually congenital, or it may be related to recurrent infections or poorly controlled diabetes. You should not chart this finding as paraphimosis.

Retracting the foreskin forcibly would lead to further adhesion formation and worsening phimosis. Transillumination is indicated for masses of the scrotum.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 7. Which type of hernia lies within the inguinal canal? a. Umbilical b. Direct c. Indirect d. Femoral ANS: C

Hernias found within the inguinal canal are called indirect hernias.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 8. Which condition is of minor consequence in an adult male? a. Adhesions of the foreskin b. Continuous penile erection c. Lumps in the scrotal skin d. Venous dilation in the spermatic cord

ANS: C

Lumps in the scrotal skin are related to numerous sebaceous cysts and are within normal limits.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 9. Mr. L has an unusually thick scrotum, with edema and pitting. He has a history of cardiac

problems. The appearance of his scrotum is most likely a(n) a. b. c. d.

congenital defect that has worsened. indication of general fluid retention. normal consequence of aging. complication of the development of mumps.

ANS: B

General fluid retention can cause scrotal thickening and pitting edema, and is usually seen as a result of cardiac, renal, or hepatic disease. This swelling does not imply a condition of the genitalia, but rather a condition of these related systems.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 10. A characteristic related to syphilis or diabetic neuropathy is testicular a. dropping, with asymmetry. b. enlargement. c. insensitivity to painful stimulation. d. recession into the abdomen.

ANS: C

Diabetic neuropathy or syphilis can cause a marked reduction of tactile perceptions.

Asymmetry is a normal finding; enlargement and recession are not related to diabetes or syphilis.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 11. On palpation, a normal vas deferens should feel a. beaded. b. smooth. c. ridged. d. spongy.

ANS: B

The vas deferens should feel smooth and discrete as it is palpated from the testicle to the inguinal ring. A beaded or lumpy vas deferens might indicate diabetes or the presence of old inflammatory changes.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 12. A premature infant’s scrotum will appear a. bifid. b. loose. c. ridged. d. smooth.

ANS: D

The premature male scrotum will appear underdeveloped, smooth, without rugae, and without testes; the full-term infant should have a loose, pendulous scrotum, with rugae and a midline raphe.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 13. An enlarged painless testicle in an adolescent or adult male may indicate a. epididymitis. b. testicular torsion. c. a tumor. d. an undescended testicle.

ANS: C

A hard, enlarged, painless testicle can indicate a tumor in the adolescent or adult male.

Epididymitis and torsion are painful; an undescended testicle is common in infants and is usually resolved by 12 months.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 14. You palpate a soft, slightly tender mass in the right scrotum of an adult male. You attempt to

reduce the size of the mass, and there is no change in the mass size. Your next assessment maneuver is to a. use two fingers to attempt to reduce the mass. b. palpate the left scrotum simultaneously. c. lift the right testicle and then compare pain level. d. transilluminate the mass.

ANS: D

A soft mass is a hernia or hydrocele. If the mass can be reduced, it is probably a hernia; a nonreducible mass should be transilluminated to determine whether it contains fluid and is possibly caused by a hydrocele. Lifting the scrotum should be done when epididymitis is suspected.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 15. The most common cancer in young men ages 15 to 30 years is a. testicular. b. penile. c. prostate. d. anal.

ANS: A

Because testicular tumors are the most common cancer occurring in young adults, self-examination is encouraged.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 16. The most emergent cause of testicular pain in a young male is a. testicular torsion. b. epididymitis. c. tumor.

d. hydrocele.

ANS: A

Testicular torsion is a surgical emergency. If surgery is performed within 12 hours after the onset of symptoms, the testis can be saved in about 90% of cases. Delayed treatment results in a much lower salvage rate.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 17. An adolescent male is being seen for acute onset of left testicular pain. The pain started 3

hours ago. He complains of nausea and denies dysuria or fever. Your priority action should be to a. obtain urine and DNA probe urethral samples. b. lift the left scrotum to confirm epididymitis. c. establish absent cremasteric reflex. d. transilluminate the left and right scrotum.

ANS: C

The patient is displaying symptoms of testicular torsion. An absent cremasteric reflex is a supporting finding to differentiate torsion from epididymitis.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—diagnosis MSC: Physiologic Integrity: Basic Care and Comfort 18. The most common type of hernia occurring in young males is a. hiatal. b. incarcerated femoral. c. indirect inguinal. d. umbilical.

ANS: C

The most common type of hernia in children and young males is an indirect inguinal hernia.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 19. Difficulty replacing the retracted foreskin of the penis to its normal position is called a. paraphimosis. b. Peyronie disease. c. phimosis. d. priapism.

ANS: A

Paraphimosis refers to the inability to replace the foreskin to its original position after it has been retracted behind the glans.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 20. Which genital virus infection is known to have a latent phase followed by the production of

viral DNA capsids and particles? a. Condyloma acuminatum b. Molluscum contagiosum c. Herpetic lesions d. Lymphogranuloma venereum

ANS: A

Condyloma acuminatum (genital warts) are soft, reddish lesions commonly present on the prepuce, glans penis, and shaft. These lesions can undergo latency, followed by viral DNA capsids and particles, which are produced in the host cells.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 21. Pearly gray, smooth, dome-shaped, often umbilicated lesions of the glans penis are probably a. herpetic lesions. b. condylomata. c. molluscum contagiosum. d. chancres.

ANS: C

Smooth, dome-shaped lesions with an umbilicated center of a pearly gray color are indicative of molluscum contagiosum.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 22. A 12-year-old boy relates that his left scrotum has a soft swollen mass. The scrotum is not

painful on palpation. The left inguinal canal is without masses. The mass transilluminates with a penlight. This collection of symptoms is consistent with a. orchitis. b. a hydrocele. c. a rectocele. d. a scrotal hernia.

ANS: B

A hydrocele is a soft scrotal mass that occurs as a result of fluid accumulation and therefore transilluminates. Orchitis results in a swollen, tender testis. A rectocele does not result in scrotal swelling. A scrotal hernia would also be palpable along the inguinal canal.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—diagnosis MSC: Physiologic Integrity: Physiologic Adaptation 23. Which condition is a complication of mumps in the adolescent or adult? a. Cystitis b. Epididymitis c. Orchitis d. Paraphimosis ANS: C

Orchitis is uncommon unless seen as a complication of mumps in the adolescent or adult.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

24. Parents of a 6-year-old boy should be asked if he has a. erections. b. nocturnal emissions. c. rapid detumescence. d. scrotal swelling.

ANS: D

Scrotal swelling, especially with crying or with bowel movements, signals the presence of a hernia. The questions about erections and rapid detumescence are for the older male. The question about nocturnal emissions is asked of adolescents.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 25. The male with Peyronie disease will usually complain of a. painful, inflamed testicles. b. deviation of the penis during erection. c. lack of sexual interest. d. painful lesions of the penis.

ANS: B

Peyronie disease is characterized by a fibrous band in the corpus cavernous. It results in unilateral deviation of the penis during erection.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 26. A cremasteric reflex should result in a. testicular and scrotal rise on the stroked side. b. penile deviation to the left side. c. bilateral elevation of the scrotum. d. immediate erection of the penis.

ANS: A

On stroking the inner thigh with a blunt instrument or finger, the testicle and scrotum should rise on the stroked side.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 21: Anus, Rectum, and Prostate Ball: Seidel’s Guide to Physical Examination, 10th Edition MULTIPLE CHOICE 1. Baby Sue is born with an imperforate anus. However, her outward anal appearance is normal.

Which sign would indicate to the healthcare provider that she has a closed anal passageway? a. Development of a scaphoid abdomen b. Vomiting after her first feeding c. Bleeding from the rectum d. Failure to pass meconium stool ANS: D

Failure to pass meconium stool indicates that a newborn has an imperforate anus.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

2. In males, which surface of the prostate gland is accessible by digital examination? a. Median lobe b. Posterior c. Superior d. Anterior ANS: B

The posterior surface of the prostate gland lies close to the anterior wall of the rectum and is palpable through digital rectal examination.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. The prostatic sulcus a. divides the right and left lateral lobes. b. is the site of the seminal vesicle emergence. c. refers to the anterior aspect of the prostate. d. secretes clear viscous mucus.

ANS: A

The prostatic sulcus divides the two lateral lobes and is palpated as a shallow groove.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 4. The rectal past medical history of all patients should include inquiry about a. bowel habits. b. dietary habits. c. hemorrhoid surgery. d. laxative use.

ANS: C

Past medical history should include inquiry about hemorrhoids, spinal cord injury, benign prostatic hypertrophy (BPH), prostate, colorectal, breast, ovarian, or endometrial cancers, and

episiotomies of fourth-degree lacerations during delivery. Habits are part of the personal and social history; the use of laxatives is part of the history of the present illness.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 5. The effects of aging on the gastrointestinal system leads to more frequent experiences of a. constipation. b. prolonged satiety. c. diarrhea. d. prostate glandular atrophy.

ANS: A

Older adults experience an elevated pressure threshold for the sensation of rectal distention and are therefore susceptible to constipation. They also experience early satiety, fecal incontinence, and prostate glandular hypertrophy.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 6. Factors associated with increased risk of prostate cancer include a. African descent. b. cigarette smoking. c. a low-fat diet. d. alcoholism.

ANS: A

The incidence rate of prostate cancer is 50% higher for African American men compared with white American men. African American men also have a higher mortality rate.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 7. The caliber of the urinary stream is routine information in the history of a. adolescents. b. infants. c. older adults. d. sexually active young men.

ANS: C

Routine questions about the caliber of the urinary stream and dribbling are directed toward older men because hypertrophy of the prostate gradually impedes urine flow.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 8. Equipment for examination of the anus, rectum, and prostate routinely includes gloves and a. a hand mirror and gauze. b. a lubricant and penlight. c. slides and normal saline. d. swabs and culture medium.

ANS: B

Equipment for the examination includes a penlight, lubricating jelly, gloves, and fecal occult blood testing materials.

DIF:Cognitive Level: Understanding (Comprehension)

OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

9. Which is a risk factor for colorectal cancer? a. High-fiber diet b. Diet low in animal fats and proteins c. Irish descent d. Inherited BRAC2 mutation ANS: D

History of intestinal polyps is considered a risk factor for colorectal cancer, as are diets low in fiber and high in animal fats and an ethnic background of Ashkenazi Jewish descent.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 10. Nodules found in the peritoneum through the anterior rectal wall a. are found with bi-digital palpation. b. are called shelf lesions. c. are chronic fibrosis. d. are found by having the patient bear down.

ANS: B

Because the anterior rectal wall is in contact with the peritoneum, you may be able to detect the tenderness of peritoneal inflammation and the nodularity of peritoneal metastasis. The nodules called shelf lesions are palpable just above the prostate in males and in the cul-de-sac of females.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 11. Perianal abscesses, fissures, or pilonidal cysts will cause the patient to experience a. bulging and wrinkling. b. constipation and pallor. c. diarrhea and redness. d. tenderness and inflammation.

ANS: D

Tenderness and inflammation to the perianal area may be related to an abscess, fistula, fissure, pilonidal cyst, or pruritus ani.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 12. Palpation of the anal ring is done by a. Bi-digital palpation with the thumbs. b. inserting the smallest finger into the anus. c. pressing a gauze pad over the anus. d. rotation of the forefinger inside the anus.

ANS: D

The anal muscular ring is palpated by rotating the examination finger.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 13. The posterior surface of the prostate can be located by palpation of the a. anal canal and perineum.

b. anterior wall of the rectum. c. lateral wall of the anus. d. lower abdomen and perineum.

ANS: B

Palpation of the rectal anterior wall facilitates posterior prostate location.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 14. The cervix may be palpated through the a. anterior rectal wall. b. internal umbilical wall. c. lateral urethral meatus. d. posterior uterine surface.

ANS: A

In women, the cervix can be palpated through the anterior rectal wall. It feels like a small, round mass.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 15. Your patient’s chief complaint is repeated, pencil-like stools. Further examination should

include a. a stool culture. b. parasite testing. c. a digital rectal examination (DRE). d. a prostate examination.

ANS: C

Persistent pencil-shaped stools are indicative of stenosis from scarring or pressure from a mass. DRE should be performed to assess for a mass.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 16. Very light tan or gray stools may indicate a. upper gastrointestinal bleeding. b. obstructive jaundice. c. lower gastrointestinal bleeding. d. polyposis.

ANS: B

Very light tan or gray stools suggest obstructive jaundice.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 17. Tarry black stools should increase suspicion for a. internal hemorrhoids. b. rectal fistula. c. upper intestinal tract bleeding. d. prostatic cancer.

ANS: C

Upper intestinal tract bleeding results in tarry black stools.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

18. Prostate-specific antigen (PSA) screening is controversial because a. there are many false-negative results. b. PSA is produced by many other tissues. c. it is less sensitive than digital rectal examination. d. no data have proved that it decreases mortality.

ANS: D

There are no data confirming that PSA screening decreases mortality from prostate cancer.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 19. Which finding in an infant may indicate lower spinal deformities? a. Perirectal redness b. Shrunken buttocks c. Rectal prolapse d. Dimpling in the pilonidal area ANS: D

Sinuses, tufts of hair, and dimpling in the pilonidal area may indicate lower spinal deformities such as a pilonidal cyst.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 20. A lower spinal cord lesion may be indicated by which finding? a. Lack of an anal wink b. Rectal prolapse c. Anal fistula d. Small flaps of anal skin ANS: A

Lightly touching the anal opening of an infant should produce a contraction referred to as an anal wink. A negative wink may indicate a lower spinal cord lesion.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 21. Pinworms and Candida may both cause a. constipation. b. hemorrhoids. c. perirectal irritation. d. perirectal protrusion.

ANS: C

Pinworms and Candida both cause perirectal irritation and itching.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 22. Thrombosed hemorrhoids are

a. b. c. d.

flabby skin sacs. red, inflamed, and painful. fluctuant soft papules. blue, shiny, painful masses.

ANS: D

Thrombosed hemorrhoids appear as blue shiny masses at the anus; they contain clotted blood and are edematous and painful.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 23. Palpation of a normal prostate in an older adult is likely to feel a. cool. b. grainy. c. polypoid. d. rubbery.

ANS: D

Older men are more likely to experience prostate hypertrophy, which when palpated feels smooth, rubbery, and symmetric.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 24. Mr. Dunn is a 62-year-old man who has presented for a routine annual examination. On

examination of the prostate you note a hard, irregular, painless nodule and obliteration of the median sulcus. These are signs of a. benign prostatic hypertrophy. b. cancer of the prostate. c. long-standing prostatitis. d. swelling as a result of aging.

ANS: B

Obliteration of the median sulcus is consistent with organ enlargement; however, the associated findings of a hard, irregular, and painless nodule indicate a cancerous growth.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 25. The mother brings her 4-year-old to the clinic because the child complains of perianal itching.

As part of your examination you complete a cellulose tape test. The cellulose tape test is used for the detection of a. enterobiasis. b. carcinoma. c. amebiasis. d. steatorrhea.

ANS: A

Enterobiasis (pinworm infestation) is detected by the cellulose tape test. Pinworms are collected by applying tape to the perianal folds and then pressing the tape on a glass slide.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

MULTIPLE RESPONSE 1. Mr. Sweeney is a 58-year-old man who has presented for a routine annual prostate

examination. On examination, you note a normal prostate gland. Which of the following characteristics should describe the normal prostate? (Select all that apply.) a. Rubbery consistency b. About 4 cm in diameter c. Fluctuant softness d. Gland protruding 1 cm into the rectum e. Firm, smooth, and slightly movable ANS: B, D, E

The gland should feel like a pencil eraser, firm, smooth, and slightly movable and should be nontender. It has a diameter of 4 cm, with a 1-cm protrusion into the rectum.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 22: Musculoskeletal System Ball: Seidel’s Guide to Physical Examination, 10th Edition MULTIPLE CHOICE 1. The type of joint that has the widest range of motion in all planes is the a. ball-and-socket. b. condyloid. c. gliding. d. saddle.

ANS: A

The ball-and-socket joint is the joint that has the widest range of motion (e.g., the hip joint). A condyloid joint may only move in two planes. A gliding joint is only able to glide. A saddle joint has no axial rotation.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. Spinal vertebrae are separated from each other by a. bursae. b. tendons. c. disks. d. ligaments.

ANS: C

Except for sacral vertebrae, the spinal vertebrae are separated from one another by disks.

Spinal movement is achieved by paraspinous muscles, tendons, and ligaments. Bursae are located in the knee, elbow, shoulder, and hip.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. The joint where the humerus, radius, and ulna articulate is the a. wrist. b. elbow. c. shoulder. d. clavicle.

ANS: B

The elbow is the site where the humerus, radius, and ulna meet. The wrist is made up of the radius and the carpal bones of the hand. The shoulder is made up of the humerus and scapula.

The clavicle connects to the scapula but not to the humerus.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 4. The articulation of the radius and carpal bones is the a. wrist. b. elbow. c. shoulder. d. clavicle.

ANS: A

The joint comprising the radius and carpal bones is called the wrist.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 5. The tibia, fibula, and talus articulate to form the a. ankle. b. knee. c. hip. d. pelvis.

ANS: A

The tibia, fibula, and talus (or heel) join to form the ankle.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 6. Long bones in children have growth plates known as a. epiphyses. b. epicondyles. c. synovium. d. fossae.

ANS: A

Epiphyses are the growth plates found in long bones in children.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 7. The elasticity of pelvic ligaments and softening of cartilage in a pregnant woman are the result

of a. b. c. d.

decreased mineral deposition. increased hormone secretion. uterine enlargement. gait changes.

ANS: B

Increased hormone secretion during pregnancy is responsible for the elasticity of pelvic ligaments and softening of the cartilage. These changes help accommodate the growing fetus.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 8. Skeletal changes in older adults are the result of a. increased bone deposition. b. increased bone resorption. c. decreased bone deposition. d. decreased bone resorption.

ANS: B

With age, the skeletal system changes. One of the dramatic changes in skeletal equilibrium is that bone resorption dominates bone deposition.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 9. The family history for a patient with joint pain should include information about siblings with a. trauma to the skeletal system. b. chronic atopic dermatitis.

c. genetic disorders. d. obesity.

ANS: C

An important history to obtain for a patient with joint pain would be family history of genetic disorders, such as osteogenesis imperfecta, dwarfing syndrome, rickets, hypophosphatemia, and hypercalciuria.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 10. Risk factors for sports-related injuries include a. competing in colder climates. b. previous fracture. c. history of recent weight loss. d. failure to warm up before activity.

ANS: D

Failure to warm up before exercise is one risk factor for sports-related injuries. Climate, previous fractures, and weight loss are not as strong risk factors for sports-related injuries.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

11. Light skin and thin body habitus are risk factors for a. rheumatoid arthritis. b. osteoarthritis. c. congenital bony defects. d. osteoporosis.

ANS: D

People with light skin and a thin body frame are at greater risk for developing osteoporosis.

Rheumatoid arthritis, osteoarthritis, and bony defects are not found to have a correlation with light skin and small frame.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 12. Inquiry about nocturnal muscle spasms would be most significant when taking the

musculoskeletal history of a. adolescents. b. infants. c. older adults. d. middle-age adults.

ANS: C

History taking of older adults should consist of symptoms of nocturnal muscle spasms.

Pregnant women and older adults commonly experience nocturnal leg cramps resulting from imbalances of fluids, hormones, minerals, or electrolytes or dehydration. A particular concern with the older adults is that this may be a sign of intermittent claudication.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 13. The musculoskeletal examination should begin when a. the patient enters the examination room.

b. during the collection of subjective data. c. when height is measured. d. when joint mobility is assessed.

ANS: A

When the patient first walks in the room, the examiner should be observing his or her gait and posture as part of the musculoskeletal examination.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 14. Fasciculation occurs after injury to a muscle’s a. b. c. d.

venous return. motor neuron. strength. tendon.

ANS: B

Fasciculations can often be visualized as muscle twitching or dimpling under the skin, but they usually do not generate sufficient force to move a limb. They may represent a benign condition or occur as a manifestation of motor neuron disease or peripheral nervous system diseases.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 15. The physical assessment technique most frequently used to assess joint symmetry is a. inspection. b. palpation. c. percussion. d. the use of joint calipers.

ANS: A

The assessment technique most commonly used to assess joint symmetry is inspection.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 16. A goniometer is used to assess a. bone maturity. b. joint proportions. c. range of motion. d. muscle strength.

ANS: C

The angle of a joint can be accurately measured by using a goniometer. A goniometer is used when the joint range of motion is beyond normal limits.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 17. When palpating joints, crepitus may occur when a. irregular bony surfaces rub together. b. supporting muscles are excessively spastic. c. joints are excessively lax.

d. there is excess fluid within the synovial membrane.

ANS: A

Crepitus is felt or heard when irregular bony surfaces rub together.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 18. The temporomandibular joint is palpated a. b. c. d.

under the mandible, anterior to the sternocleidomastoid muscle. above the mandible at midline. anterior to the tragus. at the mastoid process.

ANS: C

The temporomandibular joint is palpated just anterior to the tragus of the ear; the fingertips are placed inside the joint space as the patient opens and closes the mouth.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 19. The temporalis and masseter muscles are evaluated by a. having the patient shrug his or her shoulders. b. having the patient clench his or her teeth. c. asking the patient to fully extend his or her neck. d. passively opening the patient’s jaw.

ANS: B

Having the patient to bite down and clench their teeth is the method for evaluating the strength of the temporalis and masseter muscles. Cranial nerve V is tested with this same maneuver.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 20. The strength of the trapezius muscle is evaluated by having the patient a. clench his or her teeth during muscle palpation. b. push his or her head against the examiner’s hand. c. straighten his or her leg with examiner opposition. d. uncross his or her legs with examiner resistance.

ANS: B

Having the patient apply opposite force with differing head motions, against the examiner’s hand, assesses the sternocleidomastoid and trapezius muscles.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 21. Expected normal findings during the inspection of spinal alignment include a. asymmetric skin folds at the neck. b. slight right-sided scapular elevation. c. concave lumbar curve. d. the head positioned superiorly to the gluteal cleft.

ANS: D

Spinal alignment is considered within normal limits when the patient’s head is positioned

directly over the gluteal cleft. The skin folds should be symmetric, the scapulae are at even heights, and both the cervical and lumbar curves are convex.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

22. A common finding in markedly obese patients and pregnant women is a. kyphosis. b. lordosis. c. paraphimosis. d. scoliosis.

ANS: B

Bowing of the back, or lordosis, is more commonly found in pregnant women or obese patients because of an altered center of gravity. Kyphosis is more commonly seen in older adults. Paraphimosis is a penile condition. Scoliosis is more commonly seen in teenagers.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 23. A wheelchair-dependent older woman would most likely develop skin breakdown at a. C7. b. the iliac crests. c. L4. d. the gibbus.

ANS: D

This older woman, most likely kyphotic from osteoporosis, would have the greatest friction point at the gibbus. The gibbus results from collapsed vertebrae, resulting in a sharp, pointy deformity of the back. C7 and L4 remain as concave curves, with less friction. The iliac crests would not protrude as far as the gibbus.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 24. When the patient flexes forward at the waist, which spinal observation would lead you to

suspect scoliosis? a. Prominent lumbar hump b. Prominent cervical concave curve c. Lateral curvature of the spine d. Restricted ability to flex at the hips ANS: C

Scoliosis is suspected when there is a noticeable lateral curvature of the spine, or rib hump, as the patient bends forward at the waist.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 25. When a patient abducts an arm and the ipsilateral scapula becomes more prominent (winged),

this usually means that a. there has been an injury to the nerve of the anterior serratus muscle. b. one of the clavicles has been fractured. c. there is a unilateral trapezius muscle separation. d. one shoulder is dislocated.

ANS: A

If the long thoracic nerve is damaged or bruised, it can cause paralysis of the serratus anterior muscle and winging of the scapula, or shoulder blade. This is not a symptom of a fractured clavicle or trapezius muscle separation. A dislocated shoulder would result in a hollowing effect.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Physiologic Adaptation

26. When the shoulder contour is asymmetric and one shoulder has hollows in the rounding

contour, you would suspect a. kyphosis. b. fractured scapula. c. a dislocated shoulder. d. muscle wasting.

ANS: C

Asymmetric contours to the shoulder with a hollowing in the socket are symptoms of a shoulder dislocation. Kyphosis is a condition of the back; muscle wasting and a scapular fracture do not present with these symptoms.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 27. Ulnar deviation and swan neck deformities are characteristics of a. rheumatoid arthritis. b. osteoarthritis. c. osteoporosis. d. congenital defects.

ANS: A

Deviation of the fingers toward the ulnar side and swan neck deformities are classic symptoms of rheumatoid arthritis. Osteoarthritis, congenital defects, and osteoporosis do not present with these symptoms.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 28. A finding that is indicative of osteoarthritis is (are) a. swan neck deformities. b. Bouchard nodes. c. ganglions. d. Heberden nodes.

ANS: D

Heberden nodes are bony overgrowths of the distal end of the fingers and are associated with osteoarthritis. When the overgrowths are concentrated in the proximal interphalangeal joint, they are known as Bouchard nodes and are associated with rheumatoid arthritis, as are swan neck deformities; ganglions are present in nerve conditions.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 29. Carpal tunnel syndrome would result in a. a negative Tinel sign.

b. a negative Phalen test. c. reduced abduction of the thumb. d. palm tingling.

ANS: C

Median nerve compression, as in carpal tunnel syndrome, results in a positive Tinel sign, positive Phalen test, reduced abduction of the thumb, and sparing of palm tingling.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation MULTIPLE RESPONSE 1. Cardinal signs for rheumatoid disorders include which of the following? (Select all that

apply.) a. Gradual onset b. Weakness that is usually localized and not severe c. Coarse crepitus on motion d. Joint tenderness e. Sleep disturbance ANS: A, D, E

Hallmark signs of rheumatoid arthritis are gradual onset of stiffness for 1 hour after rising, sleep disturbance, joint tenderness, and medium to fine crepitus.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. The wrist moves in (Select all that apply.) a. eversion and inversion. b. proximal radius and ulna articulation. c. flexion and extension. d. adduction and abduction.

ANS: C, D

The wrist movement is in two planes, flexion and extension or radial and ulnar rotation.

Adduction and abduction are for shoulder and hip joints, and eversion and inversion are for ankle movement.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

Chapter 23: Neurologic System Ball: Seidel’s Guide to Physical Examination, 10th Edition MULTIPLE CHOICE 1. The autonomic nervous system coordinates which of the following? a. High-level cognitive function b. Balance and affect c. Internal organs of the body d. Balance and equilibrium ANS: C

The autonomic nervous system coordinates the internal environment of the body by the sympathetic and parasympathetic nervous systems. The other options are associated with the cerebral cortex; its function consists of determining intelligence, personality, and motor function.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 2. The major function of the sympathetic nervous system is to a. orchestrate the stress response. b. coordinate fine motor movement. c. determine proprioception. d. perceive stereognosis.

ANS: A

Stimulation of the sympathetic branch of the autonomic nervous system prepares the body for emergencies for fight or flight (stress response). The cerebellum plays a key role in the coordination of fine motor movements. Recognition of body parts and awareness of body position (proprioception) are dependent on the parietal lobe. Stereognosis is the ability to perceive the weight and form of solid objects by touch and is not under sympathetic control.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 3. The parasympathetic nervous system maintains the day-to-day function of a. digestion. b. response to stress. c. lymphatic supply to the brain. d. lymphatic drainage of the brain.

ANS: A

The parasympathetic division functions in a complementary and counterbalancing manner to conserve body resources and maintain day-to-day body functions, such as digestion and elimination.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 4.

Cerebrospinal fluid serves as a a. nerve impulse transmitter. b. red blood cell conveyer. c. shock absorber.

d. mediator of voluntary skeletal movement.

ANS: C

Cerebrospinal fluid circulates between an interconnecting system of ventricles in the brain and around the brain and spinal cord, serving as a shock absorber.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 5. Diabetic peripheral neuropathy will likely produce a. b. c. d.

hyperactive ankle reflexes. diminished pain sensation. exaggerated vibratory sense. hypersensitive temperature perception.

ANS: B

Peripheral neuropathy is a disorder of the peripheral nervous system that results in motor and sensory loss in the distribution of one or more nerves, usually in the hands and feet. Patients may have sensations of numbness, tingling, burning, and cramping. In moderate to severe diabetic neuropathy, there is wasting of the foot muscles, absent ankle and knee reflexes, decreased or no vibratory sensation below the knees, and/or loss of pain or sharp touch sensation to the midcalf level.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 6. The thalamus is the major integration center for the perception of a. speech. b. olfaction. c. pain. d. thoughts.

ANS: C

The thalamus is the major integrating center for the perception of various sensations such as pain and temperature, serving as the relay center between the basal ganglia and cerebellum.

The reception of speech and interpretation of speech are located in the Wernicke area. The olfactory sense is processed in the parietal lobe. The cerebrum holds memories, allows you to plan, and enables you to imagine and think.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 7. The awareness of body position is known as a. proprioception. b. graphesthesia. c. stereognosis. d. two-point discrimination.

ANS: A

Recognition of body parts and awareness of body position are known as proprioception. This is dependent on the parietal lobe. The other options are assessment techniques that test for sensory impairment.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation

8. Which area of the brain maintains temperature control? a. Epithalamus b. Thalamus c. Abducens d. Hypothalamus ANS: D

The hypothalamus is the major processing center of internal stimuli for the autonomic nervous system. It maintains temperature control, water metabolism, body fluid osmolarity, feeding behavior, and neuroendocrine activity. The epithalamus houses the pineal body and is responsible for sexual development and behavior. The thalamus conveys all sensory impulses, except olfaction, to and from the cerebrum before their distribution to appropriate associative sensory areas. The abducens is the sixth cranial nerve with motor function responsible for lateral eye movement.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 9. If a patient cannot shrug his or her shoulders against resistance, which cranial nerve (CN)

requires further evaluation? a. CN I, olfactory b. CN V, trigeminal c. CN IX, glossopharyngeal d. CN XI, spinal accessory ANS: D

CN XI is responsible for the motor ability to shrug the shoulders. CN I is associated with smell reception and interpretation. CN V is associated with opening of the jaw, chewing, and sensation of the cornea, iris, conjunctiva, eyelids, forehead, nose, teeth, tongue, ear, and facial skin. CN IX is associated with swallowing function, sensation of the nasopharynx, gag reflex, taste, secretion of salivary glands, carotid reflex, and swallowing.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 10. Motor maturation proceeds in an orderly progression from a. peripheral to central. b. head to toe. c. lateral to medial. d. pedal to cephalic.

ANS: B

Motor maturation proceeds in a cephalocaudal direction. Motor control of the head and neck develops first, followed by the trunk and extremities. The other choices are incorrect because they relate the maturation sequence inappropriately, from outward to central.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 11.

Normal changes of the aging brain include a. increased velocity of nerve conduction. b. diminished perception of touch. c. increased total number of neurons. d. diminished intelligence quotient.

ANS: B

Sensory perceptions of touch and pain are diminished by aging. The velocity of nerve impulse conduction declines, so responses to stimuli take longer. The number of cerebral neurons is thought to decrease by 1% a year, beginning at 50 years of age; however, the vast number of reserve cells inhibits the appearance of clinical signs.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 12. The area of body surface innervated by a particular spinal nerve is called a a. dermatome. b. nerve pathway. c. spinal accessory area. d. cutaneous zone.

ANS: A

The sensory and motor fibers of each spinal nerve supply and receive information to a segment of skin known as a dermatome. Nerve pathway and spinal accessory area refer to nerve routes. Cutaneous zone refers to a skin area that transmits fine mechanical information and normal exogenous thermal information at the same time.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 13. A neurologic past medical history should include data about a. allergies. b. circulatory problems. c. educational level. d. immunizations.

ANS: B

The neurologic past medical history should include data concerning neurovascular problems such as stroke, aneurysm, and brain surgery. The other answers are not pertinent medical information for the neurologic past medical history.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 14. Which is the technique most often used for evaluating the neurologic system? a. Auscultation b. Inspection c. Palpation d. Percussion ANS: B

The evaluation tool of inspection is used most often. Inspection of gait and response to questions can provide data concerning neurologic system function.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 15. When assessing superficial pain, touch, vibration, and position perceptions, you are testing a. cerebellar function. b. emotional status. c. sensory function.

d. tendon reflexes.

ANS: C

Superficial pain, touch, vibration, and position perceptions are sensory functions.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 16. You are initially evaluating the equilibrium of Ms. Q. You ask her to stand, with her feet

together and arms at her sides. She loses her balance. Ms. Q has a positive a. Kernig sign. b. Homan sign. c. McMurray test. d. Romberg sign.

ANS: D

The Romberg test has the patient stand with the eyes closed, feet together, and arms at the sides. A slight swaying movement of the body is expected, but not to the extent of falling.

Loss of balance results in a positive Romberg test. The Kernig sign indicates meningeal irritation, the Homan sign indicates venous thrombosis, and the McMurray test is a rotation test for demonstrating a torn meniscus.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 17. The finger to nose test allows assessment of a. coordination and fine motor function. b. point location. c. sensory function. d. stereognosis.

ANS: A

To perform the finger to nose test, the patient closes both eyes and touches his or her nose with the index finger, alternating hands while gradually increasing the speed. This tests coordination and fine motor skills. All the other choices test sensory function without motor function.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 18. You are performing a two-point discrimination test as part of a well physical examination.

The area with the ability to discern two points in the shortest distance is the a. back. b. palms. c. fingertips. d. upper arms.

ANS: C

The fingertips can discern two points with a minimal distance of 2 to 8 mm, the back, 40 to 70 mm, the palms, 8 to 12 mm, and the upper arms, 75 mm.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Physiologic Adaptation 19. As Mr. B enters the room, you observe that his gait is wide-based and he staggers from side to

side while swaying his trunk. You would document Mr. B’s pattern as

a. b. c. d.

dystonic ataxia. cerebellar ataxia. steppage gait. tabetic stamping.

ANS: B

A cerebellar gait (cerebellar ataxia) occurs when the patient’s feet are wide-based, with a staggering gait, lurching from side to side, often accompanied by swaying of the trunk.

Dystonic ataxia is jerky dancing movements that appear nondirectional. Steppage gait is noted when the hip and knee are elevated excessively high to lift the plantar-flexed foot off the ground. The foot is brought down with a slap and the patient is unable to walk on the heels.

Tabetic stamping occurs when the legs are positioned far apart, lifted high, and forcibly brought down with each step; in this case, the heel stamps on the ground.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Safe and Effective Care: Management of Care 20. Deep pressure tests are used mostly for patients who are experiencing a. absent superficial pain sensation. b. gait and stepping disturbances. c. lordosis, osteoporosis, or arthritis. d. tonic neck or torso spasms.

ANS: A

Deep pressure sensation is tested by squeezing the trapezius, calf, or biceps muscle, thus causing discomfort. When superficial pain sensation is not intact, further assessments of temperature and deep pressure sensation are performed.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Safe and Effective Care: Management of Care 21. Vibratory sensory testing should be routinely done for the patient with a. Parkinson disease. b. diabetes. c. cerebral palsy. d. Guillain-Barré syndrome.

ANS: B

Diabetic neuropathy must be routinely assessed in all diabetic patients. In moderate to severe cases, decreased or absent vibratory sensation occurs below the knees, which should be assessed with a tuning fork. The other choices do not result in sensation deficits.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Safe and Effective Care: Management of Care 22. To assess a cremasteric reflex, the nurse strokes the a. b. c. d.

sole of the foot and observes whether the toes fan down and out. abdomen and observes whether the umbilicus moves away from the stimulus. inner thigh and observes whether the testicle and scrotum rise on the stroked side. palm and observes whether the fingers attempt to grasp.

ANS: C

Stroking the inner thigh of a male patient (proximal to distal) will elicit the cremasteric reflex.

The testicle and scrotum rise on the stroked side. Stroking the sole of the foot elicits a Babinski sign. Stroking the abdomen elicits an abdominal reflex. Stroking the palm elicits a

palmar grasp.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Safe and Effective Care: Management of Care 23. When you ask a patient to close his or her eyes and identify an object placed in the hand, you

are evaluating a. stereognosis. b. graphesthesia. c. vibratory sensation. d. extinction phenomenon.

ANS: A

Stereognosis is the ability to recognize an object through touch and manipulation. Tactile agnosia, an inability to recognize objects by touch, suggests a parietal lobe lesion.

Graphesthesia tests the patient’s ability to identify the figure being drawn on the palm. The vibratory sense uses a tuning fork placed on a bony prominence, and the extinction phenomenon tests sensation by simultaneously touching bilateral sides of the body with a sterile needle.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Safe and Effective Care: Management of Care 24. The ability to recognize a number traced on the skin is called a. stereognosis. b. graphesthesia. c. an extinction phenomenon. d. two-point discrimination.

ANS: B

The ability to recognize a number traced on the skin is called graphesthesia. Stereognosis is the ability to recognize an object through touch and manipulation. The extinction phenomenon test and two-point discrimination assess a person’s ability to discern the number of pinpoints and their location.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Safe and Effective Care: Management of Care

25. Which condition is consistent with Brown-Séquard syndrome? a. Central sensory loss that is generalized b. Motor paralysis on the lesion side of the body c. Multiple peripheral neuropathy of the joints d. Spinal root paralysis below the umbilicus ANS: B

Parietal spinal sensory syndrome (Brown-Séquard syndrome) is noted when pain and temperature sensation occur one to two dermatomes below the lesion on the opposite side of the body from the lesion. Proprioceptive loss and motor paralysis occur on the lesion side of the body.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Safe and Effective Care: Management of Care 26. To assess spinal levels L2, L3, and L4, which deep tendon reflex should be tested? a. Triceps b. Patellar

c. Biceps d. Achilles ANS: B

To assess spinal levels L2 to L4, the patellar reflex should be tested. The patellar tendon is the only deep tendon that assesses the lumbar spinal level. The triceps and biceps tendon are tested to assess the cervical spine, whereas the Achilles tendon is tested to assess the sacral spine.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Safe and Effective Care: Management of Care 27. When using a monofilament to assess sensory function, the nurse a. uses two simultaneous monofilaments on similar bilateral points and then

compares results. b. applies both a monofilament and a pin on similar bilateral points and then compares results. c. applies pressure to the monofilament until the filament bends. d. strokes the monofilament along the skin from proximal to distal areas.

ANS: C

The monofilament is placed on several smooth spots of the patient’s plantar foot for seconds.

Adequate pressure applied by the monofilament is measured by the bend of the monofilament.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Safe and Effective Care: Management of Care 28. Visible or palpable extension of the elbow is caused by reflex contraction of which muscle? a. Achilles b. Biceps c. Patellar d. Triceps ANS: D

The triceps tendon, when directly hit with the reflex hammer just above the elbow, will cause contraction of the triceps muscle and extension of the elbow.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Safe and Effective Care: Management of Care 29. It is especially important to test for ankle clonus if a. deep tendon reflexes are hyperactive. b. deep tendon reflexes are hypoactive. c. the Romberg sign is positive. d. the patient has peripheral neuropathy.

ANS: A

Test the ankle clonus when reflexes are hyperactive. Support the patient’s knee in a flexed position and briskly dorsiflex the foot with your other hand. If clonus is present, there is recurrent ankle plantar flexion movement as long as the examiner retains the foot in dorsiflexion. Sustained clonus signifies the hypertonia of an upper motor neuron lesion.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Safe and Effective Care: Management of Care 30. On a scale of 1+ to 4+, which deep tendon reflex score is appropriate for a finding of clonus in

a patient? a. 1+ b. 2+ c. 3+ d. 4+ ANS: D

1+ indicates a sluggish or diminished reflex. 2+ indicates an active or expected response. 3+ indicates more brisk than expected, slightly hyperactive. 4+ indicates brisk, hyperactive, with intermittent or transient clonus.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Safe and Effective Care: Management of Care 31. Which sign is associated with meningitis and intracranial hemorrhage? a. Babinski sign b. Asymmetric tonic neck reflex c. Doll’s eye movement d. Nuchal rigidity ANS: D

A stiff neck or nuchal rigidity is a sign associated with meningitis and intracranial hemorrhage. Test this by lifting the head of the patient to touch the chin while the patient lies in a supine position. Pain and resistance to neck motion are associated with nuchal rigidity.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Safe and Effective Care: Management of Care 32. Cranial nerve XII may be assessed in an infant by a. watching the infant’s facial expressions when crying. b. observing the infant suck and swallow. c. clapping hands and watching the infant blink. d. observing the infant’s rooting reflex.

ANS: B

Cranial nerve (CN) XII may be assessed in an infant by observing the infant suck and swallow, by pinching the nose, and then observing for the mouth to open and the tip of the tongue to rise in a midline position. Watching the infant’s facial expressions when crying assesses CN VII. Clapping hands and watching the infant blink tests CN VIII. Observing the rooting reflex assesses CN V. DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Safe and Effective Care: Management of Care 33. You are most concerned for the infant who has a a. weak palmar grasp at 3 months. b. strong stepping reflex at 2 months. c. weak plantar reflex at 9 months. d. strong tonic neck at 6 months.

ANS: D

The tonic neck reflex must disappear before the infant can roll over or bring his or her hands to their face; it should disappear by 6 months. The other choices are within expected ranges.

DIF:Cognitive Level: Analyzing (Analysis)

OBJ:Nursing process—assessment

MSC: Safe and Effective Care: Management of Care

34. At what age should the infant begin to transfer objects from hand to hand? a. 2 months b. 4 months c. 7 months d. 10 months ANS: C

Transferring objects hand to hand begins at 7 months. Purposeful release of objects is noted as a normal finding by 10 months. Purposeful movements, such as reaching and grasping for objects, begin at about 2 months of age. The progress of taking objects with one hand begins at 6 months. There should be no tremors or constant overshooting of movements.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Safe and Effective Care: Management of Care 35. An acute polyneuropathy that commonly follows a nonspecific infection occurring 10 to 14

days earlier and that primarily affects the motor and autonomic peripheral nerves in an ascending pattern is a. cerebral palsy. b. HIV encephalopathy. c. Guillain-Barré syndrome. d. Rett syndrome.

ANS: C

Guillain-Barré syndrome—acute idiopathic polyneuritis—is an acute polyradiculoneuropathy that commonly follows a nonspecific infection that occurred 10 to 14 days earlier. It is characterized by ascending symmetric weakness with sensation preserved. An increase in severity occurs over days or weeks. A decrease in or absent strength and sensory loss may result, along with motor paralysis and respiratory muscle failure.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Safe and Effective Care: Management of Care 36. Which is a concern, rather than an expected finding, in older adults? a. Reduced ability to differentiate colors b. Bilateral pillrolling of the fingers c. Absent plantar reflex d. Reduction in upward gaze ANS: B

Bilateral pillrolling is indicative of Parkinson disease; the other choices are expected findings with aging.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Safe and Effective Care: Management of Care 37. Which condition is potentially life-threatening if not treated expeditiously with antibiotics? a. HIV encephalopathy b. Dementia c. Parkinson disease d. Bacterial meningitis ANS: D

Meningitis is an inflammatory process in the meninges. Bacterial meningitis is a

life-threatening illness if not rapidly treated with appropriate antibiotics. All the other diseases are neurologic disorders not treatable by antibiotics.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Safe and Effective Care: Management of Care 38. Ipsilateral Horner syndrome indicates a cerebrovascular accident (CVA) occurring in the a. anterior portion of the pons. b. internal or middle cerebral artery. c. posterior inferior cerebellar artery. d. vertebral or basilar arteries.

ANS: C

The posterior inferior cerebellar artery supplies the lateral and posterior portion of the medulla. A CVA involving this artery can produce a neurologic sign of ipsilateral Horner syndrome in the eye.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Safe and Effective Care: Management of Care 39. The immune system attacks the synaptic junction between the nerve and muscle fibers,

blocking acetylcholine receptor sites in a. b. c. d.

myasthenia gravis. encephalitis. multiple sclerosis. cerebral palsy.

ANS: A

Myasthenia gravis is a chronic autoimmune neuromuscular disease involving the lower motor neurons and muscle fibers. The immune system of infected individuals produces antibodies that destroy acetylcholine receptor sites at the neuromuscular junction. This blocks the nerve impulse from reaching the muscle and produces muscle fatigue. Encephalitis is acute inflammation of the brain and spinal cord involving the meninges. It is often caused by a virus, such as the herpes simplex virus. Multiple sclerosis is a progressive autoimmune disorder characterized by a combination of inflammation and degeneration of the myelin in the brain’s white matter, leading to obstructed transmission of nerve impulses and decreased brain mass. Cerebral palsy is a permanent disorder of movement and posture development associated with nonprogressive (static) disturbances that occurred in the developing fetal or infant brain.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Safe and Effective Care: Management of Care 40. Persons with Parkinson disease have an altered gait characterized by a. short shuffling steps. b. the trunk in a backward position. c. exaggerated swinging of the arms. d. lifting the legs in a high-stepping fashion.

ANS: A

The altered gait of Parkinson disease has short shuffling steps, the posture is stooped forward, and the arms have limited swing.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Safe and Effective Care: Management of Care

MULTIPLE RESPONSE 1. The tests for cortical sensory function include which of the following? (Select all that apply.) a. Two-point discrimination b. Extinction phenomenon c. Superficial pain d. Stereognosis e. Touch ANS: A, B, D

The following tests are tests for cortical sensory function—stereognosis, two-point discrimination, extinction phenomenon, graphesthesia, and point location.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Safe and Effective Care: Management of Care

Chapter 24: Putting it All Together Ball: Seidel’s Guide to Physical Examination, 10th Edition

MULTIPLE CHOICE 1. Which is true regarding the relationship between the examiner and patient? a. It is the examiner’s responsibility to help the patient understand that he or she is

qualified to make decisions regarding health care. b. The patient must trust the examiner completely. c. The examiner-patient relationship is enhanced by ignoring cultural issues. d. The patient is a full partner with the examiner.

ANS: D

The patient is a full partner with the examiner. The examiner should keep the patient informed and should develop a relationship to ensure trust. Cultural issues should be acknowledged, not ignored. The examiner should keep the patient informed, but it is not the examiner’s responsibility to help the patient understand that he or she is qualified to make healthcare decisions. The examiner should develop a relationship to ensure trust, but it is not necessary for the patient to trust the examiner completely.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 2. Which examiner behavior would help minimize your patient’s dissatisfaction? a. Assume a busy and rushed attitude. b. Convey your own feelings of discomfort. c. Keep the patient waiting for more than 30 minutes. d. Seek information about the patient’s problem.

ANS: D

When performing an examination, you are seeking information about the patient and the problem that brings the patient to you. This process teaches you about the patient and teaches the patient about your personal discipline, professional composure, and respect for others.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 3. An examiner might be able to help a patient who seems uncomfortable with close contact

during an examination by a. acknowledging the discomfort. b. backing away from the patient. c. joking about the patient’s discomfort. d. moving briskly to completion.

ANS: A

Acknowledging the patient’s discomfort during the examination will help the patient feel more relaxed. Your professional concern can be reassuring to the patient. You should explain what you are doing to the patient before the assessment and what the patient will experience; if not, you will run the risk of losing trust. The other choices would make the patient more uneasy.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort

4. When performing a history and physical assessment, the examiner should a. change the sequence of observation with each interview. b. develop a sequence of standard observations. c. develop a preliminary diagnosis at the onset. d. direct patient responses to fit the history sequence.

ANS: B

When performing a history and physical assessment, you should develop an approach that is comfortable to you and ensures comfort for the patient. Part of the history can be obtained while you are doing the physical examination.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 5. The examiner should develop a demeanor that is exemplified by which one of the following

behaviors? a. Exhibits visible distaste about the condition. b. Gives immediate reassurances to the patient. c. Gives patient unsolicited advice. d. Validates the patient’s justified concerns.

ANS: D

The examiner needs to learn a gentle and balanced demeanor. By showing concern for the patient’s feelings, you gain the patient’s trust; giving unsolicited advice can cause the patient to lose trust in the relationship.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 6. At your first meeting with a patient, it is usually best to say a. ―Let’s get to the point.‖ b. ―I hope you will learn to trust me.‖ c. ―Let me tell you what I can do for you.‖ d. ―Tell me about yourself.‖ ANS: D

Take the time to ask open-ended questions to ensure that the patient has the opportunity to report accurately. Too great an adherence to routine may prevent the true story from emerging. The other statements are not open-ended, which would not allow the patient to elaborate. In addition, they are not comforting statements and would make the patient feel uncomfortable at the initial meeting.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 7. Which patient characteristic is most likely to limit patient reliability during history taking? a. The patient’s measured IQ is above average. b. The patient is alert and oriented to time and place. c. The patient is depressed. d. The patient speaks the same language as examiner.

ANS: C

Emotional constraints can limit a patient’s reliability as a historian. Language barriers, cultural barriers, and an unresponsive or comatose patient can all affect a patient’s ability to be a thorough historian. All the other options would not limit a patient’s reliability.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Basic Care and Comfort

8. The reliability of health-related findings and observations is the responsibility of the a. patient. b. professional and medical assistants. c. attending clinician. d. professional and the patient.

ANS: D

It is the responsibility of the health professional and patient to present reliable findings and observations. They work as a team.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 9. Which is most likely to enhance examiner reliability? a. The examiner who seeks input from others. b. The examiner is uncomfortable with his or her own skills. c. The examiner believes that he or she must always be correct. d. The examiner prejudges the patient and family.

ANS: A

As the examiner, you may not always be correct, but questioning yourself and seeking confirmation from others when necessary will serve to assure your reliability. Showing that you are uncomfortable with your skills can make the patient feel uncomfortable and see you as unreliable. Believing that you must always be correct will not enhance your reliability as an examiner. A person should never be prejudged, because this can interfere with the examination and findings.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 10. Which statement accurately reflects the sensitivity and specificity of laboratory tests? a. The gold standard test has 100% sensitivity and specificity. b. Sensitivity and specificity are inversely correlated. c. Sensitivity and specificity are directly correlated. d. No test has 100% sensitivity and specificity.

ANS: D

No test has 100% sensitivity and specificity.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 11. As you greet the patient, which examination technique is first implemented? a. Auscultation b. Inspection c. Measurement d. Palpation ANS: B

Begin to inspect the patient as you greet him or her as you look for signs of distress or disease.

Inspect the appearance, gait, orientation, and difficulty in hearing or speech.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 12. Which data is not part of your general inspection? a. Dress and habitus b. Sinus tenderness c. Gait d. Facial expression ANS: B

On meeting the patient, the facial expression, gait, dress, and habitus should be inspected.

Inspecting for sinus tenderness is performed afterward, if indicated.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 13. The sequence of the physical examination should be individualized to a. minimize the number of times that the patient must change positions. b. maximize the convenience of the examiner. c. improve patient flow. d. minimize the time that the patient is in the room.

ANS: A

There is no one right way to put together the parts of the physical examination. The sequence should be individualized to minimize the number of times the patient has to change positions to conserve the patient’s energy.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 14. According to the usual examination procedure, you would first assist your patient to assume

which position? a. Lithotomy b. Prone c. Sitting d. Supine ANS: C

On entering the examination room, you should assist the patient in the sitting position on the examining table. In the sitting position, you can examine the patient’s anterior and posterior upper trunk and head, which comprise most of the focused assessments.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Basic Care and Comfort

15. An ophthalmoscopic eye examination involves a. lens inspection. b. near vision evaluation. c. sclera observation. d. visual field assessment.

ANS: A

Ophthalmoscope eye examination involves testing the red reflex and inspecting the lens, disc, cup margins, vessels, and retinal surface. The other assessments do not involve the use of the ophthalmoscope.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 16. Palpation of the epitrochlear nodes is part of the a. examination of the upper extremities. b. assessment of the chest and thorax. c. palpation of the abdomen. d. examination of the head and neck.

ANS: A

Palpation of the epitrochlear nodes is part of the examination of the upper extremities. To palpate the epitrochlear nodes, support the elbow in one hand and palpate in the depression above and posterior to the medial condyle of the humerus.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 17. Which are examined with the patient in a reclining 45-degree position? a. Bilateral hips and popliteal angles b. Facial bones and cranial nerves V and VII c. Jugular venous pulsation and pressure d. Oropharynx and thyroid gland placement ANS: C

With the patient in a reclining 45-degree position, you can examine jugular venous pulsations and measure jugular venous pressure. All the other choices can be examined with the patient in a sitting position.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 18. Which patient position facilitates inspection of the chest and shoulders? a. Sitting b. Supine c. Trendelenburg d. Prone ANS: A

With the patient in the sitting position, the examiner can inspect the chest and shoulders. The area being inspected is exposed for the examiner to do a thorough assessment. The other positions are not used to assess the chest and shoulders.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 19. When assessing the abdomen, the examiner needs to expose the patient a. from the waist down. b. from the pubis to the epigastrium. c. in entirety. d. at no point during the examination.

ANS: B

While the patient is in the supine position, the examiner can assess the abdomen. Arrange draping to expose the abdomen from the pubis to epigastrium, ensuring that the private areas of the patient are covered.

DIF:Cognitive Level: Understanding (Comprehension)

OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Basic Care and Comfort

20. To inspect the abdominal muscles, ask the a. supine patient to raise their head. b. standing patient to bend forward. c. prone patient to raise their lower legs. d. standing patient to stand on tiptoes.

ANS: A

Asking the supine patient to raise his or her head will contract the rectus abdominis muscles, which produces muscle prominence, making abdominal wall masses visible.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 21. Proprioception should be assessed while the patient is a. prone. b. supine. c. seated. d. standing.

ANS: D

The proprioception examination involves the Romberg test, heel to toe walking, standing on one foot and then the other with the eyes closed, hopping in place, and deep knee bends. The standing position is required to conduct these examinations.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 22. Examination of the patient in the lithotomy, or knee-chest, position includes a. inspection for inguinal hernias. b. palpation of anal sphincter tone. c. percussion of pelvic structures. d. stereognosis testing.

ANS: B

With the patient in the lithotomy position, the examiner can inspect the external and internal female genitalia and perform a rectal examination to assess and palpate anal sphincter tone.

The other choices require the patient to be in the supine or standing position.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 23. Which portion of the physical examination is best done with the patient standing? a. Spinal b. Rectal c. Neurologic d. Musculoskeletal ANS: A

With the patient in the standing position, the examiner can inspect and palpate the spine as the patient bends over at the waist and can also test a patient’s range of motion.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 24. The greatest risk for potential health problems occurs in which age group?

a. b. c. d.

Newborn Toddler School-age Adolescence

ANS: A

Newborns have a greater risk for potential health problems than other age groups but also have the potential for better health than the other age groups.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 25. A common method for estimating gestational age of a newborn is to assess a. middle finger length. b. creases on the sole of the foot. c. umbilical placement. d. visual acuity.

ANS: B

To determine gestational age, look at the soles of the feet. Before 36 weeks’ gestation, only one or two transverse creases are present; by 40 weeks’ gestation, many creases are present on the soles of the feet. Other clues to gestational age include a breast nodule less than 3 cm, cartilage in the helix of the ear, descending of the scrotum and amount of rugae, and extremities in flexed positions.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 26. To promote a child’s cooperation during your examination, your approach to the examination

should be to a. ask the parent to give the child a bottle during the examination. b. sing songs with the child during the examination. c. conduct the physical examination on the child while the parent is holding the child. d. let the child play with examination room equipment to feel more comfortable.

ANS: C

For children, the examination sequence depends on their cooperation for as long as possible.

To promote this, examine the child while the parent is holding the child, which maximizes inspection and opportunities for physical examination.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 27. Which cannot be assessed in the crying infant? a. Tactile fremitus b. Respiratory rate c. Lung excursion d. Facial symmetry ANS: B

Respirations cannot be counted in the crying infant. Tactile fremitus can be felt when the infant is crying.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort

28. The Ballard Gestational Age Test is completed within 36 hours of birth to a. determine if the menstrual estimated age is correct. b. determine if the newborn is premature. c. determine an actual quantitative measure. d. determine combined objective and subjective observations.

ANS: B

Because menstrual histories are inaccurate, the Ballard Gestational Age assessment tool contains newborn characteristics that can determine prematurity.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 29. Mrs. Kia has brought her newborn infant in for a 2-week examination. The examination of the

newborn should begin with a. inspection. b. palpation. c. vital signs. d. auscultation.

ANS: A

The examination of a newborn should begin with inspection; skin color, flaccidity, tension, gross deformities, or distortions of faces should be noted. All the other examination techniques follow inspection.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 30. The best way to ease the apprehension of a 3-year-old child before a physical examination is

to a. explain that you will be gentle. b. hand the child a picture book. c. let the child hold the stethoscope while you listen. d. tell the child that he or she will get a lollipop for good behavior.

ANS: C

The best way to ease the apprehension of a 3-year-old child before a physical examination is to encourage the child to participate by helping you. Ask the child to hold the endpiece of the stethoscope or to ―blow out‖ your flashlight.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 31. In crying infants, it is often difficult to a. perform tactile fremitus assessments. b. determine lung expansion. c. auscultate heart sounds. d. visualize the pharynx.

ANS: C

For the crying infant, lungs can be auscultated between consolable moments. While the infant is crying, the examiner can assess the lustiness of cry, tactile fremitus, lung excursion, facial symmetry, and appearance of the mouth and pharynx. Each time a breath is taken, heart tone can be auscultated.

DIF:Cognitive Level: Understanding (Comprehension)

OBJ:Nursing process—assessment

MSC: Physiologic Integrity: Basic Care and Comfort

32. When you attempt to move a 10-month-old child from his mother’s lap to the examination

table, he screams loudly. Your best action is to a. move the child to the examination table and proceed matter of factly with the examination. b. ask the mother to try to get the child to stop crying. c. perform the examination while the child is in the mother’s lap. d. defer the examination until another day.

ANS: C

The parent’s lap is a great examination table because it helps the child feel more at ease and is also a good way to observe the nature of the parent-child relationship. All the other actions would not comfort the patient or make the situation better.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 33. When conducting a geriatric assessment, keep in mind that basic activities of daily living

(ADL) include a. bathing. b. housekeeping. c. medication compliance. d. communication skills.

ANS: A

Basic ADL include bathing, dressing, toileting, ambulating, and feeding. All the other options represent instrumental ADL. DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 34. When examining a ―difficult‖ patient, it is best to allow which person in the examination

room? a. The clinician b. Patient’s small children c. An interpreter d. A chaperone ANS: D

A chaperone for ―difficult‖ patients ensures the examination goes smoothly. The chaperone may also assist with patient positioning.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 35. Functional assessment is most important during the examination of a(n) a. adolescent. b. infant. c. older adult. d. young adult.

ANS: C

Functional assessment is most important when examining the older adult. Initial observation and interaction can provide a great deal of information about the individual’s independent

functional capacity. Attention should be given to self-care activities and instrumental activities.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 36. Observation of the child playing in the playroom provides information about which two

systems? a. Dermatologic and cardiovascular b. Neurologic and musculoskeletal c. Respiratory and ear, nose, and throat d. Gastrointestinal and genitourinary ANS: B

The child playing on the floor offers an opportunity to evaluate the musculoskeletal and neurologic systems by noting the child’s coordination of activities, such as when throwing a ball, drawing, coloring, walking, and jumping.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 37. Throughout the history and physical examination, the clinician should a. concentrate on emotional issues. b. follow an inflexible sequence. c. evaluate the whole patient. d. deal only with previously identified problems.

ANS: C

The clinician should evaluate the whole patient, including physical, emotional, and social needs. Learning how to follow a disciplined course and be flexible will help the clinician during the history and physical examination. The information obtained should be kept organized to provide essential patient care.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 38. For a routine physical examination, which equipment is not necessary? a. A penlight b. A measuring tape c. Examination gloves d. A monofilament ANS: D

A penlight, measuring tape, and examination gloves are needed for every routine examination; a monofilament is not.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 39. The cranial nerves are usually assessed while the patient is in which position? a. Standing b. Supine c. Sitting d. Prone

ANS: C

While the patient is in the sitting position, you can assess all cranial nerve functions.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 40. Which action should the nurse take before auscultating bowel sounds in an 18-month-old

child? a. Stand to the left of the child. b. Palpate the abdomen. c. Loosen the diaper. d. Position the child prone.

ANS: C

The diaper must be loosened so the nurse is able to place the stethoscope on the child’s skin and not the diaper. Placing the stethoscope on the child’s diaper will interfere with the nurse’s ability to hear the bowel sounds.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 41. Which position is most likely the most comfortable for a patient who is 6 months pregnant? a. Side-lying b. Lithotomy c. Prone d. Flexed-knee ANS: A

Late in pregnancy, the patient may find it difficult to assume the lithotomy or supine position.

The nurse should position pillows so that the patient is in the side-lying position as much as possible during the examination.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 42. What is the ―brown-bag approach‖ in regard to examining an older adult? a. The patient’s stool sample is brought to the examination in a brown bag. b. The patient’s medications are brought to the examination in a brown bag. c. The patient’s change of clothes is brought to the examination in a brown bag. d. The patient’s assistive device is brought to the examination in a brown bag.

ANS: B

Older adults are often asked to bring in all of their medications, prescription and non-prescription, from all healthcare providers to their physical examination appointment.

This is referred to as the ―brown-bag approach.‖ DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort COMPLETION 1. Mrs. Jones is a 44-year-old patient who presents for a routine physical examination. The

patient is unable to shrug her shoulders against the examiner’s hands during the examination.

The cranial nerve involved with successful shoulder shrugging is CN .

ANS:

XI Cranial nerve XI enables the patient to shrug her shoulders.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 2. Ms. Stein visits the nurse practitioner for an annual examination. The nurse practitioner tests

Ms. Stein’s tongue for movement and strength. The nurse practitioner is assessing CN .

ANS:

XII Cranial nerve XII enables the patient to demonstrate tongue movement and strength.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort

Chapter 25: Sports Participation Evaluation Ball: Seidel’s Guide to Physical Examination, 10th Edition MULTIPLE CHOICE 1. The goals of preparticipation sports evaluation include a. screening for steroid use or abuse. b. determining the best fit for positions in each sport. c. determining the risk of injury or death during sports participation. d. securing a legal contract before recommending limiting participation.

ANS: C

The ultimate goal of preparticipation physical evaluation is to ensure safe participation in an appropriate sports activity.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Health Promotion and Maintenance 2. The checkout station for preparticipation physical evaluation is critical because at this point a. all completed forms are distributed. b. parental signatures are obtained. c. the relevant history is obtained. d. the coordination of follow-ups is reviewed.

ANS: D

At the checkout station, data collected during the evaluation are reviewed and necessary follow-up actions are shared with the athlete and/or parents. In addition, the written report is distributed.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Health Promotion and Maintenance 3. You are conducting a preparticipation physical examination for a 10-year-old girl with Down

syndrome who will be playing basketball. She has slight torticollis and mild ankle clonus.

Which additional diagnostic test would be required for her? a. Cervical spine radiography b. Visual acuity c. Mini-Mental State Examination d. Nerve conduction studies ANS: A

This girl is experiencing symptoms of atlantoaxial joint instability and should therefore have cervical spine radiography with neurologic consultation before beginning sports activities.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Health Promotion and Maintenance 4. Part of the screening orthopedic component of the examination includes evaluating the person

while he or she is a. performing push-ups. b. duck walking. c. twisting at the waist.

d. crossing the arms over the chest.

ANS: B

Duck walking for four steps assesses hip, knee, and ankle range of motion, strength, and balance.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Health Promotion and Maintenance 5. Your 15-year-old patient is athletic and thin. Radiography of an ankle injury reveals a stress

fracture. You should question this patient about her a. sleep patterns. b. salt intake. c. aerobic workouts. d. menstrual cycles.

ANS: D

The lean body encourages a hypoestrogenic state that can lead to menstrual dysfunction and osteopenia or osteoporosis. This state increases the risk of stress fractures. The patient should be questioned about amenorrhea.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Health Promotion and Maintenance 6. One of the most important aspects to consider in the orthopedic screening examination is a. muscle contraction. b. flexibility. c. symmetry. d. balance.

ANS: C

The most important aspects to consider when conducting an orthopedic examination are symmetry of muscle, stature, and joint movement.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Health Promotion and Maintenance 7. Which medical condition would exclude a person from sports participation? a. Asthma b. Fever c. Controlled seizures d. HIV-positive status ANS: B

Fever can increase cardiopulmonary effort and impair exercise capacity; fever can indicate myocarditis or other infections that make exercise dangerous.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Health Promotion and Maintenance 8. A parent is advised to restrict contact sports participation for their child. An example of a

sport in which this child could participate is a. hockey. b. roller skating. c. riflery. d. skateboarding.

ANS: C

Riflery is a noncontact sport. Hockey is considered a collision sport. Roller skating and skateboarding are considered to be limited contact sports.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Health Promotion and Maintenance 9. A child has a poorly controlled seizure disorder. He has restricted sports participation but

would be able to engage in a. archery. b. swimming. c. weight lifting. d. badminton.

ANS: D

Badminton does not pose an added risk to self or others if the child experiences a seizure during participation.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Health Promotion and Maintenance 10. You are auscultating heart tones as part of a sports physical examination. You hear a murmur

at the right second intercostal space (aortic area). The murmur increases in intensity when this teenager goes from a sitting to standing position. The subsequent recommendation should be to a. consult a cardiologist as soon as possible. b. have a stress test before completion of the form. c. participate in low-static, high-dynamic sports. d. limit contact sports and have an echocardiogram.

ANS: A

The murmur of aortic stenosis is indicative of hypertrophic cardiomyopathy, which may be the cause of sudden death in children and adolescents at rest or during exercise. Therefore, a cardiology consult should be requested as soon as possible.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment

MSC: Health Promotion and Maintenance

MULTIPLE RESPONSE 1. Why should the preparticipation sports examination take place well in advance of the planned

sports activity? (Select all that apply.) a. To allow completion of therapy for identified problems b. Because routine health maintenance needs to be addressed c. Because it should be 6 weeks prior to the planned sports event d. To allow completion of follow-up testing ANS: A, D

The preparticipation sports examination should be completed well enough in advance of the planned sports activity so that rehabilitation or therapy for any problems can be completed, as well as any follow-up testing or referrals.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Health Promotion and Maintenance

Chapter 26: Emergency or Life-Threatening Situations Ball: Seidel’s Guide to Physical Examination, 10th Edition MULTIPLE CHOICE 1. During initial ABCDE assessments of life-threatening conditions, D (disability) in neurologic

status is assessed by the patient’s a. pupil size. b. degree of responsiveness. c. nuchal rigidity. d. mood and affect.

ANS: B

The D (disability) in neurologic status of the primary assessment is assessed by determination of the patient’s degree of responsiveness to stimuli.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 2. You have gone by ambulance to a construction site where an adult male is lying on the street.

The only information you have is that he fell three stories. His neck is immobilized with sacks of concrete mix on either side. Your first action should be to determine a. airway patency. b. bleeding sites. c. cranial nerve function. d. limb position.

ANS: A

On arriving at the site, the patency of the upper airway is the priority and should be managed before proceeding with further assessments.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 3. The ABCs of a primary survey would be interrupted to a. complete the assessment record. b. manage life-threatening conditions. c. reassess the patient’s temperature. d. transport the patient via airlift.

ANS: B

The primary assessment is interrupted to manage a life-threatening condition as soon as it is detected. Once the condition is stabilized, the primary assessment is continued. Recording of events as they occur should be completed in a manner that does not interrupt continued care or transport. Reassessment of the patient’s temperature is inappropriate because it would interrupt the continued assessment process. Transporting the patient may begin after the primary assessment has been completed to determine the needs of the patient adequately.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—implementing MSC: Safe and Effective Care: Management of Care 4. The term status epilepticus is defined as a. convulsive activity uncontrolled by medication. b. nonconvulsive brain wave disturbance, with psychomotor dysfunction. c. prolonged seizures that occur without recovery of consciousness.

d. seizures that result in hypotension, pallor, and prolonged diaphoresis.

ANS: C

Status epilepticus is a prolonged seizure or series of seizures that occur without recovery of consciousness.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 5. Pulsus paradoxus greater than 20 mm Hg, tachycardia greater than 130 beats/min, and

increasing dyspnea are signs of a. intracranial pressure. b. pulmonary hypertension. c. status asthmaticus. d. tetanic contractions.

ANS: C

Status asthmaticus is a severe and prolonged asthma attack that resists the usual therapeutic approaches. The patient experiences dyspnea, can only get out a few words between breaths, and has tachycardia often greater than 130 beats/min and pulsus paradoxus greater than 20 mm Hg. Pulsus paradoxus is more likely in pericardial effusion, constrictive pericarditis, and severe asthma.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—diagnosis MSC: Physiologic Integrity: Basic Care and Comfort 6. The Cushing triad includes a. tachycardia. b. irregular respirations. c. tachypnea. d. constricted pupils.

ANS: B

The Cushing triad is associated with increased intracranial pressure. It includes bradycardia, hypertension, and irregular respirations, even Cheyne-Stokes respirations.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—diagnosis MSC: Physiologic Integrity: Basic Care and Comfort 7. Blood, vomitus, and foreign bodies are removed from the oropharynx of the unconscious

patient by a. stimulating the cough reflex. b. using a sweeping motion with the finger. c. performing a back thrust. d. using suction.

ANS: D

Suction is used to remove blood, vomitus, or foreign bodies from the airway of an unconscious patient. The other choices put the patient at risk for aspiration or further injury if a neck injury is involved.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—implementing MSC: Safe and Effective Care: Management of Care 8. While performing the primary survey on a trauma victim, the patient is answering your

questions. You may assume that during the time of the questioning a. his airway is open. b. he is alert and oriented. c. no head injury has occurred. d. there is no respiratory compromise.

ANS: A

The patency of the upper airway is assessed at the start by asking the patient a question. If the patient answers, this is a sign that the airway is open at this time.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 9. If trauma above the clavicle is suspected, it is important to a. test range of motion of the neck. b. remove any headgear. c. arrange for neck extension x-ray studies. d. stabilize the neck in a neutral position.

ANS: D

If trauma above the clavicle is suspected, it is necessary to control the cervical spine by stabilizing the neck in a neutral position. Excessive movement can convert a fracture or dislocation without neurologic damage to one with neurologic damage.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 10. Paradoxical chest movement suggests a a. spontaneous pneumothorax. b. flail chest. c. clavicle fracture. d. pulmonary contusion.

ANS: B

Paradoxical chest movement is associated with fractured ribs or a flail chest. This fracture should be stabilized immediately.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 11. Respiratory distress may be evidenced by a. retractions of accessory muscles. b. bradycardia. c. flushed skin. d. decreased capillary refill time.

ANS: A

Respiratory distress results in an increased intrathoracic negative pressure as the body attempts to suck in more atmospheric air. This increased negative pressure causes the chest wall skin to retract around the ribs during inspiration. The other choices are related to cardiovascular distress.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 12. On palpating the chest wall of a trauma patient, you feel subcutaneous crepitus (emphysema),

which is a sign that a. air has leaked into soft tissue. b. a fracture underlies the injury. c. a foreign body is present. d. there is vascular obstruction.

ANS: A

Crepitus is a sign of air leakage into soft tissue. Crepitus in soft tissues is caused by air that has penetrated the area as a result of injury; it is also referred to as subcutaneous emphysema.

Bony crepitus is a grating or grinding sensation caused by fractured bone ends or joints rubbing together. A foreign body could obstruct the patient’s airway, producing stridor, or a bark may be heard with an obstructed airway.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 13. Clear or amber drainage from the nose or ears of a blunt trauma patient may indicate a. epiglottitis. b. a retropharyngeal abscess. c. a basilar skull fracture. d. a perforated tympanic membrane.

ANS: C

Clear or amber drainage from the nose or ears may indicate a basilar skull fracture. Bloody drainage is associated with a perforated tympanic membrane.

DIF:Cognitive Level: Applying (Application) MSC: Physiologic Integrity: Basic Care and Comfort

OBJ:Nursing process—diagnosis

14. Delayed capillary refill may alert you to a. hypovolemic shock. b. moderate hypoxemia. c. subnormal intracranial pressure. d. upper respiratory infection.

ANS: A

Delayed capillary refill means that the vessels are taking an extended time to fill, which is a sign of decreased cardiac output. To assess peripheral perfusion further and detect hypovolemic shock, note the skin color, presence and quality of pulses, and temperature of the extremities.

DIF:Cognitive Level: Applying (Application) MSC: Physiologic Integrity: Basic Care and Comfort

OBJ:Nursing process—diagnosis

15. Capillary refill can be assessed by applying pressure over a nail bed or a(n) a. bony prominence. b. eyelid. c. mucous membrane. d. femoral vein.

ANS: A

Capillary refill can be assessed by pressing firmly over a nail bed or bony prominence such as the chin, forehead, or sternum until the skin blanches. Count the seconds it takes for color to return. Less than 2 seconds is a normal finding, and longer than 2 seconds indicates poor perfusion.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 16. The secondary survey of a patient with hypotension would begin with the assessment of a. blood type. b. level of consciousness. c. number of fractures. d. swallowing ability.

ANS: B

Secondary assessments are done after life-threatening problems are determined. For the hypotensive patient, it would be most important to begin secondary assessment of cerebral perfusion by determining the patient’s level of consciousness.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort

17. You would complete a Glasgow Coma Scale rating during the a. health history. b. physical examination. c. primary survey. d. secondary survey.

ANS: D

During the secondary survey, the full range of injuries is determined. The level of consciousness is determined, and the Glasgow Coma Scale is scored as indicated.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 18. Mr. Stinson is a 34-year-old patient who presents to the emergency department after an auto

accident. On examination, you note raccoon eyes and a positive Battle sign. Raccoon eyes and the Battle sign are associated with a. multisystem trauma. b. orbital fractures. c. basilar skull fractures. d. subdural hematoma.

ANS: C

Raccoon eyes (bruising around the eyes) and the Battle sign (bruising behind the ears) both indicate a basilar skull fracture. Symptoms of orbital fractures are swelling of the eyelid, bruising of the eye, pain in the eye, double vision, and decreased movement of the affected eye. Signs and symptoms of a subdural hematoma are loss of consciousness after the original injury, steady or fluctuating headache, weakness, numbness or inability to speak, slurred speech, nausea, vomiting, lethargy, and seizures.

DIF:Cognitive Level: Applying (Application) MSC: Physiologic Integrity: Basic Care and Comfort

OBJ:Nursing process—diagnosis

19. A life-threatening condition is recognized with the assessment of a. pain with downward pressure on both anterior superior iliac spines. b. guarding and intense pain with deep palpation of the abdomen. c. distant and muffled heart sounds, with distended neck veins. d. severe throbbing pain in one eye, with photophobia.

ANS: C

Distant, muffled heart sounds and distended neck veins may indicate cardiac tamponade, a life-threatening condition. Iliac spine pain indicates a pelvic fracture that may become life-threatening depending on the extent of occult bleeding. Intense pain with deep palpation is not certain to be deadly. Eye pain with photophobia signals acute glaucoma, which can lead to blindness if treatment is delayed.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—diagnosis MSC: Physiologic Integrity: Basic Care and Comfort 20. The application of blunt sternal pressure is used to detect a. a fracture of attached ribs. b. the motor function of the T7 dermatome. c. pneumothorax. d. cardiac contusion.

ANS: A

Blunt sternal pressure will be painful if any attached ribs are fractured. Sternal pressure is applied to the chest to assess the stability of the chest wall.

DIF:Cognitive Level: Understanding (Comprehension) MSC: Physiologic Integrity: Basic Care and Comfort

OBJ:Nursing process—diagnosis

21. Until they are stabilized, trauma patients require reevaluation a. every 2 minutes. b. every 5 minutes. c. every 10 minutes. d. every hour.

ANS: B

An unstable patient must be reevaluated frequently so that any new signs and symptoms are not overlooked. A primary survey should be performed every 5 minutes and the results compared with those obtained in previous surveys.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 22. During injury assessment, one of the most crucial historical components is a. number of siblings. b. history of prior fractures. c. mechanism of injury. d. past and current occupational exposure.

ANS: C

In cases of trauma, the secondary assessment is intended to identify the full range of injuries, with particular focus on body systems affected by the mechanism of injury. All the other choices are not crucial for the emergency.

DIF:Cognitive Level: Understanding (Comprehension) OBJ:Nursing process—assessment MSC: Physiologic Integrity: Basic Care and Comfort 23. Which condition manifests as unexplained shortness of breath (SOB) and cough with

hemoptysis? a. Bleeding ulcer b. Myocardial infarction c. Pulmonary embolism d. Transient ischemia

ANS: C

Symptoms of pulmonary embolism include sudden onset of unexplained SOB, pleuritic chest pain, and coughing, with pink frothy sputum. Bleeding ulcer symptoms are coffee grounds emesis with gnawing pain in the upper abdomen. Myocardial infarction is signified by crushing pain in the center of the chest radiating to the arm, neck, or jaw, diaphoresis, nausea and vomiting, SOB, and a feeling of impending doom. Transient ischemia occurs with a sudden feeling of weakness and loss of movement of the arms or legs, numbness and/or tingling in any part of the body, excruciating headache, and/or difficulty speaking.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—diagnosis MSC: Physiologic Integrity: Basic Care and Comfort 24. Which injury is the most common precipitator of blunt trauma? a. b. c. d.

Age-related falls Motor vehicle accidents Work-related injuries Childhood play injuries

ANS: B

Motor vehicle accidents account for the majority of severe blunt trauma cases.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—planning MSC: Physiologic Integrity: Basic Care and Comfort 25. When calculating the force of impact of a penetrating object, use a. the size of the missile and size of the patient. b. the time of the incident and depth of the wound. c. the amount of blood loss and level of consciousness. d. the velocity of the missile and distance from the source.

ANS: D

When calculating the force of impact of a penetrating object, the amount of force is measured by the velocity of the missile and distance from the source. The force of the penetrating object on impact determines the transfer of energy.

DIF:Cognitive Level: Analyzing (Analysis) OBJ:Nursing process—diagnosis MSC: Physiologic Integrity: Basic Care and Comfort 26. Adults and children display different physiologic responses to injury and acute illness. An

important concept to remember when assessing infants and children is that they a. experience lethal dysrhythmias first, progressing to respiratory failure. b. usually experience cardiac arrest before respiratory failure. c. usually experience respiratory arrest before circulatory failure. d. tolerate greater volume changes, with less severe consequences.

ANS: C

Cardiac arrest is rarely a primary event in children, as it is in adults. The child usually experiences respiratory and ventilatory failure that progresses to respiratory arrest first.

Without rapid intervention, a cardiac arrest occurs as a secondary event.

DIF:Cognitive Level: Understanding (Comprehension) MSC: Physiologic Integrity: Basic Care and Comfort

OBJ:Nursing process—diagnosis

27. The approximate expected systolic blood pressure for a child older than 1 year is a. 120 + child’s age in years.

b. 80 – child’s age in years. c. 120 – child’s age in years. d. 80 + (the child’s age in years).

ANS: D

Use the equation 80 + (the child’s age in years) to calculate the expected systolic blood pressure for a child older than 1 year.

DIF:Cognitive Level: Remembering (Knowledge) OBJ:Nursing process—diagnosis MSC: Physiologic Integrity: Basic Care and Comfort 28. In life-threatening emergencies, consent for treatment a. is obtained before treatment to protect the facility from liability. b. is not necessary. c. occurs after treatment is administered. d. is not valid because the patient is not competent.

ANS: C

In life-threatening emergencies, the needed treatment should usually be given and formal consent obtained later.

DIF:Cognitive Level: Applying (Application) OBJ:Nursing process—implementing MSC: Physiologic Integrity: Basic Care and Comfort